1. By Hani S. AlMoharib

2. Outline Endocrine Disorders: - Diabets Mellitus. Hematologic Disorders: - Anemia. - Leukemia. Genetic Disorders: - Down Syndrome. - Papillon-Lefevre Syndrome. Hormonal Changes: - Female Sex Hormones.

3. Introduction Many systemic diseases, disorders, and conditions have been implicated as risk factors in periodontal disease. Systemic diseases have several effects that includes: 1. Physiological response. 2. Vascular system. 3. Inflammatory response. 4. Immune system. 5. Tissue repair.

4. Outline Endocrine Disorders and Hormonal Changes: - Diabets Mellitus. Hematologic Disorders: - Anemia. - Leukemia. Genetic Disorders: - Down Syndrome. - Papillon-Lefevre Syndrome. Hormonal Changes: - Female Sex Hormones.

7. Diabetes Mellitus It is a complex metabolic disorder characterized by chronic hyperglycemia. DM may either diminish insulin production, impair insulin action, or combination of both. This result in inability of glucose to be transported from blood stream into tissues.

9. Diabetes Mellitus 1. Insulin-dependent DM (IDDM-Type I): Caused by cell-mediated autoimmune destruction of the insulin-producing beta cells of the islets of Langerhans in the pancreas. This results in a lack of insulin production. Age? Occurs in children and young adults. Precentage? 5-10% of DM cases.

10. Diabetes Mellitus 2. Non-insulin-dependent DM (NIDDM-Type II): Caused by: a. Peripheral resistance to insulin action. b. Impaired insulin secretion. c. Increased glucose production by liver. Usually has an adult onset. 90-95% of DM cases.

12. Diabetes Mellitus Typical signs and symptoms include: 1. Polydipsia. 2. Polyphagia. 3. Polyuria. 4. Pruritus. 5. Weakness and fatigue.

14. Diabetes Mellitus Uncontrolled DM complications includes: 1. Microvascular diseases: Retinopathy, nephropathy, or neuropathy. 2. Macrovascular diseases: Cardiovascular or cerebrovascular. 3. Increased susceptibility to infections. 4. Poor wound healing.

16. Diabetes Mellitus Oral changes in diabetic patient includes: 1. Cheilosis. 2. Mucosal drying and cracking. 3. Burning mouth and tongue. 4. Diminshed salivary flow. 5. Alterations in the flora of the oral cavity. 6. Increased rate of dental caries. These changes are less likely to be observed in well- controlled diabetic patients.

18. Diabetes Mellitus Changes of DM on periodontium includes: 1. Tendency toward enlarged gingiva.

19. Diabetes Mellitus Changes of DM on periodontium includes: 2. Sessile or pedunculated gingival polyps. 3. Polypoid gingival proliferations. 4. Abscess formation.

20. Diabetes Mellitus Changes of DM on periodontium includes: 5. Periodontitis.

22. Diabetes Mellitus A. Bacterial Pathogens: Glucose content of gingival fluid is higher in diabetic patient. This increase change the environment of the microflora. This induce qualitative changes in bacteria and severity of disease.

23. Diabetes Mellitus B. Polymorphonuclear Leukocyte Function: DM results in: i. Impaired chemotaxis. ii. Defective phagocytosis. iii. Impaired adherence. This leads to increased susceptibility to infections.

24. Diabetes Mellitus C. Altered Collagen Metabolism: Chronic hyperglycemia adversely affects the synthesis, maturation, and maintenance of collagen and extracellular matrix. As a result, collagen in the tissues of DM patients are more susceptible to pathogenic breakdown. This also will affect vascularity, in such:

25. Thickening of the capillary basement membrane. Impair oxygen diffusion Impair waste elimination Impair PMN migration Impair diffusion of antibodies

26. Outline Endocrine Disorders and Hormonal Changes: - Diabets Mellitus. Hematologic Disorders: - Anemia. - Leukemia. Genetic Disorders: - Down Syndrome. - Papillon-Lefevre Syndrome. Hormonal Changes: - Female Sex Hormones.

29. Anemia Anemia is reduction in the number of erythrocytes and in the amount of hemoglobin. Anemia results in poor tissue oxygenation, making tissues more friable and susceptible to breakdown. Anemia results from: 1. Extensive blood loss. 2. Defective blood formation. 3. Increased RBC destruction.

31. Anemia The tongue appears red, smooth, and shiny because of atrophy of the papillae. There is also marked pallor of the gingiva.

