Influence of systemic diseases on periodontal diseases
Introduction
- Diabetes
- Definition of diabetes
- Classification of diabetes
- Influence of diabetes on the periodontium
2. pregnancy
3. infectious diseases
3.1. Hepatitis
3.2. HIV infection
3.3. Herpes infection
3.4. Syphilis
3.5. Tuberculosis
4. autoimmune diseases
4.1. Lupus erythematosus
4.2. CROHN’S disease
4.3. Rheumatoid arthritis
4.4. Histiocytosis X
4.5. Sarcoidosis
5. drug treatments
6. genetic disorders
6.1. Cyclic neutropenia
6.2. DOWN syndrome
6.3. Lefevre butterfly syndrome
6.4. HELERS DANLOS syndrome
6.5. CHEDIAK HIGASHI syndrome
6.6. Leukocyte adhesion deficiency
6.7. Gingival fibromatosis
7. Blood coagulation disorders
7.1. Leukemia
7.2. Thrombocytopenia
7.3. Neutropenia and agranulocytosis
Conclusion
Introduction
The pathogenesis of periodontal diseases is influenced by various host factors, including the immune response, anatomical factors, and tissue structural factors. Most of these factors are determined by the host genetic profile and can be modified by environmental and behavioral factors. Periodontal diseases and some systemic disorders share similar genetic and/or environmental etiological factors, and therefore, affected individuals may exhibit manifestations of both diseases. Therefore, periodontal tissue loss is a common manifestation of some systemic disorders, which could have important diagnostic value and therapeutic implications.
- Diabetes
- Definition
Diabetes is a chronic condition caused by the body’s inability to produce enough insulin or use it properly.
Today, nearly 10% of the world’s population is diabetic.
- Classification
- Type I diabetes (insulin-dependent).
- Type II diabetes (non-insulin dependent).
- Gestational diabetes.
- Other types of diabetes:
- Genetic defects in β-cell function.
- Genetic defects in insulin action.
- Pancreatic diseases or pancreatitis, neoplasia, cystic fibrosis, trauma, pancreatectomy.
- Infections: Cytomegalovirus, congenital rubella.
- Drug-induced diabetes:
Glucocorticoids, thyroid hormone.
- Endocrinopathies: Acromegaly, pheochromocytoma, glucagonoma, hyperthyroidism, Cushing’s syndrome.
- Other genetic syndromes associated with diabetes
- Influence of diabetes on the periodontium
It is well known that diabetes is a predisposing factor for periodontal disease. The results of studies are sometimes contradictory, however most agree that:
- Diabetic adults (type I) have the same degree of gingival inflammation as non-diabetics (same plaque rate). However, the number of bleeding sites on probing in these patients is higher in cases of poorly controlled blood sugar.
- In patients with T2DM, inflammation is more pronounced than that observed in healthy patients, and even more so in cases of poorly controlled blood sugar.
- A study of 3,500 adult diabetics clearly shows that diabetes predisposes to periodontitis.
- Pregnancy
- Hormonal changes that punctuate the different phases of a woman’s life (puberty, menstrual cycles, oral contraception, pregnancy, breastfeeding and menopause) have an influence on the oral sphere.
- Pregnancy causes significant and rapid hormonal changes over a short period of time.
- The effects of estrogen on gingival vascularity may potentially explain the increased edema, erythema, crevicular fluid exudation, and gingival bleeding during pregnancy.
- An increase in crevicular fluid flow has been correlated with an increase in steroid levels, indicating that these hormones may affect permeability in the gingival sulcus.
- As with other systemic conditions, pregnancy alone does not cause gingivitis.
- Gingivitis during pregnancy is caused by bacterial biofilm. The hormonal change of pregnancy accentuates the gingival response to the biofilm and alters the clinical outcome. No gingival changes occur during pregnancy in the absence of local factors.
- Pyogenic granuloma
Pyogenic granuloma is a non-specific inflammatory lesion of the mucosa that affects both female and male sexes. However, it occurs more frequently during pregnancy, with a percentage of 0.5-2.0%.
When gingival lesions are found in association with pregnancy, they are sometimes called “pregnancy tumors” or pregnancy granulomas. The lesion presents as a rapid increase in gingival volume that may bleed profusely when touched.
Based on histologic features, it is a vascular proliferative lesion that resembles granulation tissue.
- Infectious diseases
Infectious diseases present a number of oral and periodontal manifestations that can guide the periodontist or dental practitioner in the diagnosis. They can be classified into viral, bacterial and fungal infections.
The following classification is particularly selective of infectious diseases that may have periodontal manifestations represented for the most part by gingival lesions. Infectious diseases such as hepatitis do not present gingival lesions but other manifestations such as jaundice or gingivorrhagia.
