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C HAPTER 9 Systemic Factors Influencing Periodontal Diseases Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

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Presentation on theme: "C HAPTER 9 Systemic Factors Influencing Periodontal Diseases Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc."— Presentation transcript:

1 C HAPTER 9 Systemic Factors Influencing Periodontal Diseases Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

2 I NTRODUCTION Systemic factors can have a profound effect on the diagnosis, pathogenesis, and treatment of periodontal infections. Some systemic diseases have signs and symptoms that mimic those of plaque-induced gingivitis or periodontitis. 2 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

3 I NTRODUCTION (C ONT.) Systemic problems in some patients can: Increase their susceptibility to infection. Interfere with wound healing. Require modification of standard approaches to treatment. Complicate factors associated with patient cooperation. Medical treatment of systemic diseases can affect the clinical presentation and course of periodontal infections. 3 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

4 C ARDIOVASCULAR D ISEASES The most common cardiovascular diseases include hypertension, coronary artery disease, heart-valve disease, cardiac arrhythmias, and congestive heart failure. In general, dental and periodontal treatment is not contraindicated in most patients with cardiovascular disease. In certain patients, however, written medical consultation from the patient’s physician may be necessary before treatment is initiated. 4 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

5 C ARDIOVASCULAR D ISEASES (C ONT.) Hypertension (High Blood Pressure) Patients with readings of 140/90 mm Hg or higher are considered to be hypertensive. Patients with a systolic pressure from 120 to 139 mm Hg and a diastolic pressure from 80 to 89 mm Hg are considered to have prehypertension. 5 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

6 C ARDIOVASCULAR D ISEASES (C ONT.) Adult dental patients should routinely have their blood pressure measured at each visit. When elevated blood pressure is detected, patients should be advised to consult their physician. Patients with medically well-controlled hypertension can safely receive nearly all forms of dental and periodontal therapy. 6 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

7 C ARDIOVASCULAR D ISEASES (C ONT.) Use of epinephrine-containing local anesthetics is not contraindicated in patients with well- controlled hypertension. Minimal amounts of epinephrine (0.04 mg per dental visit; approximately two cartridges containing 1:100,000 parts epinephrine) should be used. 7 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

8 C ARDIOVASCULAR D ISEASES (C ONT.) Medications for hypertension include: Diuretic agents (thiazides) Sympatholytic drugs (beta-adrenergic blockers, such as propranolol) Vasodilator medications (hydralazine hydrochloride) Angiotensin-converting enzyme inhibitors (enalapril) Side effects from these medications include drowsiness, mental depression, confusion, and xerostomia. 8 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

9 C ARDIOVASCULAR D ISEASES (C ONT.) Coronary Artery (Ischemic Heart) Disease Atherosclerosis is the deposition of cholesterol- containing material in the walls of arteries that results in a narrowing of the affected blood vessels. These changes can lead to ischemic heart disease, which is the leading cause of sudden death in the United States. Two common clinical manifestations of ischemic heart disease are angina pectoris and myocardial infarction, commonly referred to as a heart attack. 9 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

10 C ARDIOVASCULAR D ISEASES (C ONT.) Angina pectoris is a severe, recurring chest pain that can radiate into the left shoulder and arm, move across the chest and down each arm. Sometimes this pain involves the neck, lower jaw, and face. A condition in which anginal pain is predictable and controlled by medication is called stable angina. 10 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

11 C ARDIOVASCULAR D ISEASES (C ONT.) Patients with stable angina frequently control their anginal pain by taking one or more of the following types of drugs: Nitrate medications (nitroglycerin) Beta-adrenergic blockers Calcium channel blockers (nifedipine) Gingival enlargement is one of the common side effects of nifedipine (Procardia) and certain other calcium channel blockers. 11 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

12 C ARDIOVASCULAR D ISEASES (C ONT.) Gingival enlargement can make oral hygiene difficult and increase the risk of plaque-induced diseases, such as dental caries and periodontal disease, as demonstrated in the following figure. 12 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

