S2 - Perio-systemic relationships 1 Flashcards
5 overall types of systemic diseases and disorders affecting the periodontium
- endocrine disorders
- haematological disorders
- genetic factors
- stress
- nutritional influences
Hormonal disturbances may affect periodontal tissues in 3 ways. What are they?
- directly as periodontal manifestations of endocrine diseases
- modify the tissue response to plaque in gingival and periodontal disease
- produce anatomic changes in oral cavity that may favour plaque accumulation or trauma from occlusion
3 oral manifestations of diabetes mellitus
- frequent perio abscesses
- diminished salivary flow resulting in mucosal drying, cracking, burning mouth and tongue
- increased rate of caries (in poorly controlled diabetes)
Effects of uncontrolled diabetes on periodontium? Both limited to the gingiva (2) and extending to attachment (4)
Limited to gingiva:
- severe inflammation
- sessile or pedunculated gingival enlargements - polyps
Features extending to attachment:
- abscesses
- mobility
- deep pockets
- rapid bone loss (rate)
What is the only systemic disease positively associated with attachment loss?
diabetes mellitus
Which bacteria have a greater prevalence in the oral cavity in diabetes? (3)
candida albicans
hemolytic streptococci
staphylococci
What is poorly controlled diabetes in HbA1c results?
>9%
How can poorly controlled diabetes cause severe perio (contributing pathogenic mechanicms)?
Change in PMN function and bacterial composition lead to altered collagen metabolism
Which types of cells’ function is affected by poorly controlled diabetes. What does this mean for perio risk?
- impaired function of PMNs, monocytes and macrophages
- PMN deficiencies → result in impaired chemotaxis, defective phagocytosis or impaired adherence (main function is to adhere then go into area of inflammation through chemotaxis then phagocyte bacteria) therefore lower defence mechanism
How does uncontrolled diabetes affect bacterial pathogens implicated in perio? Give examples of some for type I and II
glucose content of GCF and blood higher → bacteria which need glucose will have higher incidence
type I: A.A, P.intermedia, Campylobacter rectus
type II: P.gingivalis, P.intermedia, C. rectus
How are collagen turnover defects implicated in poorly controlled diabetes. (2) What medication might alter this?
marked decreased in collagen production and impaired collagen degradation (2 prong)
insulin prevents the onset and correct defective collagen production (but perio is not a reason to start insulin)
AGE-RAGE interaction instrumental
How does collagen changes lead to impaired wound healing in diabetes? (4)
increased cross linkage (happens to get to mature stage, usually limited)
when this happens they become resistant to digestion
if not degraded or recycled, there is impaired remodelling
→ impaired wound healing
What are the 4 mechanisms of bone destruction of diabetes? And how do they cause alveolar bone loss? (3)
- increased RANKL/OPG
- increased AGEs
- increased ROS
- increased cytokines/inflammation
- enhanced PDL and osteoblast apoptosis
- reduced bone formed
- enhanced osteoclastogenesis
explanation extra:
- increased RANKL/OPG (molecules that interact w RANK ligands which are on the activation path of osteoclasts → increased bone destruction)
- increased AGEs (increase in BG leads to increased bone destruction)
- increased ROS (active molecuels released by immune cells, mostly neutrophils, directly involved in tissue destruction)
- increased cytokines/inflammation (cytokines increase inflammation)
What is the AGE-RAGE axis
RAGE = receptor that sits on different cell types (monocytes and endothelial cells)
AGE = advanced glycated end products, which are present in patients with diabetes bind to their receptor RAGE → this triggers increase in ROS and inflammation
Inflammatory cytokines involved in diabetes
TNF
IL-1B
IL-6
*****Perio and diabetes mechanism/relationship summary*****
Perio is the ‘6th’ complication of diabetes, only systemic disease positively associated w attachment loss
PMN function (defective phagocytosis, impaired chemotaxis and adherence → therefore reduced defence mechanism) and change in bacterial composition (due to BG and GCF glucose content) lead to altered collagen metabolism → decrease in collagen production and impaired collagen degradation (why? increased cross-linkage → resistant to digestion → impaired remodelling → impaired wound healing)
Bone destruction mechanisms (4)-
- increased RANKL/OPG
- increased AGEs
- increased ROS
- increased cytokines/inflammation
/AGE-RAGE axis: advanced glycated end products present in diabetic pt bind to RAGE receptor triggering increase in ROS and inflammation
How they^ cause enhanced bone loss: increased PDL and osteoblast apoptosis, reduced bone formed, enhanced osteoclastogenesis
What are the 3 general effects of female sex hormones in puberty, pregnancy and menopause
- non specific inflammatory reaction
- increased vascularity
- increased bleeding
Effect of menstrual cycle on periodontium. (3 things that can happen and when in cycle, what DOESNT happen)
- transient
- increased prevalence of gingivitis
- bleeding gums or bloated, tense feeling in gums in days preceding menstrual flow
- increased salivary bacteria during menstruation and ovulation
- NO increase in tooth mobility
What determines if gingival changes will happen during pregnancy?