- Viral infections: Viral hepatitis, HIV infection, Herpes infections (herpes, varicella-zoster and infectious mononucleosis), Coxsackievirus group A infection.
- Bacterial infections: Tuberculosis, Streptococcal infection, Gonorrhea, Syphilis, Helicobacter pylori infection
- Fungal infections: Histoplasmosis
- Hepatitis
Hepatitis is a disease affecting the entire hepatic parenchyma and accompanied by an inflammatory reaction. The main etiologies are: ■ viral infections (viruses A, B, C, D, infectious mononucleosis virus and cytomegalovirus) and bacterial (leptospirosis, listeria or septicemia); ■ drug-related: cytolytic, cholestatic or mixed; ■ toxic (alcohol for example); ■ autoimmune.
Acute viral hepatitis can manifest itself in the mouth by jaundice. The oral cavity can also show hemorrhagic signs of liver dysfunction (petechiae, hematoma, gingivorrhagia). The latter associated with other hemorrhages (ecchymoses, nasal hemorrhages, or even digestive) would signal the transition to fulminant hepatitis. Chronic hepatitis C has been associated with oral lichen planus.
- HIV infection
HIV (human immunodeficiency virus) from the retrovirus group causes a fatal disease characterized by progressive immune deficiency and whose final stage is AIDS (acquired immunodeficiency syndrome). AIDS can be defined as a group of opportunistic diseases, such as pneumocystosis, and/or tumors, such as Kaposi’s sarcoma or lymphomas. The viral infection is transmitted by contaminated fluids (blood, semen, and vaginal secretions).
The dentist plays a key role in diagnosis since oral lesions associated with HIV infection (oral candidiasis and hairy leukoplakia) may be the first expression of this infection.
Atypical forms of periodontal disease may also be observed, such as ulcerative-necrotic gingivitis, ulcerative-necrotic periodontitis, and linear gingival erythema. The latter is a fungal gingival disease that may present with intense, ribbon-like erythema of the marginal gingiva or diffuse erythema that may extend to the mucogingival line.
Histoplasmosis, an opportunistic fungal infection observed during AIDS, can be accompanied in its African entity by nodular lesions located at the level of the tongue. These lesions can extend to the palate, lips, pharynx and gums.
HIV-infected patients may also present with classic forms of periodontal disease such as chronic periodontitis. Epidemiological studies have shown that HIV-infected patients, compared with control populations, have greater bone loss and attachment loss, and a greater number of gingival recessions, particularly when the CD4 lymphocyte count is low. However, probing depths are less important. This increase in attachment loss and periodontal recession may be due to atypical fungal, viral, and bacterial infections.
- Herpes infection
Herpes viruses are opportunistic viruses that cause diseases of the oral cavity. They include Herpes simplex hominis (HSV), varicella zoster virus (VZV), Epstein-Barr virus (EBV), and cytomegliovirus (CMV). The latter is rarely responsible for oral ulcers, which are observed mainly in immunocompromised patients.
- Herpes Simplex Infections
Cold sores are the most common herpes infection caused by the herpes simplex virus type I.
Primary infection with herpes simplex virus can lead to generalized gingivitis called acute herpetic gingivostomatitis. The latter is one of the gingival diseases not induced by bacterial plaque and represents the clinical translation of primary herpetic infection. It is observed mainly in children between 6 months and 5 years, often during dental eruption, but it is not uncommon in
Adolescent or young adult. The infection is transmitted by aerosol droplets and direct contact.
After an incubation period of a few days to two weeks, a primary vesicular-eruptive eruption develops on any oral mucosal surface, especially the gingiva, which becomes red and painful. Primary herpetic gingivostomatitis may be asymptomatic, but the patient usually presents with fever and malaise. The vesicular lesions, very rapidly ulcerated, spread to the cheek, lingual, palatine, tonsillar and pharyngeal mucosa.
- Infectious mononucleosis
It is a highly contagious infection due to the Epstein-Barr virus, transmitted by saliva and affecting mainly adolescents and young adults. It manifests clinically as erythematous or erythematopultaceous angina. There are adenopathies and often splenomegaly.
Oral manifestations are early and frequent, the most common being palatal petechiae, stomatitis, gingival ulcerations and cervical lymphadenopathy.
- Varicella-zoster
Chickenpox and shingles are eruptive, blistering infections. Chickenpox is a viral infection that usually occurs during childhood. It is highly contagious and is transmitted by droplets. It is caused by a virus from the herpes group that causes both chickenpox and shingles.
Shingles results from a resurgence of this virus and is seen mainly in the elderly and patients suffering from neoplasia, blood diseases, or undergoing immunosuppressive treatments.
In chickenpox, oral lesions are one of the characteristics of this infection. The oral mucosa, particularly the gums, are the site of erythematous vesicles that develop into rounded erosions,
Painful with drooling. In case of superinfection, cervical adenopathies are observed.
