PERIO - systemic disease Flashcards
what is a periodontal pocket filled with in the presence of periodontal disease?
pathogenic anaerobic biofilm
what makes the periodontal pocket ulcerated and leaky?
inflammatory reaction between pathogenic anaerobic biofilm and adjacent gingival tissues
what do inflamed periodontal tissues contain?
large numbers of invading bacteria and host inflammatory cells (secrete pro-inflammatory mediators IL-1, TNFa, PGE2)
how may periodontal bacteria (bacteraemia) and inflammatory mediators spill over into the systemic bloodstream?
periodontal tissues are very vascular
blood vessels within inflamed tissue are very leaky
what accounts for the link between periodontal disease and systemic chronic disease?
leaking of pro-inflammatory mediators and/or perio bacteria into the systemic bloodstream:
- raise systemic inflammation
- direct effects of bacteraemia
- or both
what systemic disease has a bi-directional relationship with periodontal disease?
diabetes
list some systemic disease that could be linked to perio disease?
diabetes
CVD
resp disease
kidney disease
osteoporosis
alzheimers
IBD
why is it difficult to confirm a link between chronic conditions and periodontal disease?
they share the same risk factors (smoking, poor diet, genetic factors)
what are ways in which systemic diseases can affect the periodontal tissues?
progression of plaque induced periodontitis (negative effect of host response to plaque)
periodontium independently of dental induced inflammation
what can systemic disease be classified into regarding periodontitis?
- systemic disorders that have a major impact on the loss of periodontal tissues by influencing periodontal inflammation (conditions that make perio worse)
- other systemic disorders that influence the pathogenesis of periodontal diseases
- systemic disorders that can result in loss of periodontal tissues independent of periodontitis
describe group 1 systemic conditions?
have a negative effect on the host response to plaque bacteria - lowering immune response to the invading bacteria promoting periodontal disease progression
what are examples of group 1 systemic conditions (make perio worse)?
Down syndrome
Papillon-Lefevre syndrome
Ehlers-Danlos syndrome (type IV and VIII)
HIV
what is the medical name for Down syndrome?
Trisomy chromosome 21
how many people with Down syndrome have cardiac abnormalities?
40-50%
what immune defect presents with down syndrome?
neutrophil (PNM) defects - no chemotaxis to gingival tissues, no phagocytosis
T-cell migration to perio tissues so increase release of matrix metalloproteinases = tissue damage
other than immune defects, what else does down syndrome present with that results in perio problems?
abnormal collagen biosynthesis (lots of collagen breakdown)
how rare is papillon-lefevre ?
1 in 4 million - typically in ethnic groups from india/ pakistan
what type of disorder is papillon-lefevre?
autosomal recessive - defect chromosome 11, reduced function of neutrophils
what are clinical signs of papillon-lefevre disorder in 2-4 year olds?
palmar (hand) plantar (feet) hyperkeratosis
severe periodontitis soon after eruption and early loss of primary and secondary teeth
what type of disorder is Chediak-Higashi syndrome?
rare autosomal recessive condition - defects in neutrophil and monocyte chemotaxis, phagocytosis and reduced intracellular killing
what effects does Chediak-higashi syndrome have on the periodontium?
very little bone
severe perio with high risk of early loss of primary and secondary teeth - responds poorly to perio tx
what type of disorder is cyclic neutropenia?
rare autosomal dominant condition - reduced leukocyte numbers and cyclic depression of neutrophils (PNMs)
what is a cyclic depression?
levels fluctuate in cycles
describe cyclic neutropenia?
when neutrophils levels drop, gingival inflammation increases (lots of ulcers, severe perio)
what are symptoms of Ehlers danlos syndrome?
stretchy skin and mobile joints
cardiac valve defects
how does ehlers danlos syndrome affect the periodontium?
type IV - bleeding tendency
type VIII - grade C perio
what is hypophosphatasia?
rare autosomal recessive condition (1:100000)
what causes hypophosphatasia?
deficiency in enzyme alkaline phosphatase
how does hypophosphatase affect the periodontium?
abnormal mineralisation of bones and teeth - abnormal cementum
premature loss of deciduous teeth
*permanent teeth appear not to be affected
what 2 periodontal conditions are associated with HIV infection?
necrotizing gingivitis (NG)
necrotizing periodontitis (NP)
- necrotizing stomatitis (NS)
NOTE: usual types of perio also seen
are NG and NP associated?
yes, thought to be different ends of the spectrum of the same disease (NS being most severe)
what drug therapy may reduce incidence of HIV related perio disease?
anti-viral drug therapy (HAART - highly active antiretroviral therapy)
how does HIV-associated NPD compare to non-HIV associated NPD?
CLINICALLY IDENTICAL
HIV-associated has higher risk of progression to more severe lesions, recurrence and poorer response to tx
what type of HIV pts are at more risk of NPD?
low CD4 levels (<200 cells mm-3) and detectable viral load
what does a detectable viral load in an HIV pt present with?
failing immune system
AIDS
what pathogens are present in HIV-related perio which could explain it’s resistance to perio tx?
isolated candida
list features of NG
painful red swollen gingivae
yellowish-greyish marginal necrosis with loss of interdental papillae
gingival bleeding
halitosis
no LOA
anterior gingivae mostly affected
what are severe symptoms of NP?
ulceration/ necrosis leading to soft tissue loss
destruction or sequestration of bone
severe deep pain localised to jaw bone
why may HIV-associated NP not always have deep pockets?
rapid hard and soft tissue loss (rapid increase in mobility)
how would you class widespread BOP?
