Perio Tx 3 Flashcards
peridontal disease
a group of diseases affecting the periodontal tissues, representing an immune reaction (innate and adaptive) to adjacent microbial plaque
- Gingivitis does not always progress to periodontitis
- Periodontitis may progress at a different rates at different sites in the mouth in different people
periodontal health
outcome of the balance between the bacteria of the dental plaque and the host immune system
2 ways to periodontal disease
Host immune response launches inflammatory to microbiome -> localised inflammation without self-resolution
Or
immune system not controlling oral bacteria
- Genetic conditions associated with the impairment of immune system:
- Papillon-Lefevre syndrome, Chediak-Higashi syndrome, LAS syndrome, Down’s syndrome, chronic granulomatous disease
- Diseases leading to impairment of immune system:
- Leukaemia, agranulocytosis, neutropenia, HIV infection
periodontal disease aetiopathogenesis
multifactorial
- Any factor influencing immune system function or number or diversity of bacteria is a potential risk factor for periodontal disease
general health factors for periodontal disease
- stress
- smoking
- fatigue
- diet
- medications
- hygienic habits
risk factor
something that increases a person’s chance of developing a disease
local risk factors
plaque retentive factors
either
- acquired
- anatomical
acquired local risk factors for perio
plaque,
calculus,
overhanging and poorly contoured restorations and prosthetic crowns,
orthodontic appliances,
occlusal trauma (bone loss not perio)
anatomical local risk factors for perio
malpositioned teeth,
root groves,
concavities and furcations,
enamel pearls
systemic risk factors
either
- modifiable
- non-modifiable
non-modifiable systemic risk factors for perio
(impairment of immune system)
- aging,
- genetic factors,
- gender (males),
- genetic disorders: Down syndrome, Papillon Lefevre syndrome
modifiable systemic risk factors for perio
(impact on immune system)
- smoking,
- poorly controlled diabetes,
- HIV,
- leukaemia,
- osteopenia,
- osteoporosis,
- stress,
- medications,
- hormonal changes,
- poor nutrition,
- socioeconomic status
how can occlusal trauma impact perio health
- May cause the bone loss but not periodontitis
- If suffering from periodontal disease and has occlusal trauma will have faster clinical attachment loss
- Need to address to help slow down bone resorption
smoking impact on perio
Effect on oral microbiota
- anaerobic inc so more traumatic for periodontal tissue
Increase activation of the immune system
- activation of immune system, trigger inflammation so no longer just controlling oral microbiome and causing damage
Decreased healing capacity (reduced blood flow)
Vaping? Not enough data currently
how does sub-optimally controlled diabetes contribute to perio
- Hyperglycaemia in diabetes may modulate RANKL (the receptor activator of nuclear factorkappa β): OPG (osteoprotegerin) ratio and thus contribute to alveolar bone destruction
- In hyperglycemia production of AGE (advanced glycation end products) – increase of inflammation (production of pro-inflammatory cytokines and destructive metalloproteinases)
do not see hyperglyceamia in well controlled diabetes
important factors contributing to periodontal disease severity in diabetics
- degree of diabetic control (hyperglycaemia chance)
- age of onset
- duration of disease
what to look at to assess diabetic control
glycated haemoglobin (HbA1c)
- Not glucose level - only short period of time*
- Whereas HbA1c assesses stores (8-12 weeks)*
Look at diabetes – below 48mmol/mol or below 6.5%
obestiy and nutrition impact on perio health
Severe vit. C deficiency
- scorbutic gingivitis - scurvy
Lack of nutrients
- decrease function of the immune system
Obesity
- adipose tissue can become endocrine organ, adipocytes secrete variety of metabolically and immunologically active molecules – produce pro-inflammatory cytokines contribute development of inflammation
ALL HAVE proinflammatory effect
3 drug groups that contribute to gingival enlargement
- Anticonvulsant: phenytoin
- Immunosupresants: cyclosporin (transplant patients)
- Calcium channel blockers (nifedipine,amlodipine)
- (majority of pts seen as age risk factors so many 50+ who are suffering from both perio and hypertension)
Interaction between the drug and host fibroblasts resulting in a increased deposition of connective tissue supporting a hyperproliferative epithelium – accelerated by inflamed tissue due to poor plaque control
systemic diseases that has periodontitis as a symptom
Defect of function of some cells of immune system – if immune system not working correctly not able to protect periodontal tissue against ubiquitous periodontal bacteria
- papillon-lefevre syndrome
- Chediak-Higaski syndrome
- lazy leucocyte syndrom
- LAD syndrome
- chronic granulomatous disease
- Down’s syndrome
- Ehlers-danlos syndrome
- hypophostasia
HIV infection effect on perio tissue
Increased risk of necrotising conditions, but no evidence of increased progression of periodontitis
blood dyscrasias (e.g. neutropenia, agranulocytosis, leukaemia) effect on perio tissues
Reduced numbers/function of neutrophils and macrophages, increasing risk of NUG and progressive periodontitis
scury effect on perio tissues
Vitamin C deficiency causing abnormal collagen turnover resulting in increased risk of periodontal attachment loss
pregnancy effect on perio tissues
Increased risk of gingival inflammation (pregnancy gingivitis)
acquired systemic diseases and syndromes that have negative affect on perio health
- HIV infection
- blood dyscrasias e.g. neutropenia, agranulocytosis, leukaemia
- scurvy
- pregnancy
impairs immune system function
osteoporosis and osteopenia affect on perio tissues
Complex
- Not direct risk factor
If quality of bone is poor, then bone resorption progresses quicker – accelerate bone loss once pt has both conditions simultaneously
psychological stress effect on perio tissues
Influencing function of immune system through corticosteroid hormones
- Hypothalamus-pituitary-adrenal axis stimulated release corticosteroids (cortisol)
Inhibiting function of immune system
- Once function of immune system is impacted so is periodontal health impacted
Several stress markers reported in blood, saliva, GCF of perio pts
most common chronic inflammation in world
periodontal disease
estmated 70% have some form
periodontal disease a risk factor for other systemic diseases?
