Periodontal Health And Systemic Disorders Of Periodontium Question And Answers

Periodontal Medicine And Influence Of Systemic Disorders And Stress On The Periodontium

Question 1. What is periodontal medicine. What is the impact of periodontal infection on systemic health?
Or
Write in brief about periodontal medicine.
Or
Write short answer on periodontal medicine.
Answer. Periodontal medicine is described as a new field of investigations based on scientific data which suggests that periodontal infections contribute to the morbidity and mortality of certain systemic conditions such as diabetes, atherosclerosis, chronic obstructive pulmonary disease (COPD), ischemic heart disease, stroke.

Read And Learn More: Periodontics Question And Answers

Impact of Periodontal Infection on Systemic Health

Impact of Periodontal Infection on Diabetics

• Systemic antibiotics may eliminate residual bacteria following scaling and root planning, further decreasing the bacterial challenge to the host.
• Tetracyclines are also known to suppress glycation of proteins and to decrease activity of tissue degrading enzymes, such as matrix metalloproteinases.
• Acute bacterial and viral infections have been shown to increase insulin resistance and aggravate glycemic control.
• Systemic infections increase tissue resistance to insulin, preventing glucose from entering target cells, causing elevated blood glucose levels.
• Periodontal treatment designed to decrease the bacterial insult and reduce inflammation might restore insulin sensitivity over time, resulting in improved metabolic control and in diabetic patients with periodontitis, periodontal therapy may have beneficial effects on glycemic control.

Periodontal Disease and Cardiovascular Disease

• Cardiovascular diseases consist of heart and vascular conditions, i.e. ischemia, atherosclerosis, peripheral artery disease, infective endocarditis and acute myocardial infarction and stroke. Periodontal disease and cardiovascular diseases are both related to lifestyle and share numerous risk factors, such as smoking, diabetes and low socioeconomic status.
• Biological basis for hypothetical association of cardiovascular disease and periodontal disease is presently unclear.
• Packet et al. specified four specific pathways have been proposed to explain the plausibility of link between cardiovascular disease and periodontal infections.

These Pathways Include the Following:

• Direct bacterial effects on platelets.
• Autoimmune responses.
• Invasion or uptake of bacteria in endothelial cells and macrophages.
• Endocrine-like effects of proinflammatory mediators.

Periodontal Disease and Pregnancy

• Low birth weight infants are those which are less than 2.5 kg weigh during birth.
• Primary cause of low birth weight infant delivery is preterm labor.
• Factors such as smoking, alcohol, low socioeconomic status, hypertension, high or low maternal age and genitourinary infections increase the risk of preterm low birth weight.
• Recently, periodontal infection has also been recognized to induce preterm low birth weight.

Periodontal Disease and Respiratory Disease

Periodontal Disease and Acute Respiratory Infections

Pneumonia is an infection of the lungs caused by bacteria, viruses, fungi or mycoplasma, and is broadly categorized as either community-acquired or nosocomial.

• Till today no association has been found between oral hygiene and periodontal disease, and risk for pneumonia in community-dwelling individuals.
• Hospital-acquired pneumonia is usually caused by aspiration of oropharyngeal contents that serve as a rich source for potential respiratory pathogens.
• Potential respiratory pathogens may also originate in oral cavity with dental plaque serving as a reservoir of these organisms.
• Potential respiratory pathogens are more commonly isolated from supragingival plaque and buccal mucosa of the patients in intensive care unit than in outdoor patients.

Periodontal Disease and Chronic Obstructive Pulmonary Disease (COPD)

• COPD shares similar pathogenic mechanism with periodontal disease.
• In both diseases, a host inflammatory response is mounted in response to chronic challenge by bacteria in periodontal disease and by factors, such as cigarette smoke in COPD.
• The resulting neutrophil influx leads to release of oxidative and hydrolytic enzymes that cause tissue destruction directly.
• Individuals with poor oral hygiene have been found to be at increased risk for chronic respiratory diseases such as bronchitis and emphysema; however, these associations remain to be confirmed by further research.

Periodontal Disease and Cancer

• Chronic infections such as periodontitis can play a direct or indirect role in carcinogenesis.
• Microorganisms and their products such as endotoxins, enzymes and metabolic by product are toxic to surrounding cells and may directly induce mutations in tumor suppressive genes and proto-oncogenes, or altered signaling pathways that affect cell proliferation.
• Microorganisms and their products activate host cells, such as neutrophils, macrophages, lymphocytes and fibroblasts to generate reactive oxygen species, which can induce DNA damage in epithelial cells.

