Periodontal manifestations of systemic disease

Periodontitis is a chronic bacterial infection of the supporting structures of the teeth. The host response to infection is an important factor in determining the extent and severity of periodontal disease. Systemic factors modify periodontitis principally through their effects on the normal immune and inflammatory mechanisms. Several conditions may give rise to an increased prevalence, incidence or severity of gingivitis and periodontitis. The effects of a significant number of systemic diseases upon periodontitis are unclear and often it is difficult to causally link such diseases to periodontitis. In many cases the literature is insufficient to make definite statements on links between certain systemic factors and periodontitis and for several conditions only case reports exist whereas in other areas an extensive literature is present. A reduction in number or function of polymorphonuclear leukocytes (PMNs) can result in an increased rate and severity of periodontal destruction. Medications such as phenytoin, nifedipine, and cyclosporin predispose to gingival overgrowth in response to plaque and changes in hormone levels may increase severity of plaque-induced gingival inflammation. Immuno-suppressive drug therapy and any disease resulting in suppression of the normal inflammatory and immune mechanisms (such as HIV infection) may predispose the individual to periodontal destruction. There is convincing evidence that smoking has a detrimental effect on periodontal health. The histiocytoses diseases may present as necrotizing ulcerative periodontitis and numerous genetic polymorphisms relevant to inflammatory and immune processes are being evaluated as modifying factors in periodontal disease. Periodontitis severity and prevalence are increased in diabetics and worse in poorly controlled diabetics. Periodontitis may exacerbate diabetes by decreasing glycaemic control. This indicates a degree of synergism between the two diseases. The relative risk of cardiovascular disease is doubled in subjects with periodontal disease. Periodontal and cardiovascular disease share many common risk and socio-economic factors, particularly smoking, which is a powerful risk factor for both diseases. The actual underlying aetiology of both diseases is complex as are the potential mechanisms whereby the diseases may be causally linked. It is thought that the chronic inflammatory and microbial burden in periodontal disease may predispose to cardiovascular disease in ways proposed for other infections such as with Chlamydia pneumoniae. To move from the current association status of both diseases to causality requires much additional evidence. Determining the role a systemic disease plays in the pathogenesis of periodontal disease is very difficult as several obstacles affect the design of the necessary studies. Control groups need to be carefully matched in respect of age, gender, oral hygiene and socio-economic status. Many studies, particularly before the aetiological importance of dental plaque was recognised, failed to include such controls. Longitudinal studies spanning several years are preferable in individuals both with and without systemic disease, due to the time period in which periodontitis will develop.     

Periodontal health and periodontal disease in young people: global epidemiology

A review of epidemiological surveys of the periodontal conditions of young people has shown that chronic marginal gingivitis associated primarily with plaque, is global, very common and even endemic in some population groups. Data on the prevalence of transient gingival conditions associated with tooth eruption, puberty and systemic factors are lacking and therefore their contribution to the prevalence of periodontal disease is unknown. Reports of periodontitis in young people are relatively uncommon except in a few populations where it appears as an adult-type of chronic marginal periodontitis. Juvenile periodontitis and other more destructive forms of periodontitis are not common. However, problems in epidemiological methodology and clinical differential diagnosis make comparative evaluation of survey data difficult and subjective. Two epidemiological indices, the Periodontal Index and the Community Periodontal Index of Treatment Needs (CPITN) have been used for many surveys in varied population groups. They provide data which agree on the ubiquity of gingivitis, whether identified visually or by bleeding-on-probing, and the low frequency of periodontitis. Data from CPITN surveys reveal a higher prevalence of calculus (sub-gingival) associated with gingivitis in young people than previously reported. All the epidemiological data reviewed point to plaque as the primary aetiological agent in gingivitis. There is little evidence of the involvement of other factors except that host resistance/susceptibility in this age group may modify the microbial effect.     

Periodontal disease in juvenile and adult diabetic patients: a review of the literature

Epidemiologic studies have suggested that the severity of periodontitis is greater in juvenile and adult onset diabetes. In juvenile diabetic patients, the periodontal disease seems to be initiated around puberty and progresses by age. Reviewing the medical literature indicates a similar age of onset for known systemic complications resulting from diabetes. Angiopathy, abnormal collagen metabolism, abnormal PMN function, and altered sulcular microbial flora have been found to be closely associated with the severity of periodontitis in diabetic patients. The association between abnormal neutrophil function and severity of periodontal disease in diabetic patients provides an opportunity for examining the role of neutrophil in periodontal disease. Future investigation in the function of sulcular PMN may shed light on the complex mechanism of periodontal disease.     

