Local and Systemic Factors in Periodontal Disease PDF

BY PROF. HAKEM HUSSEIN EL SAYED  ILO,s At the end of this lecture, the students will understand  Local predisposing factors for periodontal disease; including (Malocclusion, Anatomical variations, Hypofunction, Habits, Food impaction &Retention, Chemical irritation, Radiation,...

BY PROF. HAKEM HUSSEIN EL SAYED  ILO,s At the end of this lecture, the students will understand  Local predisposing factors for periodontal disease; including (Malocclusion, Anatomical variations, Hypofunction, Habits, Food impaction &Retention, Chemical irritation, Radiation, Mouth Breathing, Iatrogenic factors).  Systemic predisposing factors for periodontal disease; including (Endocrinal disorders, Hematologic disorders, Genetic disorder, Drug induced disorders, Nutritional influences, Psychosomatic, Aging, Viral, Smoking) LECTURE OUTLINE Definition of Predisposing factors for periodontal diseases  Classifications of Local & Systemic Predisposing factors 1. Malocclusion  Endocrinal disorders ( Hormonal). 2. Anatomical variations  Hematologic disorders. 3. Hypofunction  Genetic disorder 4. Habits  Drug induced disorders 5. Food impaction & Retention  Nutritional influences 6. Chemical irritation& Radiation 7. Mouth Breathing  Psychosomatic 8. Iatrogenic factors  Aging  Viral  Smoking  The primary cause of gingival inflammation is Bacterial plaque Predisposing factors These are factors that do not initiate Periodontal disease But Capable of influencing the tissue response to the intiating factor ( Bacterial Plaque )  Predisposing factors Local Systemic ( Influence of Systemic Disease & Disorders on the Periodontium ) 1. Malocclusion  Endocrinal disorders ( Hormonal). 2. Anatomical variations 3. Hypofunction  Hematologic disorders. 4. Habits  Genetic disorder 5. Food impaction &  Drug induced disorders Retention  Nutritional influences 6. Chemical irritation&  Psychosomatic Radiation 7. Mouth Breathing  Aging 8. Iatrogenic factors  Viral  Smoking Local Predisposing factors 1. Malocclusion 2. Anatomical variations 3. Hypofunction 4. Habits 5. Food impaction & Retention 6. Chemical irritation& Radiation 7. Mouth Breathing 8. Iatrogenic factors 1. Malocclusion : Irregular alignment of teeth ( mal–occlusion ) may make plaque control more difficult 1. May be responsible for occlusal trauma & Plaque retention 2. Severely labially inclined teeth portion of the root out of the alveolar housing Dehiscence / Fenestration  2. Anatomical variations of teeth & soft tissues a. Peg teeth: Defective incisal biting and food impaction around this teeth b. Enamel pearls : Minute blebs at or epical to CEJ that are formed totally of enamel this will allow retention of bacteria and resulting in inflammation and periodontal destruction c. Palatal grooves : Palatal clefts in the upper centrals & laterals allows bacterial plaque accumulation , that are difficult to clean d. High frenum & diminished attached gingiva : the fibrous frenum insert into the gingival margin and tend to pull the gingiva leading to Inadequate attached gingiva  difficult in dental brush cleaning & gingival recession 3. Hypo function & unreplaced teeth : reduction or absence of functional stimulation due to loss of antagonist A 1. Misial drifting of neighbouring 3 teeth 2. Over eruption of the opposing tooth 2 3. Open contact between the teeth 1 Food impaction – gingival inflammation – bone loss 3. Hypo function & unreplaced teeth : reduction or absence of functional stimulation due to loss of antagonist B 1. Disuse atrophy 2. Plaque & calculus accumulation on the hypofunctional teeth 3. Long term hypo function results in increasing tooth mobility 4. Habits and Self-Inflicted Injuries “ A voluntary repetition of an act which becomes by time involuntary “ a. Neuroses b.Occupational c. Miscellaneous Fingernail pressure Application of fingernail pressure against the gingiva Gingival recession  Tongue thrusting Forceful wedging of the tongue against the teeth ( in the anterior region ) ….. Leading to tilting & lateral spreading of teeth – Labial drift of maxillary anterior teeth Excessive Lateral force traumatic pressure to the periodontium  Toothbrush Trauma aggressive brushing Acute changes Chronic changes Abrasions & ulceration of Recession of the gingiva + denudation the gingiva of the root surface.  