ROLE OF SYSTEMIC DISEASE IN ETIOLOGY OF PERIODONTAL DISEASE

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ROLE OF SYSTEMIC DISEASE
IN ETIOLOGY OF
PERIODONTAL DISEASE
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• It is a well established fact that the primary
  etiological agent in periodontal disease is
  bacterial plaque. The toxins and enzymes produced
  by the bacterial plaque elicit inflammatory and
  immunologic changes in the periodontal tissues at
  both cellular and molecular levels.
• These responses can be affected by a variety of
  systemic factors that can alter the response of
  the tissue to plaque.
• Certain systemic disorders can have a direct
  effect on the periodontal tissues and these
  represent the periodontal manifestations of
  systemic diseases.

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Dietary and Nutritional Aspects of Periodontal
Disease

• The majority of opinions and research findings
  point to the following
• Nutritional deficiencies produce changes in the
  oral cavity
• These are no nutritional deficiencies that by
  them selves cause gingivitis or periodontal
  pockets.

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The consistency of Diet

• From the view point of promoting and maintaining
  gingival and periodontal health DIET is often
  stated that a firm and fibrous diet is more
  beneficial than an intake of soft and more
  loosely textured food.
• Diets that are predominantly fibrous are
  considered advantageous as they posses the
  ability to impart a natural cleansing action to
  the teeth and the periodontium.
• A coarse diet requires vigorous mastication and
  the plaque that forms approximately tends to be
  towards the cleansable buccal and lingual
  surfaces of the teeth. However coarse and
  granular diets can predispose to a direct
  traumatic injury to the supporting tissues

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Protein Deficiency and Periodontal Disease

• Proteins are constituents of the organic matrices
  of all the dental tissues including the alveolar
  bone. The integrity of to periodontal ligament is
  also depend upon proteins (amino acid).
• Deprivation of proteins, extreme pathologic
  changes or and there is marked degeneration of
  periodontal support.

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Vitamins and Periodontal Disease

• Vitamin C
• Its deficiency in humans results in SCURVY a
  disease characterized by hemorrhagic diathesis
  and retardation of wound healing.
• Clinical manifestations
• Increased susceptibility to infections
• Impaired wound healing
• Bleeding and swollen gums
• Mobile teeth

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• Histopathological features
• Defective formation and maintenance of collagen.
• Retardation or cessation of osteoid formation and
  impaired osteoblatic function.
• Increased capillary permeability
• Suceptibility to traumatic hemorrhage
• Hyperactivity of contractile elements of the
  peripheral blood vessels
• Sluggishness of blood flow.

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• Etiologic Relationships between Ascorbic
  Acid and Periodontal Disease
• Low levels of Ascorbic acid influences the
  metabolism of collagen within the periodontium,
  thereby affecting the ability of the tissue to
  regenerate and repair by itself.
• It interferes with bone formation leading to the
  loss of the alveolar bone.
• Increases the permeability of oral mucosa to
  tritiated endotoxin and inulin.
• Increased levels of Ascorbic acid enhances both
  the chemotactic and migratory action of
  leukocytes without influencing phagocytic
  activity.
• Depletion of vitamin C may interfere with the
  ecologic equilibrium of bacteria in plaque and
  increases its pathogenicity.

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Periodontal Features of Scurvy

• The oral symptoms are same as chronic gingivitis
  which can involve the attached gingiva and
  alveolar mucosa.
• In severe cases the gingiva becomes brilliant red
  tender and grossly swollen.
• The spongy tissues 'are extremly hyperemic and
  bleed spontaneously.
• In long standing cases the tissues attain a
  dark blue or purple hue.
• Alveolar bone resorption with indreased tooth
  mobility has also been reported.

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• SCURVY

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SCURVY IN SEVERE FORM
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Vitamin D Deficiency

• Vitamin D is essential for the absorption of
  calcium from the gastrointestinal tract and the
  maintenance of calcium phosphorus balance.
• Radiographically
• There is a generalized partial to complete
  disappearance of the lamina dura
• Reduced density of supporting bone ,loss of
  trabeculae.
• Increased radiolucency of the trabecular
  interstices and-increased prominenece of the
  remaining trabelculane.

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VITAMIN E

• Evidence suggests that vitamin E acts as an
  antioxidant. Severe familial neutropenia. and
  plays an important role in maintaining the
  stability of the cell mebrances and protecting
  blood cells against hemolysis.
• The possible role is based upon its ability to
  interfere with the production of prostaglandins.