Periodontal complications with age

The present literature review on periodontal complications in aging focuses on the diagnosis, etiology and development of periodontal complications as a complete entity. In addition, the review also focuses on some of the common systemic diseases that either may further add to periodontal complications or, as result of anti‐inflammatory treatment, limit the expression of periodontal disease. There is no evidence to suggest that clinical methods to provide periodontal therapies have been developed especially for older individuals. There is evidence that aging can be associated with periodontally healthy conditions through life and with a high level of tooth retention and function. Periodontal complications that are difficult to manage are usually associated with concurrent medical diseases and complications, or with socio‐economic factors that limit the ability to provide dental care for the aging population. Currently, some systemic medical conditions are managed with anti‐inflammatory medications with positive effects, while slowing the progression and expression of chronic periodontitis. The lack of data from clinical studies on how to manage periodontal complications in aging is obvious.     

Changing periodontal paradigms: therapeutic implications

Many paradigms concerning the epidemiology, pathogenesis, and systemic impact of periodontal diseases have been modified. For example, bacterial biofilms are essential to induce periodontitis, but their mere presence is not sufficient to initiate disease. It is also now recognized that the host response to these biofilms causes most of the destruction of the periodontal tissues. Codeterminants that influence the clinical severity of the disease process include environmental, genetic, and acquired factors. In general, the prevalence of advanced periodontitis and the incidence of disease progression are lower than previously believed. However, periodontitis remains the most common chronic illness. In addition, the finding that acquired systemic diseases may predispose individuals to periodontitis, and conversely that periodontitis may be a risk factor for certain systemic diseases, has expanded the scope of periodontics. These changed paradigms and their consequences with regard to selecting therapies are discussed in this review article.     

Risk factors for periodontal disease

Risk factors play an important role in an individual’s response to periodontal infection. Identification of these risk factors helps to target patients for prevention and treatment, with modification of risk factors critical to the control of periodontal disease. Shifts in our understanding of periodontal disease prevalence, and advances in scientific methodology and statistical analysis in the last few decades, have allowed identification of several major systemic risk factors for periodontal disease. The first change in our thinking was the understanding that periodontal disease is not universal, but that severe forms are found only in a portion of the adult population who show abnormal susceptibility. Analysis of risk factors and the ability to statistically adjust and stratify populations to eliminate the effects of confounding factors have allowed identification of independent risk factors. These independent but modifiable, risk factors for periodontal disease include lifestyle factors, such as smoking and alcohol consumption. They also include diseases and unhealthy conditions such as diabetes mellitus, obesity, metabolic syndrome, osteoporosis, and low dietary calcium and vitamin D. These risk factors are modifiable and their management is a major component of the contemporary care of many periodontal patients. Genetic factors also play a role in periodontal disease and allow one to target individuals for prevention and early detection. The role of genetic factors in aggressive periodontitis is clear. However, although genetic factors (i.e., specific genes) are strongly suspected to have an association with chronic adult periodontitis, there is as yet no clear evidence for this in the general population. It is important to pursue efforts to identify genetic factors associated with chronic periodontitis because such factors have potential in identifying patients who have a high susceptibility for development of this disease. Many of the systemic risk factors for periodontal disease, such as smoking, diabetes and obesity, and osteoporosis in postmenopausal women, are relatively common and can be expected to affect most patients with periodontal disease seen in clinics and dental practices. Hence, risk factor identification and management has become a key component of care for periodontal patients.     

Osteoporosis,jawbones and periodontal disease

The association between osteoporosis and jawbones remains an argument of debate. Both osteoporosis and periodontal diseases are bone resorptive diseases; it has been hypothesized that osteoporosis could be a risk factor for the progression of periodontal disease and vice versa. Hypothetical models linking the two conditions exist: in particular, it is supposed that the osteoporosis-related bone mass density reduction may accelerate alveolar bone resorption caused by periodontitis, resulting in a facilitated periodontal bacteria invasion. Invading bacteria, in turn, may alter the normal homeostasis of bone tissue, increasing osteoclastic activity and reducing local and systemic bone density by both direct effects (release of toxins) and/or indirect mechanisms (release of inflammatory mediators). Current evidence provides conflicting results due to potential biases related to study design, samples size and endpoints. The aim of this article is to review and summarize the published literature on the associations between osteoporosis and different oral conditions such as bone loss in the jaws, periodontal diseases, and tooth loss. Further well-controlled studies are needed to better elucidate the inter-relationship between systemic and oral bone loss and to clarify whether dentists could usefully provide early warning for osteoporosis risk. Key words:Osteoporosis, periodontitis, oral bone loss, tooth loss, edentulism, bone mineral density.     

