Relationship Between

Periodontal And Systemic

Disease
Dr. Manal Abu Al Ghanam

Many systemic diseases, disorders, and

conditions have been implicated as risk
indicators or risk factors in periodontal
disease.
Recent evidence suggests that periodontal
infections can adversely affect systemic
health with manifestations such as coronary
heart disease, stroke, diabetes, preterm
labor, low-birth-weight delivery, and
respiratory disease.

Endocrine Disorders and Hormonal

Changes

Diabetes Mellitus
Female Sex Hormones
Hyperparathyroidism

Diabetes Mellitus

A complex metabolic disorder characterized

by chronic hyperglycemia.
Diminished insulin production, impaired
insulin action, or a combination of both result
in the inability of glucose to be transported
from the bloodstream into the tissues, which
in turn results in high blood glucose levels
and excretion of sugar in the urine.

Diabetes Mellitus

1.
2.

3.
4.

Uncontrolled diabetes (Chronic

hyperglycemia) is associated with several
long-term complications:
Microvascular diseases .
Macrovascular diseases .
Increased susceptibility to infections.
Poor wound healing.

Diabetes Mellitus

There are two major types of diabetes:

1.

Type 1 diabetes mellitus (IDDM)

caused by a cell-mediated autoimmune
destruction of the insulin-producing beta cells of
the islets of Langerhans in the pancreas, which
results in insulin deficiency.
Present with the symptoms traditionally
associated with diabetes, including polyphagia,

polydipsia,
infections.

polyuria,

and

predisposition

to

Diabetes Mellitus
2. Type 2 diabetes mellitus, (NIDDM)
Is caused by peripheral resistance to insulin
action, impaired insulin secretion, and increased
glucose production in the liver.
Occurs in obese individuals and can often be
controlled by diet and oral hypoglycemic agents.
Ketosis and coma are uncommon. Type 2
diabetes can present with the same symptoms
as type 1 diabetes but typically in a less severe
form.

Diabetes Mellitus

1.
2.

3.

4.
5.
6.

An additional category of diabetes is hyperglycemia

secondary to other diseases or conditions:
Gestational diabetes associated with pregnancy.
Diseases that involve the pancreas and destruction
of the insulin-producing cells.
Endocrine diseases, such as acromegaly and
Cushing's syndrome.
Tumors.
Pancreatectomy.
Drugs or chemicals that cause altered insulin levels.

Oral Manifestations
1.
2.
3.
4.
5.
6.

7.

Cheilosis.
Mucosal drying.
Cracking.
Burning mouth and tongue.
Diminished salivary flow.
Alterations in the flora of the oral cavity, with
greater predominance of candida albicans,
hemolytic streptococci, and staphylococci.
An increased rate of dental caries has also
been observed in poorly controlled diabetes.

Influence of Diabetes on the

periodontium
1.
2.
3.
4.
5.

6.

A tendency toward enlarged gingiva.

Sessile or pedunculated gingival polyps.
Polypoid gingival proliferations.
Abscess formation.
Periodontitis (deep periodontal pockets,
rapid bone loss)
Loosened teeth.

Influence of Diabetes on the

periodontium

Most striking changes in uncontrolled

diabetes are:
The reduction in defense mechanisms and
the increased susceptibility to infections,
leading to destructive periodontal disease.
In fact, periodontal disease is considered to
be the sixth complication of diabetes.

Influence of Diabetes on the

periodontium

The increased glucose in the gingival fluid and blood of diabetic

patients could change the environment of the microflora.

Type 1 diabetes mellitus and periodontitis have been reported to

have a subgingival flora composed mainly of Capnocytophaga,
anaerobic vibrios, and Actinomyces species.

Porphyromonas gingivalis, Prevotella intermedia, and

Aggregatibacter actinomycetemcomitans, which are common in
periodontal lesions of individuals without diabetes, are present in
low numbers in those with the disease.

Polymorphonuclear Leukocyte
Function

The increased susceptibility of diabetic

patients to infection has been hypothesized
as being caused by polymorphonuclear
leukocyte (PMN) deficiencies resulting in
impaired chemotaxis, defective phagocytosis,
or impaired adherence.
No alteration of immunoglobulin A (IgA),
G (IgG), or M (IgM) has been found in
diabetic
patients

Altered Collagen Metabolism

Chronic hyperglycemia impairs collagen

structure and function, which may directly
impact the integrity of the periodontium.
Altered collagen metabolism undoubtedly
play a significant role in the susceptibility of
diabetic patients to infections and destructive
periodontal disease.

