Influence of Systemic Conditions on the periodontium
 Endocrine diseases such as diabetes and hormonal fluctuations,that are
associated with puberty and pregnancy are well known examples of
systemic conditions that adversally affect the condition of the periodontium.
 Endocrine disturbances and hormonal fluctuations affect the periodontal
tissue directly,modify the tissue response to local factors and produce
anatomic changes in the gingiva that may favor the plaque accumulation
and disease progression.
DIABETES MELLITUS
 Diabetes mellitus is an extremely important disease from a periodontal
standpoint.
 It is complex metabolic disorder characterized by chronic hyperglycemia.
 Diminished insulin production,impaired insulin action or a combination of
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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.
Lipid and protein metabolism is altered in diabetes as well.
Uncontrolled diabetes(chronic hyperglycemia) is associated with several
long term complications,including
Microvascular diseases(retinopathy,nephropathy,neuropathy).
Macrovascular diseases(cardiovascular,cerebrovascular).
Increased susceptibility to infection.
Poor wound healing.
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TYPES OF DIABETES
Type 1 diabetes mellitus:Formerly known as insulin dependent diabetes
mellitus(IDDM).
It is cased 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.
Type I diabetes accounts for 5%-10% of all cases of diabetes and most often occurs in
children and young adults.
This type of diabetes results from a lack of insulin production, and is very unstable and is
difficult to control.
It has a marked tendency towards ketosis and coma.
It is not preceded by obesity and requires injected insulin to be controlled.
Patients with type I diabetes present with the symptoms traditionally associated with
diabetes,including polyphagia,polydipsia,polyurea and predisposition to infection.
Type II diabetes mellitus:
 Formerly it was known as non-insulin dependent diabetes mellitus(NIDDM)
It is caused by:
 peripheral resistance to insulin action
 Impaired insulin secretion
 Increased glucose production in the liver
 The insulin producing beta cells in the pancreas are not destroyed by cell
mediated autoimmune reaction.
 Type II diabetes is most common form of diabetes accounting for 90-95% of
all cases and usually has an adult onset.
 Individuals often are not aware they have the dieasese until severe
symptoms or complications occurs.
 Type II diabetes generally occurs in obese individuals and can often be
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controlled by diet and oral hypoglycemic agents.
Ketosis and coma are uncommon in type II diabetes
Type II diabetes can present with the same symptoms as type I diabetes,but
typically in a less severe form.
An additional category of diabetes is hyperglycemia secondary to other
diseases or conditions.
A primary example of this type of hyperglycemia is gestational diabetes
associated with pregnancy.
Gestational diabetes develops in 2%-5% of all pregnancies but disappears
after delivery.
Women who have had gestational diabetes are at increased risk of
developing type II diabetes later in the life.
 Oral Manifestations:
 Oral manifestations like cheilosis,mucosal drying and cracking ,burning
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mouth and tongue,diminished salivary secretions.
Alteration in the flora of 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
Individuals with well controlled diabetes have a normal tissue response, a
normally developed dentition and a normal defense against infections and
no increase in the incidence of dental caries.
A tendency towards enlarged gingiva,sessile or pedunculated gingival
polyps,abscess formation,periodontitis,and loosened teeth.
 Most striking changes in the uncontrolled diabetes are the reduction in the
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defense mechanism and increased susceptibility to infections,leading to
destructive periodontal disease.
Periodontal disease is considered to be the sixth complications of diabetes.
Children with type I diabetes tends to have more destruction around the first
molars and incisors than elsewhere.
But this destruction becomes more generalized at older ages.
Some investigators have reported that the rate of periodontal destruction
appears to be similar for those with diabetes and those without diabetes upto
30 years of age
After age of 30 years diabetic patients have a greater degree of periodontal
destruction.
 patients showing diabetes more than 10 years have greater loss of periodontal
support than those with a diabetic history of less than 10 years.
 Frequent periodontal abscess appears to be an important feature of periodontal
disease in diabetic patients.
Bacterial pathogens:
 The glucose contents of gingival fluid and blood is higher in individuals with
diabetes than in those without diabetes with similar plaque and gingival index.
 The increased glucose in the gingival fluid and blood of diabetes patients can
change the environment of microflora that can change the severity of
periodontal disease observed in those with poorly controlled diabetes.
 Patients with type I 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 leukocytes Functions
 The increased susceptibility of diabetic patients to infection have been
caused by deficiency in PMNs,resulting in impaired chemotaxis,defective
phagocytosis,or impaired adherence.
 In patients with poorly controlled diabetes the function of PMNs and
monocytes/macrophages is impaired, as a result the primary defense(PMNs)
against periodontal pathogens is diminished and bacterial proliferation
increases.