Epidemiology of periodontal diseases: an update

This article provides a brief review of findings from epidemiological studies of periodontal disease that have been generated over the past five years. In line with the conclusions of the 1996 World Workshop in Periodontics, the recent data support the concept that early onset periodontitis appears to be rather infrequent, while advanced adult periodontitis, leading to severe loss of supporting periodontal tissues and tooth loss, does not exceed a prevalence of 10-15% in most populations. However, a number of important issues remain unresolved. It is still not clear whether the prevalence of these diseases has shown an overall decline in recent years. In fact, retention of teeth in older age may contribute to an increase. Analytical epidemiological studies have been increasingly successful in identifying a handful of risk factors for disease onset and progression. These include colonisation at high levels by certain subgingival bacteria, environmental exposures such as cigarette smoking, and systemic conditions such as diabetes mellitus. Importantly, the molecular basis of host susceptibility has recently begun to be unraveled. Research efforts are now focused on creating multi-factorial models to assess the risk for disease, prior to the development of irreversible damage. Importantly, the role of periodontal infections as a modifier of systemic health is being increasingly explored.     

Prevalence of systemic diseases in Brisbane general and periodontal practice patients

BACKGROUND: Periodontitis has been associated with a number of systemic diseases such as atherosclerosis, coronary heart diseases, and respiratory diseases. This study aimed to determine whether there is a significant difference in the prevalence of systemic diseases (a) in patients referred for periodontal care compared to the general practice population, (b) in patients attending a public hospital and private practices, (c) in patients attending public and private periodontal practices, and (d) among patients with periodontitis of varying severity. METHODS: Charts of 1000 adult patients were selected from four clinics (University of Queensland (UQ) School of Dentistry Admissions Clinic, UQ School of Dentistry Periodontics Clinic, Private Periodontal Practice, and Private General Dental Practice). The prevalence of medical conditions was evaluated using validated self-reported health questionnaires. The periodontal condition was assessed from the most recent relevant radiographs in the files. RESULTS: Periodontal patients had a higher prevalence of systemic diseases compared to the general practice population. Public patients had a greater prevalence of systemic diseases compared to patients in private practice for both general practice and periodontal patients. In patients with advanced periodontitis, bronchitis, hepatitis and rheumatoid arthritis were most prevalent. Patients with periodontitis also took more medications and were more likely to suffer from multiple conditions compared to the general dental population. CONCLUSIONS: Patients attending public dental facilities have an increased prevalence of systemic disease compared to those attending private practices. Furthermore periodontal patients have a greater prevalence of diseases compared to general practice patients. Patients with moderate or advanced periodontitis show an increase in the prevalence of some systemic diseases previously reported to be risk factors for periodontal disease.     

Periodontal diseases in the child and adolescent

BACKGROUND: Periodontal diseases are among the most frequent diseases affecting children and adolescents. These include gingivitis, localized or generalized aggressive periodontitis (a.k.a., early onset periodontitis which includes generalized or localized prepubertal periodontitis and juvenile periodontitis) and periodontal diseases associated with systemic disorders. The best approach to managing periodontal diseases is prevention, followed by early detection and treatment. METHODS: This paper reviews the current literature concerning the most common periodontal diseases affecting children: chronic gingivitis (or dental plaque-induced gingival diseases) and early onset periodontitis (or aggressive periodontitis), including prepubertal and juvenile periodontitis. In addition, systemic diseases that affect the periodontium and oral lesions commonly found in young children are addressed. The prevalence, diagnostic characteristics, microbiology, host-related factors, and therapeutic management of each of these disease entities are thoroughly discussed.     

Diagnosis and classification of the periodontal diseases

A classification for gingivitis and periodontitis has been proposed based on clinical observations and immunologic parameters (summarized in Table 10). Overlapping clinical situations and exceptions to the rule certainly exist and pose challenges to clinicians during diagnosis, prognosis, and treatment planning. The clinical significance of making the diagnosis of either rapidly progressive periodontitis, juvenile, or prepubertal forms of periodontitis compared with adult periodontitis must be considered. A diagnosis of early-onset disease may (1) modify the periodontal treatment plan and may include the use of systemic antibiotics (for example, tetracyclines) or antiplaque agents (for example, sanguinarine, chlorhexidine); (2) modify the prosthetic treatment plan and require longer periods of monitoring before extensive replacement or splinting is initiated; (3) increase the frequency of periodontal recall appointments (at least four to six times during the first year or two following peridontal therapy); (4) implicate a genetic basis for the disease with the possibility of peridontal involvement of other family members; (5) influence decisions on prognosis; and (6) alert the clinician for potential future rapid periodontal breakdown. Future studies will further define and characterize all forms of periodontal diseases. Clinical, microbial, and immunologic information may permit inclusion of the relatively rare forms of periodontitis such as ANUG periodontitis and refractory periodontitis. Understanding the underlying biologic mechanisms of the pathogenesis of the periodontal diseases, coupled with clinical observations, will permit improved clinical investigations that ultimately will improve therapeutic approaches.     

