Periodontitis as Manifestation of Systemic Disease

Question 1

Disorder of glucose metabolism
Accumulation of AGEs AGEs - RAGE (Receptor of AGEs) interaction
Chronic status of elevated blood glucose level

Answer 1

Diabetes mellitus

Question 2

Early onset
5-10% of cases
Destruction of beta cells
Absolute insulin deficiency
Marked tendency toward ketosis and coma

Answer 2

Type 1 DM

Question 3

Adult onset
90-95% of cases
Obesity is a factor
Blood level of insulin is normal, increased or decreased
Development of ketosis and coma is uncommon

Answer 3

Type 2 DM

Question 4

______as a risk factor for periodontal disease
-Increased prevalence and severity of attachment loss
Multiple periodontal abscess

Answer 4

Diabetes

Question 5

Periodontitis ALSO affects ______ in relation to DM

Answer 5

glycemic control

Question 6

What occurs when a pt is obese that causes more systemic effects?

Answer 6

State of low grade inflammation

Question 7

Trisomy 21 or mongolism
Characteristic physical appearance
Mental deficiency and growth retardation

Answer 7

Down syndrome

Question 8

Moderate to severe periodontitis with rapid progression
Local factors alone failed to explain the severity of
periodontal destruction
Intrinsic immune system defects Poor PMN chemotaxis, phagocytosis, intracellular killing

Answer 8

Down syndrome

Question 9

Mutation in beta-2 integrin (ITGB2) gene Lack of beta-2 integrin mRNA in leukocytes
Low integrin (CD18 or CD15) expression on neutrophils
Neutrophils are confined to blood vessels Disruption of neutrophil-associated homeostasis
History of severe recurrent infection but no pus Leukocytosis is common

Severe gingival inflammation, acute gingival lesions
Early-onset and rapidly progressive alveolar bone loss
Early loss of the primary and permanent teeth

– Seen in Down Syndrome too

Answer 9

Leukocyte Adhesion Deficiency

Question 10

Mutations in the cathepsin C gene (CTSC) Chromosome 11q14
Compromised neutrophil function Decreased phagocytosis (Rathi, 2002)
Hyperkeratotic lesions Palms, soles of the feet, elbows, knees

Severe gingival inflammation
Early-onset and rapidly progressive alveolar bone loss
Early loss of the primary and permanent teeth

Answer 10

Papillon–Lefèvre

Syndrome

Question 11

Mutations in CHS1, LYST gene Lysosomal trafficking defect
Partial oculocutaneous albinism Defects in melanin granules
Recurrent pyogenic infections Circulating leukocytes exhibit defective lysosomes
Decrease in phagocytosis
Varying neurologic problems Intellectual deficit and dementia

Severe gingival inflammation
Early-onset and rapidly progressive alveolar bone loss
Early loss of the primary and permanent teeth
Poor response to dental treatment

Answer 11

Chediak-Higashi Syndrome

Question 12

Mutations in the ELANE (50%), HAX1(10%) gene 1/3 causes remain unknown
Decrease in number of neutrophils ANC < 500 cell/uL and static
Deficiency in the immune response Severe and recurrent infections

Severe periodontitis is common
Higher risk for tooth loss
Oral ulcers

Answer 12

Congenital Neutropenia

Question 13

For the genetic systemic diseases, when is the onset of periodontitis?

Answer 13

Early onset

Question 14

For the genetic systemic diseases, does dental tx help the prognosis of perio tooth loss?

Answer 14

Not effectively in most cases

Question 15

Which of the following statement is incorrect?
A. Periodontitis as a manifestation of a systemic disease is defined
by influencing the course of periodontitis.
B. Periodontitis as a manifestation of a systemic disease is defined
by affecting the periodontal supporting tissues independently of
dental plaque biofilm‐induced inflammation
C. Acquired immunodeficiency diseases have a major impact on the
loss of periodontal tissue by influencing periodontal inflammation
D. Genetic disorders having a impact on the loss periodontal tissue
are related to early-onset periodontitis

Answer 15

B. Periodontitis as a manifestation of a systemic disease is defined
by affecting the periodontal supporting tissues independently of
dental plaque biofilm‐induced inflammation

Question 16

Mutation in the fermitin family homologue 1 gene (kindlin-1; FERMT1)
Lack of integrin activation Affect keratinocyte cell adhesion
Lead to molecular defects in basement membrane zone
Photosensitivity
Recurrent blister formation

Oral blisters formation
Severe periodontitis Alveolar bone loss that progress rapidly
Need immunofluorescence to confirm diagnosis Skin biopsy of an included blister

Answer 16

Epidermolysis Bullosa / Kindler syndrome

Question 17

Mutations in genes encoding fibrillar collagens or
enzymes involved in the biosynthesis of these proteins
Affecting collagen production and composition Mainly involves joint, skins and walls of the blood vessels
Joint hypermobility, skin extensibility, and tissue fragility

Generalized, early-onset severe periodontitis and
gingival recession
Early loss of the primary and permanent teeth

Answer 17

Ehlers-Danlos Syndrome

Question 18

Alcaline phosphatase (ALPL) gene mutation
Mild form and severe form
Defective cementum, alveolar bone loss and premature
loss of teeth

Impaired bone/tooth mineralization
Defects in root cementum
Compromised periodontal attachment, reduction in alveolar bone height
The teeth are not adequately anchored to the alveolar bone via the PDL

Answer 18

Hypophosphatasia

Question 19

Estrogen withdrawal 
Increased bone turnover  
Net systemic bone loss 
Decrease in bone mineral density 
Weaken bone microarchitecture 
High risk of bone fracture

Answer 19

Osteoporosis

Question 19

Estrogen withdrawal 
Increased bone turnover  
Net systemic bone loss 
Decrease in bone mineral density 
Weaken bone microarchitecture 
High risk of bone fracture

Higher prevalence and severity of radiographic alveolar bone loss

Answer 19

Osteoporosis

Question 20

Does osteoporosis and periodontitis have a clear association?