Periodontal Disease and Arthritis

• Periodontitis has remarkably similar cytokine profile to rheumatoid arthritis, including IL-l beta, TNF-alpha, TGF-beta, and cytokines that suppress the immunoinflammatory response.
• The destruction of extracellular matrix in both diseases is determined by the balance of matrix metalloproteinases and their inhibitors.
• Bone destruction in periodontitis and rheumatoid arthritis is a result of uncoupling the normally coupled processes of bone resorption and bone formation, with PGE2, IL-l, TNF-alpha, and IL-6 as mediators of bone destruction.
• Periodontitis and rheumatoid arthritis have many pathological features in common, and hence the possibility exist that both conditions result from a common under-lying dysregulation of the host inflammatory response; however, the precise nature of which remains to be established.

Periodontal Disease and Renal Disease

Chronic renal disease can affect oral tissues and can greatly influence the dental management of renal patients, various studies also suggest that chronic periodontitis can contribute to overall systemic inflammatory burden, and may have consequences in the management of the end-stage renal disease patient on hemodialysis maintenance therapy.

Question 2. Discuss periodontal management plan for a medically compromised patient.
Or
Describe management of hypertensive and diabetic patients in periodontal clinic.
Answer. There are various types of medically compromised patients for which there are various management plans which are as follows:

Cardiovascular Disease

Hypertension

Management for Hypertension

• No routine periodontal treatment should be carried out if the patient is hypertensive.
• During dental treatment stress of hypertensive patient should be minimized.
• While treating hypertensive patients, clinician should not use a local anesthetic solution containing epinephrine concentration greater than 1:100000.
• If hypertensive patient exhibit anxiety, use of conscious sedation in conjunction with periodontal procedures may be warranted.
• b-blockers are used to treat hypertension.

Ischemic Heart Disease (Angina Pectoris)

• Preoperative glyceryl trinitrate and sometimes oral sedation are advised.
• Dental care should be carried without minimal anxiety and oxygen saturation, blood pressure and pulse monitoring.
• If a patient with a history of angina experiences chest pain during dental surgery, dental treatment should be stopped. The patient should be given glyceryl trinitrate 0.3–0.6 mg sublingually and oxygen and be kept sitting upright.
• If chest pain is not relieved within about 3 min, myocardial infarction is a possible cause and medical help should be summoned.
• Pain that persists after 3 doses of nitrogen glycerin given every 5 min that lasts more than 15–20 min, or that is associated with nausea, vomiting, syncope or hypertension is highly suggestive of myocardial infarction.

Endocrine Disorders

Diabetes Mellitus

Pretreatment Assessment

Assess the patient whether the patient is prone to diabetic coma or insulin shock.

• If Tolbutamide, Chlorpropamide or small doses of insulin is taken by the patient, there will be less chances of not occurring.
• If the patient take large daily doses of insulin, then there is possibility of diabetic coma or insulin shock.
• If the patient complains of being thirsty, nauseous and shortness of breath and has warm dry skin, the patient is most likely hyperglycemic and should be immediately refer to the physician, No treatment is required by the dentist.
• Glucose drink should be available, if the patient complaints of hypoglycemia.

Preferable Appointments

• Appointment should be of short duration, especially in the morning.
• Morning appointments are ideal after breakfast because of optimum insulin levels.
• It is best to plan treatment to occur either before or after periods of peak insulin activity; this reduces the risk of perioperative hypoglycemic reactions.
• Morning appointments results in well-rested diabetic patient with maximum tolerance for potentially stressful dental procedures.
• While the patients receiving intermediate or long-acting insulin may be treated in the afternoon.

Tissue Management

• Patients with diabetes mellitus are managed in such a way as to minimize disturbances of metabolic balance.
• Tissues should be handled atraumatically as minimally as possible (Less than 2 hours).
• The physical and emotional stress, infection and surgical procedures may tend to alter patients disease.

Sedation and Antibiotic Prophylaxis

• Antibiotic prophylaxis is recommended for extensive therapy.
• For anxious diabetic patients preoperative sedation is required.
• Stress-reduction protocol may help to stabilize the patient’s insulin requirement and assists in maintenance of metabolic homeostasis.

Periodontal Procedures

• Periodontal treatment is contraindicated in uncontrolled diabetes.
• If there are periodontal conditions that require immediate care, prophylactic antibiotics should be given. Penicillin is the drug of choice.

