a change in the dogma periodontal medicine the two way street

PM

1. Periodontitis and Systemic Disease “The Perio -Systemic Connection” PERIODONTAL MEDICINE (two way street)

2. This means a two-way relationship in which periodontal disease in an individual may have a powerful influence on an individual’s systemic health or disease Periodontal medicine: Impact of periodontal Infection on systemic health

3. Offenbacher 1996 : Periodontal medicine defines a rapidly emerging branch of Periodontology focusing on the wealth of new data establishing a strong relationship between periodontal health or disease and systemic health or disease.

4. Pathobiology Of Periodontitis: The subgingival microbiota from a periodontitis patient provides a persistent gram-negative bacterial challenge to the host. Complete eradication is not possible and reemergence is often rapid.

5. Bacteremias /Endotoxemia after mechanical periodontal therapy, normal daily function, oral hygiene procedures and even chewing and swallowing . LPS from it via the sulcular epithelium to the circulation is easily accessed. The immunoinflammatory response happened here to bacteria, and their product's vascular response is the same for oral and systemic disorders. From oral cavity-Entry to the extra oral part

6. Importance Of Host: Role Of A Susceptible Host: Although pathogenic bacteria are necessary for periodontal disease, they are not sufficient alone to cause the disease. A susceptible host is also required.

7. There are many systemic conditions that can modify the host’s susceptibility to periodontitis. Patients with immune suppression may not be able to mount an effective host response to subgingival microorganisms, resulting in more rapid and severe attachment loss.

8. Seymour et al. suggest that periodontal infection may significantly enhance the risk for certain systemic conditions or alter the course of systemic conditions .

9. The field of periodontal medicine addresses the following questions:- 1. Can periodontitis, have an effect remote from the oral cavity? 2. Is periodontal infection a risk factor for systemic disease or conditions that affect human health?

10. William Hunter ,1900 – 1 st developed an idea that oral microorganisms were responsible for a wide range of systemic conditions that were not easily recognized as being infectious in nature. Caries, Abscess, Gingivitis & Periodontitis – As Foci of infection. Through tooth extraction 1940 & 1950- this theory fell into disrepute ..whole dentition got extracted. Focal infection theory :

11. Nonspecific accumulation of bacterial plaque was once thought to be the cause of periodontal destruction, but now it is recognized that periodontitis is an infectious disease associated with predominantly gram-negative bacteria.

12. Organ Systems and Conditions Possibly Influenced by Periodontal Infection Recently Hematological System : Anemia And many more systems involved like liver diseases and kidney diseases

13. DIABETES AND PERIODONTAL DISEASE Complication of DM:- Retinopathy Nephropathy Neuropathy Macrovascular disease Altered wound healing Periodontal disease ( Loe H :Diabetes care 1993,16( suppl 1) :329-334 )

14. AGE’s: They become glycated when exposed to sugar. They cause the destruction of tissues and the worsening of all types of degenerative diseases. It is the biomarker in aging and development because: Reactive Oxidative Stress Generation of Aberrant Proteins or Growth Factors Alteration of ECM structure Secretion of Pro-inflammatory Cytokines Elasticity Of Collagen Turn turnover rate and the metabolism of collagen increases Advanced Glycation End Products

15. Diabetes Glucose mediated advanced glycation end products(AGEs), AGE-protein+ Macrophage Uncontrolled Diabetes and 6 th complication periodontitis Impairs chemotactic & phagocytic function of PMNLs IL-1 β ; PGE2; TNF- α ; IL-6, IL-1 TNF- α (Responsible for insulin resistance.) Bacteria products + mononuclear phagocytic cells & fibroblast Hyperglycemia( HbA1C) hyperglycemia IL-1 & TNF- α Diabetes 6 th complication periodontitis Periodontitis

16. Potential effects of periodontal infection and periodontal therapy on glycemia in patients with diabetes. PERIODONTAL DISEASE AND DIABETES MELLITUS

