Stress and nutritional factors on periodontal disease april 12013


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Stress and nutritional factors on periodontal disease april 12013

  1. 1. Stress and Nutritional Deficiencies on Periodontium
  2. 2. What is Stress An inharmonious fit between the person and the environment, one in which the person’s resources are taxed or exceeded, forcing the person to struggle, usually in complex ways to cope.” Richard S. Lazarus. Puzzles in the study of daily hassles. J Behavioral Med. 1984; 7(4): 375-389
  3. 3. A reasonable amount of researches indicate the association of psychosocial stress, financial stress, occupational stress, distress, the negative impact of life-events and depression with Periodontitis Linden GJ, Mullally BH, Freeman R. Stress and the progression ofperiodontal disease. J Clin Periodontol. 1996; 23(7): 675-680.
  4. 4. Stress can be viewed as a process with both psychological and physiological components Reners M, Brecx M. Stress and periodontal disease. Int J Dent Hyg.2007;5(4):199-204.
  5. 5. DIRECT Alteration of Resistance of Periodontium to infection INDIRECT Psychological aspect of a person with health impairing behaviour like • Poor Oral Hygiene • Smoking • Alcohol Consumption • Poor Nutrition Stress affects the periodontium directly or indirectly
  6. 6. • The most documented example between stress and Periodontal disease is NUG • NUG in soldiers during wartime in trenches lead to diagnostic term Trench mouth
  7. 7.  Chronic or long term stress is more like be associated with Periodontal destruction than acute stress  Individual with Problem focussed (Practical coping) skills fared better than individuals with emotion-focussed (avoidance) coping skills with respect to periodontal disease
  8. 8. Chronic stress and inadequate coping could lead to changes in daily habits, such as – Poor oral hygiene – Clenching & Grinding – Decreased salivary flow – Suppressed Immunity
  9. 9. Stress induced Immunosuppression • Stress and psychosomatic disorder impact the periodontal health • Complex Interaction among
  10. 10. Stress Implications
  11. 11. Pshychiatric influence or Self induced injury Self-induced or Factitious Injury Neurotic Habits: Grinding, Clenching Teeth, Nibbling on Foreign Objects(pens etc),Nail Biting, excessive use of tobacco Self-inflicted injuries such as Gingival Recession have been described both in children and adults
  12. 12. Nutritional Influences
  13. 13. • No Nutritional defencies that by themselves may cause Gingivitis or Periodontitis • There are Nutritional defencies that produce changes in oral cavity. – Changes include alterations of tissue of lips, oral mucosa,gingiva and bone
  14. 14. Vitamin Deficiency • Fat soluble : A,D,E,K • Water soluble: B,C
  15. 15. Vitamin A • Major function is to maintain health of epithelial cells of skin & mucous membrane • Prevent microbial invasion by maintaining epithelial integrity • Deficiency in experimental animals – Hyperkeratosis, Hyperplasia of gingiva, increased pocket formation, proliferation of Junctional epithelium, Retardation of wound healing
  16. 16. Vitamin D • Essential for absorption of Ca from GIT and maintenance of Ca- P balance • Deficiency Rickets in children, osteomalcia in adults • Animals – Osteoporosis of alveolar bone
  17. 17. Vitamin E • Serves an Antioxidant to prevent free radical reactions • Protect cells from Lipid Peroxidation • Cell membranes which contain highest content of Polyunsaturated Fatty Acids are major site of Vitamin E deficiency
  18. 18. • No direct relation have been found between Vitamin E deficiency and Oral Disease • Systemic Vitamin E have been shown to accelerate gingival wound healing in rats
  19. 19. Oral Changes associated  Gingivitis  Glossitis  Glossodynia  Angular Cheilitis  Inflammation of entire oral mucosa  Oral disease is rarely caused by a deficiency in just one component of the B-complex group, the deficiency is generally multiple Vitamin B Complex Deficiencies
  20. 20. Gingivitis in Vitamin Deficiencies is non- specific because it is caused by bacterial plaque rather than by deficiency but deficiency can have modifying effect
  21. 21. B1 or Thiamine Deficiency Characterised by • Paralysis • CVS symptoms including Edema • Loss of Apetite Oral symtoms- • Hypersenstivity of Oral Mucosa, • Minute vesicles on oral mucosa, buccal vesicles on buccal mucosa, under the tongue or on palate
  22. 22. B2 Riboflavin Deficiency • Glossitis-Magenta Discoloartion • Angular Cheilitis • Seborrheic Dermatitis • Superficial Vascularising Keratitis • Atrophy of Papillae • Angular Chelitis-Perleche
  23. 23. B3 Niacin Deficiency • Pellagra characterised by • 3Ds – Dermatitis – Diarrhea – Dementia • 3Gs – Glossitis – Gingivitis – Generalised Stomatitis
  24. 24. • Glossitis and Stomatitis are the earliest signs of Niacin Deficiency • Gingiva may be involved with or without tongue changes • MC finding is NUG in areas of irritation
  25. 25. Folic acid Deficiency • Results in Macrocytic Anemia with Megaloblastic Erythropoiesis • Oral Changes • GI lesions • Diarrhea • Intestinal Malabsorption
