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Influence of systemic conditions on the periodontium.

When we covered the etiology of periodontal disease we said that the Primary cause of periodontal disease is microbial plaque which we call biofilm give rise to human or body defense mechanisms against these bacteria which exceed the needed limit. -We always say that the tissue destruction that takes place in periodontal disease is not done by bacteria directly it is done by the host response to this bacteria. -We talked about the local predisposing factors which are basically responsible for providing environment for plaque accumulation and make the plaque control measures claiming the teeth difficult. -How to control plaque?? by brushing, medications, mouthwashes and so on.. - We mentioned last time that there are some systemic conditions that are responsible for providing some environment for periodontal disease to take place and this is what we call : systemic predisposing factors. - Systemic predisposing factors are systemic conditions or diseases that reduce the immune response. We said before that the tissue destruction is made by the host response so you will think that if we reduce the immune response there will be less destruction BUT when the immune response reduces this will make bacteria survive so this will lead to denser destruction. ** So you have to remember that we should maintain : BALANCE between the bacterial load and human respone . - If the immune response is higher than needed a problem will take place (main stream of periodontal distruction). - If the immune response lower than the bacterial load, the bacteria will cause

the destruction. -We have some diseases that : 1- Lower the immune system. 2- Change the composition of periodontal tissue : this change in the nature of the tissue itself make these tissues more prone to periodontal destruction. 3- Change the turnover or the buildup breakdown of tissues : such collagen related diseases some of them are related to the lower turnover mechanisim of collagen in the body which make these collagen fibers aged(become old), if this fibers become aged they will become less functional and less resistant to external load or bacterial attack.

So these complex of conditions are called the systemic predisposing factors for periodontal disease and we are going to highlight some informations about these conditions and their relationship to periodontal tissue. DONE BY : Gewanna J. Ghazal __________________________________________________

Many systemic diseases, disorders, and conditions have been implicated as risk indicators or risk factors in periodontal disease. If someone have periodontal disease, dos that disease affect the whole body? The answer is YES, since the periodontal disease is inflammatory disease so will make effect to the body in general. Systemic diseases, disorders, and conditions alter host tissues and physiology, which may impair the hosts barrier function and immune defense against periodontal pathogens.


Endocrine disorders; endocrine disturbances and hormone fluctuations affect the periodontal tissues directly, modify the tissue response to local factors, and produce anatomic changes in the gingiva that may favor plaque accumulation and disease progression. Diabetes Mellitus; complex metabolic disease characterized by chronic hyperglycemia. Female sex hormones Corticosteroid hormones; involved in a wide range of physiological processes, including stress response, immune response, and regulation of inflammation, carbohydrate metabolism, control carbohydrate, fat and protein metabolism and are anti-inflammatory, this hormone responsible to lowering the immune system. Hyperparathyroidism; is over activity of the parathyroid glands resulting in excess production of parathyroid hormone. The parathyroid hormone regulates calcium and phosphate levels and helps to maintain these levels, so will affect the maxilla and the mandible by increasing bone resorption, allowing flow of calcium from bone to blood.

Hematological disorders Leukemia Anemia Thrombocytopenia Leukocytes disorders Antibody deficiency disorders Stress and psychosomatic disorders Nutritional influences


Other systemic conditions

DIABETES MELLITUS Important disease from a periodontal standpoint. It is 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. Previous definition of diabetes mellitus was the disease that relate to carbohydrate metabolism only but nowadays the definition is changed to include the lipid metabolism also. So diabetes mellitus a complex group of metabolic disorders with a common feature of impaired CARBOHYDRATE and LIPID metabolism. We ask the patient to reduce sugar and lipid intake, keep in mind the amount of calories in lipid is higher than sugar in same volume. Insulin causes cells in the liver, skeletal muscles, and fat tissue to absorb glucose from the blood.

There are two major types of diabetes, type 1 and type 2, with several less common secondary types. Type 1 diabetes mellitus; formerly insulin-dependent diabetes mellitus (IDDM) and also called juvenile diabetes, is 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. Previously was called insulindependent diabetes mellitus, but nowadays stop to use this name because its not likely to classify the disease according to the treatment, classification the disease should bases on the etiology rather than the treatment option.