Female Sex Hormones

Gingival alterations during puberty,

pregnancy, and menopause are associated
with physiologic hormonal changes in the
female patient.

Puberty

Puberty is often accompanied by an

exaggerated response of the gingiva to plaque.
Pronounced inflammation, edema, and gingival
enlargement result from local factors that might
ordinarily elicit a comparatively mild gingival
response .
As adulthood approaches, the severity of the
gingival reaction diminishes, even when local
factors persist.

Menstruation

During the menstrual period, the prevalence

of gingivitis increases.
Some patients may complain of bleeding

gums or a bloated, tense feeling in the gums

in the days preceding menstrual flow.

The exudate from inflamed gingiva is

increased during menstruation, suggesting
that preexisting gingivitis is aggravated by
menstruation.

Pregnancy

Pregnancy itself does not cause gingivitis.

The hormonal changes of pregnancy accentuate

the gingival response to plaque and modify the
resultant clinical picture. No notable changes

occur in the gingiva during pregnancy in the

absence of local factors.

Pronounced ease of bleeding is the most striking

clinical feature.
In some cases the inflamed gingiva forms
discrete tumorlike masses, referred to as

pregnancy tumors .

Hormonal Contraceptives

Hormonal contraceptives aggravate the

gingival response to local factors in a manner
similar to that seen in pregnancy and when
taken for more than 1.5 years, increase
periodontal destruction.

Menopause

1.
2.

3.

The usual rhythmic hormonal fluctuations of

the female cycle are ended as estradiol
ceases to be the major circulating estrogen.
The gingiva and remaining oral mucosa are
Dry and shiny.
Vary in color from abnormal paleness to
redness, and bleed easily.
Fissuring occurs in the mucobuccal fold in
some women.

Menopause

The patient complains of a dry, burning

sensation throughout the oral cavity,

associated with extreme sensitivity to thermal
changes; abnormal taste sensations
described as salty, peppery, or sour; and
difficulty with removable partial prostheses.

Hyperparathyroidism

Parathyroid hypersecretion produces

generalized demineralization of the skeleton,
increased osteoclasis with proliferation of the
connective tissue in the enlarged marrow
spaces, and formation of bone cysts and giant
cell tumors.
The disease is called osteitis fibrosa cystica, or
von Recklinghausen's bone disease.
Loss of the lamina dura and giant cell tumors in
the jaws are late signs of hyperparathyroid bone
disease, which in itself is uncommon.

Hyperparathyroidism

1.
2.
3.

4.
5.
6.

25% to 50% of patients with hyperparathyroidism have

associated oral changes:
Malocclusion.
Tooth mobility.
Radiographic evidence of alveolar osteoporosis with
closely meshed trabeculae.
Widening of the periodontal ligament space.
Absence of the lamina dura.
Radiolucent cystlike spaces .
Bone cysts become filled with fibrous tissue with
abundant hemosiderin-laden macrophages and giant
cells. These cysts have been called brown tumors.

Hyperparathyroidism

Brown tumor in patient with

hyperparathyroidism. A, Periapical
radiograph of brown tumor in patient
with hyperparathyroidism. B, Occlusal
radiographic view of brown tumor.
Note expansion of lingual cortical
plate and movement of premolar.

HEMATOLOGIC DISORDERS
AND IMMUNE DEFICIENCIES

Hematologic Disorders and Immune

Deficiencies
1.
2.
3.

Leukocyte (Neutrophil) Disorders.

Leukemia.
Antibody Deficiency Disorders.

Hematologic Disorders and Immune

Deficiencies

Petechiae and
ecchymosis observed
most often in the soft
palate area are signs of
an underlying bleeding
disorder. It is essential
to diagnose the specific
etiology to appropriately
address any bleeding or
immunological disorder.

Leukocyte (Neutrophil) Disorders

The PMN (neutrophil) in

particular plays a critical
role in bacterial infections
because PMNs are the
first line of defense .
Quantitative deficiency of
leukocytes (neutropenia,
agranulocytosis) are
typically associated with a
more generalized
periodontal destruction
affecting all teeth.