- NO notable changes in gingiva in absence of local factors
What 3 changes happen to diseased periodontium during pregnancy?
tooth mobility
pocket depth
gingival fluid
How does severity of gingivitis vary across pregnancy?
peaks around 8m, drastically reduces after 9m when baby born, then takes around 1yr after birth to go down to normal
Clinical presentation of pregnaancy gingivitis (4) Specify the most striking feature.
- striking feature: pronounced ease of bleeding
- edematous, pitting, smooth and shiny, soft and pliable
- extreme redness resulting from marked vascularity
- usually painless unless complicated by acute infection
Microscopic presentation of pregnancy gingivitis
newly formed engorged capillaries
Hypotheses for pregnancy gingivitis/bleeding (4)
- P. intermedia increase significantly coincide w peak in gingival bleeding
- Depressed maternal T-lymphocyte response alters tissue response to plaque
- Elevations in systemic levels of hormones (1st trim - gonadotropins, 3rd trim - estradiol and progesterone)
- Gingival mast cells
How do progesterone and other sex hormones affect periodontium?
increase irritability of tissue
Features of pregnancy granuloma (4)
- localised (usually)
- semi-firm, various degrees of softness, or soft/friable
- association w food impaction
- discrete mushroom-like mass that protrudes from interproximal space/gingival margin (unless on labial - flattened by lip)
- does not invade the underlying bone
- usually painless
- appears after 3rd month of pregnancy but may occur earlier
When can a pregnancy granuloma become painful?
- secondary infection
- ulceration due to:
- size and shape leads to accumulation of debris under margin
- interfere w occlusion
What is the histology of pregnancy granuloma and how does this pertain to its other name?
angiogranuloma
granulation tissue w lots of blood vessels
What is menopausal gingivostomatitis (senile atrophic gingivitis), when does it occur?
gingiva and remaining oral mucosa are dry and shiny, vary in colour from abnormal paleness to redness and bleed easily
occurs during menopause or in post-menopausal period
not common
3 broad groups of haematological disorders
- hemostatic disorders
- RBC disorders
- WBC disorders (most commonly affects periodontium)
Classification of WBC disorders and how they affect periodontium
quantitative or qualitative, most commonly related to WBC function or number
quantitative PMN defiencies associated w generalised periodontal destruction
functional defects associated with localised destruction (defects in chemotaxis, phagocytosis)
What is neutropenia,causes and types?
characterised by decrease or absence of circulating PMNs
causes: diseases, medications, chemicals, infections, idiopathic conditions or hereditary disorders
types: chronic or cyclic and severe or benign
cyclic can be cause in itself
What is needed for chronic neutropenia diagnosis?
low ANC (absolute neutrophil count) for >6m
What is cyclic neutropenia? When does it present and how does it affect periodontium?
periodic recurring symptoms of fever, malaise, mucosal ulcers and possibly life threatening infections related to cyclic fluctuations
usually presents before age 10 (most of time pt will alr know)
generalised severe periodontitis
a complete blood count, twice weekly for 6 weeks to get accurate picture of cycle
What is Leukemia?
malignant neoplasia of WBC precursors
What is Leukemia characterised by?
