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Periodontitis as a Risk Factor for Systemic Disease

Today we will talk about periodontitis as a risk factor for systemic diseases and go through these topics : -pathogenesis of gingivitis and periodontitis . - Periodontitis and Systemic Inflammation . - Oral Disease and Systemic Disorders ; Cardiovascular Disease & Diabetes & Adverse Pregnancy Outcomes . ________________________________________________________________________

Periodontium Bone + periodontal ligament + cementum

Bone : very dynamic tissue , Considered to be highly vascularized . PDL : high turnover rate in the tissues inside. Cementum : there is no vascular tissue or innervations.

Plaque is the principal etiological factor that forms periodontal diseases the inflammatory response to the presence of dental plaque is detectable both clinically and histologically , and is certainly responsible for some of the periodontal destruction which occurs.

Stages of periodontal diseases :

- I have initial, early and established stages; those three stages are considered to be gingivitis. Periodontal diseases in general are categorized into two stages the first one is inflammation of the gingiva which is gingivitis, and the second one is periodontitis; the inflammation of the periodontium (cementum, PDL and bone) which are the supporting structures. The fourth stage which is the advanced lesion is considered to be periodontitis.

Initial stage :
Bacteria colonize the tooth near the gingival margin and initiate host response. PMNs (they are the type of cells which dominate in this stage.) pass from bloodstream into the gingival connective tissue then they release cytokines that destroy gingival connective tissue, allowing PMNs to move quickly through the tissue. PMNs migrate into the sulcus and phagocytize bacteria.

Early :
Early lesion is when the clinical signs start showing (within 4-5 days). Bacteria penetrate into the connective tissue. Increase number of PMNs that release cytokines and causing more localized destruction of the connective tissue. Macrophages release cytokines, PGE2(initiate most of the alveolar bone destruction in periodontitis by Triggering osteoclasts bone-consuming cells to destroy the alveolar bone) , and MMPs.

Lymphocytes and PMNs predominate in this stage

Established stage :
I start having congested blood vessels & GCF flow increases . Plaque biofilm extends subgingivally Host cells produce more toxic chemicals cytokines, PGE2, and MMPs. Increase in proportions of gram-negative anaerobes.

Advanced stage :
loss of connective tissue attachment and alveolar bone, extensive damage to collagen fibers and the junctional epithelium migrates apically from the cement-enamel junction. Cytokines include IL-1, IL-6, IL-8, and TNF-alpha destroy the connective tissue and PDL fibers. Cytokines, PGE2, and MMPs destroy the connective tissue and bone. PGE2 initiates bone destruction and Increases vascular permeability increases movement of immune cells into the tissues.

Specific microorganisms: P.gingivalis, T.forsythus, T.denticola, P.intermedia, A.a,F.nucleatum, E.corroens, C. rectus ________________________________________________________________________

Periodontitis and Systemic Inflammation

55% of patients with severe periodontitis manifest positive arterial blood cultures after chewing paraffin wax (1) . Immediately following dental scaling , bacteremia(2) resulted in increased circulating serum TNF- and IL-6. Perio treatment decreases systemic inflammation

(1) : Paraffin wax is a white or colorless soft solid , used to impregnate tissue prior to sectioning thin samples of tissue. (Wiki) (2) bacteremia : Bacteremia is the presence of viable bacteria in the blood stream .

Oral Disease and Systemic Disorders


Adverse Pregnancy Outcomes




Pulmonary Disease

Risk for Cardiovascular Disease (CDV)

29.2% of global deaths are attributed to CVD. Atherosclerosis is a major component of CVD. Which is a focal thickening of the arterial intima, the innermost layer lining the vessel lumen, Early in the formation of atherosclerotic plaques, circulating monocytes adhere to the vascular endothelium , this adherence is mediated through several adhesion molecules on the endothelial cell surface These adhesion molecules are up-regulated by a number of factors, including bacterial LPS, prostaglandins, and pro-inflammatory cytokines. A host of pro-inflammatory cytokines, such as interleukin-1 (IL-1), tumor necrosis factor alpha (TNF-),and prostaglandin E2 (PGE2), are then produced, which propagate the atheromatous lesion and stimulate smooth muscle and collagen proliferation within thickening the arterial wall thickening of the vessel wall narrow the lumen and dramatically decrease blood flow through the vessel Platelet and fibrin accumulation forms a thrombus that may occlude the vessel.

Always begins with injury to the endothelium of blood vessels ; the endothelium needs at least six months to be recovered , so any patient who did any operation associated with heart, vascular tissue I have to wait six months to say that this patient does not need any prophylactic antibiotic. Periodontal pathogens have been found in atherosclerotic lesions porphyromonas gingivalis was found in significant number in the atherosclerotic plaque also accelerates inflammatory atherosclerosis in the innominate artery of ApoE deficient mice .

