dentistry

1. Relationship Between
Systemic Health &
Periodontal Diseases
Presentor:
Dr. Carlos T. Capitan II
MScD- Periodontics
CEU- 1st Yr./ 2nd Sem

2. Many systemic diseases, disorders, and conditions
have been implicated as risk indicators or risk factors
in periodontal disease.
Evidence also 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.

3. ENDOCRINE DISORDERS
AND
HORMONAL CHANGES
Endocrine diseases and hormonal
fluctuations that are associated with
puberty and pregnancy are well-
known examples of systemic
conditions that adversely affect the
condition of the periodontium.

4. ENDOCRINE DISORDERS
AND
HORMONAL CHANGES
During pregnancy, your progesterone hormone
levels are high. This increase makes you more
susceptible to developing the bacterial plaque that
can attack your gums.
Symptoms of gingivitis include:
swollen gums
tender, puffy gums
bleeding gums
receding gums
red gums
bad breath

5. Fig. 1 Periodontal condition in patients with diabetes. (A) Adult with diabetes. (B)
The same patient. (C)Adult patient with uncontrolled diabetes. (D) The same patient
as shown in C. (E)Adult patient with uncontrolled diabetes.

6. Severe gingival inflammation, deep periodontal pockets, rapid bone
loss, and frequent periodontal abscesses often occur in patients with
poorly controlled diabetes and poor oral hygiene (Figs. 2 and 3).
Children with type I diabetes tend to have more destruction
around the first molars and incisors, but this destruction becomes
more generalized at older ages.
In patients with juvenile diabetes, extensive periodontal destruction
often occurs as a consequence of having more severe disease at a
younger age.

7. Fig. 2 patient with a long-term history of
type 2 diabetes
Severe gingival inflammation, deep periodontal pockets, rapid bone loss, and
frequent periodontal abscesses often occur in patients with poorly controlled
diabetes and poor oral hygiene (Figs. 2 and 3).
Fig. 3 Periodontal abscess in type 1 diabetes.

8. The glucose content of gingival fluid and blood is higher in individuals
with diabetes than in those without diabetes with similar plaque and
gingival index scores.
BACTERIAL PATHOGENS
The increased glucose in the gingival fluid and blood of patients with diabetes
could change the environment of the microflora, thereby inducing qualitative
changes in bacteria that may contribute to the severity of periodontal disease
observed in those with poorly controlled diabetes.

9. It has been reported that the prevalence of periodontal disease in diabetic patients is >85% (27.3% of
patients had gingivitis and 59.5% had periodontitis) whereas the prevalence of periodontitis in the general
population is 46% (1,7).
Epidemiological data confirm that diabetes is a major risk factor for periodontitis; susceptibility to
periodontitis is increased by approximately threefold in people with diabetes
Source: Diabetologia. 2012; 55(1): 21–31.
Published online 2011 Nov 6. doi: 10.1007/s00125-011-2342-y
There is emerging evidence to support the existence of a two-way relationship between diabetes and periodontitis, with
diabetes increasing the risk for periodontitis, and periodontal inflammation negatively affecting glycaemic control.
Incidences of macroalbuminuria and end-stage renal disease are increased twofold and threefold, respectively, in diabetic
individuals who also have severe periodontitis compared to diabetic individuals without severe periodontitis.
Furthermore, the risk of cardiorenal mortality (ischaemic heart disease and diabetic nephropathy combined) is three
times higher in diabetic people with severe periodontitis than in diabetic people without severe periodontitis. Treatment
of periodontitis is associated with HbA1c reductions of approximately 0.4%. Oral and periodontal health should be
promoted as integral components of diabetes management.

10. POLYMORPHONUCLEAR LEUKOCYTE FUNCTION
In patients with poorly controlled diabetes, the functions of
PMNs, monocytes, and macrophages are impaired.
As a result, the primary defense mounted by PMNs against
periodontal pathogens is diminished, and bacterial proliferation
is more likely.
No alteration of immunoglobulinA(IgA), G (IgG), or M (IgM)
has been found in patients with diabetes.

11. ALTERED COLLAGEN METABOLISM
Chronic hyperglycemia impairs collagen structure and
function, which may directly impact the integrity of the
periodontium.
Collagen in the tissues of patients with poorly controlled
diabetes is older and more susceptible to pathogenic
breakdown (i.e., less resistant to destruction by periodontal
infections).

