2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the

Periodontal Supporting Tissues
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the

Periodontal Supporting Tissues

Which systemic disorder and medications can

cause or be associated with loss of periodontal
support?

What is the strength of the evidence of the reported

association between the identified
disorders/medications and loss of periodontal support?
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Review: literature research

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Review: Literature Research

The strength of association between these disorders and loss of periodontal attachment
apparatus is evaluated:

- Not reported: published studies in persons affected with the systemic disorder did not
described the dental or periodontal status of these individuals.

- No association: published studies in persons affected with the systemic disorder did not report
loss of alveolar bone or periodontal attachment. MCQ: Consider the different
systemic disease, which one
- Inconclusive: few studies, with conflicting findings. has great association to
periodontal disease?
- Weak association: a single case report or case-control study showing an association or a few
studies with consistent findings showing a modest increased risk for loss of alveolar bone or
periodontal attachment.

- Moderate association: case reports, case-control studies, and narrative reviews showing
consistent increased risk for loss of periodontal tissue, but systematic reviews were not available.

- Significant association: multiple case reports with consistent findings showing profound loss
of periodontal tissue or one or more systematic reviews showing significantly increased risk for
loss of alveolar bone or periodontal attachment.
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

2. Other systemic disorders that may contribute to periodontal tissue

loss by influencing the pathogenesis of periodontal diseases.
Moderate impact on the severity of periodontitis, but don’t have a
specific clinical presentation that differs from periodontitis.

3. Systemic disorders that can result in loss of periodontal tissue

independent of plaque-induced periodontitis.
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

2. Other systemic disorders that may contribute to periodontal

tissue loss by influencing the pathogenesis of periodontal diseases.

3. Systemic disorders that can result in loss of periodontal tissue

independent of periodontitis.
2017 WORLD WORKSHOP

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders
1.1.2 Diseases affecting the oral mucosa and gingival tissue
1.1.3 Diseases affecting the connective tissue
1.1.4 Metabolic and endocrine disorders

1.2 Acquired Immunodeficiency Diseases

1.3 Inflammatory Diseases

2017 WORLD WORKSHOP

1. Systemic Disorders that have a major impact on the loss of periodontal tissue
by influencing periodontal inflammation

1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders
1.1.2 Diseases affecting the oral mucosa and gingival tissue
1.1.3 Diseases affecting the connective tissue
1.1.4 Metabolic and endocrine disorders

Genetic disorders are caused by gene mutations or

chromosome disorders that cause a change in the number
or structure of chromosomes
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1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders

moderate
Significant
Significant
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1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders
Down syndrome
- Higher prevalence and severity of periodontal disease than individuals without
down syndrome.
- Periodontal attachment starts in adolescence.
- Intrinsic abnormalities of the immune system may predispose these
individuals to infections.
- Strength of association: moderate.
Leukocyte adhesion deficiency (LAD) syndrome
- Neutrophils fail to adhere to blood vessels and thus cannot transmigrate to
peripheral tissues, being absent from the periodontium.
- Periodontal tissue loss may be caused by the lack of neutrophil immune
surveillance.
- Periodontal signs: severe gingival inflammation, early-onset and rapidly
progressive alveolar bone loss, early loss of the primary and permanent teeth.
- Strength of association: significant. Innate system altered
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1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders

Down syndrome

- Strength of association: moderate.

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1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders

Leukocyte adhesion deficiency syndrome

- Strength of association: significant.