13 C ARDIOVASCULAR D ISEASES (C ONT.) Patients with stable angina can safely receive routine dental care. If an anginal attack occurs, then treatment should be discontinued. The patient should be placed in a semi-supine position, and standard emergency procedures should be performed. Patients who are recovering from a recent heart attack should not receive elective dental treatment until their condition is medically stabilized, usually 6 months or until treatment is approved by their physician. 13 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

14 D ISEASES OF H EART V ALVES Any dental or periodontal procedure that introduces bacteria into the bloodstream of patients with heart-valve disease can increase their risk of a potentially fatal heart infection called infective endocarditis. In general, damaged heart valves are more susceptible to colonization by bacteria. The American Heart Association has guidelines on when antibiotic prophylaxis for dental procedures is recommended. 14 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

15 D ISEASES OF H EART V ALVES (C ONT.) Diseases of the heart valves can be either acquired or congenital. Acquired diseases are far more common. Approximately one half of all acquired heart valve lesions occur as stenosis, or a narrowing, of either the aortic or the mitral valve. Stenosis leads to the failure of the valve to open completely, retarding the forward flow of blood through the heart, which leads to regurgitation or the flow of blood in a reverse direction. 15 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

16 D ISEASES OF H EART V ALVES (C ONT.) Acquired heart-valve disease is often found in patients with a history of rheumatic fever and several other systemic diseases. Rheumatic fever is an acute systemic inflammatory disease that can cause inflammation and damage to the valves. Valve damage may lead to rheumatic heart disease in which scarring of the heart valves is the result. 16 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

17 C ARDIAC A RRHYTHMIAS An irregular heartbeat can be associated with: High fevers from certain infectious diseases Ischemic heart disease Congestive heart failure Mitral valve prolapse Rheumatic heart disease Myocardial infarction Hypertension Certain allergic reactions (anaphylaxis) Hyperthyroidism 17 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

18 C ARDIAC A RRHYTHMIAS (C ONT.) Medications can control many forms of cardiac arrhythmia. Others arrhythmias require the insertion of electronic devices, such as pacemakers and defibrillators. 18 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

19 C ARDIAC A RRHYTHMIAS (C ONT.) Patients taking antiarrhythmic drugs can experience side effects that may complicate or worsen their dental and periodontal problems. Some antiarrhythmic drugs may lead to xerostomia or gingival enlargement; or some may cause neutropenia, which is a decrease in circulating neutrophils. 19 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

20 C ARDIAC A RRHYTHMIAS (C ONT.) Some patients with cardiac arrhythmia are treated by the surgical insertion of a battery- operated electronic device (pacemaker). Wire leads connect the pacemaker to an electrode that is placed in contact with the heart tissue. The pacemaker sends periodic electrical impulses to the heart, thereby regulating its rate of contraction. The American Heart Association guidelines do not recommend that antibiotics be administered to patients with pacemakers before dental procedures. 20 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

21 C ARDIAC A RRHYTHMIAS (C ONT.) In one type of arrhythmia, portions of the heart undergo rapid irregular twitching (fibrillation). Defibrillators send electrical impulses to the heart to shock it into a normal pattern of contraction. Defibrillators subcutaneously implanted have electrodes connected to the heart that automatically send small electrical shocks to the heart to correct fibrillation. Prophylactic antibiotic coverage is not usually required before dental procedures. 21 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

22 C ONGESTIVE H EART F AILURE In patients with congestive heart failure, the heart is unable to supply the body with sufficient oxygenated blood. As a result, the patient has difficulty breathing after minimal exertion. Elective dental procedures should not be performed in patients with congestive heart failure unless their condition has been stabilized by medical treatment. 22 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

23 C ONGESTIVE H EART F AILURE (C ONT.) Patients whose condition is under good medical control can safely receive routine dental treatment. Appointments should be short to minimize stress. The dental chair should be kept in an erect or partially reclining position to facilitate breathing. Supplemental oxygen should be available in case difficulty in breathing is encountered. 23 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

24 P ATIENTS W HO A RE T AKING A NTICOAGULANT M EDICATIONS Many patients with a history of cardiovascular disease often take anticoagulant medications (blood thinners). This therapy reduces the risk of developing blood clots. Patients who have prosthetic heart valves or have had a recent heart attack or stroke are frequently prescribed anticoagulant therapy. Subgingival instrumentation can result in more gingival bleeding than is ordinarily encountered. 24 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