12. INTERACTION BETWEEN DIABETES & PERIODONTAL DISEASE
Figure 3. Illustration of the mechanisms of interaction between diabetes and periodontal diseases. The most
widely accepted hypothesis is that diabetes increases inflammatory responses of the peridontal tissues. Exacerbated
and dysregulated inflammatory responses are the key to the proposed two-way relationship between diabetes and
periodontal diseases. AGE: advanced glycosylation end-products; MMP: extracellular matrix metalloproteinases;
PMN: polymorphonuclear leukocytes; RAGE: receptor of advanced glycosylation end-products.

13. METABOLIC
SYNDROME
Obesity is associated with increased cytokine production as well as T-
cell and monocyte/macrophage dysfunction, factors known to contribute
to periodontitis.
Female Sex Hormones
Gingival alterations during puberty, pregnancy, and menopause are
associated with physiologic hormonal changes in the female patient.
Oral changes during menopause may include thinning of the oral
mucosa, gingival recession, xerostomia, altered taste, and burning
mouth.

14. HEMATOLOGIC DISORDERS
AND
IMMUNE DEFICIENCIES
Abnormal bleeding from the gingiva or other areas of the oral
mucosa that is difficult to control is an important clinical sign that
suggests a hematologic disorder.
Petechiae (Fig. 4) and ecchymosis (Fig. 5), 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 immunologic disorder.

15. Fig. 4 Petechiae evident on the soft palate of a patient with an underlying bleeding
disorder (thrombocytopenia).

16. Fig. 5 Ecchymosis that is evident on the lateral aspects of the soft palate and
tonsillar pillars of a patient with chemotherapy-induced thrombocytopenia.

17. Disorders that affect the production or function of leukocytes may result in severe
periodontal destruction.
A quantitative deficiency of leukocytes (e.g., neutropenia, agranulocytosis) is
typically associated with a more generalized periodontal destruction that affects
all teeth.
LEUKOCYTE (NEUTROPHIL)
DISORDERS

18. Systemic conditions that are associated with or that predispose an individual to periodontal destruction
include genetic disorders that result in an inadequate number or reduced function of circulating
neutrophils.
Severe periodontitis has been observed in individuals with primary neutrophil disorders such as cyclic
neutropenia (Fig. 6), agranulocytosis, Chédiak–Higashi syndrome, and lazy leukocyte syndrome, secondary
neutrophil impairment, such as those with Down syndrome, Papillon– Lefèvre syndrome, and
inflammatory bowel disease.
GENETIC DISORDERS

19. Fig. 6 Aggressive periodontitis with cyclic neutropenia and agammaglobulinemia.
(A) Clinical presentation of the periodontal condition. (B) Panoramic radiograph
demonstrating severe bone.

20. LEUKEMIA
The leukemias are malignant neoplasias of WBC
precursors. According to their evolution,
leukemias can be acute (which is rapidly fatal),
subacute, or chronic.
Oral and periodontal manifestations of leukemia
may include leukemic infiltration, bleeding, oral
ulcerations, and infections.

21. Fig. 7. Spontaneous bleeding from the gingival sulcus in a patient with thrombocytopenia. Normal
coagulation is evident by the appearance of the large clot that forms in the mouth. However, platelets
are inadequate to establish hemostasis at the site of hemorrhage.
Thrombocytopenia leads to bleeding tendency, which can occur in any
tissue but which in particular affects the oral cavity, especially the gingival
sulcus.

22. LEUKEMIC INFILTRATION
It consists of a basic infiltration of the gingival corium by leukemic cells that
increases the gingival thickness and creates gingival pockets in which bacterial
plaque accumulates, thereby initiating a secondary inflammatory lesion that
contributes to the enlargement of the gingiva.

23. Fig. 8 Leukemic infiltration that causes localized gingival
swelling of the interdental papillae between the maxillary
lateral and central incisors. Note the tense induration of
the area.
Fig. 9 Adult male with acute myelocytic leukemia. (A) A view of
the patient’s face.(B) Close-up view of skin lesions. (C) Gingival
enlargements of the entire gingival margin and interdental papilla
areas of both arches. (D) Occlusal view of the maxillary anterior
teeth.

24. Bleeding
Gingival haemorrhage is a common finding in leukemic patients even in
the absence of clinically detectable gingivitis. Bleeding gingiva can be
an early sign of leukemia.

25. ORAL ULCERATION AND INFECTION
Acute gingivitis and lesions that resemble necrotizing
ulcerative gingivitis are more frequent and more severe in
patients with terminal cases of acute leukemia (Figs. 10).
This greatly altered and degenerated tissue is extremely
susceptible to bacterial infection, which can be so severe as to
cause acute gingival necrosis with pseudo-membrane formation
or bone exposure.