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1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders

Papillon-Lefèvre syndrome (PLS)

- Possible compromised neutrophil function.
- Hyperkeratotic lesions affecting multiple organs (palms, soles of the feet, elbows,
and knees).
- Periodontal signs: severe gingival inflammation, early-onset and rapidly
progressive alveolar bone loss, early loss of the primary and permanent teeth.
- Strength of association: significant.
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1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders

Papillon-Lefèvre syndrome (PLS)

Significant association
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1.1 Genetic Diseases

1.1.2 Diseases affecting the oral mucosa and gingival tissue

Significant
Significant
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1.1 Genetic Disorders

1.1.2 Diseases affecting the oral mucosa and gingival tissue

Epidermolysis Bullosa (EB): Kindler Syndrome

- Periodontal diseases have been mainly associated with Kindler syndrome (a type of EB).
- Hypothesis: molecular defects in the basement membrane zone in certain
epidermolysis bullosa (particularly Kindler syndrome) may result in reduced
resistance at the junctional epithelium, which predisposes the development of
periodontitis, even in the absence of periodontal pathogens.
- Recurrent blister formation of skin and oral cavity.
- Periodontal signs: severe periodontitis and alveolar bone loss that progress rapidly.
- Strength of association: significant.
Plasminogen deficiency
- Plasminogen plays an important role in intravascular and extravascular fibrinolysis,
wound healing, cell migration, tissue remodeling and angiogenesis. Possible
deficiency in these functions may result in the loss of periodontal attachment.
- Chronic inflammatory disease of the mucous membranes of various organs, chronic
conjunctivitis.
- Periodontal signs: gingiva enlarged and ulcerated may be covered with white-yellowish
membrane, progressive alveolar bone loss and early loss of the teeth.
- Strength of association: significant.
Can be mistaken with blisters such as Pemphigus
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1.1 Genetic Disorders

1.1.2 Diseases affecting the oral mucosa and gingival tissue

Plasminogen Deficiency

- Periodontal signs: gingiva enlarged and ulcerated may be covered with white-
yellowish membrane, progressive alveolar bone loss and early loss of the teeth.
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1.1 Genetic Diseases

1.1.3 Diseases affecting the connective tissue
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1.1 Genetic Diseases

1.1.3 Diseases affecting the connective tissue

Ehlers-Danlos syndrome (EDS) (type IV, VIII)

- EDS disorders are often caused by mutations in genes encoding fibrillary

collagens or enzymes involved in the biosynthesis of these proteins.

- Joint hypermobility, skin extensibility, and abnormal scarring. May have life-
threatening vascular complications.

- Periodontal signs: generalized, early-onset severe periodontitis and gingival

recessions. Early loss of the primary and permanent teeth.

- Strength of association: significant.

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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders
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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders

Diabetes mellitus (DM) and chronic hyperglycemia

- Diabetes has been recognized as an important risk factor for periodontal

diseases and associated with significantly higher prevalence and severity of
periodontitis.
- There is accumulating evidence that periodontal inflammation may contribute to
the onset and persistence of hyperglycemia, and that inflammation is associated
with poorer glycemic control in individuals with DM.
- Recently, a significant association between chronic hyperglycemia and a high
prevalence of severe periodontitis has been confirmed.
- There is little evidence that the clinical features of periodontitis in patients with DM are
distinct from periodontitis in individuals who do not have DM. It has been suggested
that dental and periodontal abscesses may be a common complication in DM (not well
documented).
- Strength of association: significant.
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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders

Diabetes mellitus (DM) and chronic hyperglycemia

Pathogenic Mechanisms Responsible for the Effects of Hyperglycemia on Periodontitis

Hyperglycemia
Advanced glycation end products (AGEs) are harmful compounds that
are formed when protein or fat combine with sugar in the bloodstream
Accumulation of advanced
Hyperinflammatory response to glycation products (AGEs), and the
bacterial challenge interaction with their key receptors
(RAGE)

Changes in the host

(neutrophil defects, hyperinflammatory responsive monocytes, increased release of
proinflammatory cytokines, oxidative stress reactions, impaired healing responses)
Wound healing worse
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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders

Need precise amnesias to

Diabetes mellitus (DM) and chronic hyperglycemia distinguish between DM or
Necrotizing gingivitis

Periodontitis case in a bad-controlled glycemic DM patient.

