Systemic FactorsSystemic FactorsSystemic FactorsSystemic Factors

Perry Ch. 16/ Nield-Gehrig Ch. 7Perry Ch. 16/ Nield-Gehrig Ch. 7

Important Concepts• Periodontal disease is bacterial

infection of the periodontium• Host responds to the bacterial invaders

by mobilizing its defensive cells and releasing chemicals

• Host response is responsible for most of the tissue destruction in periodontitis

Important Concepts• Everyone who is infected with periodontal

pathogens does not experience periodontitis; some only experience gingivitis

• Additional factors, such as systemic disease, genetic variations, and smoking, play a significant role in determining the onset and progression of periodontitis

Risk factors for Periodontitis

• Presence of pathogenic bacteria– A. actinomycetemcomitans– P. gingivalis– B. forsythus

• Heredity• Smoking• Diabetes• Systemic disease• Psychosocial stress• Faulty restorations

Cardiovascular diseases

• More than 40 million people in US• Hypertension• Coronary artery disease• Valvular heart disease• Cardiac arrhythmias• Congestive heart failure

Hypertension• High BP is major risk factor for

cardiovascular disease, stroke, and kidney failure.

• “Silent killer” frequently asymptomatic and more than half of patients do not realize they have it.

Hypertension• See table 16-1 pg. 365• Systolic 180-209• Diastolic 110-119

– Not to be treated….sent immediately to physician

Hypertension medications

• Diuretics (thiazides)• Sympatholytics (beta-adrenergic

blockers such as propanolol• Vasodiators ( hydralazine HCI)• Angiotensin-converting enzyme

inhibitors (enalapril)

Coronary Artery Disease

• Cholesterol-containing material is deposited in the walls of arteries

• Two most common clinical manifestations:– Angina pectoris– Myocardial infarction

Cardiovascular Disease

Angina pectoris• Severe recurring chest pain that radiates into

the left shoulder and arm.• May involve neck lower jaw and face• Oxygen demands of heart are not being met• Stable angina is achieved by taking one or

more of the following medications:– Nitrates– Beta-adrenergic blockers– Calcium channel blockers-nifedipine (Procardia)

Angina pectoris• Nifedipine (Procardia) common

side effect is…..

• Gingival Enlargement

Valvar Heart Disease• Dental or periodontal procedures

that introduce bacteria into the bloodstream with valvar heart disease can increase their risk of a potentially fatal heart infection called infective endocarditis.

To prevent infective endocarditis

• Pre-med with antibiotics• Heart valves allow unidirectional

forward flow of blood through the heart

• disease can be acquired or congenital

Valvar heart disease• Acquired are more common than

congenital• Half of all acquired occur as isolated

stenosis (narrowing) of orifice of either the aortic or the mitral valve.

• Valvar insufficiency is the failure of a hear valve to close completely leading to regurgitation

Aquired heart murmurs• Often found with history of:• rheumatic fever• Ischemic heart disease• Systemic lupus erythematosus• connective tissue disorders• Other systemic diseases

Acquired heart murmurs

• Rheumatic fever is an acute systemic inflammatory disease that sometimes follows a streptococcal antigens associated with the infection.

• This may cause scarring of the heart valves.

• No periodontal probing or exploring

Mitral valve prolapse• 7% of the US population between

the ages of 20 and 40 years have this cardiac abnormality.

• Pre-med is needed if there is regurgitation or backward flow

• See table 16-1 for cardiac conditions associated with endocarditis

Cardiac Arrhythmias• Irregular heartbeat

– Can be associated with a variety of systemic conditions

HIGH FEVERISCHEMIC HEART DISEASECONGESTIVE HEART DISEASEMITRAL VALVE PROLAPSERHEUMATIC HEART DIEASEMYOCARDIAL INFARCTIONHYPERTENSIONACERTAIN ALLERGIC

REACTIONS(ANAAPHYLAXIS) HYPERTHYROIDISM

Cardiac Arrhythmia Medications

• disopyramide (Norpace)• mexiletine (Mexitil)• verapmil (Calan)• diltiazem (Cardizem)• May lead to xerostomia • Phenytoin (Dilantin),verapamil and

diltiazem may cause ging.enlargement

Pacemaker• Some cases of cardiac arrhythmia

under the skin of the upper chest wall. Wire leas connect to an electrode that is placed in contact with heart tissue.