25 J OINT D ISEASES AND D ISORDERS Joint diseases and disorders that are frequently observed in dental patients and can complicate or modify the approach to dental or periodontal treatment include: Arthritis Artificial or prosthetic joints 25 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

26 A RTHRITIS Arthritis is a term that means inflammation of a joint. It is associated with many systemic diseases, including rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus, scleroderma, and gout. The primary dental problem with patients who have arthritis is difficulty in performing daily oral hygiene procedures, especially if arthritis involves the hands. Patients with arthritis often take antiinflammatory medications that can increase bleeding. 26 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

27 A RTHRITIS (C ONT.) The following figure demonstrates severe arthritis and a stiffening of the hands. 27 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

28 A RTHRITIS (C ONT.) Patients with progressive systemic sclerosis (PSS) or scleroderma experience multiple dental and periodontal problems that are directly attributable to their systemic disease. PSS is a chronic connective tissue disease of an unknown cause during which abnormal amounts of collagen are continuously deposited in a variety of organ systems, including the skin, lungs, and kidneys. Death as a result of PSS often occurs because of kidney or respiratory failure. As the disease progresses, the skin loses much of its elasticity and becomes almost like leather. 28 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

29 A RTHRITIS (C ONT.) Significant gingival recession is a common feature in individuals with PSS as demonstrated in the following figure. 29 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

30 A RTHRITIS (C ONT.) The following figure demonstrates the uniform widening of the periodontal ligament space, which is an unusual oral finding that is observed in some patients with PSS. 30 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

31 A RTIFICIAL J OINTS In some patients with arthritis, replacing an affected joint with an artificial or a prosthetic device is necessary. The American Academy of Orthopaedic Surgeons recommends that antibiotic prophylaxis may be considered for all patients with a history of previous prosthetic joint infections and for all people with conditions that may predispose them to infection. Most patients with orthopedic pins and plates do not routinely require antibiotic prophylaxis before dental treatment. 31 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

32 E NDOCRINE D ISTURBANCES AND A BNORMALITIES Diabetes Mellitus (DM) DM is a group of disorders that share the common feature of an elevated glucose level in the blood. The underlying problem is an insufficient supply or an impaired availability of insulin, a pancreatic hormone that is necessary for the regulation of carbohydrate metabolism. Based on the newest method of classification, the two main forms of DM are type 1 and type Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

33 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Diabetes Mellitus—Type 1 A severe deficiency of insulin, secondary to the destruction of pancreatic β-cells, is present. Destruction occurs as a result of autoimmune reactions to β-cells that develop in response to environmental injury from some viruses. In other instances, tumors, surgery, and toxic reactions to drugs or chemicals may cause the destruction of β-cells. 33 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

34 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Diabetes Mellitus—Type 1 (cont.) Onset is usually rapid and occurs around the time of puberty. Medical control of type 1 DM requires periodic self-injection with one or more prescribed insulin preparations. 34 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

35 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Diabetes Mellitus—Type 2 In the early stages, the pancreatic β-cells are intact and capable of producing insulin. Two general metabolic defects are associated with the development of type 2 DM: 1. Impaired secretion of insulin 2. Insulin resistance 35 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

36 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Diabetes Mellitus—Type 2 (cont.) Defective cell receptors for insulin are believed to play a role in insulin resistance. Dietary modifications can frequently achieve medical control of the early forms of type 2 DM. If problems persist, then oral hypoglycemic agents are prescribed. In certain patients with long-standing type 2 DM, the loss of pancreatic β-cells eventually occurs and insulin injections are required to achieve medical control. 36 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

37 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Patients with uncontrolled or poorly controlled DM appear to be more susceptible to infections, including periodontal diseases. Other common oral problems associated with diabetes include asymptomatic parotid gland enlargement and dry mouth, secondary to decreased salivary flow. Evidence suggests that control of gingival inflammation through good daily oral hygiene reduces insulin requirements in patients with DM. 37 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