Periodontitis

Patients with severe periodontitis, adjunctive use of the tetracyclines in conjugation with mechanical periodontal therapy may have beneficial effects on glycemic control as well as on periodontal status.

Periodontal Abscess

• In case of pain and swelling with multiple periodontal abscess antibiotic prophylaxis should be given. Relieve the abscess by incision and drainage.
• The incisions must be given parallel to the long axis of the tooth on the most dependent part of gingiva under LA without adrenaline.
• Local anesthetic without Epinephrine is to be used in dental surgical procedures, as epinephrine can elevate the blood glucose concentration.

Pocket Elimination

• Periodontal pockets can be eliminated with modified Widman flap procedures.
• Periodontal surgeries for pocket elimination must be done with strict asepsis on antibiotic coverage after consent from physician.

Maintenance Care

• Most diabetic patients can be effectively treated in the dental office on a routine outpatient basis.
• Maintenance care of all diabetic patients with periodontal problems must be done frequently at intervals of every 3 months.
• Dietary recommendations for the patient should be advised according to the insulin level.
• Postoperative oral hygiene methods could try to reduce the onslaught of periodontal breakdown.
• Recall appointments and fastidious home oral care should be stressed.

Adrenal Insufficiency

• Terminate periodontal treatment.
• Summon medical assistance.
• Give an oxygen
• Monitor vital signs
• Place the patient in supine position
• Administer 100 mg of hydrocortisone sodium succinate 4 over 30 seconds or IM.

Liver Diseases

• Consult with the physician about the current status of disease, risk for bleeding, potential drugs to be prescribed during treatment and required alterations to periodontal therapy.
• Screen for hepatitis B and C
• Check laboratory values for PT and PTT.

Leukemia

• Refer the patient for medical evaluation and treatment. Close cooperation with the physician is required.
• Before chemotherapy, a complete periodontal treatment plan should be developed.
  • Monitor hematologic laboratory values daily: bleeding time, coagulation time, prothrombin time, and platelet count.
  • Administer antibiotic coverage before any periodontal treatment because infection is a major concern.
  • Extract all hopeless, non-maintainable, or potentially infectious teeth at least l0 days before the initiation of chemotherapy, if systemic conditions allow.
  • Periodontal debridement should be performed and thorough oral hygiene instructions given if the patient’s condition allow. Twice-daily rinsing with 0.12% chlorhexidine gluconate is recommended after oral hygiene procedures. Recognize the potential for bleeding caused by thrombocytopenia. Use pressure and topical hemostatic agents as indicated.
• During the acute phases of leukemia, patients receive only emergency periodontal care. Any source of potential infection must be eliminated to prevent systemic dissemination. Antibiotic therapy is frequently the treatment of choice, combined with nonsurgical or surgical debridement as indicated.
• Oral ulcerations and mucositis are treated palliatively with agents such as viscous lidocaine. Systemic antibiotics may be indicated to prevent secondary infection.
• Oral candidiasis is common in the leukemic patient and can be treated with nystatin suspensions or clotrimazole vaginal suppositories.
• For patients with chronic leukemia and those in remission, scaling and root planing can be performed without complication, but periodontal surgery should be avoided, if possible.

Question 3. Explain the underlying mechanism of influence of diabetes on progression of periodontitis and influence of periodontal therapy on glycemic control.
Or
Explain etiological relationship between diabetes and periodontium.
Or
In context to periodontal medicine, write about the two-way relationship between diabetes and periodontics.
Or
Write short note on diabetes and periodontium.
Answer.

Mechanism of Influence of Diabetes on Progression of Periodontitis

The risk of developing destructive peiodontitis increase threefold in diabetic individuals. Following are the various mechanisms which lead to the progression of periodontal therapy on diabetics:

Alteration in Bacterial Pathogens

• The glucose content in the blood and gingival fluid of individuals with diabetes could change the environment of the microflora, inducing qualitative changes in bacteria that could account for the severity of periodontal disease observed in poorly controlled individuals with diabetes.
• There is altered flora in the periodontal pockets of patients with diabetes.
• Patients with type 1 diabetes with periodontitis have been reported to have a subgingival flora composed mainly of Capnocytophaga, anaerobic vibrio and Actinomyces species.
• P. gingivalis, P. intermedia and C. rectus are more prominent in Type 2 diabetics.