In shingles, the vesicles rupture rapidly to give erosions surrounded by a broad erythematous border.
Shingles of the superior maxillary nerve causes a skin and mucous membrane rash (palate, velum, upper gum, inner side of the cheek and upper lip). Shingles of the mandibular nerve affects either the entire territory (tongue, lower gum, chin) or only one of its branches (lingual, auriculotemporal branch)
- Syphilis
Chronic contagious general disease whose pathogen is treponema pallidum. Sexual contamination (+++), oral, blood, maternal-fetal route.
The gum can be the site of syphilitic lesions in the first two stages of syphilitic disease.
- Primary syphilis:
The chancre manifests itself by a painless, round or oval erosion, with a well-defined edge, sometimes a red peripheral halo. The base is flat and smooth with a gray exudate (teeming with treponemes), its base is indurated but not very thick (cardboard). The chancre can develop on the lips, on the tip of the tongue, the tonsils or the gum. It is accompanied by unilateral regional adenopathy.
- Secondary syphilis:
In secondary syphilis, the oral mucosa is often affected. Usually painless and highly contagious maculopapular lesions are located on the inner side of the cheeks, the gums and the tongue.
- Tuberculosis
Pulmonary tuberculosis is an infectious disease of the lung or pleura caused by Koch’s bacillus (BK) or Mycobacterium tuberculosis. The infection begins with inhalation of droplets containing the tuberculosis bacilli that have been expelled into the air by a person with active tuberculosis. The inhaled organisms enter the lungs and pass into the alveoli.
Oral tuberculosis is rare and is considered to result from infection by organisms from the lungs via sputum. The BK carried in bronchial secretions inoculates the mucosa from a pre-existing erosion and progresses to ulceration. The base of the tongue is the most common site of oral tuberculosis. It presents as a dark red submucosal abscess that will give a polycyclic ulceration of 3 to 4 mm in diameter with an irregular but not indurated outline, covered with a coating of yellowish fibrin.
The lingual localization of tuberculosis does not exclude periodontal, labial and palatal localizations. Gingival lesions associated with Mycobacterium tuberculosis are part of the 1999 classification of periodontal diseases. At this level, the appearance is nonspecific, showing ulceration, diffuse inflammatory lesions and sometimes bone destruction.
- Autoimmune diseases
- Lupus erythematosus
Lupus erythematosus is an autoimmune disease of unknown etiology, characterized by cutaneous-articular, visceral and hematological involvement. There are two forms of lupus, the discoid form which affects only the skin and the disseminated systemic form.
Oral ulcers are common, easily confused with those of erosive lichen planus, because of their superficial appearance with poorly defined erythematous borders. The palate, the buccal and labial mucosa and the tongue are the most affected sites.
- CROHN’S DISEASE
Inflammatory bowel disease, it can however affect the entire digestive tract including the oral cavity.
Oral manifestations are:
- Lip edema
- Aphthous ulcers
- Hyperplastic gingivitis; usually painless in the anterior areas
- Rheumatoid arthritis
Rheumatoid arthritis is a chronic inflammatory disease characterized by involvement of synovial joints and variable extra-articular manifestations.
TMJ involvement appears evident, so signs and symptoms of TMJ dysfunction may exist such as pain, joint noises, tenderness of the masticatory muscles and limited mouth opening.
Studies have also shown associations between periodontal disease and RA. In fact, in addition to factors such as smoking, hygiene difficulties due to TMJ involvement, the effects of anti-inflammatory and immunosuppressive drugs and SJOGREN’s xerostomia, all these factors promote the development of periodontal disease.
- Histocytosis X
A disease involving the proliferation of histiocytes, which are cells born from the transformation of certain white blood cells, monocytes, destined to become macrophages
Oral symptoms are represented by gingival ulceration, mutilating periodontitis with bone loss, mobility and dental expulsion.
- Sarcoidosis
Sarcoidosis is a systemic disease of undetermined origin, characterized histologically by the presence of a granuloma without caseous necrosis.
Intraoral lesions in sarcoidosis are rare. They are usually ulcers or firm, painless, persistent nodules. Gingival hyperplasia or gingivitis may also be seen.
- Drug treatments
Inflammatory gingival hyperplasia is an enlargement of the gums due to abnormal cell multiplication, accompanied by redness and bleeding. It can cause pain, discomfort, excess plaque and halitosis. Its consequences on chewing, speech and aesthetics can lead to a significant deterioration in the patient’s quality of life.
Gingival hyperplasia can be caused by drug treatment. Three categories of drugs are, in fact, known to be potentially responsible for gingival hyperplasia:
- Immunosuppressants, including cyclosporine A, which is the first-line treatment after kidney, heart or other organ transplantation.
- Anticonvulsants, antiepileptics such as phenytoin and valproic acid.