34. Leukemia Leukemias are malignant neoplasias of WBC precursors. Leukemia is characterized by: 1. Diffuse replacement of the bone marrow with proliferating leukemic cells. 2. Abnormal numbers and forms of immature WBCs in the circulating blood. 3. Widespread infiltrates in the liver, spleen, lymph nodes, and other body sites. This leads to anemia, leukopenia and thrombocytopenia.

36. Leukemia 1. Leukemic gingival enlargement: Caused by infiltration of gingiva by leukemic cells.

38. Infiltration of gingival corium by leukemic cells Increases gingival thickness Creates gingival pockets Bacterial plaque accumulates and secondary inflammation Enlargement of gingiva

39. Leukemia 2. Bleeding: Spontaneous gingival hemorrhage can be an early sign of leukemia. It is caused by the thrombocytopenia.

40. Leukemia 3. Oral Infection: Granulocytopenia (diminished WBC count) results from the displacement of normal bone marrow cells by leukemic cells. This increases the host susceptibility to opportunistic microorganisms and leads to ulcerations and infections.

41. Leukemia 3. Oral Infection:

42. Leukemia 4. Oral Ulceration: These lesions occur in sites of trauma such as the buccal mucosa in relation to the line of occlusion or on the palate.

43. Outline Endocrine Disorders and Hormonal Changes: - Diabets Mellitus. Hematologic Disorders: - Anemia. - Leukemia. Genetic Disorders: - Down Syndrome. - Papillon-Lefevre Syndrome. Hormonal Changes: - Female Sex Hormones.

46. Down Syndrome Down syndrome is a congenital disease caused by a chromosomal abnormality. Characterized by mental deficiency and growth retardation. Almost 100% of patients have periodontal diseases.

48. Down Syndrome Periodontal condition characterized by deep pockets with substantial local factors and moderate recessions. The disease progresses rapidly because of: 1. Poor PMN chemotaxis. 2. Deficient phagocytosis. 3. Intercellular killing.

49. Down Syndrome

52. Papillon-Lefevre Syndrome Very rare inherited condition that appears to follow an autosomal recessive pattern. The syndrome is characterized by: 1. Hyperkeratotic skin lesions. 2. Severe destruction of the periodontium. 3. Calcification of the dura.

53. Papillon-Lefevre Syndrome The cutaneous and periodontal changes usually appear together between the ages of 2 and 4 years. The skin lesions consist of hyperkeratosis and ichthyosis of localized areas on palms, soles, knees, and elbows.

55. Papillon-Lefevre Syndrome Periodontal involvement consists of early inflammatory changes that lead to bone loss and exfoliation of teeth. Primary teeth are lost by 5 or 6 years of age. The permanent dentition then erupts normally, but within a few years, the permanent teeth are also lost because of destructive periodontal disease. At a very early age, usually 15 to 20 years, patients are often edentulous except for the third molars. These may be lost as well a few years after eruption.

56. Papillon-Lefevre Syndrome

57. Outline Endocrine Disorders and Hormonal Changes: - Diabets Mellitus. Hematologic Disorders: - Anemia. - Leukemia. Genetic Disorders: - Down Syndrome. - Papillon-Lefevre Syndrome. Hormonal Changes: - Female Sex Hormones.

60. Female Sex Hormones 1. Puberty: Puberty is often accompanied by an exaggerated response of the gingiva to plaque. Pronounced inflammation, edema, and gingival enlargement result from slight local factors. As adulthood approaches, the severity of the gingival reaction diminishes, even when local factors persist.

61. Female Sex Hormones 2. Pregnancy: The hormonal changes of pregnancy accentuate the gingival response to plaque. Extreme redness results from marked vascularity, and there is an increased tendency to bleed. Increased levels of progesterone produce dilation of the gingival microvasculature and increased susceptibility to mechanical irritation.

62. Female Sex Hormones 2. Pregnancy: The marginal and interdental gingivae are edematous, smooth and shiny, are soft and pliable, and sometimes present a raspberry-like appearance. In some cases the inflamed gingiva forms discrete “tumorlike” masses, referred to as pregnancy tumors.

63. Hani S. AlMoharib References: 1- Carranza’s Clinical Periodontology 11th Ed. Pages 304-319. 2- Clinical Periodontology and Implant Dentistry 5th Ed by Jan Lindhe Pages 307-327.