Type 2 diabetes mellitus; formerly noninsulin-dependent diabetes mellitus (NIDDM), is caused by peripheral resistance to insulin action. Is the most common form of diabetes, accounting for 90% to 95% of all cases, and usually has an adult onset. Individuals often are not aware they have the disease until severe symptoms or complications occur. If we take a high sugar meal, the body start to secrete a huge amount of insulin in order to reduce accumulation of sugar in blood, in case of type 2 diabetes mellitus the insulin nonfunctioning because of peripheral resistance to insulin action, so the complication of high levels of glucose in GCF and blood result in change in oral flora and increased periodontal pathogens, and the glucose start to bind with some cells like RBC and endothelial cells and form products like complexes cant be removed by the body, this particles called advanced glycation endproducts. The treatment of type 2 diabetes mellitus focusing on improvement the body sensitivity to insulin. In advance stage of the disease and after accumulation of nonfunctioning insulin in the body gives negative feedback to beta cells in order to reduce the amount of insulin secretion. So the problem of type 2 diabetes mellitus 1) Peripheral resistance to insulin action. 2) Insulin deficiency caused by the negative feedback, so giving insulin to type 2 diabetic patient important to reverse the action of negative feedback effect.

Gestational; an additional category of diabetes is hyperglycemia secondary to other diseases or conditions. A prime example of this type of hyperglycemia is gestational diabetes associated with pregnancy. Develops in 2% to 5% of all pregnancies but disappears after delivery. Women who have had gestational diabetes are at increased risk of developing type 2 diabetes later in life. So gestational diabetes appear in pregnant ladies, most of cases is temporally disease, after the delivery the glucose and insulin level get back to normal level, but in some ladies will not recover from the disease and develops type 2 diabetes mellitus because of genetics and other factors rather than pregnancy itself. In normal situation the recovery from the disease take weeks after the delivery.

Others due to cancer, trauma, etc...; other secondary types of diabetes are those associated with diseases that involve the pancreas and destruction of the insulin-producing cells. Endocrine diseases, such as acromegaly and Cushings syndrome, tumors, pancreatectomy, and drugs or chemicals that cause altered insulin levels, are included in this group. DIAGNOSIS Clinical picture; diagnosis diabetes mellitus depend on symptoms and sings, so the doctor suspect the disease from observing signs and symptoms, keep in your mind this symptoms start to appear in advanced stage of the disease uncontrolled diabetes. Blood glucose levels; blood tests are used to diagnosis diabetes and prediabetes because early in the disease type 2 diabetes may have no symptoms. Testing enables health care providers to find and treat diabetes before complications occur and to find and treat prediabetes, which can delay or prevent type 2 diabetes from developing. Any test used to diagnose diabetes requires confirmation with a second measurement unless clear symptoms of diabetes exist. A fasting blood glucose test; this test is performed after you have fasted (no food or liquids other than water) for eight hours. A random blood glucose test taken at any time. SYMPTOMS OF DIABETES increased urination increased thirst unexplained weight loss Other symptoms can include fatigue, blurred vision, increased hunger, and sores that do not heal.

Aspirin: is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. So aspirin is analgesic drugs and with antiplatelet function.

Done by: Eyad Massalha Good luck on your exams Basically we have two types of testing blood glucose : 1- Fasting blood glucose test : which is the gold standard for diagnoses that measures the amount of blood glucose level in patients blood at that moment , and reflexes a day concentration of blood glucose , however if the patient is normal or close to normal he might be diabetic for long period but maybe he didnt have that much food in the last few days so we order another blood test . 2- Glycated hemoglobin or glycosylated hemoglobin : a form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time . it reflects the amount of blood glucose that attach to body cells which dont go away unless this tissue itself is removed , and they found that blood cells one of these cells (that dont go away) ,, so they found that sugar attaches to RBCs and this amount of attachment reflects the concentration attachment of sugar to these cells . So again , that is called glycated hemoglobin and if the patient reduces the amount of sugar intake for two weeks for example , the reading of glucose level will not be changed because it is irreversible molecule attachment . we have to wait enough time for these RBCs to be replaced . so this glycated hemoglobin gives us blood glucose concentration over the last 3 months (which is the life span of RBCs) So the diagnoses is based basically on : 1)Clinical picture

2) Blood glucose levels patient is diabetic but we should make the test more than one time . however if the patients blood glucose level is 125 and down to 110 then he is considered pretreat themselves as diabetic patients .

Sign of diabetes mellitus : 1-Polydipsia (the patient displays excessive thirst.). 2-Poly urea : place more in the kidney. 3although the blood glucose level is high but the cells are not able to use this glucose so the cells keep asking for food and the body start to eat itself and that is called muscle wasting especially in uncontrolled cases .