- Calcium channel blockers such as Nifedipine, Diltiazem and Verapamil which act mainly at the cardiac and vascular levels, they are prescribed in cases of high blood pressure or for their antiarrhythmic, antianginal and vasodilatory properties.
- Genetic disorders
- Cyclic neutropenia
Rare childhood disease, characterized by the repetition every 21 days of febrile infection mainly affecting the oral and anal mucous membranes.
Periodontal signs can vary from simple gingivitis to progressive periodontitis that affects both mixed and permanent dentition.
- DOWN syndrome
Associated with early periodontitis, characterized by:
- A decrease in neutrophil chemotaxis and phagocytosis,
- An alteration in the functioning of B and T lymphocytes.
- LEFEVRE BUTTERFLY SYNDROME
Autosomal recessive hereditary diseases that manifest as hyperkeratosis of the balls of the hands and soles of the feet and very destructive periodontal disease.
- EHLERS DANLOS syndrome
It groups together 12 pathologies affecting the synthesis or secretion of collagen, thus leading to modifications of connective tissues.
Only type 4 and 8 syndromes are associated with early, sometimes severe, periodontitis.
6.5. CHEDIAK HIGASHI syndrome
It is a rare autosomal recessive hereditary disease which manifests itself by:
- Recurrent ulceration
- Premature exfoliation of temporary teeth
- Severe gingivitis and periodontitis mainly linked to immune deficiency.
- Leukocyte adhesion deficiency
This is a rare autosomal recessive condition. The inability of phagocytes and lymphocytes to adhere to endothelial cells and migrate to inflammatory foci may predispose patients to recurrent infections with neutrophilia and periodontitis.
The periodontal symptoms found are: severe gingival inflammation, gingival proliferation, severe loss of alveolar bone and early loss of temporary teeth and often permanent teeth.
- Hereditary gingival fibromatosis
This is a rare entity whose etiology is not determined. Gingival hyperplasia is due to excessive production of collagen in the gingival epithelium. The increased gingival tissue appears firm and pink.
Hyperplasia progresses to completely cover the crowns of the teeth and can interfere with speech and chewing and may delay tooth eruption.
- Blood clot disorders
- Leukemia
Leukemias are blood cancers characterized by the uncontrolled proliferation in the medullary tissue of cells that give rise to white blood cells: leukoblasts. The production of too many of these cells by the body contributes to weakening the immune system, as they do not have time to mature.
Leukemias are classified according to their clinical form, acute or chronic, and according to the cytological characteristics of the affected cells, lymphoid or myeloid. According to the classification of the Organization
According to the World Health Organization, leukemia is considered acute when the presence of blasts in the bone marrow is greater than 20%.
Periodontal manifestations observed during acute and subacute leukemia are: diffuse bluish-red coloration of the entire gingival mucosa with a smooth, hypertrophied, edematous surface, and blunting of the interdental papillae.
These manifestations evolve with the disease, they are aggravated by chemotherapy and radiotherapy which cause immunosuppression which potentiates bacterial infectious processes and local hemorrhages.
Oral infections are often present and can cause septicemia in up to a third of cases.
- Thrombocytopenia
Thrombocytopenia is defined by a decrease in the blood platelet count below the low normal value of the population (150 G/L). Acquired thrombocytopenia is very common. Constitutional thrombocytopenia is a rare disease whose prevalence is probably underestimated, with strong geographical variations. It is present from birth and generally stable throughout life.
Oral manifestations are:
- Numerous petechiae located mainly on the palate
- Purpuras
- Bruises
- Spontaneous or induced gingival bleeding
- Bloody blisters in the oral cavity.
- Neutropenia and agranulocytosis
Neutropenia is defined by a neutrophil count of less than 1500/mm3 in adults, and agranulocytosis by the total absence of neutrophils. In reality, severe neutropenia is grouped under the term agranulocytosis. In reality, severe neutropenia with a neutrophil count of less than 500/ mm3 is grouped under the term agranulocytosis .
The severity of periodontal manifestations is directly related to the severity of neutropenia, and can be aggravated by the presence of local factors (biofilm and tartar)
In the most malignant forms, there is ulcerative-necrotic gingivitis, which manifests itself by ulceration and necrosis at the level of the marginal gingiva, accompanied by spontaneous bleeding.
Conclusion
The presence of ulcerations, xerostomia, periodontal disease , difficulty opening the mouth , aphthous ulcers or bullous lesions are all clinical signs that allow the diagnosis of systemic diseases, and are therefore often part of the diagnostic criteria for the latter.
The dentist must therefore be aware of these manifestations in order to know how to uncover them and establish a diagnosis within the framework of a multidisciplinary collaboration with other health professionals with the aim of optimal diagnostic and therapeutic care.
Influence of systemic diseases on periodontal diseases
Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.