Perio 3: Influence of Systemic Factors on Periodontal Status

Rheumatoid arthritis

Chronic autoimmune disease that is depicted by synovial inflammation and hyperplasia leading to damage of the cartilage and bone in the joints, loss of function, chronic pain, and progressive disability

Cardiovascular illness, skeletal disorders

Significant RA comorbidities

Complex associations between environmental factors (e.g. long term smoking), genetics, hormones, infectious risk factors

Development of RA is dependent on...

Similar cellular participation at inflammatory focus

Microenvironmental and serum cytokine

Matrix metalloproteinase and mediator profiles, and osteoclast-mediated bone destruction

RA and periodontal disease share a number of pathobiologic processes that have been preciously reviewed, including:

Periopathogenic

Studies have shown the presence of ______________ bacteria in the synovium of patients with RA indicating that joint seeding and localized inflammatory amplification may be operative.

P. gingivalis

The gram - anaerobic _ __________ has received considerable attention for its role in the development of periodontal disease.

Pg colonization

One of the most permissive steps in the propagation of the periodontal lesion

Polyuria

Polydypsia

Polyphagia

Ketoacidosis

Acute symptoms of diabetes

Retinopathy

Glomerulosclerosis

Cardiovascular complications

Neuropathy

Impaired wound healing

Periodontal disease

Chronic complications of diabetes

Major

Diabetes is a _____ risk factor for periodontitis.

2x

Risk of periodontitis is approx __ in diabetic individuals compared with nondiabetic individuals.

Glycemic

For diabetic patients, level of ________ control is important.

9%

Adults with HbA1c of > _% had a significantly higher prevalence of severe periodontitis than those without

Endothelial and vascular injury

Altered leukocyte function

Advanced glycation end products and collagen metabolism

Mechanisms behind diabetes and periodontitis

Leukocyte attachment to endothelium

Basement membrane thickening

Blood vessel leakage; new vessel growth

Blood vessel closes up

Endothelial cells are in intimate contact with high glucose in blood. Endothelial cells take up glucose passively. What are the microscopic consequences of this?

White

______ blood cells are also directly exposed to high blood glucose in diabetes.

Impaired neutrophil migration to site of inflammation

Decreased phagocytosis

Decreased microbial killing

In addition to vascular damage, diabetes also alters neutrophil function and innate immune response in which ways?

Advanced glycation end products

Considered one factor of aging, is implicated in diabetes, CVD, and Alzheimer's

Collagen

In advanced glycation end products, a multitude of molecules may be affected, including ________.

AGE

___-modifies collagen turnover rate and thus wound healing is impaired.

BOP, attachment loss

Uncontrolled diabetes results in increased ___ and _________ ____.

True

T/F: Effective control of diabetes lowers the risk of periodontitis progression.

True

T/F: There is a bidirectional relationship between the effect of periodontal therapy on diabetes.

HbA1c

Periodontal therapy can reduce _____ levels.

False; strong

T/F: Moderate evidence supports association of diabetes with periodontitis.

False

T/F: Well controlled diabetes is a contraindication for periodontal surgery and implants.

25, 30

BMI for overweight vs. obese

Elevated BP

Elevated central adiposity

Elevated triglycerides

Periodontal disease

Describe periodontal disease as a component of metabolic syndrome

Macrophages; adipocytes

Changes in ___________ and ___________ leads to chronic inflammation and insulin resistance.

Increased M1 macrophages, B cells, reg B cells, T helper cells etc.

Pro-inflammatory cytokines recirculate between different tissues

Decreased phagocytic activity

Impaired antigen presentation

Describe the mechanism of obesity/diabetes and periodontitis.

True

T/F: There is moderate evidence for the relationship between obesity and periodontitis.

False

T/F: There is an indication that the response to periodontal treatment should differ for individuals who are obese versus individuals who are not.

Smoking

Most important non-genetic influence on periodontal disease pathogenesis

Deeper periodontal pockets

More supra-gingival calculus

More attachment loss

More bone and tooth less

Less erythema

Less BOP

When smokers and non-smokers with comparable plaque levels are compared, smokers have:

Vasoconstriction

Does smoking cause vasoconstriction or vasodilation?

Decreased GCF

Does smoking cause increased or decreased gingival crevicular fluid volume?

Immune; wound healing

Smokers have impaired _______ response and _____ ______.

Smoking status

Lifetime exposure

Biochemical assessment

How to assess smoking?

4x

Current smokers are _x more likely to have periodontitis compared to non-smokers.

True

T/F: Longer time since quitting means lower likelihood of periodontitis.

Phenytoin

DIGE was first reported in the 1930s with _________.

Drug type and dose

Duration of use

Oral hygiene and plaque status

Genetic predisposition

DIGE is influenced by...

Not fully understood but proposed mechanisms:

Increased fibroblast activity

Reduced collagenase activity

Inflammatory changes

Interaction with growth factors and cytokines

Plaque-induced inflammation acts as a co-factor

DIGE MoA

Hyperplasia of epithelial and connective tissues

Elongated rete pegs into CT

Dense, collagen-rich stroma

Varying degrees of inflammatory infiltrate

Acanthosis of epithelium

Vascular proliferation

Histological findings of DIGE

Weeks to months after starting med

DIGE onset

Often begins in interdental papillae, may extend to marginal and attached gingiva

DIGE distribution

Lobulated, firm, may appear inflamed if plaque is present

DIGE surface

Anterior facial gingiva

Most commonly affected areas for DIGE

Discontinue or substitute drug

Emphasize meticulous oral hygiene

SRP to reduce inflammation

Gingivectomy or flap surgery if overgrowth persists

Adjunctive therapies: azithromycin, folic acid, chlorhexidine (limited evidence)

Treatment of DIGE

Phenytoin

Anti-epileptic with DIGE

Cyclosporin

Immunosuppressant with DIGE

Nifedipine

Amlodipine

Verapamil

Diltiazem

Ca++ channel blockers with DIGE

True

T/F: Neoplasms are a systemic disorder that can result in loss of periodontal tissue independent of periodontitis.