Perio Tx 3

Question 1

peridontal disease

Answer 1

a group of diseases affecting the periodontal tissues, representing an immune reaction (innate and adaptive) to adjacent microbial plaque

• Gingivitis does not always progress to periodontitis
• Periodontitis may progress at a different rates at different sites in the mouth in different people

Question 2

periodontal health

Answer 2

outcome of the balance between the bacteria of the dental plaque and the host immune system

Question 3

2 ways to periodontal disease

Answer 3

Host immune response launches inflammatory to microbiome -> localised inflammation without self-resolution

Or

immune system not controlling oral bacteria

• Genetic conditions associated with the impairment of immune system:
  
  • Papillon-Lefevre syndrome, Chediak-Higashi syndrome, LAS syndrome, Down’s syndrome, chronic granulomatous disease
• Diseases leading to impairment of immune system:
  • Leukaemia, agranulocytosis, neutropenia, HIV infection

Question 4

periodontal disease aetiopathogenesis

Answer 4

multifactorial

• Any factor influencing immune system function or number or diversity of bacteria is a potential risk factor for periodontal disease

Question 5

general health factors for periodontal disease

Answer 5

• stress
• smoking
• fatigue
• diet
• medications
• hygienic habits

Question 6

risk factor

Answer 6

something that increases a person’s chance of developing a disease

Question 7

local risk factors

Answer 7

plaque retentive factors

either

• acquired
• anatomical

Question 8

acquired local risk factors for perio

Answer 8

plaque,

calculus,

overhanging and poorly contoured restorations and prosthetic crowns,

orthodontic appliances,

occlusal trauma (bone loss not perio)

Question 9

anatomical local risk factors for perio

Answer 9

malpositioned teeth,

root groves,

concavities and furcations,

enamel pearls

Question 10

systemic risk factors

Answer 10

either

• modifiable
• non-modifiable

Question 11

non-modifiable systemic risk factors for perio

Answer 11

(impairment of immune system)

• aging,
• genetic factors,
• gender (males),
• genetic disorders: Down syndrome, Papillon Lefevre syndrome

Question 12

modifiable systemic risk factors for perio

Answer 12

(impact on immune system)

• smoking,
• poorly controlled diabetes,
• HIV,
• leukaemia,
• osteopenia,
• osteoporosis,
• stress,
• medications,
• hormonal changes,
• poor nutrition,
• socioeconomic status

Question 13

how can occlusal trauma impact perio health

Answer 13

• May cause the bone loss but not periodontitis
• If suffering from periodontal disease and has occlusal trauma will have faster clinical attachment loss
  
  • Need to address to help slow down bone resorption

Question 14

smoking impact on perio

Answer 14

Effect on oral microbiota

• anaerobic inc so more traumatic for periodontal tissue

Increase activation of the immune system

• activation of immune system, trigger inflammation so no longer just controlling oral microbiome and causing damage

Decreased healing capacity (reduced blood flow)

Vaping? Not enough data currently

Question 15

how does sub-optimally controlled diabetes contribute to perio

Answer 15

• Hyperglycaemia in diabetes may modulate RANKL (the receptor activator of nuclear factorkappa β): OPG (osteoprotegerin) ratio and thus contribute to alveolar bone destruction
• In hyperglycemia production of AGE (advanced glycation end products) – increase of inflammation (production of pro-inflammatory cytokines and destructive metalloproteinases)

do not see hyperglyceamia in well controlled diabetes

Question 16

important factors contributing to periodontal disease severity in diabetics

Answer 16

• degree of diabetic control (hyperglycaemia chance)
• age of onset
• duration of disease

Question 17

what to look at to assess diabetic control

Answer 17

glycated haemoglobin (HbA1c)

• Not glucose level - only short period of time*
• Whereas HbA1c assesses stores (8-12 weeks)*

Look at diabetes – below 48mmol/mol or below 6.5%

Question 18

obestiy and nutrition impact on perio health

Answer 18

Severe vit. C deficiency

• scorbutic gingivitis - scurvy

Lack of nutrients

• decrease function of the immune system

Obesity

• adipose tissue can become endocrine organ, adipocytes secrete variety of metabolically and immunologically active molecules – produce pro-inflammatory cytokines  contribute development of inflammation

ALL HAVE proinflammatory effect

Question 19

3 drug groups that contribute to gingival enlargement

Answer 19

• Anticonvulsant: phenytoin
• Immunosupresants: cyclosporin (transplant patients)
• Calcium channel blockers (nifedipine,amlodipine)
  
  • (majority of pts seen as age risk factors so many 50+ who are suffering from both perio and hypertension)

Interaction between the drug and host fibroblasts resulting in a increased deposition of connective tissue supporting a hyperproliferative epithelium – accelerated by inflamed tissue due to poor plaque control

Question 20

systemic diseases that has periodontitis as a symptom

Answer 20

Defect of function of some cells of immune system – if immune system not working correctly not able to protect periodontal tissue against ubiquitous periodontal bacteria

• papillon-lefevre syndrome
• Chediak-Higaski syndrome
• lazy leucocyte syndrom
• LAD syndrome
• chronic granulomatous disease
• Down’s syndrome
• Ehlers-danlos syndrome
• hypophostasia

Question 21

HIV infection effect on perio tissue

Answer 21

Increased risk of necrotising conditions, but no evidence of increased progression of periodontitis

Question 22

blood dyscrasias (e.g. neutropenia, agranulocytosis, leukaemia) effect on perio tissues

Answer 22

Reduced numbers/function of neutrophils and macrophages, increasing risk of NUG and progressive periodontitis

