MS2 - Perio Systemic Relationships 2

Question 1

worm

Learning Objectives

Answer 1

• understand the basic concepts of periodontal medicine
• Explain the role of focal infection theory in periodontal medicine
• explain the role of perio in the etiopathogenesis of systemic diseases
• understand how management of perio can reduce the risk of adverse systemic disease outcomes

Question 2

What is periodontal medicine?

Answer 2

The means by which periodontal infections can affect systemic health

Question 3

What is a focal infection?

What are some examples of foci of infections in the oral cavity?

Answer 3

Oral cavity is seen as the doorway of the body and must be ‘clean’ to protect the body from contamination

Focal infection = local infection in one area of the body which can adversely affect distant target organs

eg:

• caries
• Periodontal disease
• abscess
• PA lesions
• non-vital teeth
• pericoronitis
• fungal and viral infections

Question 4

What are some of the microbes present in periodontal infections?

Answer 4

• Porphyromonas gingivalis (dementia related, Alzheimers)
• Tanerella forsythia
• Aggregatibacter actinomycetemcomitans
• P. intermedia
• Campylobacter rectus
• P. micros
• Selenomonas

Question 5

What viruses can support the overgrowth of periodontal pathogens and why? (2, 1)

Answer 5

• EBV and HSV

→are immunosuppressive and can support overgrowth of periopathogens

Question 6

What is the volume of pathogenic bacteria in a patient with generalised moderate periodontitis and how does this link to periodontal medicine?

Answer 6

Approx. equal the surface area of the palm of your hands → a large volume of pathogenic bacteria.

the volume of bacteria is the link between perio and systemic disease

Question 7

Briefly, how can periodontal disease affect systemic health?

Answer 7

Microbes in dental plaque induce local and systemic inflammatory and immune responses

→ the immune reactions affect other systems in the body, and in turn, affect systemic health

Question 8

What are the most commonly reported systemic effects of periodontal disease? (6)

Answer 8

• Coronary heart disease (atherosclerosis)
• Stroke
• Pre-term, low birth weight (LBW) baby
• Diabetes
• Lung infection
• Osteoporosis

Question 9

has periodontal disease been identified as a causality of systemic conditions such as diabetes, stroke, pre-term LBW baby, etc?

Answer 9

An increased risk has been associated with perio, but it has not been established as a causative factor

evidence from cross-sectional/association studies not prospective or longitudinal studies (can’t exposure pt to a disease to confirm)

Question 10

What are some similarities in patients who have Cardiovascular disease and pts who have periodontal disease? (6)

Answer 10

• More common in older populations
• Predominantly males
• higher rate of tobacco use
• higher stress levels
• fewer financial resources
• are socially isolated

Question 11

What is the link between perio and ischaemic heart disease / MI?

Answer 11

Poor dental health was found to be associated with MI, independent of other known risk factors

(eg. high cholesterol, hypertension, old age, smoking, etc)

There was a greater risk of CHD-related events in pts where perio affected more teeth vs those where perio affected less teeth

i.e. poor oral health is a risk factor IN ITSELF

Question 12

Briefly, what are 3 ways periodontal disease may lead to CHD/IHD/MI?

Answer 12

All are from periodontal pathogens entering the blood stream.

1. MI → Periodontal pathogens cause significant increase in pro-inflammatory cytokines → leads to formation of factors which can cause vascular effects and may lead to CHD
2. MI → P. gingivalis and Strep. sanguines cause PAAP (protein) expression → causes thromboembolism, leading to MI
3. Atherosclerosis (IHD or Stroke) → Gram -ve bacteria cause endothelial damage and monocyte migration-proliferation and lead to vessel wall thickening
4. With any systemic or perio infection → increase in blood factors - fibrinogen, WBC and VWF → increase blood viscocity → can lead to IHD

(PAAP = platelet aggregation-associated protein)

essentially, bacteria in plaque goes into system and triggers different reactions within the body, ultimately leading to IHD

theory that C-reactive protein (from liver) is a mediator in this

Question 13

Flow charts (in Q and A)

Answer 13

Question 14

How might a pt without diabetes get it after perio?

Answer 14

bacterial products and host response in perio increase cytokines/inflammation and in turn, lead to diabetes

Question 15

How can periodontal disease potentially worsen glyceamic control in pts with diabetes?

Answer 15

Gram negative periodontal infection leads to increased insulin resistance

→worsened glycaemic control

Question 16

How may periodontal therapy (in pts with perio) improve glycaemic control in diabetic pts?

Answer 16

Decreased inflammation after periodontal therapy will lead to improved insulin sensitivity

→improved glycaemic control

Question 17

What can happen if a pregnant women’s has periodontal disease?

Answer 17

Can lead to a pre-term, low birth weight (LBW) baby

(<37 weeks, <2.5kg)

related to 60% of infant deaths

risk factors: smoking, alcohol, nutrition, UTI, level of education, prenatal care

Question 18

What is the belief for why periodontal disease can lead to a pre-term, LBW baby?

Answer 18

Bacterial and products can flow into amniotic fluid, causing an increase in prostaglandins in amnion, can cause uterine contractions

Question 19

What is the role of a dental health professional if a pregnant woman presents with perio?

Answer 19

• inform her of the potential risks (Pre-term LBW baby)
• preventative oral care should be provided early during pregnancy
• if periodontal therapy is indicated, should be commenced early in the 2nd trimester
• Any acute infections/abscesses: potential sources of sepsis require immediate intervention (irrespective of pregnancy stage)

Question 20

When should periodontal therapy be commenced in pregnant patients who have periodontal disease?

Answer 20

early in the 2nd trimester

Question 21

How can periodontal disease affect patient in ICU who require ventillators?

Answer 21

Pneumonia causing bacteria in dental plaque can be aspirated through the ventilator device, causing bacterial pneumonia

(some periodontal pathogens also cause pneumonia/COPD)

Question 22

How fast can periodontal disease take to affect systemic conditions?

Answer 22

Long incubation period

Local periodontal factors can present for a long time before any systemic interactions are present → treat perio quickly

Question 23

What do you need to tell pt’s re: perio medicine

Answer 23

• Your oral health is NOT seperate from general health, oral health is important for general health
• Be careful, perio cant be considered a CAUSE of CVD or stroke yet, just an additional risk factor
• perio intervention may prevent the onset or progression of atherosclerosis-induced disease
• risk factor for pre-term birth (many pregnant pt’s ignore their OH) and periodontal tx prior to the 3rd trimester can decrease the risk
• poor OH and perio bone loss increases risk of chronic and acute respiratory illnesses, particularly bacterial pneumonia

rmb: pt’s with DM more susceptible and also may negatively affect glycemic control (potentially able to reduce dose if improve perio)