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• VITAMIN A
• It is essential for normal functions of the
  retina, for growth, differentiation and
  maintenance of epithelial tissues and for bone
  growth and embryonic development
• VITAMIN B-COMPLEX
• Oral disease is rarely due to a deficiency in
  just one component of the B-complex group. Oral
  changes common to-Vitamin B-complex deficiencies
  are gingivitis, glossitis, glossodynia, angular
  chelitis and inflammation of the entire oral
  mucosa.

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METABOLIC AND ENDOCRINE DISORDERS

• The endocrine glands produce hormones that
  control metabolism and maintain homeostasis.
• Diabetes mellitus is the main endocrine disorder
  that affects the periodontium.
• The sex hormone can alter the response of
  periodontal tissues to plaque. Disorders of the
  pituitary, thyroid and adrenal glands have little
  direct effect on the periodontal structures or in
  altering the host response to bacterial plaque.

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Diabetes Mellitus and Periodontal Disease

• Diabetic patient is more susceptible to
  periodontal breakdown, which is characterized by
  extensive bone loss, increased tooth mobility,
  widening of periodontal ligament, suppuration
  and abscess formation.
• Pathogenesis
• There are several underlying factors that
  accompany diabetes mellitus which may account for
  the apparent increased prevalence of periodontal
  disease in this condition. These factors are

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• 1. Vascular changes- Changes include thickening
  and hyalinization of vascular walls, thickening
  of capillary basement membranes, swelling and
  occasional proliferation of the endothelial
  cells, and splitting of capillary basement
  membrane. Diabetic-induced changes in the
  capillary basement membrane may have an
  inhibitory effect on the transport of oxygen,
  WBC, immune factors and waste products all of
  which could affect tissue repair and regeneration.

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• 2. Impairment of PMN function is a feature of
  diabetes mellitus. Disorders include reduced
  phagocytosis and intracellular killing, impaired
  adherence and impaired chemotactic response.
• Suggested causes include inhibition of the
  glycolytic pathway with the PMNLs abnormal
  cyclic nucleotide metabolism, which disrupts the
  organization of microtubules and microfilaments,
  or a reduction in leukocyte membrane receptors.

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• 3. Biochemistry of crevicular fluid- Alterations
  in the constituents and flow rate of crevicular
  fluid have been shown to be associated with
  diabetes. Cyclic AMP levels seems to be reduced
  in the diabetes group when compared with control.
  
• 4. Changes in plaque microflora- Studies have
  indicated that proteolytic activity has not been
  altered but hyaluronidase activity is lower in
  plaque from diabetes.

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• severe gingival inflammation due to
  diabetes

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• Bone loss in diabetes

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• PERIODONTAL ABSCESS FORMATION

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Treatment

• a. Periodontal treatment in patient with
  uncontrolled diabetes is contraindicated.
• b. If suspected to be a diabetic, following
  procedures should be performed.
• 1.Consult the patients physician
• 2. Analyze laboratory tests blood glucose
  ,post-prandial blood glucose, glycated
  hemoglobin, glucose tolerance test (GTT), urinary
  glucose.

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• If there is periodontal condition that requires
  immediate care, prophylactic antibiotics should
  be given.
• If patient is a 'brittle' diabetic, optimal
  periodontal health is a necessity. Glucose levels
  should be continuously monitored and periodontal
  treatment should be performed when the disease
  is in a well-controlled state. Prophylactic
  antibiotics should be started 2 days
  preoperatively, Penicillin is the drug of first
  choice.

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• Guidelines
• 1. Clinician should make certain that the
  prescribed insulin has been taken followed by a
  meal. Morning appointments, are ideal, after
  breakfast because of optimal insulin levels.
• 2.After any surgical procedures, postoperative
  insulin dose should be altered.
• 3. Tissues should be handled as atraumatically
  and as minimally (less than 2 hours) as possible.
  For anxious patient's patients preoperative
  sedation is required, epinephrine concentration
  should not be greater than 11,00,000.
• 4.Diet recommendation should be made.
• 5.Antibiotic prophylaxis is recommended for
  extensive therapy.
• 6.Recall appointments and fastidious home oral
  care should be stressed.

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Thyroid Gland

• Hypothyroidism leads to cretinism in
  children and myxedema in adults. There are no
  notable periodontal changes.
• Treatment
• Patients with thyrotoxicosis and those with
  inadequate medical management should not receive
  periodontal therapy until the condition is
  stabilized.
• Medications such as epinephrine, atropine
  and other pressor amines should be given with
  caution.
• Hypothyroid patients require careful
  administration of sedatives and narcotics because
  of their diminished ability to tolerate drugs.