Aggressive forms of periodontitis secondary to systemic disorders

A number of systemic disorders increase a patient’s susceptibility to destructive periodontitis and have impacts on periodontal disease progression and severity. The underlying factors are usually genetic and are mainly related to alterations in the immune response and in certain endocrine functions, leading to various syndromes in which periodontitis and/or early tooth loss are secondary manifestations. Neutrophils are important immune defense cells that play a significant role in controlling the spread of microbial plaque infections in the dentogingival region. This review focuses on a selected group of systemic disorders that are associated with alterations in either neutrophil counts (quantitative disorders) or function (qualitative disorders), and defects in the mineralization of bone and dental tissues. In most of these diseases controlling the periodontal disease progression is very challenging. Proper diagnosis is a prerequisite for proper management of the periodontal problem. Future advances in research, including gene targeting and the resolution of enzyme deficiencies, may bring about remedies of the underlying systemic disorders and may significantly improve the outcome of periodontal treatment in these patients.     

Cardiovascular disease and periodontitis: an update on the associations and risk

Background: Associations between periodontitis and cardiovascular diseases have been recognized.
Material and Methods: New literature since the last European Workshop on Periodontology has been reviewed.
Results: The lack of reliable epidemiological data on disease prevalence makes an assessment of the associations and risks between periodontitis and cardiovascular diseases difficult. Two recent meta-analysis reports have identified associations between periodontitis and cardiovascular diseases (odds ratios: 1.1–2.2). Different surrogate markers for both disease entities, including serum biomarkers, have been investigated. Brachial artery flow-mediated dilatation, and carotid intima media thickness have in some studies been linked to periodontitis. Studies are needed to confirm early results of improvements of such surrogate markers following periodontal therapy. While intensive periodontal therapy may enhance inflammatory responses and impair vascular functions, studies are needed to assess the outcome of periodontal therapies in subjects with confirmed cardiovascular conditions. Tooth eradication may also reduce the systemic inflammatory burden of individuals with severe periodontitis. The role of confounders remain unclear.
Conclusions: Periodontitis may contribute to cardiovascular disease and stroke in susceptible subjects. Properly powered longitudinal case–control and intervention trials are needed to identify how periodontitis and periodontal interventions may have an impact on cardiovascular diseases.     

Changing periodontal concepts: treatment considerations

Many clinical trials conducted during the last decade have clarified controversial issues and resulted in changed periodontal paradigms. These modified concepts have therapeutic implications. Some salient altered periodontal concepts include the following: The mere presence of pathogens will not initiate periodontal diseases. Most subgingival bacteria reside in biofilms. Periodontal diseases are infections. Periodontal pathogens can be transferred between family members. The host response can be protective and destructive. Gingivitis does not usually proceed to periodontitis. Risk factors in conjunction with bacteria and the host response can affect the severity of disease, patterns of destruction, and the response to therapy. Many medical conditions (eg, diabetes, smoking, and HIV infection) may predispose patients to periodontitis. Associations between periodontitis and a number of systemic ailments (eg, diabetes, adverse pregnancy outcomes, and cardiovascular disease) have been detected and are being investigated to determine if there is a cause-and-effect relationship. Diagnostic and therapeutic implications of these altered paradigms are addressed throughout the article.     

Periodontal disease in sickle cell disease subjects

Various systemic diseases and conditions have been associated with an increase in periodontal disease severity. These studies indicate that host-response mechanisms influence the initiation and/or progression of inflammatory periodontal diseases. Diseases that have been associated with an increased severity of periodontal disease include various neutrophil abnormalities, Down's syndrome, diabetes, and recently, the acquired immunodeficiency syndrome. Sickle cell disease is strongly associated with a predisposition to various infections; therefore, the objective of this study was to determine whether sickle cell disease is also associated with an increase in the severity of periodontal disease. A total of 78 patients with sickle cell anemia (SS), hemoglobin SC disease (SC) or S Thalassemia were evaluated blind and compared with an appropriate control population using clinical and radiographic indices of periodontal disease severity. The results clearly indicate that, in this population of patients, sickle cell disease is not associated with increased levels of gingivitis or periodontitis.     