Answer 20

No

Question 21

Which of the following statement about the
relationship between metabolic and endocrine
disorders and periodontitis is incorrect?
A. Elevated inflammation state in obesity patients increases the risk
of periodontitis
B. Estrogen withdrawal in osteoporosis is related to high
prevalence and severity of radiographic alveolar bone loss
C. Accumulation of AGEs in the periodontal tissues down regulate
the inflammatory response and increase the severity of attachment
loss
D. Effective periodontal therapy aids in the glycemic control

Answer 21

C. Accumulation of AGEs in the periodontal tissues down regulate
the inflammatory response and increase the severity of attachment
loss

Question 22

•Caused by autoimmune 
disease, cytotoxic 
chemotherapy or other 
drug or idiopathic etiology 
•Due to decreased 
production or 
increased 
destruction of 
granulocytes

Increased risk for 
infections and 
periodontitis 
correlated with 
severity of 
neutropenia 
•ANC 
< 1500 cell/uL: mild 
< 1000 cell/uL: moderate 
< 500 cell/uL: severe

Answer 22

Acquired neutropenia

Question 23

Deficiency of the immune 
system due to infection 
with the HIV virus
Increased risk for 
opportunistic 
infections, 
neoplasms (eg. 
kaposi sarcoma)
•Depends on the stage 
of infection 
•Test HIV antibody/
p24 antigen and 
PCR-based HIV

Answer 23

HIV Infection

Question 24

Pathogenic autoantibodies bind to target antigens Mechanobullous type 
Inflammatory form (mimic pemphigoid) 
Recurrent blister formation  

Generalized gingival inflammation, severe alveolar bone loss
Immunofluorescence on basement membrane zone - split skin

Answer 24

Epidermolysis Bullosa Acquisita

Question 25

Hypersensitivity of immune response

Inflammation and alveolar bone loss in a susceptible host
Increased prevalence and severity of periodontitis

Related to periodontitis due to similarity of bacteria

Answer 25

Inflammatory Bowel Disease

Question 26

Chronic auto-inflammatory disease

Increased risk for loss of periodontal attachment, alveolar bone
Biological link between rheumatoid arthritis and periodontitis

Answer 26

Rheumatoid Arthritis

Question 27

Increased Serum Cortisol
Activate the limbic-hypothalamic-pituitary-adrenal axis
Immune System Depression
Change in behavior/mood/physiological markers
Risk factor for necrotizing periodontal disease

Answer 27

Stress

Question 28

4x Attachment loss
Leukoplakia 
Carcinoma
Gingival recession
Tooth loss

Answer 28

Smoking

Question 29

Impaired immune response

Subgingival anaerobic infection

Connective tissue cytotoxicity

Impaired wound healing

Increased severity of periodontal disease

Answer 29

Smoking

Question 30

Chronic ______ exposure
Impairment of antigen-mediated T cell signaling
Inhibits antibody-forming cell response
(Sopori et al 1998)
The inflammation in response to plaque accumulation is reduced

Answer 30

nicotine

Question 31

Treat cancer (IV administration) 
Treat osteoporosis (oral administration) 
Inhibit osteoclast activity and interfere with bone turnover

Answer 31

Bisphosphonates

Question 32

How do bisphosphonates impact bone density and blood flow?

Answer 32

Increase bone density

Decrease blood flow

Question 33

Diseases and conditions 
that can affect the 
periodontal tissues by 
affecting the periodontal 
supporting tissues 
\_\_\_\_\_\_\_ of dental 
plaque biofilm‐induced 
inflammation.

Answer 33

independently

Question 34

The following have an ______ etiology of perio disease
Neoplasms
Other disorders langerhans cell histiocytosis, giant cell granuloma,
hyperparathyroidism, systemic sclerosis

Answer 34

Independent

Question 35

_______ diseases of periodontal tissue Oral squamous cell carcinoma
Odontogenic tumors
Other primary neoplasms of periodontal tissue
Secondary metastatic neoplasms of periodontal tissue

Answer 35

Neoplastic diseases

Question 36

Peripheral small vessel necrotizing vasculitis
Respiratory and renal impairment
Characteristic fiery and hyperplastic gingival inflammation
Alveolar bone loss

Answer 36

Langerhans cell histiocytosis

Question 37

Reactive proliferation, benign lesion
No systemic features

Peripheral version:
•Expanding epulis-like gingival swelling
•Occasional loss of periodontal
supporting tissue

Central version:
•Loss of periodontal supporting tissue
•May expand toward marginal
periodontal tissue

Answer 37

Giant cell granuloma

Question 38

Primary : benign adenoma of parathyroid glands
Secondary: result of hypercalcemia
Tertiary: parathyroid hypertrophy following 2o type

Widening PDL, single/multiple osteolytic lesions
in the jaw that mimic periodontal bone loss
(brown tumors)

Answer 38

Hyperparathyroidism

Question 39

Autoimmune disease of the connective tissues
Many different systemic presentations
Widening PDL and higher prevalence of periodontitis

Answer 39

Systemic sclerosis

scleroderma

Question 40

Which of the following systemic conditions can
result in loss of periodontal tissue independent
of the etiology of periodontitis?
A. Leukocyte Adhesion Deficiency
B. Reumatoid arthritis
C. Giant cell granuloma
D. Bisphosphonates IV administration

Answer 40

C. Giant cell granuloma