Periodontal Medicine Question And Answers

Periodontal Medicine Question And Answers

• Periodontal disease is accepted today as a chronic low-grade inflammatory process that does not resolve spontaneously.
• Consequently, there are a number of ways in which this chronic inflammation may affect systemic health.
• Acute phase proteins such as C-reactive protein (CRP) have been reported to be elevated in systemic circulation following periodontal disease.
• Proinflammatory cytokines and MMP which are produced excessively in the gingival tissue may gain entry into the systemic circulation.
• Chemical mediators such as PGE2 have also been reported to be increased.

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• All these are known to influence the inflammatory/immune responses that may affect the course of several diseases such as cardiovascular disease, pre-term low-birth-weight, and diabetes mellitus.
• This branch of periodontics has thus been termed periodontal medicine.

Question 1. Describe the two-way relationship between diabetes mellitus and periodontal disease.
Answer:

• The influence of diabetes mellitus (DM) on periodontal tissue has been well recognized. In recent years, it has been suggested that periodontal disease in turn may modulate the progression of diabetes mellitus.
• DM type 2 is a disease that is associated with increased peripheral insulin resistance rather than decreased insulin production at least in its earlier stages.
• It has been suggested that proinflammatory cytokines such as TNF-a, and IL-6 are increased in systemic circulation in periodontal disease and may contribute to insulin resistance.
• In addition, periodontal disease may affect the monocyte-macrophage cells that participate in increased low-grade inflammatory response.
• Clinical studies have shown that patients with advanced periodontal disease tend to have poorer control of their blood glucose levels when compared with patients without periodontal disease.
• Further, treatment of periodontal disease has been shown to improve glycemic/HbA1c levels in diabetic individuals.

Question 2. Write a note on pre-term low birth weight and periodontal disease.
Answer:

• Several mechanisms have been suggested between PD and PTLBW. P. gingivalis is thought to cross the placental barrier and invoke an inflammatory response in vitro.
• Excessive circulatory PGE2 produced may induce preterm labor and low birth weight.
• Clinical evidence seems to suggest that patients with poor periodontal health and gingival inflammation seem to be more prone for PTLBW than patients who have good oral health.

Question 3. Describe the relationship between cardiovascular disease and periodontal disease.
Answer:

Cardiovascular Disease

• There is extensive literature evidence showing an association between periodontal disease and atherosclerotic changes.
• Bacteremia following periodontal disease, the presence of P. gingivalis from atherosclerotic plaque points to a role for bacteria in the process.
• P. gingivalis has been shown to invade endothelial cells, participate in local inflammatory response and affect the coagulation cascade.
• It may therefore influence platelet plug formation, macrophage infiltration, foam cell formation, which are the hallmark of atherosclerotic plaque.
• Atherosclerosis has been shown to be closely associated with chronic inflammatory mediators such as CRP and other pro-inflammatory cytokines, which may influence vasculitis atherosclerosis.
• In addition, hyperinflammatory monocyte response has also been associated with
  atherosclerosis.
• Bradford and Hill have proposed a set of criteria to prove association between two diseases.

The criteria are as follows:

1. Strength of association: There is strong evidence of an association between two diseases. Strong evidence means not merely case reports or case series but the presence of well-constructed randomized clinical trials and systematic reviews that show such an association.
2. Consistency: There must be a strong association between cause and effect even after multiple studies by different investigators.
3. Temporality: Causes precede their effects, so in periodontal medicine studies it must be ideally be demonstrated that periodontal disease lead to and worsening of the systemic conditions.
   • Both the above-mentioned criteria have been somewhat difficult to establish because
   • Periodontitis and conditions such as diabetes and atherosclerosis have a slow insidious onset and their natural history is difficult to establish.
4. Specificity:
   • This criterion proposes that a specific cause leads to a disease, the removal of which will establish a cure.
   • In multifactorial diseases with many clinical forms of presentation, this criteria is also somewhat difficult to establish, especially in cardiovascular disease.
5. Biologic plausibility/mechanisms: Biological plausibility means that the association is biologically believable and consistent with existing knowledge.
6. This criterion is reasonably well established in most studies in periodontal medicine.
7. Experiment evidence will provide direct proof for cause and effect. It is not yet fully established the association between periodontal disease and the above-mentioned systemic disease to fulfill this criterion.
8. There is a need for further evidence to fully understand the systemic implications of periodontal disease.
9. However, the prevalent hypothesis as of date is that the inflammatory process that affects the periodontal tissue, may not be a purely local process.