Psychosocial factors in inflammatory periodontal diseases

Abstract. Reviewing the literature concerning the possible role of psychosocial factors in the aetiology of inflammatory periodontal diseases, it may be concluded that there is evidence which strongly suggests that emotional stress is one of the predisposing factors to ANUG. On the other hand, it is not clear that the scientific evidence is sufficient to substantiate the hypothesis that psychosocial factors are of aetiological importance in periodontitis. The proposed mechanisms which may mediate the putative relationship between psychosocial conditions and inflammatory periodontal diseases remain to be tested. However, psychoneuroimmunologic studies make lowered host resistance especially interesting as a possible mechanism. Although available studies do not definitively support causal relationships, they suggest that psychosocial factors may be involved in the aetiology of inflammatory periodontal diseases, which, in turn, would relate to clinical management of these conditions.     

Risk factors and prevalence of periodontitis in community-dwelling elders in Mexico

AIM: The objective of this study was to determine whether an association existed between chronic systemic diseases/conditions, risk factors common in old age, and the extent and severity of chronic periodontal disease. MATERIALS AND METHODS: Sociodemographic and lifestyle characteristics were examined by contrasting rural, urban-marginal, and urban social environments in Central Mexico. Data were analysed with Analysis of Variance, chi2 tests, and multivariable logistic regression. RESULTS: A total of 473 adults 60 years old and over were interviewed; 315 were also examined and underwent laboratory assays (participation rate, 66%); women, 62%; mean age 73+/-8 years; 23% edentulous. The distribution of periodontitis by sociodemographic variables showed differences across locales (73% low-urban, 57% middle-urban, 29% rural). The regression model indicated that periodontitis was more frequently associated with low-urban locale, higher systolic blood pressure, higher body mass index, and worse calculus readings, with an interaction whereby being obese and having a high calculus index was associated with a high probability of having periodontitis. CONCLUSIONS: Overall periodontal conditions were fair. While we identified oral, systemic, and social variables that modulated the experience of periodontitis, it would appear that urban, low social class elders appeared to have worse periodontal conditions.     

Risk factors in periodontal disease

Some life styles and systemic pathologies represent risk factors for the periodontal disease. Cigarette smoking in particular increases the speed of progression of periodontitis. Other conditions such as diabetes mellitus, presence of genetic markers and some bacteria are significantly correlated with the periodontal disease.     

内质网应激在牙周炎影响全身疾病过程 中的作用

牙周炎是发生在牙周组织的慢性感染性疾病,其发病机制及对全身系统疾病的影响一直是学术界关注的热点问题。许多学者认为,牙周炎不仅是一种常见的口腔疾病,更是全身疾病的潜在危险因素之一,但是目前关于牙周炎诱发全身系统疾病的具体机制尚不明确,可能与牙周致病菌、炎症因子及内质网应激等有关。近年来的研究发现,内质网应激是介导细胞凋亡的重要通路之一,并且与全身疾病密切相关。有研究显示,内质网应激在牙周炎诱导全身疾病过程中存在调控作用,但是目前关于内质网应激在牙周炎影响全身疾病过程中的作用研究较少,需要进一步探索。本文就内质网应激在牙周炎影响全身系统疾病中的研究进展进行综述,旨在探究牙周炎和全身系统疾病的内在联系,以期为牙周炎与其相关全身系统疾病的防治提供新的思路。     

Trends in the Prevalence and Severity of Periodontal Diseases in the US: A Public Health Problem?

This article reviews trends in the prevalence and severity of periodontal diseases in US adults and examines the implications of these trends regarding the recognition of periodontal disease as a public health problem. Data from the National Center for Health Statistics (NCHS) examination surveys, 1960-62 and 1971-74, and the National Institute of Dental Research (NIDR) 1985-86 Survey of Employed and Senior Adults are examined. Issues of comparability and generalizability are discussed. Changes in the prevalence and severity of gingivitis and periodontitis are presented for the time periods 1960-62 to 1971-74 and 1971-74 to 1985-86. We concluded (1) it is difficult to document the changes occurring in the prevalence of gingivitis; however, given the available evidence, the prevalence and severity of gingivitis have probably declined; (2) it appears that periodontitis continues to affect approximately the same proportions of the overall US adult population; but with those affected, the extent and severity of the disease have declined; and (3) older adults continue to exhibit more disease and greater levels of severe disease than the younger age groups. Renewed efforts to clarify the epidemiologic confusion concerning trends in the prevalence and severity of periodontal disease should remain high on the agenda for public health dentistry.