Complication -Macro-vascular : veins . Micro-nephrop hypertension. . Periodontal disease.


changes in small arteries and veins which may lead to : lindness. that end up with renal failure ,

The most risk factors that may lead to diabetic mellitus related to our age are : 1)The lazy Life style 2)Overweight

DM pts (especially the un-controlled cases) more frequently have : 1) Mucosal drying and cracking ; dryness makes the tissues less resilient and dysfunctional 2) Burning mouth and tongue

3) Reduced salivary flow ; we know that salivary flow is responsible for flushing the bacteria away so that will not happen in uncontrolled cases. 4) Alteration of the oral flora and predominance of candida albicans angular cheilitis 5) They are at higher risk of developing periodontal disease Destruction is more severe in type I pts . Controlled pts have better periodontal health. In diabetic patients , there are some mechanisms happen which lead to some complications :

1) Bacterial change that makes the patient more susceptible to periodontal disease; Porphyromonag gingivalis , Provetella intermedia, Aggrigatibacteractinomyceemcomitans.


2) Defective polymorphonuclear neutrophils ; the neutrophils will become adherence to the attacking microorganisms is lowered too .

3) Altered collagen metabolism especially in chronic uncontrolled pts ; we said that viability and freshness of collagen metabolism is very important for the well being of the body in general , so increased in collagenase activity (which is an enzyme responsible for collagen destruction) will cause periodontal diseases.

4) Advanced Glycation Endproducts (AGEs) ; which are products responsible for attachment of blood glucose to different types of body cells like RBCs , also lead to :

Reduce collagen turn-over rate . Cause hyperresponsive cellular state of endothelial cells . Increase production of cytokines.

Done by : Rasha Al-Shboul _______________________________

Hormonal change: Generally these changes of hormonal do not cause periodontal disease by them selves but aggravate body response to tract.

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Lady before pregnancy or before menopause for example in menstrual cycle they have acetien response to bacteria plaque which is generally similar to the main contact part but generally during these period where the progesterone , estoregen levels change the body cells become hyperresponsive so they have very angry response to these bacteria this is general role. Puberty: We know the first time in girls life that real hormonal change take place is at puberty. And similarly in males at puberty they have higher incidence of gingival inflammation. But this inflammation is not very destructive it is gingival related rather than periodontal related. They have gingivitis not periodontitis. So they have some inflammation, discoloration. And inflammation means production or flow of fluid(46:30)and enlarge so any part of body when become inflamed become red , inflamed and increase in size because of flow of fluids. Not always present may be few fluid. But if you have patients specially when she comes and have good oral hygiene and has erythema and she has this area that has recurrent infection, you need to consider the age. And if she at age of puberty we have to increase the oral hygiene practice and wait this will heal by it self. During menstrual cycle** bcz of hormonal changes increase progesterone, estrogen- u know u have 2 cycles during the menstruation --.generally they do not cause disease they aggravate the response to already present parts . At pregnancy this imp. Bcz pregnancy takes place for long time and we have problem is that some ladies when become pregnant they become less compliant they do not brush teeth as regular. U know that in some ladies preg. Is very bad. Some ladies have lucky life during preg. But if of your pts have difficulty, especially if they have problem with eating with vomiting they have periodontal disease.
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And they need to pay attention and you will see in your clinic practice sometimes the lady comes to u with big gingival enlargement that even when she bits it bits on this tissue become really big. U have to do something about it and in some cases u have to go to surgery to reduce the size of lesion to make her able at least to bite on her teeth so this again exsalerated response to plaque. We have the preg. Tumor it's just reaction to some amount of plaque or margin of composit filling that before preg. No problem but during preg. The local factors start to take place. This case of preg. Gingivitis this is imp. Microorganism ,when ever women come in to account when we took about periodontal disease ((prevotella intermedia )) imp. That it is linked to hormonal changes. So need to remember that ((prevotella intermedia )) likes to be in females in high concentration than in males and cause disease more than do in males. Oral contraceptive: Again it is common, the general title is that effect periodontal tissue just like preg. Bcz the contraceptive is hormonal related drugs so again just make things higher than normal. Menopause: Very common and they have some disease basically the (manymouth syndrome ?? ) related condition. So they have gingival infection but it's very less than the mucosal change that make oral mucosa more sensitive to brushing becomes dehydration become thin that's why even this group of pts might be prone to fungal infections. Corticosteroid hormones: These are very imp. Bcz we said they lower the immunity.