 No alteretion of immunoglobulin A(IgA),G(IgG)or M(IgM) have been
found in diabetic patients.
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Altered Collagen Metabolism
Chronic hyperglycemia impairs collagen structure and function which may
directly affect the integrity of periodontium.
Decreased collagen synthesis,osteoporosis as well as reduction in alveolar
bone height have been demonstrated in diabetic animals.
Chronic hyperglycemia adversally affects the synthesis,maturation and
maintenance of collagen and extracellular matrix.
In the hyperglycemic state numerous proteins and matrix molecule undergo
a nonenzymatic glycosylation,resulting in accumulated glycation end
products(AGEs).
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Hematologic disorders
All blood cells play an essential role in the maintenance of healthy
periodontium.
White blood cells (WBCs) are involved in inflammatory reactions and are
responsible for cellular defense against microorganisms as well as for
proinflammatory cytokine release.
Red blood cells(RBCs) are responsible for gas exchange and nutrient supply
to the periodontal tissues.
Platelets are necessary for normal hemostasis as well as recruitment of cells
during inflammation and wound healing.
Disorders of any blood cells or blood forming organs can have a profound
effect on the periodontium.
 Certain oral changes such as hemorrhage may suggest the existence of
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blood dyscrasias.
However complete diagnosis requires a complete physical examination and
a thorough hematologic study.
Hemorrhagic tendencies occur when the normal hemostatic mechanisms are
disturbed.
Abnormal bleeding from gingiva or other areas of the oral mucosa that is
difficult to control is an important clinical sign suggesting a hematologic
disorder.
Deficiencies in the host immune response may lead to severely destructive
periodontal lesion.
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Leucocyte(Neutrophil) disorders
Disorders that affects production or function of leucocytes may result in
severe periodontal destruction.
The PMNs/neutrophils in particular plays an important role in bacterial
infections because PMNs are the first line of defense.
Quantitative deficiencies of leucocytes (neutropenia,agranulocytosis) are
typically associated with a more generalized periodontal destruction
affecting all teeth.
Neutropenia:Neutropenia is a blood disorder that results in low levels of
circulating neutrophils.
It is a serious condition that may be caused by
diseases,medications,chemicals, infections,idiopathic conditions or
hereditary disorders.
 It affects as many as one in three patients receiving chemotherapy for
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cancer.
An absolute neutrophil count(ANC) of 1000 to 1500 cells/µl is diagnostic
for mild neutropenia.
ANC 500 to 1000 cells/µl is considered moderate neutropenia.
ANC less than 500 cells/µl is a severe neutropenia.
Infections are some times difficult to control and may be life
threatening,particularly in severe neutropenia.
Agranulocytosis
 Agranulocytosis is a more severe neutropenia involvolving not only the
neutrophils but also the basophils and eosinophils.
 It is defined as an ANC of less than 100 cells/µl.
 It is characterized by a reduction in the number of circulating granulocytes
and results in severe infections,including ulcerative necrotizing lesions of
oral mucosa,skin and gastrointestinal and genitourinary tracts.
 Less severe forms of the disease are called Neutropenia/Granulocytopenia.
 Agranulocytosis has been reported after the administration of drugs such as
barbiturates and their derivatives,aminopyrine,benzene ring derivative,gold
salts,sulphonamides etc.
 The onset of the disease is accompanied by fever,malaise,general
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weakness,and sore throat.
Ulceration in the oral cavity,oropharynx,and throat is characteristic.
Mucosa shows isolated necrotic patches which are black and gray and are
sharply demarcated from adjacent involved areas.
Absence of notable inflammatory reaction caused by lack of granulocytes is
striking feature.
Gingival margin may or may not be involved.
Gingival hemorrhage,necrosis,increased salivation and fetid odor are
accompanying clinical features.
Because infection is a common feature of agranulocytosis D/D involves
NUG,noma,acute necrotizing inflammation of the tonsils and diphtheria.
1. Which among below is not a complication of uncontrolled diabetes.
a.Retinopathy
b.Neuropathy
c.Retropathy
d.Nephropathy
2. Which among below is not a symptom of diabetes.
a.Polyphagia
b.Polydipsia
c.Polyurea
d.Anemia
3.Which among below is not a correct statement.
The increased susceptibility of diabetic patients to infection is due to:
a.Decreased bacterial proliferation
b.Impaired chemotaxis
c.Defective phagocytosis
d.Decreased defence mechanism of PMNs
4.Which is not seen as oral changes in Diabetes mellitus.
a.Cheilosis
b.Mucosal drying
c.Diminished salivary secretion
d.Decrease in Candida albicans population
5.In Neutropenia there is:
a. Increased level of neutrophils
b. Decreased level of neutrophils
c. Changes in the shape of neutrophils
d. No change in the neutrophils level