Systemic activation of the immune system
- Significant risk factor (70% of world)
- early symptoms not problematic so delay medical help
- surface of inflammation is large – folded in gingival crevice (gingiva and root) but approx. size of palm
goes untreated for years - chronic inflammation with little symptoms
most common mortality in world population in 21st century (pre-covid)
hypertension
Why is it difficult to document the cause-effect association between cardiovascular diseases and periodontitis?
- The same risk factors for both diseases (smoking, diabetes, stress
- Common pathomechanisms associated with systemic inflammation and activation of the immune system
3 mechanisms as periodontitis as risk factor for CVD
which is the main theory currently
- molecular mimicry
- direct action of pathogenic bacteria from periodontal pocket travelling within the blood stream to vessel
- indirect activation of immune cells that play significant role in sites of CVD pathologies (heart, kidney, vessels etc)
evidence for and against molecular mimicry as mechanism of periodontitis and CVD linke
for
- Evidence of cross reactivity between oral pathogens and both inflammatory and endothelial cell components
against
- might be the case in all bacterial infections
evidence for and against direct action of pathogenic bacteria from perio pocket travelling to vessels
for
- Transient bacteremia – after brushing, chewing etc
- immediately contained by competent immune system
- but perio bacteria can get to vessels and attach to wall surfaces – inflammation and plaque
- Periodontal bacteria detected in atherosclerotic plaque
against
- But, hard for bacteria to adhere to healthy endothelium – needs to be already inflamed and expressing adhesins - thus rare occurrence
evidence for and against indirect activation of immunce cells in perio link to CVD
for
- Systemic inflammation, with chronically elevated inflammatory markers, is common in both diseases processes
against
- To what extent anatomically remote sources of inflammation interact in causative fashion is unclear
atherosclerosis
inflammation of the vessel’s wall
- Activation of immune system needs to occur
increase of blood pressure link to immune system
depends on activation of lymphocytes T (hypertension)
- need source of activation of T cells - chronic inflammaiton - periodontal disease?
to investigate cause-effect need
interventional studies
indirect link of preeclampsia and periodontal disease
indirect mechanism activation of immune system
- trophoblast invasion depends on production of cytokines and relies on activation of immune system – help in invasion
- if imbalance of cells and cytokines – invasion of trophoblast incorrect (too little or too deep)
- translates as dysfunctional placenta and ischaemia -> adverse pregnancy outcomes
direct link between periodontal disease and preeclampsia
direct mechanisms
- barrier between mother and foetus
- periodontal bacteria have adhesins that can go through endothelial cells and traverse barrier and invade foetus circulation
periodontal risk factor for rheumatoid arthritis
autoimmune disease – action of immune system towards self-tissue of cartilage of joints
if there is additional activation of immune system from site of periodontal bacteria
- response towards cartilage is stronger
some periodontal (P.gingivalis) has PPAD enzyme
- cause proteins change conformation –
- detected as foreign so increasing activation of immune system
increasing activation of immune system increases magnitude of response towards self-tissue in cartilaginous joints
periodontal risk factor for Alzeheimer’s disease
activation of immune system causes increases production of plaques and tangles
- Plaques are deposits of a protein fragment called beta-amyloid that build up in the spaces between nerve cells.
- Tangles are twisted fibres of another protein called tau that build up inside cells
Contributes to impairment of memory and function of pt
In experimental models oral P. gingivalis infection in mice resulted in brain colonization and increased production of Aβ1-42 (amyloid), a component of amyloid plaques
peridontal risk factor for respiratory pathologies
Periodontal bacteria debilitate immune protection (damage surfactant) of the reparatory epithelium making colonisation by other respiratory viruses and bacteria easier
- Impair immune protection of respiratory epithelium
Periodontal bacteria can also cooperate with resp viruses and bacteria aiding their colonisation
- Facilitate colonisation of respiratory epithelium of respiratory viruses and bacteria
prevention and treatment of periodontal disease can
help prevent development of systemic diseases
but only one of many risk factors