26. Fig. 10Adult female with acute myelocytic leukemia. (A)Anterior view of a patient
with acute myelocytic leukemia. (B) Palatal view demonstrating extensive necrosis
of the interdental and palatal tissues behind the maxillary incisors.

27. Individuals under stress may have poorer oral hygiene; they may start or
increase the clenching and grinding of their teeth; and they may smoke more
frequently.
All of these behavioral changes increase their susceptibility to periodontal
disease destruction. Likewise, individuals who are under stress may be less
likely to seek professional care.
STRESS-INDUCED
IMMUNOSUPPRESSION

28. MEDICATIONS
Bisphosphonates
Bisphosphonate medications are primarily used to treat cancer and
osteoporosis or bone thinning—which occurs when the bones lose
calcium and other minerals that help keep them strong and compact.
They act by inhibiting osteoclastic activity, which leads to less bone
resorption, less bone remodeling, and less bone turnover.
During the treatment of osteoporosis, the goal is simply to harness
osteoclastic activity to minimize or prevent bone loss and, in many cases,
to increase bone mass by creating an advantage for osteoblastic activity.
Figure 11.

29. Bisphosphonate-induced osteonecrosis of the jaws (BIONJ) refers to a
condition characterized by exposure of bone in mandible or maxilla
persisting for more than 8 weeks in patient who has taken or is currently
taking bisphosphonate and who has no radiation therapy to the jaws.
Among cancer patients receiving high-dose
intravenous bisphosphonates, osteonecrosis of
the jaw is dependent on dose and duration of
therapy,17–20 and has an estimated incidence
of 1% to 12%. Fig. 11 exposed bone of the maxilla with
bisphosphonate-induced osteonecrosis of the bone
(maxilla).

30. Radiographic evidence of treatment with bisphosphonates
Panoramic radiograph of osteoporotic patient treated with bisphosphonates,
demonstrating marked increase in depth and density of mandibular inferior
border, periapical osteosclerosis, and increased number and density of
trabeculae in the body and symphaseal areas of the mandible
Panoramic radiograph: Patient: 77 years old, male, metastatic
prostate cancer, ibandronic acid & later another antiresorptive drug:
denosumab. Red arrows point to the necrotic area. Artefact due to
thyroid shield.
Bisphosphonate-induced osteonecrosis of the jaws (BIONJ)

31. The systemic administration of cortisone and adreno- corticotropic
hormone appears to have no effect on the incidence or severity of
gingival and periodontal disease.
However, renal transplantation patients receiving immunosuppressive
therapy have significantly less gingival inflammation than control subjects
with similar amounts of plaque.
CORTICOSTEROIDS

32. Malignancy
Earlier literature review showed that chronic periodontitis is an independent
clinical high-risk profile for head and neck squamous cell carcinoma (HNSCC),
especially in the oral cavity, followed by the oropharynx and larynx.[In a
prospective cohort study by Michaud et al., a significant association was found
between the history of periodontitis and risk of developing lung, kidney,
pancreas, and hematological cancers. These associations are said to persist in a
number of studies, after adjustment for major risk factors, including cigarette
smoking and socioeconomic status. However, the most consistent increased risk
was noted in the studies of oral and esophageal cancers and periodontal disease.
Reference: Med Oral Patol Oral Cir Bucal. 2021 Jul; 26(4): e430–e436. Published online 2020 Dec 19. doi: 10.4317/medoral.24270
PMCID: PMC8254889 PMID: 33340075 Periodontitis as a risk factor for head and neck cancer
Letícia Miquelitto Gasparoni,1 Fábio Abreu Alves,1,2 Marinella Holzhausen,1 Cláudio Mendes Pannuti,1 and Marianna Sampaio Serpacorresponding author2
Gastric and pancreatic cancers had an association in most, but not all studies.
Lung, hematological, and other cancers were less consistently associated or did
not have sufficient studies to determine a predictable pattern. Furthermore,
Tezal et al. reported that patients with periodontal disease were more likely to
have poorly differentiated oral cavity squamous cell carcinoma (SCC) than those
without periodontitis. These findings were said to have implications for practical
and safe strategies for prevention, diagnosis, and treatment of HNSCC . The
possible link between periodontitis and malignancy is not clear, but lifetime
cumulative infection exposure is being queried.

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