Leukemia
The leukemias are malignant neoplasias of
WBC precursors characterized by:
(1) diffuse replacement of the bone marrow
with proliferating leukemic cells.
(2) abnormal numbers and forms of immature
WBCs in the circulating blood.
(3) widespread infiltrates in the liver, spleen,
lymph nodes, and other body sites.

Leukemia

lymphocytic indicates that the malignant

change occurs in cells that normally form

lymphocytes.
myelogenous indicates that the malignant
change occurs in cells that normally form
RBCs, some types of WBCs and platelets.

The Periodontium in Leukemic

Patients

1.
2.
3.
4.

Oral and periodontal manifestations of leukemia

may include:
leukemic infiltration
bleeding
oral ulcerations
infections.
The expression of these signs is more common
in acute and subacute forms of leukemia than in
chronic forms.

The Periodontium in Leukemic

Patients

Adult female with acute

myelocytic leukemia

Large ulcerations on the

palate

Antibody Deficiency Disorders.

Agammaglobulinemia, or
hypogammaglobulinemia, is an immune
deficiency resulting from inadequate antibody
production caused by a deficiency in B cells.
The disease is characterized by recurrent
bacterial infections (ear, sinus, and lung
infections).
Patients are also susceptible to periodontal
infections. Aggressive periodontitis is a common
finding in children.

Genetic disorders

Genetic disorders

Genetic disorders that result in an inadequate

number or function of circulating neutrophils.

Severe periodontitis has been observed in

individuals with primary and secondary
neutrophil disorders.

Genetic disorders
Primary Neutrophil
Disorders
Neutropenia

Secondary Neutrophil
Impairment
Down Syndrome

Agranulocytosis
Chdiak-higashi
Syndrome
Lazy Leukocyte
Syndrome

Papillon-lefvre
Syndrome

Inflammatory Bowel
Disease

Papillon-Lefvre Syndrome

Characterized by hyperkeratotic skin lesions,

severe destruction of the periodontium, and
in some cases, calcification of the dura.
The cutaneous and periodontal changes
usually appear together between the ages of
2 and 4 years. The skin lesions consist of
hyperkeratosis and ichthyosis of localized
areas on palms, soles, knees, and elbows.

Papillon-Lefvre Syndrome

Periodontal involvement consists of early

inflammatory changes that lead to bone loss and
exfoliation of teeth.
Primary teeth are lost by 5 or 6 years of age. The
permanent dentition then erupts normally, but within
a few years, the permanent teeth are also lost
because of destructive periodontal disease.
At a very early age, usually 15 to 20 years, patients
are often edentulous except for the third molars.
These may be lost as well a few years after
eruption. Tooth extraction sites heal uneventfully.

Papillon-Lefvre Syndrome

Down Syndrome

Periodontal disease in Down syndrome is

characterized by formation of deep
periodontal pockets associated with
substantial plaque accumulation and
moderate gingivitis.
These findings are usually generalized,
although they tend to be more severe in the
lower anterior region.

Stress and Psychosomatic Disorders

Psychologic conditions,
particularly psychosocial
stress, have been
implicated as risk indicators
for periodontal disease.
Some studies have failed to
recognize a relationship
between psychological
conditions and periodontal
disease despite specific
efforts to identify them.

Nutritional Influences

The majority of opinions and research findings regarding the

effects of nutrition on oral and periodontal tissues point to the
following:
1 There are no nutritional deficiencies that by themselves can
cause gingivitis or periodontitis. However, nutritional deficiencies
can affect the condition of the periodontium and thereby may
accentuate the deleterious effects of plaque-induced
inflammation in susceptible individuals.

There are nutritional deficiencies that produce changes in the

oral cavity. These changes include alterations of tissues of the

lips, oral mucosa, gingiva, and bone. These alterations are

considered to be periodontal and oral manifestations of
nutritional disease.

Medications

Some medications prescribed to cure, manage, or prevent

diseases may have an adverse effect on periodontal tissues,
wound healing, or the host immune response.

Bisphosphonates are a class of widely prescribed medications

that have recently been associated with osteonecrosis of the jaw.

Corticosteroids have long been prescribed to suppress the

immune system in the control and management of autoimmune
disease, in cancer treatment, and as an antirejection medication
in transplant patients.

Conclusion

Dentists need to appreciate the wide range of

systemic conditions that have periodontal
implications to modify the treatment of
affected patients, and in some cases, the
dentist may be the first doctor to diagnose
systemic disease based on its oral
presentation.

THANK YOU