• Sends periodic impulses to the heart• One type of arrhythmia has irregular

twitching referred to as fibrillation. • No premed is usually necessary

Congestive Heart Failure

• The heart is unable to supply the body with sufficient oxygenated blood.

• Chair should be kept partially erect

• Supplemental oxygen should be kept nearby

Pts on anticoagulants• reduce the risk of the

development of blood clots• blood thinners• Heparin or warfarin (Coumadin)

derivatives• Increased bleeding

Joint diseases and disorders

Artificial Joints- infection occurs in approximately 1%

Different orthopedic surgeons recommend different periods of premedication and different antibiotics and doses.

Diabetes Mellitus• More than 16 million people in the

US have diabetis mellitus but only half of them have been diagnosed.

• Control of gingival inflammation may help control diabetis

Diabetes Mellitus• Group of disorders that share the

common feature of an elevated glucose level in the blood

• Insufficient supply or impaired availability of insulin– Pancreatic hormone that is necessary

for the regulation of carbohydrate metabolism.

Diabetes Mellitus• Type 1 and type 2 both have genetic

predisposition to development.• 10 – 20% are type 1 – severe deficiency

of insulin as a result of the destruction of pancreatic beta cells due to autoimmune reactions in reponse injury from viruses.– Destruction can also result from tumors,

surgery and toxic reactions to drugs or chemicals

Diabetes Mellitus• Type 1 requires self-injection of

insulin• Onset is usually rapid and occurs

around the time of puberty

Diabetes Mellitus• Type 2 – 80 – 90% • Two metabolic defects associated with type 2

DM• 1) impaired secretion of insulin • 2)insulin resistance – defective cell receptors• Onset is slow• Usually over 30 years and overweight• Diet modifications and oral hypoglycemic

agents are used

Diabetes Mellitus• Poorly controlled DM appear to be

more susceptible to infections, including periodontal disease.

• Antibacterial functions of neutrophils appear to be abnormal.

Severity of Periodontal Disease Among Diabetic and Non-Diabetic Pima

Indians Periodontal tissue loss,

measured in millimeters along the tooth root, is a key indicator of periodontal disease severity. For the Pima Indians of Arizona, a population with the highest rate of diabetes in the world, periodontal infection and tooth loss are significantcomplications of the diabetic condition.

Diabetes Mellitus• There also seems to be some evidence of

the relationship going the other way -- that if you control periodontal disease, it may help you control your blood sugar.     

• Having an infection, including periodontal disease, can impair the body’s ability to process and/or use insulin. So the theory is that if you control the infection, it might be easier to control blood sugar.

Pregnancy• Increase gingival inflammation is

frequently associated with pregnancy• Elevated progesterone and estrogen

may make the gingivae respond more to plaque.

• These hormones also promote growth of periodontal pathogens such as Prevotella intermedia.

Pregnancy

Pregnancy• Maternal periodontal disease has

been associated with an increased risk of preterm birth and low birth weight.

Psychological Stress• Immunosuppression can occur during

periods of stressful life events.• Persons with chronic periodontitis

may me more prone to exacerbation during this periods.– Remember that periodontitis is episodic.

Psychological Stress• NUG – stress is modifying factor

– 1) Recent emotional stress– 2)heavy cigarette smoking– 3) lack of sleep– 4) poor diet

HIV• Those with AIDS or about manifest

symptoms of AIDS may exhibit several oral manifestations.– Epstien-Barr virus – hairy leukoplakia– NUP– HPV

Epstien-Barr virus – hairy leukoplakia