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Basically cortisone and ACTH they do not affect the gingiva directly but they have negative effect on bone ,so they make osteoporosis more so if they are used by old ladies, postmenopausal ladies or already osteoporotic this becomes more imp. Parathyroid hormone: We mentioned this responsible for Ca metabolism related to vitamin D and the oral change that u find in hyperparathyroid patients are bone related so it's really serious. The composition and the volume of alveolar bone change so might have malocclusion they have spacing and this malocclusion is by its Self predisposing factor for periodontal disease. They have osteoporosis and this shown in radiographs again in if this is in old ladies is become worse. They have absence of lamina Dura is radiographic appearance of inner socket wall that we normally call alveolar bone proper and in radiographs shown more white rim of bone around the root. So due this decrease in mineral content of the bone this lamina dura disappears which indicated periodontal problem. Hematological disorders: We will focus on leukemia . Blood cells: RBC's, wbc's ,platelate's. Rbc's: responsible for nutrition and oxygen transport wbc's: :responsible for immunity defense mechanisms platelates for hemostasis> blood clotting and prevention of blood loss . So basically, if we had deficiency in RBC's it's anemiaincrease RBC's it's polycythemia ..Increase in WBC's it's leukocytosis
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Done by : Noor Hazaymeh ___________________________________

Increase in RBC's

*leukocytosis can be seen in inflamation and more serious disease like tumors, cancer, blood cancer basiclly leukemia which is one of the main blood disorders ithas direct relation to periodontal disease When we have a lec on classification of periodontal disease we have: Chronic periodontitis MODIFIED by systemic condition like DM Chronic periodontitis CAUSED by systemic condition like leukemia so in all leukemic pts we have periodontal disease In leukemia we have increase level of WBC's the problem is even they have increase level of WBC's they have plenty of infections ,, we know that WBC's is responsible for fighting infections ,, in these pts there is a huge increase in WBC's and still have a lot of infections why ?? Bcz they are not functional ,, plenty but not useful

results in:

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oReduced RBCs anemia and poor tissue oxygenation oNormal WBCs - infections oPlatelets bleeding disorders

bleeding, ulcerations and infections -monocytic leukemia (67%), followed by acutemyelocytic-monocytic (19%) and acute myelocytic leukemia

These pts have pale gingiva and skin and sclera espically if they are not under treatment or chronic anemic pt Reduced concentration of RBC's & cosequntly hemoglabin

Types: oPernicious anemia (impaired gastric absorption) oIron-deficiency anemia (chronic bleeding) oSickle-cell anemia (in blacks) oAplastic anemia

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Clinical features: oRed, smooth and shiny tongue. oIncreased pallor of the gingiva oUlceration of the oral mucosa Done by : Hiba Abu-JUMAH _______________________________

Thrombocytopenia: reduced platelets concentration, so they have more bleeding and the bleeding will be in form of Petechiae or hemorrhage. Some other hematological disorder: -Leukocyte Adhesion Deficiency: this is very important; the leukocytes are not able to adhere to the bacteria to fight it so they have advanced destruction. - Neutropenia: generally no production of neutrophils. -Papillon-Lefevre Syndrome. -Down Syndrome. STRESS AND PSYCHOSOMATIC DISORDERS: Stress is much related to periodontal diseases one of them called: 1- NUG (necrotizing ulcerative gingivitis): so the patient under stress, stress is one of the causes in addition to other causes like smoking, they used to call it "trench mouth" and thats means " "because solders in the battle were found to have more PD destruction and ulceration and it was called trench mouth!

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So stress is responsible for periodontal destruction, causes of stress like financial crises, divorce, loss of family member, etc so if the patient is under stress this need to be discussed with the patient. Stress is very important thing to deal with because stress can give rise to PD destruction to oral ulceration, to TMJ dis-function and to poor nutrition and this is related to the ability of the patient to deal with stress! So if you have the ability to deal with it you will be less likely to have oral ulceration and PD diseases but if you can't cope with it you will have a plenty of disease! NUTRITIONAL INFLUENCES: Basically we hear a lot about vitamin C deficiency when gingival is involved because as we know in scurvy patient vitamin C is very important and collagen production so we have a problem in PD diseases. CONCLUSION: - You may be the first to discover medical conditions! For example in diabetic patient the gingival PD condition can tells you or the blood mucosa test, you suspect the disease by the nature of PD tissue, and you have to know when and who to consult when you dont know, like your college . - What if we improve the periodontal condition of patients, Will this reduce the effect of systemic conditions? Actually we dont know yet! Done by:Hadeel sumrain

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