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Pituitary Gland

• Hyperpituitarism causes enlarged lips localized
  areas of hyper-pigmentation are seen along
  nasolabial folds. It is also associated with food
  impaction and hypercementosis.
• Hypopituitarism leads to crowding and malposition
  of teeth.

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Parathyroid Glands

• Parathyroid hypersecretion produces generalized
  demineralization of the skeleton. Oral changes
  include malocclusion and tooth mobility,
  radiographic evidence of alveolar osteoporosis,
  widening of the periodontal space and absence of
  lamina dura.
• Treatment Routine periodontal therapy must be
  instituted.

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Gonads

• There are several types of gingival diseases in
  which modification of the sex hormones is
  considered to be either an initiating or
  complicating factor gingival alterations are
  associated with physiologic hormonal changes with
  a predominant marked hemorrhagic tendency.
• Gingiva in Puberty
• Pronounced inflammation, bluish-red
  discoloration, edema and enlarged gingiva may be
  seen.
• Treatment It is treated by scaling and
  curettage, removal of all sources of irritation
  and plaque control. In severe cases, surgical
  removal of enlarged tissue may be required.

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• Gingival Changes Associated with Menstrual Cycle
• There is increased prevalence of gingivitis,
  bleeding gingiva. Exudation from inflamed gingiva
  is also increased, but the crevicular fluid is
  not affected. The salivary bacterial count is
  increased. No active treatment is required.

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• Gingival Diseases in Pregnancy
• Pregnancy accentuates the gingival response to
  plaque. The severity of gingivitis is increased
  during pregnancy beginning, in the second or
  third month. It becomes more severe by the
  eight-month and decreases during ninth month.
• Clinical features
• 1.Pronounced base of bleeding.
• 2.Gingiva is bright-red to bluish-red.
• 3.Marginal and interdental gingiva is edematous,
  pits on pressure and sometime presents raspberry
  like appearance.

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• 4.It has been suggested that during pregnancy
  there is depression of maternal T-lymphocyte
  response.
• 5.Aggravation of gingivitis has been attributed
  principally to increased levels of progesterone
  which produces dilatation and tortuosity of the
  gingiva microvasculature, circulatory stasis and
  increase susceptibility to mechanical irritation.
  
• 6.Increased crevicular fluid flow, pocket depth
  and mobility are also seen.

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GINGIVA IN PREGNANCY
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• Treatment-
• Requires elimination of all local irritants that
  are responsible for precipitating gingival
  change. Marginal and interdental gingival
  inflammations and enlargement are treated with
  scaling and root planing.
• Treatment of tumor-like gingival enlargements
  consists of surgical excision, scaling and
  planing of tooth surfaces. In pregnancy emphasis
  should be on
• Preventing gingival disease before it occurs.
• Treating existing gingival disease before it
  becomes worse.

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• Menopausal Gingivostomatitis
• It occurs during menopause or in the
  postmenopausal period. Clinical manifestations
  include dry, shiny oral mucosa, dry burning
  sensation of oral mucosa, abnormal taste
  sensation described as salty, peppery or sour.

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Effects of Hematological Disorders on Periodontium

• Disorders of the blood and blood forming tissue
  can have profound effect on the periodontal
  tissues and their response to bacterial plaque.
  The WBC disorders have the most pronounced
  effect on the periodontal tissues. Disorders of
  hemostasis can be classified according to the
  underlying defect. There can be a defect in the
  vascular constriction, platelet adhesion and
  aggregation, coagulation and fibrinolysis.

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White Blood Cell Disorders

• The WBCs disorders that affect the periodontium
  can be categorized as either a disorder of
  numbers or defect in function.
• Neutropenias
• Cyclic Neutropenia
• Chronic benign neutropenia of childhood
• benign familial neutropenia
• Severe familial neutropenia
• Chronic idiopathic neutropenia

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Cyclic Neutropenia

• It is characterized by a cyclic depression of the
  PMN count in peripheral blood The cyclic
  intervals are usually between 19 and 21 days.
  Clinical problems include pyrexia, oral
  ulceration and skin infections.
• Periodontal manifestations include oral
  ulceration, inflamed gingiva, rapid periodontal
  breakdown, and alveolar bone loss. Bone loss is
  most obvious around the lower incisors and first
  permanent molars
• Treatment Plaque control, supportive measures
  like antiseptic mouth wash, antimicrobial therapy
  has been proposed.