Polymorphonuclear Leucocyte Function

• The increased susceptibility of diabetics to infection has been hypothesized as being due to polymorphonuclear leucocyte deficiencies resulting in impaired chemotaxis, defective phagocytosis, or impaired adherence.
• In patients with poorly controlled diabetes the function of PMN leucocytes and monocytes/macrophages is impaired.
• No alteration of IgA, IgG or IgM has been found in diabetics.

Altered Collagen Metabolism

• Increased collagenase activity and decreased collagen synthesis is seen in individuals with diabetes with chronic hyperglycemia.
• Chronic hyperglycemia adversely affects the synthesis, maturation and maintenance of collagen, and extracellular matrix molecules undergo a non-enzymatic glycosylation, resulting in advanced glycation end products (AGEs).
• The formation of AGEs can occur at normal glucose levels, but in hyperglycemic environments, AGE formation is excessive. AGE formation crosslinks collagen, making it less soluble and less likely to be normally repaired or replaced. As a result, collagen in the tissues of poorly controlled diabetics is aged and more susceptible to breakdown.
• AGEs play a central role in the classic complications of diabetes. They may play a significant role in the progression of periodontal disease as well.
• Poor glycemic control and increased AGEs render the periodontal tissues more susceptible to destruction.
• Cellular migration through crosslinked collagen is impeded and perhaps more importantly, tissue integrity is impaired as a result of damaged collagen remaining in the tissues for longer periods.

Influence of Periodontal Therapy in Glycemic Control

• Acute bacterial and viral infections have been shown to increase insulin resistance and aggravate glycemic control. This occurs in individuals with and without diabetes.
• Systemic infections increase tissue resistance to insulin, preventing glucose from entering target cells, causing elevated blood glucose levels, and requiring increased pancreatic insulin production to maintain normoglycemia. Insulin resistance may persist for weeks or even months after the patient has recovered clinically from their illness.
• In the individual with type 2 diabetes, who already has significant insulin resistance, further tissue resistance to insulin induced by infection may considerably exacerbate poor glycemic control.
• In type l patients, normal insulin doses may be inadequate to maintain good glycemic control in the presence of infection-induced tissue resistance. It is possible that chronic gram-negative periodontal infections may also result in increased insulin resistance and poor glycemic control.
• In patients with periodontitis, persistent systemic challenge with periodontopathic bacteria and their products may act similar to well-recognized systemic infections. This mechanism would explain the worsening of glycemic control associated with severe periodontitis. Periodontal treatment designed to decrease the bacterial insult and reduce inflammation might restore insulin sensitivity over time, resulting in improved metabolic control. The improved glycemic control seen in several studies of periodontal therapy would support such a hypothesis.

Question 4. Write short note on ascorbic acid deficiency and periodontal disease.
Answer. Ascorbic acid deficiency leads to scurvy.

• In scurvy oral symptoms are of chronic gingivitis, which can involve the free gingiva, attached gingiva and alveolar mucosa.
• In chronic cases, gingiva becomes brilliant red, tender and grossly swollen.
• Spongy tissues are extremely hyperemic and bleed simultaneously.
• In chronic cases, the tissues attain dark blue or purple hue.
• Alveolar bone resorption with increased tooth mobility is present.
• Low levels of ascorbic acid disturbs collagen metabolism in periodontium and affect the ability of tissue to regenerate and repair by itself.

Question 5. Explain the influence of female sex hormones on the initiation/progression of gingival disease.
Answer. Pregnancy itself does not cause gingival disease.