17. Evidence: -Oral radiographic examinations and diagnostic coronary angiography on men with known CHD and found significant co-relation between the severity of the dental disease and the degree of coronary atheromatosis . PERIODONTAL DISEASE & CORONARY HEART DISEASE

18. Pathway to ischemic heart disease:-

19. Factors affecting blood viscosity in health Effect of infection on blood viscosity Effect Of infection on blood viscosity

20. Periodontitis provides etiologic factors for cardiovascular diseases altered microbiota/ increased pathogenicity/Altered Inflammation Bacterial Translocation and/or systemic Inflammation Ischemic heart disease Endothelium and altered vascular response Atherosclerotic change

21. Thrombogenesis: Oral organisms may be involved in coronary thrombogenesis by triggering platelets activation through the oral route to systemic circulation. S.sanguis and P.gingivalis possess platelet aggregation-associated proteins (PAAP) for inducing, sticking, and aggregation of Platelets, and the result is the formation of thromboembolic risk. Thus, periodontitis–associated bacteremia with certain strains of S.sanguis and P.gingivalis may promote acute thromboembolic events through interaction with circulating platelets.

22. Pathogenesis of Atherosclerosis Influence of periodontal infection Atherosclerosis

23. Cardiovascular and periodontal consequences of hyperresponsive monocyte /macrophage phenotype.

24. LBW infants- < 2500 gm.- 40times more likely to die in the neonatal period than NBW infants. 7 % of all infants weigh < 2500gm at birth – 2/3 rd of neonatal death. Causes of LBW deliveries:- 1. preterm labor 2. premature rupture of membrane (PROM). Periodontal disease & pregnancy outcome:-

25. Factors of LBW delivery:- 1. smoking 2.alcohol 3.drug 4. inadequate prenatal care 5. low socioeconomic status 6. hypertension 7. high / low maternal age 8. diabetes 9. genitourinary tract infection 10. periodontitis .- P gingivalis

26. Induction of Preterm Labor By Infection :- Bacterial infection Bacteria & products in amnion Inflammatory response with cytokine production in amnion ( IL-1 , IL-6 , TNF- α ) Increased amniotic prostaglandin production ( PGE2 , PGE2 α ) Preterm labor PERIODONTAL DISEASE & PREGNANCY OUTCOME:-

27. Mechanisms by which infection may induce preterm labor . PERIODONTAL DISEASE AND PREGNANCY OUTCOME

28. Periodontal disease & COPD Pro-inflammatory cytokines in the lung tissue are activated by periodontitis by focal of infection theory, are the factors that promote inflammatory diseases like COPD

29. Periodontal disease & acute respiratory infections :- 2 types :- 1. community acquired bacterial pneumonia 2. hospital acquired bacterial pneumonia Community acquired bacterial pneumonia:- by inhalation of infectious aerosols or by aspiration of oropharyngeal organisms ( S pneumoniae , H influenzae etc.).

30. Potential Respiratory Pathogens(PRP) Hospitalization ( intubated & on mechanical ventilators ) Colonization at Gastrointestinal tract PRP at Oral cavity , dental plaque Colonization at Posterior part Oropharynx Hospital Acquired Pneumonia Aspiration

31. Liver disease: Periodontitis can be associated with the development of liver steatosis leading to lipid peroxidation and oxidative stress, which are important factors involved in the development of steatosis. However, this is a bidirectional relationship because the results of some studies have confirmed that advanced alcoholic cirrhosis increases the risk of developing advanced forms of periodontitis in these patients. Periodontitis may be of particular concern in liver cirrhosis patients due to the translocation of oral bacteria and their toxins to the intestine and the likelihood of subsequent liver-related complications

32. Periodontal disease may increase the risk for many systemic disorders. The emerging field of periodontal medicine offers new insights into the concept of the oral cavity as one system interconnected with the whole human body. CONCLUSION