4 possible biological explanations for how periodontitis is related to CDV

1- Direct effect of periodontal pathogens on platelets by coagulation or lysis .many of us who worked on a patient noticed that the subgingival calculus is dark in color , why? Because of the blood , these stains is from the hemoglobin ; bacteria lysis it and let it dark .

2- Cross reactivity like similarity of antigens (very close in the shape of the antigens) .

3-Periodontal pathogen invasion of vessels

4-Triggering of pro-inflammatory cytokines

Periodontitis as a Risk Factor for Adverse Pregnancy Outcomes

Low birth weight <2500 gm Preterm birth Short gestational period < 37 weeks

- Factors :
- High > (34 years) , Low (17 years) maternal age - Low socioeconomic status - Inadequate pre natal care - Drug use, Alcohol use, tobacco use., - Hypertension - Diabetes mellitus * And now Periodontal Infection >> 18-20% of cases could not explain why this happened , so scientist start seeking for another factors such as periodontal infections Research summary ; An association may exist between periodontal disease and adverse pregnancy outcomes.

Dental Hygiene Implications RDHs ( Registered Dental Hygienist) should educate female patients early about the association between adverse pregnancy outcomes and periodontal infection and provide early oral hygiene services for pregnant women and those considering pregnancy.

Periodontitis as a Risk Factor for Diabetes Complications (A Two-Way Relationship)

- It is clear that diabetes increases the risk for and severity of periodontal disease ; periodontitis is considered to be the sixth complication of diabetes .

- However ; Periodontal disease may exacerbate diabetes mellitus impact glycemic control. - Glycemic control refers to level of glucose of blood over a long time . -Which test that measure the glycemic control ? HbA1c ; that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time. - In a person with diabetes ; Before a meal, the goal is a level of <6.1 mmol/L (<110mg/dL). After a meal, the goal is a level of <7.8 mmol/L (<140 mg/dL).

Poor Glycemic Control - Prolonged elevated glucose in the blood will over time result in serious diabetic complications and sometimes even death. 200 to 500 mg/dL (11 to 12 mmol/L)

The end of the script ,the Dr. said we will start taking quizzes from the next week .. -These are some questions that may come : Difference between : gingivitis periodontitis Scaler- curett Aggressive periodontitis chronic periodontitis NUG - NUP classification of non-plaque induced gingivitis types of brushing technique ________________________________________________________________________ --- Gingivitis : inflammation of the gum tissue , is a non-destructive periodontal disease , is in
response to bacterial biofilms (also called plaque) adherent to tooth surfaces. ---- periodontitis : is a set of inflammatory diseases affecting the periodontium, i.e., the tissues that surround and support the teeth. Periodontitis involves progressive loss of the alveolar bone around the teeth, and if left untreated, can lead to the loosening and subsequent loss of teeth

---Chronic periodontitis : The most common form of periodontitis , Most prevalent in adults, but can occur in children and adolescents , May be associated with systemic diseases. (Diabetes mellitus, HIV infection); Localized periodontitis: less than 30% of the sites assessed in the mouth while Generalized periodontitis: 30% or more. ** Note: in gingivitis you can see inflammatory changes in marginal gingiva and periodontal pocket. So how can we determine that it is periodontitis not gingivitis? By the loss of clinical attachment. ---Aggressive Periodontitis : a disease of the periodontium occurring in an otherwise healthy adolescent which is characterized by a rapid loss of alveolar bone about more than one tooth of the permanent dentition. The amount of destruction manifested is not commensurate with the amount of local irritants. ** progression of this disease is 3-4 times more rapid and severe, than seen in chronic periodontitis. ______________________________________________________________________ --- NUG : An infection characterized by gingival necrosis presenting as punched-out papillae, with gingival bleeding and pain Young adults (mean age 23 years).

--- NUP : An infection characterized by necrosis of gingival tissues, periodontal ligament, and alveolar bone , Severe deep aching pain , Very rapid rate of bone destruction. ** types of brushing technique :

** Classification of NonPlaque-Induced Gingival Lesions (from the book) : 1234567Gingival diseases of specific bacterial origin like Neisseria gonorrhoeae. Gingival diseases of viral origin like Primary herpetic gingivostomatitis. Gingival diseases of fungal origin like Candida species infections . Gingival lesions of genetic origin like Hereditary gingival fibromatosis. Gingival manifestations of systemic conditions like Drug induced. Allergic reaction like Dental restorative materials. Traumatic lesions (factitious, iatrogenic, or accidental).

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DONE BY : Rasha A. Al-Shboul