Bruxism It is a nonfunctional voluntary or involuntary mandibular movement ( during night or day ) Manifested by Grinding , Clinching & Clicking of the teeth Applying a load of over 20 Kg on a tooth over a period of 2 -5 sec. Causes : 1. Nervous tension 2. Occlusal interference  Diagnosis wear facets Wide PDL space TMJ Discomfort As in occlusal trauma ( joint arthritis ) 1. Advanced attrition ( wear facets ) 2. Increase tooth mobility 3. Wide PDL space 4. Hypertonicity of the muscles of mastication 5. TMJ Discomfort 5. Food impaction & Retention Forceful wedging of food into the periodontium by occlusal force ( mastication ) – retained & does not pass by it self. Exaggerates To the the wedging interproximal effect of spaces opposing cusp 1. Pressure feeling… urge to dig material Absence of contact interproximal 2. Gingival inflammation & bleeding Food 3. Foul / bad taste 4. Gingival recession impaction 5. Periodontal abscess 6. Bone loss 7. Root caries 6. Chemical irritation & Radiation Chemical Irritation Radiation Radiation therapy has cytotoxic effects on both normal cells and malignant cells Frequent use of strong mouth-washes Desquamation of the Acute gingival inflammation: gingiva – ulceration erythema – vesicles – ulceration – susceptibility to due to : infection – retard - Some dentifrices – denture materials healing  7. Mouth Breathing Surface dehydration & plaque accumulation Mouth Erythema ,edema, Breathing enlargement of the gingiva of maxillary anterior region Severe gingivitis & Bleeding 8. Iatrogenic Factors : Inadequate dental procedures that contribute to the deterioration of the periodontal tissues Margins of Restorations Over hanging margins Location of gingival margins 16.5% to 75% of cases of restoration margins  Growth of gm –ve bacteria Reduce patient access to Apical to At gingival Supra remove accumulated plaque gingival margin margin gingival + + plaque Less plaque Periodontal + + gingivitis Less gingivitis health + + pockets Less pockets  Contours and Open Contacts  Over contoured crowns and restorations Opening of the contact point Over-erupted cusp that lies directly ( plunger cusps) over a contact point : wedging effect of the opposing cusp is exaggerated Food impaction  Design of Removable Partial Dentures Partial dentures should worn only during the daytime partial dentures favor the accumulation of plaque particularly if they cover the gingival tissue Restorative Dentistry Procedures rubber dam clamps, matrix bands, and burs Varying degrees of mechanical trauma and inflammation  Complications Associated with Orthodontic Therapy Plaque Retention Gingival Trauma Excessive Orthodontic Forces P.intermedia Orthodontic bands if + + Force : necrosis of the AAC forcefully placed will: periodontal ligament &  ( in 85% of children)  detach the gingiva from alveolar bone & apical root compared with only 15% of the tooth resorption. the control subjects.  gingival recession. Elastic ligature which used to Greater degree of close a diastema severe alveolar bone loss attachment loss & may migrate apically along the root Periodontal condition must be treated before initiating orthodontic therapy  An elastic ligature was used to Mucoperiosteal flap has been close a midline diastema. Note reflected to expose the elastic inflamed gingiva and deep ligature around the central probing depths. incisors. If forcefully placed will detach the gingiva Alveolar bone loss - apical from the tooth root resorption.  Systemic ( Influence of Systemic Disease & Disorders on the Periodontium )  Endocrinal disorders ( Hormonal).  Hematologic disorders.  Genetic disorder  Drug induced disorders  Nutritional influences  Psychosomatic  Aging  Viral  Smoking Endocrinal disorders { Hormonal }  1.Diabetes mellitus Definition ; It is a complex metabolic disease characterized by chronic hyperglycemia. Inability of glucose to be transported from the blood to the body cells – due to decrease Insulin production , action or both It is an extremely important disease from a periodontal standpoint.  2 Basic Types Type I Diabetes TYPE II DIABETES Before age of 25 After age of 40 10 % of all diabetics 80 – 90 % of all diabetics Required insulin injection Diet / oral hypoglycemic Viral cause / Autoimmune agents destruction of beta cells Level of plasma insulin is normal but Decreased cellular response to insulin Severe Periodontal Destruction. Bleeding gum Severe gingival inflammation Periodontal abscesses & loss of attachment ( CAL ) Periodontitis Type 1 diabetes : Start after age 12. Destruction occurred around 1st molars & incisors. At older age : generalized destruction – frequent periodontal abscesses Severe Periodontal Destruction. In Uncontrolled Diabetes : greater loss of attachment – more Bleeding on probing – more tooth mobility. Pt. showing Overt Diabetes … > 10 years have greater loss of periodontal structures than those with diabetic history of less than 10 years Periodontal disease in diabetic girl ( 13 years old ) Periodontal abscess Loss of all periodontal structures  Bacterial pathogens …. qualitative change : Due to increase glucose content in gingival fluid & gingival B.V Type I Type II P. Gingivalis A. A. Comitans P. intermedia  P.M.N function : Impaired function ( increase susceptibility to infection ) X adherence phagocytosis chemotaxis X  Altered Collagen metabolism : Due to Chronic hyperglycemia 1. Formation of advanced glycation end product ( AGE ) collagen less likely to be repaired or replaced. 