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Chronic Benign Neutropenia of Childhood

• The onset is usually between 6 to 20 months of
  age and most patients, the condition is
  self-limiting
• The main periodontal feature is brigt-red
  hyperplastic, edematous gingivia confined to the
  width of attached gingivia. THe gingival tissues
  exhibit bleeding on probing and show areas of
  desqumation, varying degrees of gingival
  recession and pocketing are seen.
• Treatment Appropriate antimicrobial agent
  should be prescribed.

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Benign Familial Neutropenia

• It is transmitted as an autosomal dominant trait.
  The periodontal manifestations include
  hyperplastic gingivliis exhibiting edematous and
  bright-red appearance. There is marked bone loss
  around the.fust molars. The gingival tissues
  bleed profusely on probing
• Treatment
• Plaque control and use of antimicrobial
• mouth washes.

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Chronic Idiopathic Neutropenia

• Thre is a persistent neutronpenia from birth and
  is not cyclical. Clinical symptoms includes
  persistent recurrent infections through out the
  patients life.
• Periodontal manfestions include persistent severe
  gingivitis. The gingival is cherry red
  edematous and hypertrophic with occasional
  desquamation.
• Treatment
• Strict oral hygiene programme, scaling and
  regular prophylaxis. Antiseptic irrigation and
  antibiotic are advisable before tissue
  manipulation.

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Leukemia

• It is a malignant caused by proliferation of WBC
  forming tissue, especially those in bone marrow.
  Acute leukemia in more frequent in people under
  20 years of age. Chronic leukemias occur in
  people over 40 years of age.
• Periodontal Manifestations
• The major manifestation being gingival
  enlargement, gingival bleeding and periodontal
  infections. The incidence and severity oof these
  problems varies according to the type and nature
  of leukemia

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• a. Gingival enlargement is primarily due to a
  massive leukemia cell infiltration into the
  gingival will hinder mechanical plaque removal
  hence there will be an inflammatory component
  enhancing this enlargement.
• b. Gingival bleeding is a common oral
  manifestation of acute leukemia. The bleeding is
  secondary to thrombocytopenia that accompanies
  leukemia.
• c. Infections of the periodontal tissues
  secondary to leukemia can be of two types, either
  an exacerbation of an existing periodontal
  disease or an increased susceptibility of the
  periodontium to fungal, viral or bacteria
  infections.

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Treatment Plan for Leukemic Patients

• 1. Refer the patient for medical evaluation and
  treatment
• 2. Prior to chemotherapy, a complete periodontal
  plan should be developed.
• a. Monitor hematologic laboratory values.
• b. Administer suitable antibiotics before any
  periodontal treatment.
• c. Periodontal treatment consist of scaling and
  root planning, twice daily rinsing with 0.12
  percent chlorhexidine gluconate is recommended.
  If there is irregular bleeding time, careful
  debridement with cotton pellets soaked in 3
  percent hydrogen peroxide is performed.

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• 3. During the acute phases of leukemia
• a. Cleanse the area with 3 percent hydrogen
  peroxide (H2O2) or 0.12 percent
  chlorhexidine.
• b. Carefully explore the area and remove any
  etiologic local factors.
• c. Re-cleanse the area with 3 percent H2 O2
• d. Place a cotton pellet soaked in thrombin
  against the bleeding point.
• e. Cover with gauze and apply pressure for 15 to
  20 minutes.
• Acute gingival or periodontal abscesses are
  treated by systemic antibiotics, gentle incision
  and drainage or by treating with 3 percentage
  H2O2/0.12 percent chlorhexidine gluconate.
• Oral ulcerations should be treated with
  antibiotics and mouth rinses.

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• In patients with chronic leukemia scaling and
  root planning can be performed but periodontal
  surgery should be avoided. Plaque control and
  frequent recall visits should receive particular
  attention.

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• Thrombocytopenic Purpura
• It is characterized by a low platelet count, a
  prolonged clot retraction and bleeding time, and
  a normal or slightly prolonged clotting time.
• Clinical manifestations include spontaneous
  bleeding into skin or from mucous membranes.
  Petechiae and hemorrhagic vesicles occur in the
  cavity. Gingiva is swollen, soft and friable.
  Bleeding occurs spontaneously
• Treatment
• 1. Physician referral for a definitive diagnosis.
• 2. Oral hygiene instructions.
• 3. Prophylactic treatment of potential abscesses.
  