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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders

Obesity
- Study findings show that obesity increases susceptibility to bacterial and viral
infections, and recent meta-analyses consistently support an
epidemiological association between obesity and periodontitis (50-80%
higher likelihood of periodontitis in individuals who are obese compared with
individuals who are not).
- Increased production by adipose tissue in obese individuals of various
humoral factors and proinflammatory cytokines may contribute to the
pathogenesis of periodontitis.
- Strength of association: significant.
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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders

Osteoporosis
- Increased bone turnover leading to net bone loss, which can also be
associated with other factors (estrogen level, vitamin D and calcium deficiency,
lifestyle and behavioral factors)

- Decrease in bone mineral density and weakening of bone microarchitecture,

leading to a high risk of bone fracture.

- Higher prevalence and severity of radiographic alveolar bone loss.

- A recent systematic review concluded that postmenopausal women with

osteoporosis or osteopenia exhibit greater loss of periodontal attachment
compared with women with normal bone mineral density. (Penoni DC et al. Bone
density and clinical periodontal attachment in postmenopausal women, J Dent Res 2017;96:261-269.)
Higher risk in older women with menopause.

- Strength of association: significant.

Prevent by exercise & diet
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1.1 Genetic Diseases

1.1.4 Metabolic and endocrine disorders

Hypophosphatasia Result in deteriorating cementum

-Dentin is not affected, although both the acellular and cellular cementum may be
absent, hypocalcified or dysplastic. These defects in root cementum result in
compromised periodontal attachment and reduction in alveolar bone height.
-Mild form: foot pain, fracture of the metatarsals.
-Severe form: skeletal deformities.
-Periodontal signs: defective cementum, alveolar bone loss, and premature loss of teeth.
-Strength of association: significant.
2017 WORLD WORKSHOP

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders
1.1.2 Diseases affecting the oral mucosa and gingival tissue
1.1.3 Diseases affecting the connective tissue
1.1.4 Metabolic and endocrine disorders

1.2 Acquired Immunodeficiency Diseases

1.3 Inflammatory Diseases

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1.2. Acquired immunodeficiency diseases

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1.2 Acquired immunodeficiency diseases

Acquired neutropenia

- Occur due to decreased production or increased destruction of

granulocytes, caused by autoimmune disease, cytotoxic chemotherapy or
other drugs.
- Increased risk of infections.
- Periodontal signs: increased risk for periodontitis correlated with the severity of
neutropenia.
- Strength of association: weak.
2017 WORLD WORKSHOP

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

1.1 Genetic Disorders

1.1.1 Diseases associated with immunological disorders
1.1.2 Diseases affecting the oral mucosa and gingival tissue
1.1.3 Diseases affecting the connective tissue
1.1.4 Metabolic and endocrine disorders

1.2 Acquired Immunodeficiency Diseases

1.3 Inflammatory Diseases

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1.3 Inflammatory diseases

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1.3 Inflammatory diseases

Epidermolysis bullosa acquisita

- Characterized by the presence of autoantibodies against type VII collagen.
- Blisters, mild mucosal involvement, and healing with dense scars.
- Periodontal signs: generalized gingival inflammation and enlargement, gingival
recession, alveolar bone loss, and mobile teeth.
- Strength of association: moderate.
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1.3 Inflammatory diseases

Arthritis
- Rheumatoid arthritis is an autoimmune disease.
- Joint pain, swelling, stiffness, redness, and limited motion.
- Periodontal signs: increased risk for loss of periodontal attachment and alveolar
bone.
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Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

2. Other systemic disorders that may contribute to periodontal

tissue loss by influencing the pathogenesis of periodontal diseases.

3. Systemic disorders that can result in loss of periodontal tissue

independent of periodontitis.
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

2. Other systemic disorders that may contribute to periodontal tissue

loss by influencing the pathogenesis of periodontal diseases.