• Gingival disease in pregnancy is caused by bacterial plaque.
• Pregnancy accentuates the gingival response to plaque and modifies the resultant clinical picture.
• Pregnancy affects the severity of previous inflamed areas; it does not alter healthy gingiva.
• Impressions of increased incidence may be created by the aggravation of previously inflamed but unnoticed areas.
• Tooth mobility, pocket depth, and gingival fluid are increased in pregnancy.
• The severity of gingivitis is increased during pregnancy beginning in the second or third month.
• Patients with slight chronic gingivitis that attracted no particular attention before the pregnancy become aware of the gingiva because previously inflamed areas become enlarged, edematous, and more notably discolored.
• Patients with little or no noticeable gingival bleeding before pregnancy become concerned about an increased tendency to bleed.
• Gingivitis becomes more severe by the 8 th month and decreases during the 9 th month of pregnancy.
• The correlation between gingivitis and the quantity of plaque is greater after parturition than during pregnancy, which suggests that pregnancy introduces other factors that aggravates the gingival response to local factors.
• Pronounced ease of bleeding is the most striking clinicalfeature. The gingiva is inflamed and varies in color from bright red to bluish red. Marginal and interdental gingivae are edematous, pit on pressure, appear smooth and shiny, soft and pliable and present raspberry like appearance.
• Gingival changes are usually painless unless complicated by acute infection. In some cases, the inflamed gingiva forms “tumor-like” masses, referred to as pregnancy gingivitis.
• Aggravation of gingivitis in pregnancy has been attributed principally to the increased levels of progesterone, which produce dilation and tortuosity of the gingival microvasculature, circulatory stasis, and increased susceptibility to mechanical irritation, all of which favor leakage of fluid into the perivascular tissues.
• A marked increase in estrogen and progesterone occurs during pregnancy, with a reduction after parturition.
• The severity of gingivitis varies with the hormonal levels in pregnancy.
• It has also been suggested that the accentuation of gingivitis in pregnancy occurs in two peaks: during the first trimester, when there is overproduction of gonadotropins, and during the third trimester, when estrogen and progesterone levels are highest.
• Destruction of gingival mast cells by the increased sex hormones and the resultant release of histamine and proteolytic enzymes may also contribute to the exaggerated inflammatory response to local factors.

Question 6. Write short note on oral manifestations of diabetes mellitus.
Or
Enumerate oral sign and symptoms of diabetes mellitus.
Answer.

Oral Manifestations of Diabetes Mellitus

• Gingival and periodontal disease
  • It will influence the onset and course of periodontal disease. Patients with diabetes are more prone to develop periodontal disease than those with normal glucose metabolism. There is tendency for bleeding on probing.
  • Patient may exhibit fulminating periodontitis with periodontal abscess formation and inflamed painful abscess and even hemorrhagic gingival papillae, this factor culminated and give rise to tooth mobility.
  • It will show more severe and rapid alveolar bone resorption and are more prone to develop periodontal abscess.
  • Insulin dependent children tends to have more destruction around first molars and incisors than elsewhere.
• Median rhomboid glossitis
  • Diabetes is considered to be factor for median rhomboid glossitis as frequency of abnormal blood sugar level in diabetes and predisposition of these subjects to candidiasis.
  • Impairment of blood supply to dorsum of tongue due to arteriosclerotic changes in blood vessels supplying area.
  • Impairment of Local immense mechanisms which decreases concentration of Langerhans’ cells in lesion.
• Oral candidiasis: It is infection with Candida albicans which occurs due to encouragement of local multiplication of Candida albicans due to impaired glucose level and immune mechanism.
• Localized osteitis: Dry socket develops in the diabetes, hence they show delayed healing and impaired immunological balance.
• Burning mouth: It is associated with variety of otherwise unexplained oral symptoms such as burning sensation, atypical paresis, dysentery and dysgeusia.
• Other features:
  • Increased caries activity. Due to excessive fluid loss patient complains of xerostomia.
  • Atrophy of lingual papilla with fissuring or dry tongue.
  • Delay in healing of oral wound due to decreased polymorphonuclear chemotaxis.
  • There is also angular cheilosis, altered taste sensation, oral lichen planus and diffuse enlargement of parotid gland.

Question 7. Write short note on effect of diabetes on periodontium.
Answer. Following are the effects of diabetes on periodontium:

• Diabetes will influence the onset and course of periodontal disease. Patients with diabetes are more prone to develop periodontal disease than those with normal glucose metabolism.
• There is tendency for increased bleeding on probing, deep periodontal pockets, rapid bone loss, greater attachment loss with periodontal abscess formation and inflamed painful abscess and even hemorrhagic gingival papillae, this factor culminated and give rise to tooth mobility.
• It will show more severe and rapid alveolar bone resorption and are more prone to develop periodontal abscess.
• Juvenile diabetics tend to have more destruction around first molars and incisors than elsewhere.
• Diabetes do not cause gingivitis or periodontal pockets but there are indications that it alter the response of periodontal tissues to local factors, hastening bone loss and retard postsurgical healing of periodontal tissues.
• Increase of the glucose in gingival crevicular fluid of diabetics changes the environment of microflora which leads to severity in periodontal diseases.
• Chronic hyperglycemia adversely affects the synthesis, maturation and maintenance of collagen, and extracellular matrix molecules undergo a non-enzymatic glycosylation, resulting in advanced glycation end products. These glycation end products increases in amount which render the periodontal tissues more susceptible to destruction.