ERIODONTAL ISEASE;

The outh and ody

Connection

P D M BConnection

KhamizaZainolAbidinPakar PeriodontikKP Gunung Rapat

PERIODONTAL DISEASE

• A form of chronic bacterial infections that affects the gums & destroy attachment fibers and supporting bone that hold teeth in the mouth.

• Approximately 15 % of adults between 21-50 • Approximately 15 % of adults between 21-50 and 30% of adults over 50 have this disease

• Among the most important causes of pain, discomfort & tooth loss in adults

(Brown & Loe 1993)

What Causes Gum Disease

• Plaque and tartar accumulate at the base of the teeth. Inflammation causes a pocket to develop between the gums and the teeth, which fills with plaque and tartar. Soft tissue swelling traps the

1. Bacteria

plaque and tartar. Soft tissue swelling traps the plaque in the pocket. Continued inflammation eventually causes destruction of the tissues and bone surrounding the tooth. Because plaque contains bacteria, infection is likely and a tooth abscess may also develop, which increases the rate of bone destruction

What Causes Gum Disease

2. Host response

3. Genetics

4. Environmental conditions

Sign & Symptoms of Periodontal Disease

• SILENT disease

– Red, swollen or tender gums

– Bleeding gums during brushing

– Persistent bad breath

– Pus b/w the teeth and gums– Pus b/w the teeth and gums

– Loose or separating teeth

– Receded gums

– A change in the way your teeth fit together when you bite

Healthy gums are - PINK & FIRM,- tightly attached to the teeth- DON’T bleed upon brushing

Stages of Gum Disease

• Inflammation of the gums

• Plaque and tartar build up is present at the gum line

• Gums are red and puffy

GINGIVITIS

• Gums may bleed when you brush or floss

• Bone and fibers holding your teeth in place have not yet been affected.

• With treatment, gingivitis

can be reversed.

Stages of Gum DiseasePERIODONTITIS

• Plaque has spread to the roots of your teeth

• Infection continues to worsen

• This infection has damaged the supporting bone and fibers that hold your teeth in placethe supporting bone and fibers that hold your teeth in place

• Gums may have begun to pull away from your teeth forming a "pocket" below the gum line, which traps food, bacteria, plaque

• Immediate treatment can stop further damage and tooth loss.

Stages of Gum Disease

Healthy gum

Gingivitis - plaque

irritate gum,

ilamed,bleed

Stages of Gum Disease

Periodontitis - plaque

harden into calculus,

gum receed, pocket form

Advanced Periodontitis

- further destruction

Teeth loose

1st indication to

patients that

there is a

problem

Painless process & progress very slowly

Complications

• Infection or abscess of the soft tissue (facial

cellulitis)

• Infection of the jaw bones (osteomyelitis)

• Tooth abscess• Tooth abscess

• Tooth flaring or shifting

• Tooth loss

PERIODONTAL DISEASE

NO THERAPY

THERAPYLOOSENING

OF TEETH

CABUT

Risk factors

• Smoking

– Need another reason to

quit smoking?

– Smoking is one of the

most significant risk most significant risk

factors associated with

the development of gum

disease.

– can lower the chances

for successful treatment.

Risk factors

• Hormonal changes

• Genetic susceptibility

• Diabetes – impaired protective immune response

• Obesity • Obesity

• Genetic

• Stress – suppression of immune response

Risk Factors

• Medications

– There are hundreds of prescription and over the

counter medications that can reduce the flow of

saliva, which has a protective effect on the mouthsaliva, which has a protective effect on the mouth

– Without enough saliva, the mouth is vulnerable

to infections such as gum disease

– Some medications can cause abnormal

overgrowth of the gum tissue; this can make it

difficult to keep gums clean

Many experts believed that INFLAMMATION in

the mouth and elsewhere in the body is a

common thread linking a broad range of

health problemhealth problem

Inflammation in the mouth

PERIODONTAL DISEASE

Periodontal Disease and Systemic Side Effects

• Periodontal infection triggers systemic

inflammatory responses via transient

bacteremias in affected persons.