2. Generalized Increase in Collagenase activity due to reduction of insulin action / amount ( Decrease fibrous content of gingival tissue )  Increase thickness of the blood vessels walls ( microangiopathy): ( AGE ) Narrowing of the of gingival capillaries Decrease blood supply & O2 to gingival tissues  Treatment - Control of periodontal disease may reduce insulin requirements. - Extensive periodontal treatment in patients with uncontrolled diabetes is contraindicated - Rule out acute dental infections with antibiotics and analgesics until diabetic control is attained. -Supra and subgingival scaling ( tissue must be handled as a traumatically as possible ) Antibiotic  If therapy is extensive antibiotic coverage is recommended = Antibiotic of choice is penicillin  In non surgical ttt = Tetracycline as doxycycline due to its anticollagenase activity  If Metronidazole is prescribed, the physician should be consulted for reduction of the anti diabetic drug dose.  Frequent recall appointments & meticulous home care should be maintained  story article 2. Sex Hormones Gingival disease during pregnancy Severity of gingival inflammation increases in 2 peaks ….: 1. ( first trimester ) Second / third month due to Gonadotrpins. 2. ( 3rd trimester ) Eight month due to increase level of Estrogen – Progesteron 2nd trimester is the safest for any periodontal treatment The most striking clinical findings : Bleeding gum Extreme redness Pregnancy tumor *Hormonal contraceptives & the gingiva: Similar to that seen in pregnancy….when taken > 1.5 years may leads to periodontal destruction. Metronidazole should not be prescribed to avoid reduction of contraceptive effects Effect of Progesterone on periodontal disease during pregnancy + + Progesterone & Estradiol ++ Destruction of inhibits Prevotella Mast cells & ++ Maternal T - Intermedia Prostaglandins lymphocytes Release of Histamine + + Proteolytic enzymes + +Vascularization & ( Degeneration of gingival gingival edema tissues )  Periodontal management for Pregnant female : 1. Meticulous Plaque Control 2. Scaling / Root planing ( the only periodontal procedure during pregnancy ) 3. Second trimester is the safest period for periodontal therapy 4. Any periodontal surgery should be delayed until the post partum period 5. In case of present of Pregnancy tumor ( Post gestation surgical excision ) Hematologic disorders 1. Leukemia 2. Agranulocytosis  1. Leukemia Periodontium in leukemic patient.  Leukemic gingival enlargement : ( due to + + infiltration of C.T with leukemic cells ) 1. Bluish –red, –Sponge like gingiva. 2.Enlargement, most often in IDP partially covering the teeth Creating gingival pockets Microscopically  Bleeding gum: { Early signs of the disease }. Over production of leukemic cells Suppression of Platelet production. Gingival Hemorrhage ( common finding )  Oral ulceration : Due to granulocytopenia A –Bacterial …+ + + + Periodontal diseases. B – Viral … Herpetic oral ulceration * Periodontal lesions clinically …Not found in Edentulous pts. OR in Chronic Leukemia. Leukemic gingiva :Enlargement –Bleeding -Ulceration Herpetic ulceration on the palatal aspect of the gingival tissue  2. Agranulocytosis Disappearance of circulating granulocytes due to ingestion of medications ( drugs ) as : barbiturates – sulfonamides – gold salts 1. Painful ,large ulceration 2. Necrosis of gingival margin 3. Without inflammation Associated with genetic disorder 1. Hereditary gingival fibromatosis 2. Cyclic Neutropenia 3. Chediek Higashi S 4. Lazy Leukocyte S 5. Papillon- Lefèvre Syndrome 6. Down ,s Syndrome 7. Aggressive periodontitis 8. Hypophosphatasia 1. Hereditary gingival fibromatosis Associated with permanent teeth Enlarged gingiva Exaggerated stippling Excessive production of collagen due to permanently activated Fibroblasts 2. Cyclic Neutropenia 1. Destructive periodontitis( deep p.pockets ) 2. Gingival edema & hyperplastic 3. Periodic destruction of alveolar bone