• 4. No surgical procedures are indicated unless
  platelet count is at
• least 80,000 cells/mm3.
• 5. Scaling and root planning may be carefully
  performed at low
• platelet levels.
• If surgery indicated, it shoud be as a traumatic
  as possible, stents or thombin-soaked cotton
  pellets placed interproximally, gentle hydrogen
  peroxide month washes and close post surgical
  follow up is recommended.

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Disorders of WBC FunctionChediak-Higashi
Syndrome

• It is a rare familial and often fatal disease
  which is transmitted as an autosomal recessive
  trait. PMNLs from patients with Syndrome show
  defective migration defective chemo taxis,
  failure of post phagocytic deregulation and
  diminished intracellular bactericidal capacity.
• Server gingival inflammation appears to be a
  common finding in Chediak-Higashi syndrome. The
  nature of the inflammatory charges may be plaque
  induced, secondary to infection or related to the
  underlying PMNLs defect.

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• Lazy Leukocyte syndrome
• The featutre of the syndrome is a defect in
  leukocyte chemotaxis and random mobility. Marked
  gingivitis has also been described.
• Chronic Granulomatous Disease
• A genetically-transmitted disorder characterized
  by the inability of phagocytic cells to destroy
  certain infecting micro-organisms.
• Periodontal manifestations include marked,
  diffuse, gingivitis with an accompanying
  ulceration of buccal mucosa.

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Red Blood Cell Disorders

• Aplastic Anemia
• It is a bone marrow disorder characterized by a
  reduction in hematopoietic tissue, bone marrow is
  replaced with fat and pancytopenia. Bleeding from
  the gingival margins appears to be a feature in
  these cases.
• Fanconis Anemia
• This is a rare type of aplastic anemia
  characterized by a familial bone marrow
  hypoplasia that becomes manifested in the first
  decade of life. The periodontal manifestations
  being loss of several teeth, severe bone loss
  with pocketing in excess of 10 mm. The gingiva
  will be bluish-red, bleed on probing, and shows
  suppuration on gentle pressure.

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APLASTIC ANEMIA
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• Sickle Cell Anemia
• In this condition, the red blood cells undergoes
  sickling when subjected to hypoxia. Hence
  patients with sickle cell anemias are susceptible
  to infections. In some patients with sickle cell
  anemia, periodontal disease may provide a
  sufficient inflammatory response to precipitate a
  sickling crisis.
• Acatalasia
• It is caused by a lack of the enzyme catalase in
  many cells, especially the red blood cells and
  leukocytes. It causes hypoxia and necrosis of the
  gingival tissues. Severe periodontal destruction
  and gingival necrosis are seen.

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ANTIBODY DEFICIENCY DISORDERS Acquired
Immunodeficiency Syndrome

• It is caused by a persistent HIV virus and is
  characterized by destruction of lymphocytes,
  rendering the patient susceptible to
  opportunistic infections including destructive
  periodontal lesions.

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• Clinical Manifestations
• HIV gingivitis Persistent, linear, easily
  bleeding, erythematous gingivitis has been
  described. Linear gingivitis lesions may be
  localized or generalized in nature. The
  erythematous gingivitis may be limited to
  marginal tissue, or extend into attached gingiva
  in a punctuate or a diffuse erythema or extend
  into alveolar mucosa. A severely destructive,
  acutely painful necrotizing ulcerative stomatitis
  has been reported.
• HIV periodontitis NUP (Necrotizing ulcerative
  periodontitis) is characterized by soft tissue
  necrosis and rapid periodontal destruction that
  results in marked interproximal bone loss. It is
  severely painful at onset.

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KAPOSIS SARCOMA IN AIDS
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• Treatment
• Recommended management for linear gingival
  erythema is as follows
• Instruct the patient to perform meticulous oral
  hygiene.
• Scale and polish affected areas and perform
• subgingival irrigation with chlorhexidine.
• Prescribe chlorhexidine gluconate mouth rinse
• Reevaluation and frequent recall visits
• Systemic antibiotics such as metronidazole or
  amoxicillin should be prescribed for patients
  with moderate to severe tissue destruction. Use
  of prophylactic antifungal medication should be
  considered.

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• PSYCHOSOMATIC DISORDERS
• There are two ways by which psychosomatic
  disorders may be induced in the oral cavity,
  through the development of habits injurious to
  the periodontium and by the direct effect of the
  autonomous nervous system on the physiologic
  tissue balance.
• However, under the conditions of mental and
  emotional stress, the mouth may subconsciously
  become an outlet for the gratification of basic
  drives in the adult. Gratification may be derived
  from neurotic habits, which are potentially
  injurious to the periodontium.

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