Oral Inflammation

Bacteremia Bacteremia Bacteremia Bacteremia

Immune Immune Immune Immune Response Response Response Response

Inflammatory mediators(IL-1, IL-6,TNF-α)

Periodontopathogens or

their products (LPS)

Periodontopathogens (eg.P.gingivalis)

Liver Liver Liver Liver

Target organTarget organTarget organTarget organ(eg. Arteries, placenta)(eg. Arteries, placenta)(eg. Arteries, placenta)(eg. Arteries, placenta)

C-reactive protein,

fibrinogen

Bacteria induce platelet aggregate,

invade endothelium, digest matrix

Antibodies to bacteria & to

cross-reactive antigens such

as heat-shock proteins

Periodontal Disease

&

Diabetes

Periodontal Disease and Diabetes

• 2 very common chronic diseases in this country

• Diabetes generally increased susceptibility to many types of infections, particularly Gram –many types of infections, particularly Gram –ve anaerobic bacteria

• Diabetes is often associated with increased gingival inflammation in response to bacterial plaque

(De Pommereau et al 1992)

Periodontal Disease and Diabetes

• Periodontal disease is the sixth complication

of diabetes Loe 1993, Lowe 2001

along with neuropathy, retinopathy & micro-and

macrovascular diseases

DIABETES

IMPACTIMPACTIMPACTIMPACT

PERIODONTAL DISEASE

2 way relationship

PERIODONTAL DISEASE

Perio pathogens

Endotoxin, toxins, cell membrane product

DIABETES MELLITUS

Insulinresistance

Hyperglycemia

Synthesis + secretionTNFα + ILβ

Macrophage AGE & receptor

DIABETES MELLITUS

AGE - protein

cell membrane product

Proinflammatory cascade

Conn tissue destructionBone resorption

Secretion TNFα + ILβ

TNFα + ILβ

Degradative cascade

Hydrolase, MMP, Collagenase secretion

Conn tissue degradation

In other words….

• Both diseases share a common pathogenesis

that involves an enhanced inflammatory

response that can be observed at the local

and systemic level.and systemic level.

• The inflammatory response is mainly caused

by the chronic effects of hyperglycemia and

specifically the formation of biologically active

glycated proteins (AGE) and lipids that

promote inflammatory responses.

Peridontal disease among diabetic & non-diabetic PIMA Indians

Nelson et al 1990

What happens if Perio Disease NOT

treated

• Active periodontal disease makes glycemic

control more difficult.

• Greater risk for developing long term • Greater risk for developing long term

complications assoc with diabetes

• May be genetically predisposed to an

exaggerated inflammatory response to G –

ve bacteria

Periodontal treatment

Reduce inflammation locally Reduce seruminflammatory mediator

Reduction in insulin resistance

glycemic control

Kiran et al 2005

Can Periodontal Treatment Affect Glycaemic

ControlEffects of periodontal disease on glycemic controls results from2 year study (Taylor et al 1996)

Can Periodontal Treatment Affect Glycaemic

Control

The effect of periodontal treatment on glycemic control results from a pilotRandomised control study of 125 patients with type 2 diabetes showing the change in HbA1c at 3 months, scaling & root planing

Therefore……• Diabetic patients with gingivitis or

periodontitis need specialized care, including

tailored treatment plans

• It is reasonable to treat periodontal disease in

diabetic patients not only to save the diabetic patients not only to save the

dentition but also to help improve glycaemic

control & thereby reduce other complications

of diabetes

• Periodontal & overall systemic health should

be closely monitored

Periodontal Disease &

Cardiovascular Disease

Periodontal Disease and Cardiovascular Disease

• Share many risk factors & pathogenic process

• Common enemy � chronic inflammation & its

potential to accelerate the process of atherosclerosis

• Chronicity of perio dis provides a rich source of • Chronicity of perio dis provides a rich source of

bacteria & host response products (acute-phase

protein – C reactive protein & fibrinogen by liver)