50% bleed spontaneously
nocturnal gingival bleeding
what is the prevalence of NP in HIV + pts?
under 5%
treatment for necrotic tissue/bone sequestra?
removal under LA
lush with povidone-iodine (blunt syringe) gives pain relief
what antimicrobial tx can you give for NP?
oral metronidazole 200-400mg 3xday for 7 days
why may you give antimicrobial tx for NP?
improves healing and gives pain relief
NEVER give HIV pt antibiotic
why would you not give broad-spectrum antibiotic for NP?
risk of untreatable fungal infection
what is useful in both active tx and maintenance of NP?
chlorhexidine mouthwash twice daily
what are group 2 systemic conditions?
systemic conditions which are risk factors for perio
give examples of group 2 systemic diseases?
DM
obesity
osteoporosis
arthritis (osteoarthritis and rheumatoid)
emotional stress and depression
what are group 3 systemic diseases?
disorders that can result in loss of perio tissues independent of periodontitis
give example of group 3 disorders?
neoplasms - oral SCC, odontogenic tumours
giant cell granulomas
systemic sclerosis
another word for systemic sclerosis?
scleroderma
what are features of systemic sclerosis?
tight inflexible skin due to fibrosis - masklike face, restricted oral opening (microstomia)
what is systemic sclerosis?
autoimmune disease affecting the connective tissues
how does systemic sclerosis affect periodontium?
gingival recession common
increased prevalence of periodontitis
increased width of PDL
gradual obliteration of the lamina dura (increased tooth mobility)
what is the definition of a risk factor?
Something that increases the chance of developing a disease
give 2 examples of evidence-based periodontal risk factors for periodontitis?
smoking
stress
diabetes is categorised in the 2017 periodontal classification under “periodontitis as a manifestation of systemic disease”. true or false?
true
a squamous cell carcinoma on the gingiva is categorised in the 2017 periodontal classification under “systemic diseases or conditions affecting the periodontal supporting tissues”. true or false?
true
clinically, NP diseases associated with HIV infection have identical clinical features to NP in non-HIV Pts. true or flase?
true
HIV-associated periodontal diseases have a common clinical feature, which is it?
pain
Ehlers-danlos syndrome is categorised in the 2017 periodontal classification under “periodontitis as a manifestation of systemic disease” true or false?
true
what is the old-fashioned oral med term for a description of the gingivae when it is red, very inflamed, ulcerated and glossy, which is non-plaque induced?
desquamative gingivitis
list the diseases that can present as desquamative gingivitis?
lichen planus
benign mucous membrane pemphigoid
pemphigus vulgaris
plasma cell gingivitis
erythema multiforme
in the 2017 classification, what are the diseases that cause desquamative gingivitis classified under?
gingival diseases: non-dental biofilm-induced- section 3 inflammatory conditions and lesions
why are patients with desquamative gingivitis referred for perio tx?
poor OH will often exacerbate/ worsen the desquamative gingivitis
what is DIGE?
drug-influences gingival enlargements
results from abnormal effects not expected from the known pharmacological actions of the drug when given in normal therapeutic dose
what section in the 2017 classification does DIGE fall under?
gingivits: dental biofilm induced -C: drug influenced gingival enlargements
what does DIGE present as?
variable in extend of enlargement from being very minor to covering entire teeth
creates difficulties for patient to maintain OH, increasing risk of periodontitis
what are the 3 main groups of drugs associated with gingival enlargements?
- antiepileptics: phenytoin and sodium valproate
- calcium channel blockers: nifedipine, amlodipine, verapamil, diltiazem and felodipine
- immune regulators: cyclosporine
what is cyclosporine commonly used for?
organ transplant pts - kidney transplant
what is needed in conjunction with the drug to cause DIGE?
plaque biofilm
describe the understood cellular mechanism that causes DIGE?
increased production of fibroblasts for the ECM
reduced tissue turnover = build up of ECM
what age group has the highest prevalence of DIGE?
younger
where in the mouth is most commonly affected by DIGE?
anterior regions
affects papilla first within 3 months of starting medication
what types of enlargements is phenytoin associated with?
more fibrotic enlargements
what type of enlargements is cyclosporine associated with?
high level of inflammation with little fibrosis
what is the incidence of DIGE with the associated drugs?
phenytoin - 50%
ciclosporin - 30%
CCB - 10-15%
what is the most common cause of gingival overgrowth?
plaque
what is prevention of DIGE?
good plaque control
folic acid supplement (for phenytoin as levels of folate low)
what was the traditional prevention of DIGE?
surgical - open wound gingivectomy
list other causes of gingival enlargement that is not DIGE or plaque?
hormonal; pregnancy epulis. puberty
neoplasia; leukaemia
hereditary
granulomatosis with polyangiitis (Wegener’s granulomatosis
what is Wegener’s granulomatosis?
rare autoimmune disease resulting in disseminated granulomatous vasculitis of small vessels
“strawberry gums”
what is factitious injury?
self-harm
previously called gingivitis artefacta
how may factitious injury present?
localised lesions on gingiva of young people
may be ulcerated or have marginal keratosis from chronic trauma
notched recession defects caused by finger nails, pencils, knives etc
in the 2017 dental classification what is factitious injury classified under?
gingival diseases: non dental biofilm induced - section G traumatic lesions
which connective tissue cell is thought to be directly involved in the development of DIGE?
collagenase