Question 23

scury effect on perio tissues

Answer 23

Vitamin C deficiency causing abnormal collagen turnover resulting in increased risk of periodontal attachment loss

Question 24

pregnancy effect on perio tissues

Answer 24

Increased risk of gingival inflammation (pregnancy gingivitis)

Question 25

acquired systemic diseases and syndromes that have negative affect on perio health

Answer 25

* HIV infection * blood dyscrasias e.g. neutropenia, agranulocytosis, leukaemia * scurvy * pregnancy impairs immune system function

Question 26

osteoporosis and osteopenia affect on perio tissues

Answer 26

Complex * Not direct risk factor If quality of bone is poor, then bone resorption progresses quicker – accelerate bone loss once pt has both conditions simultaneously

Question 27

psychological stress effect on perio tissues

Answer 27

Influencing function of immune system through corticosteroid hormones * *Hypothalamus-pituitary-adrenal axis stimulated release corticosteroids (cortisol)* Inhibiting function of immune system * Once function of immune system is impacted so is periodontal health impacted Several stress markers reported in blood, saliva, GCF of perio pts

Question 28

most common chronic inflammation in world

Answer 28

periodontal disease estmated 70% have some form

Question 29

periodontal disease a risk factor for other systemic diseases?

Answer 29

Systemic activation of the immune system * Significant risk factor (70% of world) * early symptoms not problematic so delay medical help * surface of inflammation is large – folded in gingival crevice (gingiva and root) but approx. size of palm goes untreated for years - chronic inflammation with little symptoms

Question 30

most common mortality in world population in 21st century (pre-covid)

Answer 30

hypertension

Question 31

Why is it difficult to document the cause-effect association between cardiovascular diseases and periodontitis?

Answer 31

* The same risk factors for both diseases (smoking, diabetes, stress * Common pathomechanisms associated with systemic inflammation and activation of the immune system

Question 32

3 mechanisms as periodontitis as risk factor for CVD which is the main theory currently

Answer 32

* molecular mimicry * direct action of pathogenic bacteria from periodontal pocket travelling within the blood stream to vessel * **indirect activation of immune cells that play significant role in sites of CVD pathologies (heart, kidney, vessels etc)**

Question 33

evidence for and against molecular mimicry as mechanism of periodontitis and CVD linke

Answer 33

for * Evidence of cross reactivity between oral pathogens and both inflammatory and endothelial cell components against * might be the case in all bacterial infections

Question 34

evidence for and against direct action of pathogenic bacteria from perio pocket travelling to vessels

Answer 34

for * Transient bacteremia – after brushing, chewing etc * immediately contained by competent immune system * but perio bacteria can get to vessels and attach to wall surfaces – inflammation and plaque * Periodontal bacteria detected in atherosclerotic plaque against * But, hard for bacteria to adhere to healthy endothelium – needs to be already inflamed and expressing adhesins - thus rare occurrence

Question 35

evidence for and against indirect activation of immunce cells in perio link to CVD

Answer 35

for * Systemic inflammation, with chronically elevated inflammatory markers, is common in both diseases processes against * To what extent anatomically remote sources of inflammation interact in causative fashion is unclear

Question 36

atherosclerosis

Answer 36

**inflammation of the vessel’s wall** * Activation of immune system needs to occur

Question 37

increase of blood pressure link to immune system

Answer 37

**depends on activation of lymphocytes T (hypertension)** * need source of activation of T cells - chronic inflammaiton - periodontal disease?

Question 38

to investigate cause-effect need

Answer 38

interventional studies

Question 39

indirect link of preeclampsia and periodontal disease

Answer 39

indirect mechanism activation of immune system * trophoblast invasion depends on production of cytokines and relies on activation of immune system – help in invasion * if imbalance of cells and cytokines – invasion of trophoblast incorrect (too little or too deep) * translates as dysfunctional placenta and ischaemia -\> adverse pregnancy outcomes

Question 40

direct link between periodontal disease and preeclampsia

Answer 40

direct mechanisms * barrier between mother and foetus * periodontal bacteria have adhesins that can go through endothelial cells and traverse barrier and invade foetus circulation

Question 41

periodontal risk factor for rheumatoid arthritis

Answer 41

autoimmune disease – action of immune system towards self-tissue of cartilage of joints if there is additional activation of immune system from site of periodontal bacteria * response towards cartilage is stronger some periodontal (P.gingivalis) has PPAD enzyme * cause proteins change conformation – * detected as foreign so increasing activation of immune system **increasing activation of immune system increases magnitude of response towards self-tissue in cartilaginous joints**

Question 42

periodontal risk factor for Alzeheimer's disease

Answer 42

activation of immune system causes increases production of plaques and tangles * Plaques are deposits of a protein fragment called beta-amyloid that build up in the spaces between nerve cells. * Tangles are twisted fibres of another protein called tau that build up inside cells Contributes to impairment of memory and function of pt *In experimental models oral P. gingivalis infection in mice resulted in brain colonization and increased production of Aβ1-42 (amyloid), a component of amyloid plaques*

Question 43

peridontal risk factor for respiratory pathologies

Answer 43

Periodontal bacteria debilitate immune protection (damage surfactant) of the reparatory epithelium making colonisation by other respiratory viruses and bacteria easier * Impair immune protection of respiratory epithelium Periodontal bacteria can also cooperate with resp viruses and bacteria aiding their colonisation * Facilitate colonisation of respiratory epithelium of respiratory viruses and bacteria

Question 44

prevention and treatment of periodontal disease can

Answer 44

help prevent development of systemic diseases *but only one of many risk factors*