  26. 26. • Ulcerative stomatitis is an early indication of toxic effect of Folic acid antagonist (Methotrexate) used in treatment of leukemia • Gingival changes associated with pregnancy and OCP may be partly related to suboptimal levels of Folic acid in Gingiva • Phenytoin induced gingival growth and folic acid, based on interference of folic acid absorption and utilization of Phenytoin
  27. 27. Vitamin C or Ascorbic acid Deficiency • Defective formation and maintenance of collagen • Impairment or cessation of Osteoid formation • Impaired Osteoblastic function • Increased capillary permeabilty • Susceptiblity to traumatic hemorrhages • Hyporeactivity of contractile element of peripheral blood vessels
  28. 28. Clinical Manifestation • Hemorrhagic lesions into muscles & extremities,joints, nail beds • Petechial hemorrhages around hair follicles • Susceptibilty to infections • Impaired healing • Bleeding, swollen gums and loosened teeth
  29. 29. • Gingivitis in vitamin-C deficient patient is caused by dental Plaque • Vitamin C deficiency may aggravate the gingival response to dental plaque and worsen the edema, enlargement and bleeding • Acute vitamin C deficiency does not cause or increase the incidence of gingival inflammation, but it does increases its severity
  30. 30. Vitamin C deficiency alone does not cause periodontal destruction, local bacterial factors are required for increased pocket proding depth and attachment loss to occur
  31. 31. Protein Deficiency • Protein depletion reults in Hypoprotienemia • Protein deprivation has shown changes in Periodontium of experimental animals – Degeneration of gingival& Periodontal connective tissue – Osteoporosis of Alveolar bone – Impaired deposition of cementum – Delayed wound Healing – Atrophy of Tongue Epithelium
  32. 32. • Protein deficiency accentuates the destructive effects of Bacterial plaque and occlusal trauma on the periodontal tissue, but initiation of gingival inflammation and its severity depend on bacterial plaque • Protein deprivation results in Periodontal tissue that lack integrity and are more vulnerable to breakdown when challanged by bacteria
  33. 33. Other Systemic Deficiency Hypophosphatasia Familial skeletal disease characterized by • Rickets,Poor Cranial Bone Formation, Premature loss of primary teeth particularly incisors • Low level of Serum Alkaline Phosphatase • Phosphoethanolamine present in serum and urine • Teeth are lost with no clinical evidence of gingival inflamation • Reduced cementum formation
  34. 34. Early exfoliation of primary incisors in Hypophosphatasia
  35. 35. Congenital Heart Disease • Cardiac defects involve heart and adjacent vessels or combination of both • MC feature in CHD is Cyanosis • Shunting of deoxygenated blood from Right to Left • Poorly oxygenated blood in circulation
  36. 36. Chronic hypoxia causes • Impaired development, • Compensatory Polycythemia • Clubbing of toes and Fingers • Polycythemia can result in hemorrhagic or thrombotic tendencies
  37. 37. Oral manifestation • Cyanosis of Lips & Oral Mucosa • Delayed eruption of both decidious and permanent dentition • Increased positional abnormalities • Enamel Hypoplasia • Teeth color bluish white • Increased Pulp Vascular volume • More severe caries & Periodontal disease in Cyanotic Congenital Heart Disease patients
  38. 38. Teratology of Fallot Characterised by four Cardiac Defects 1. Ventricular Septal Defect 2. Pulmonary Stenosis 3. Malposition of Aorta to Right 4. Compensatory Right Ventricular enlargement
  39. 39. C/F: Severe Cyanosis, audible Heart Murmurs and Breathlessness ORAL CHANGES: • Purplish Discoloration of lips and Gingiva • Severe marginal Gingivitis and Periodontal Destruction • Tongue is coated or Fissured • Extreme reddening of of Fungiform or Filiform Pappilae • Number of Subepithelial Capillaries is increased after Heart surgeries
  40. 40. Eisenmenger’s Syndrome • VSD>1.5 cm in diameter • Greater blood flow from stronger Left ventricle to Right Ventricle(Left to Right Shunt) • Progressive Pulmonary Fibrosis • Blood Flow reversed • Right to left flow (Right to Left)
  41. 41. Oral Manifestations: Cyanosis of Lips, Cheeks, Buccal Mucosa Severe Generalised Periodontitis have been reported in Eisenmengers syndrome
  42. 42. Metal Intoxication • BISMUTH • Narrow bluish black discoloration of gingival margin in preexisting area of inflammation • Precipiation of Bismuth Sulphide associated with vascular inflammation .
  43. 43. LEAD • Salivation, coated tongue, peculiar sweetish taste, • Gingival pigmentation is linear (Burtonian line),steel gray associated with local inflammation
  44. 44. Mercury • Headache, CVS symptoms, Pronounced salivation and Metallic taste • Gingival pigmentation deposition of mercuric sulphide
  45. 45. • Phosphorous, Arsenic, Chromium can lead to necrosis of alveolar bone with loosening and exfoliation of the teeth • Benzene intoxication lead to Gingival Bleeding, ulceration and destruction of underlying bone