Periodic / monthly decrease in number of Neutrophils ( infancy & child hood )  Gingival Pathological changes RECUR with exacerbation of the disease  3. Chediek Higashi S: Defect in Neutrophils Killing mechanisms Genetically transmitted disease { defect in intracellular killing of Neutrophils }. Due to genetic defects Destructive abnormal mutation of periodontitis: neutrophils lysosomes. lack of normal Lysosomes Granules fused protection of together to form mega bodies Neutrophils  4. Lazy Leukocyte S: Defect in PMN chemotactic response Susceptibility to severe microbial infections. Exaggerated inflammatory response. Susceptible to severe periodontitis with destruction of bone and early tooth loss  5. Papillon- Lefèvre Syndrome * hyperkeratotic skin lesions, * destruction of the periodontium Skin & periodontal lesions starts at the age of 4-5 years – by the age of 10 -15 years most of permanent teeth are lost Etiology : 1. Virulent pathogens : P intermedia & AAC 2. of PMN ,monocytes & lymphocytes Palms, and, knees, hyperkeratotic, scaly lesions  6. Down ,s Syndrome 1. Mental deficiency ( mongolism,) 2. Periodontal destruction and Acute necrotizing lesions NUG Causes : 1. Poor circulation to the gingiva & the brain 2. Poor PMN chemotaxis and phagocytosis. 3. Defect in T cell maturation  7. Aggressive periodontitis Aggressive Defect in all pathogenic bacteria ( AAC ) + neutrophils functions Rapid Periodontal Destruction  8. Hypophosphatasia Patient have low serum alkaline phosphate Rickets – poor Loss of primary teeth cranial bone ( incisors ) due to severe formation bone loss Drugs induced disorders  Drugs induced disorders a. Phenytoin b.Dihydropyridine c. Cyclosporines ( Dilantin ) ( Nifedipine ) ++ + + + ++Fibroblast & inhibition of the cells production of - - Collagenase turn over – rather than collagen fibers increase cells division Treatment : 1. subgingival scaling – home care regime 2. gingivectomy operation 3. Replacing the medication Nutritional influences  Vitamin Deficiency Fat Soluble Vitamin Water Soluble Vitamin Deficiency Deficiency  Vitamin Deficiency Vitamin Deficiency Scurvy Normal level of Plasma Ascorbic acid … = Or > 4 mg /L Stimulates Stimulates Osteoblast to collagen synthesis form osteoid & gingival wound tissues healing Functions ++ Leukocytes Regulates tissue activity Antioxidant permeability Stress & Psychosomatic disorders  Stress & Psychosomatic disorders Acute NUG may be correlated with states of Stress Neurological - Hormonal – Immunological interaction Injurious habits to Periodontium ++ Cortisol ++ Epinephrine Grinding – Clenching. Suppression of Exaggerates Nibbling on foreign body. lymphocytes tissue- Nail biting. Neutrophils destructive functions Use of tobacco. activity. Long term Stress Gingival & periodontal diseases  Aging Both incidence & severity of periodontal disease increase with age Due to cumulative effect of dental plaque over time The more the age the more the duration of the disease Viral  Viral Acquired Immunodeficiency S : AIDS HIV Destroy- Helper lymphocytes ( Human immunodeficiency ) Oral finding : 1.Destructive periodontitis 2. NUG - NUP Interproximal bone loss &necrosis (sequestration ) 3. Oral candidosis 4. Kaposis`s Sarcoma  Necrotizing ulcerative Kaposi's sarcoma periodontitis. Extensive necrosis to underlying Reddish purple vascular periodontal tissue & alveolar locally malignant neoplasm bone with CAL.  Smoking 1. Nicotine has been shown to decrease gingival blood flow & GF which may impair revascularization in gingiva & alveolar bone – ( ++ NUG ) 2. Smoking decreases local O2 tension ( V.C ) of gingival capillaries ( increases anaerobic bacteria ) 3. Smoking reduces G.F ( increases bacterial adhesion to dental tissues ) 4. Smoking inhibits collagen production & increase collagenase activity of gingival fibroblast 5. Smoking (inhibits chemotaxis & phagocytosis) But ( ++ PGE2 & collagenase ) of neutrophils 6. Smoking decreases the NO. of T helper lymphocytes & Salivary IgA ( inhibits Opsonization )  Smoking O2 Increases anaerobic Smoking ( ++ NUG ) increases bacterial bacteria adhesion to dental tissues inhibits collagen production chemotaxis & & increase collagenase phagocytosis & PGE2 & Salivary IgA activity of gingival fibroblast collagenase of neutrophils References MSA. Periodontology & Periodontics Vol. I OMD 531 – 541 Local predisposing factors in periodontal disease ……………………65 Infuence of systemic diseases & disorders on periodontium ……. 76 CARRANZA`s CLINICAL PERIODONTOLOGY Thirteen edition Relationship between Periodontal Disease and Systemic Heath chapter 14