• Atherosclerotic plq are infected with periodontal

pathogens Haraszthy & Zambon 2000

Association between Perio Dis & CVD

• 4 possible pathway

– Bacterial effects on platelet

– Endocrine-like effects of inflammatory mediators

– Autoimune responses– Autoimune responses

– Endothelial invasion of bacteria

Altered vascular response � atheroma formation

Oral health predicts prevalence of carotid artery plaque

Lalla et al 2006

Contribution of Periodontal Treatment to CVS Disease

• In high risk patient:

– eradicate the infection

– prevent recurrence

• Perio Tx can reduce

– CRP levels until one yr after therapy – CRP levels until one yr after therapy

Ebersole et al 1997

– CRP & fibrinogen level to normal level Alibhai et al 2002

– IL-6 & low density lipoprotein Paraskevas et al 2008

– CRP & TNFα Inamoto et al 2003

The link…

Promote platelet adhesion to

endothelial cells

CRP

endothelial cells

Periodontal Disease ���� CRP

Therefore…..

• Periodontal intervention may prevent the

onset or progression of atherosclerosis-

induced disease

Periodontal Disease

&&

Medications

Peridontal Disease & Medications

• Side effect from medications taken by the

patient play a particularly important role in

the progression of periodontitis

GINGIVAL ENLARGEMENT / OVERGROWTH

• Medications involve:

– phenytoin (50% of pt)

– calcium channel blockers (30% of pt) –

nifedipine,diltiazem,verapamil

Peridontal Disease & Medications

nifedipine,diltiazem,verapamil

– Cyclosporin (25% of pt)

Mechanism

Phenytoin

Gingival mØ

amount of PDGF -B

Inflammatory Cytokine IL-1ß

Calcium channel blockers

Nifedipine

Alteration of the intracellular Ca level in gingival cell

Proliferation of gingival conn tissue

Production of fibroblast in conn tissue

Gingival enlargement

Cyclosporine

production of collagen degrading enzyme

Accumulation ofcollagen

Gingival enlargement

• Clinically gingiva appears thickened & enlarged

• Enlargement often occurs months after the start of medication Nishikawa et al 1991

Peridontal Disease & Medications

start of medication Nishikawa et al 1991

• Relationship b/w dosage & severity may not be causal

• Causing accumulation of plaque which will worsen condition

Effects

• Increased risk to periodontal disease

• Difficulty in maintaining proper oral hygiene

care

• Severe enlargement interfere with speech & • Severe enlargement interfere with speech &

function

• Esthetic

Periodontal therapy

• Early intervention can:

– Prevent or minimize severe gingival problem

– Minimize enlargement

CONCLUSIONS

• Oral cavity represents an ecosystem which has

to continually cope with

– bacterial challenge and

– it may impaired host responses or– it may impaired host responses or

– systemic conditions of the patients at an early

stage of the disease process

CONCLUSIONS

• Oral bacteria have been found systemically & are

associated with systemic outcome

• Inflammation anywhere in the body can adversely

affect other sites as well as the system as a wholeaffect other sites as well as the system as a whole

• These associations b/w periodontal disease & several

major chronic diseases which are major causes of

mortality & morbidity, call for an urgency in the

diagnosis, prevention & treatment of periodontal

disease

CONCLUSIONS

• Periodontal disease is a

SILENT disease which may

have other adverse

responses ; good oral responses ; good oral

hygeine & regular

professional check-ups are

the best means of

prevention.

The mouth & body connection

• Preterm low birth weight

• Respiratory disease

• Osteoporosis

• Rheumatoid arthritis• Rheumatoid arthritis

• Cancer

• Obesity

• Alzheimer’s disease

• Kidney transplant rejection

Good Health begins in MOUTHMOUTH

Keeping Risk Factors & patients Susceptibility in mindWill help us address the Person not the Mouth

What will you do

different tomorrow ??