2.1 Emotional stress and depression WEAK ASSOC

2.2 Hypertension INCONCLUSIVE

2.3 Systemic medication

2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal Supporting

Tissues

2.1 Emotional stress and depression

- Clinical studies show a positive sign correlation between periodontal disease and
stress.
- Experimental induced stress significantly increases periodontal destruction in rats,
whereas interventions to modulate the hypothalamic-pituitary-adrenal axis reverse this
effect.
- Strength of association: weak.

2.2 Hypertension

- There is inconclusive evidence that hypertension is associated with increased prevalence

of periodontal disease or severity of attachment loss.
- Strength of association: inconclusive.
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Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
2.3 Systemic Medications

- Certain medication particularly cytotoxic chemotherapeutics, could lead to

neutropenia, transient or prolonged, and hence may be associated with increased
risk for periodontitis, but few studies are available.
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

1. Systemic disorders that have a major impact on the loss of

periodontal tissue by influencing periodontal inflammation.

2. Other systemic disorders that may contribute to periodontal

tissue loss by influencing the pathogenesis of periodontal diseases.

3. Systemic disorders that can result in loss of periodontal tissue

independent of periodontitis.
Disease extends beyond epithelium tissue and to alveolar bone loss. No
accumulation of gingiva and bacteria. No host response takes place. ONLY
SYSTEMIC DISEASE RESULTS IN LOSS OF PD
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
3. Systemic disorders that can result in loss of periodontal tissue
independent of periodontitis.

A number of disorders may affect periodontal tissue and cause loss of alveolar bone
independently of plaque-induced periodontitis.

In this section we center on conditions that may extend to the marginal

periodontal tissue and, thus, at times mimic clinical features of periodontitis.

Differential diagnosis of these lesions, and distinguishing between periodontitis and

other conditions affecting periodontal tissue presents a considerable challenge.
2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

3. Systemic disorders that can result in loss of periodontal tissue

independent of periodontitis.

3.1 Neoplasms

3.2 Other disorders that may affect periodontal tissue

2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues

3. Systemic disorders that can result in loss of periodontal tissue

independent of periodontitis.

3.1 Neoplasms

3.2 Other disorders that may affect periodontal tissue

2017 WORLD WORKSHOP

Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
3.1 Neoplasms
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Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
3.1 Neoplasms

Oral squamous cell carcinoma (OSCC)

- Malignant epithelial neoplasm, 10% of all OSCC arise in the gingiva.
- Regional lymphadenopathy.
- Periodontal clinical features: resemble localized periodontitis or acute periodontal
infection, with gingival redness, swelling, increased probing depths and
radiographic bone loss.
- Risk for late-stage metastases.
- Strength of association: moderate.
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Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
3.2 Other disorders that may affect periodontal tissue
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Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
3.2 Other disorders that may affect periodontal tissue

Langerhans cell histiocytosis

- Due to proliferation of cells with characteristics similar to bone marrow-
derived Langerhans cells.
- Wide spectrum of clinical presentations: solitary chronic bone lesions, diabetes.
- Periodontal clinical features: premature eruption of primary teeth, osteolytic lesions
in the periodontal tissues, generalized periodontal inflammation and increased
pocket depths, severe alveolar bone loss and premature loss of teeth.
- Strength of association: moderate.
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Systemic Diseases or Conditions Affecting the Periodontal

Supporting Tissues
3.2 Other disorders that may affect periodontal tissue
2017 WORLD WORKSHOP

1. Systemic disorders that have a major impact on the loss of periodontal tissue by
influencing periodontal inflammation.
1 & 2: Disease that has major/moderate impact on development of perio ( THERE IS PERIO, the conditions of diseases acclerate the
progressing early tooth loss

2. Other systemic disorders that may contribute to periodontal tissue loss by influencing
the pathogenesis of periodontal diseases.

3. Systemic disorders that can result in loss of periodontal tissue independent of

periodontitis.
3. NOT PERIO but disorders that affects periodontal attachment. “Crazy wardrobe”