- diffuse replacement of bone marrow with proliferating leukemic cells
- abnormal numbers and forms of immature WBCs in circulating blood AND
- widespread infiltrates in liver, spleen, lymph nodes and other sites
Classification of leukemia according to type and evolution/presentation.
type: lymphocytic, myelogenous-monocytic
evolution/presentation: acute (fatal), subacute or chronic
Presentation of Leukemic infiltration on skin and gingiva
Leukemic Cutis: elevated/flat macules and papules
Leukemic gingival enlargement: most common in acute monocytic leukemia
Oral and periodontal manifestations of leukemia (4)
- leukemic infiltration
- bleeding
- oral ulcerations
- infections
How does leukemic infiltration cause enlargements?
Presentation of leukemic gingival enlargment (4) Why is it important to recognise?
- bluish red and cyanotic gingiva
- rounding and tenseness of gingival margin
- increase in size, most often in interdental papilla
- marginal gingiva is usually ulcerated and marginal necrosis w pseudo-membrane formation
might be the only presenting sign of leukemia
Microscopic features of leukemic gingival enlargment
- dense infiltration of immature leukocytes
- ectopic hematopoiesis “mitotic figure”
- connective tissue components displaced by leukemic cells
- blood vessels distended: leukemic cells w decreased RBCs
Generally leukocytes don’t divide in peripheral circulation, only forms in bone marrow then flows through, if you can see it forming in blood or CT –> alarm bells
What may be an early and presenting sign of leukemia and why?
bleeding
thrombocytopenia (low platelet count) due to: replacement of bone marrow cells by leukemic cells + inhibition of normal stem cell function by leukemic cells
Why do patients with leukemia have frequent opportunistic infections and ulcerations?
granulocytopenia
Describe oral ulceration lesions in patients w terminal leukemia?
frequent and severe acute lesions
What is a side effect of persistent gingival bleeding with leukemia?
blood loss and constant pain
Name some genetic disorders that can cause perio, which most commonly does?
Papillon-Lefèvre Syndrome (most likely to cause perio, but uncommon condition)
Chédiak-Higashi Syndrome
Lazy Leukocyte Syndrome
Leukocyte Adhesion Deficiency
Down Syndrome
What type of genetic disease is Papillon-Lefèvre Syndrome?
What is the presentation? What is the treatment?
rare autosomal recessive disease
diffuse palmar plantar keratosis (palms, knees, feet) + severe periodontitis affecting perm and prim dentition
appear together between age 2-4, primary teeth lost by 5/6y, perms lost by 15-20y
tx: cant do much other than help prevent tooth loss by managing local factors to some extent
What are the defects in PMN in PLS? (3)
decreased chemotactic activity
decreased phagocytosis
decreased intracellular killing (of bacteria)
Most notable documented relationship between stress and periodontal disease
soldiers at war or students during exams and NG
What are the pathways between stress and periodontal disease?
can directly affect cells (hormone related)
but more often related to habits: poor oral hygiene/compliance, smoking, overeating (high fat diet can lead to cortisol)
2 schools of thought on the effect of nutritional deficiencies on oral tissues. What is the starkest documented example?
- cannot cause gingivitis or perio themselves but they aggravate effects of local factors
- can produce periodontal or oral effects
(main link is that if nutritional defs affect immune system, they can cause perio destruction)
Noma in malnourished African children
How can vitamin deficiencies disturb the periodontium?
Vit A, B complex and C: reduce resistance of tissues to irritation and infection
Vit K: affects permeability of blood vessels or blood clotting mechanism (low Vit K means increased bleeding - rmb Vit K reduces effect of Warfarin -lowering INR)
Vit D: decrease rate of bone formation and cementum and also decrease degree of mineralisation