38 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Treatment Considerations for Patients with DM Patients should eat normally to reduce the chance of hypoglycemia. Initial signs and symptoms of hypoglycemia include mental confusion, slurred speech, rapid heartbeat, nausea, and cold and clammy skin. Emergency care involves the administration of sugar-containing beverages or food. Recovery usually begins within a few minutes. If the patient does not respond, a medical emergency response team should be called. 38 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

39 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Pregnancy Vascular alterations associated with the hormonal changes of pregnancy make the gingiva more susceptible to plaque-induced inflammation. Increased estrogen and progesterone can promote the growth of certain suspected periodontal pathogens such as Prevotella intermedia. In addition, changes in the immune system associated with pregnancy alter the host defenses against some infections. 39 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

40 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Increased gingival inflammation (gingivitis) is frequently associated with pregnancy as demonstrated in the following figure. 40 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

41 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Treatment Considerations during Pregnancy Patients who are pregnant should be shown how to perform thorough oral hygiene procedures to reduce the risk of gingivitis and periodontal disease. Scheduling professional teeth cleaning at more frequent intervals than before the pregnancy may be advisable. 41 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

42 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Fluctuations in Female Sex Hormone Levels Increased gingival inflammation associated with physiologic fluctuations in the levels of female sex hormones is observed during puberty, during the menstrual cycle, and in some patients who are taking oral contraceptives. The mechanisms responsible for an increased susceptibility to plaque-induced gingival inflammation are probably the same as those in pregnancy. The clinical features are also the same. 42 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

43 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Psychologic Stress Patients who are under emotional tension have an increased susceptibility to certain periodontal infections. Stressful life events in some patients can partially suppress certain components of the immune system. 43 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

44 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) The strongest evidence that stress is an important factor in the pathogenesis of certain periodontal diseases is shown in necrotizing ulcerative gingivitis (NUG). Most patients with NUG exhibit one or more of the following predisposing factors: 1. Recent emotional stress 2. Heavy cigarette smoking 3. Lack of sleep 4. Poor dietary habits 44 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

45 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) The rapid onset of gingival pain and the presence of interproximal necrosis and ulceration are characteristics of NUG and are demonstrated in the following figure. 45 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

46 E NDOCRINE D ISTURBANCES AND A BNORMALITIES (C ONT.) Treatment Considerations Informing patients of the possible relationship between stress and periodontal infections may be advisable. The patient should be made aware that stress is a modifying factor, not the cause of the periodontal infection. 46 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

47 I NFECTIOUS D ISEASES The presence of certain infectious diseases may have one or more of the following effects: 1. Modify or increase the patient’s susceptibility to oral diseases. 2. Create oral manifestations. 3. Cause infection-control problems that increase the risk of transmitting the disease to other patients and health care workers. 47 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

48 I NFECTIOUS D ISEASES — V IRAL H EPATITIS Viral hepatitis is a general term that refers to a group of liver infections caused by at least five distinct deoxyribonucleic acid (DNA)–containing viruses: Type A Type B Type C (non-A, non-B) Type D Type E (non-A, non-B). 48 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

49 I NFECTIOUS D ISEASES — V IRAL H EPATITIS (C ONT.) Hepatitis A virus (HAV) is primarily transmitted in food that has been contaminated with sewage. HAV is sometimes called infectious hepatitis. Hepatitis E virus (HEV) is an enteric form of non-A and non-B hepatitis and is primarily found in the water supply after seasonal flooding in third world countries. Primarily, infected blood or blood products transmit all other hepatitis viruses (B, C, and D). Liver infections caused by this group of viruses are collectively referred to as serum hepatitis. 49 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

50 I NFECTIOUS D ISEASES — V IRAL H EPATITIS (C ONT.) Serum hepatitis (types B, C, and D) is of concern to oral health care workers who are at increased risk for the disease if they come in contact with the saliva or blood from patients who are infected. Hepatitis viruses survive on inadequately sterilized dental instruments and therefore can be transmitted to other patients. 50 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

51 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME An infection with the human immunodeficiency virus (HIV), which is a ribonucleic acid (RNA)– containing retrovirus, causes acquired immunodeficiency syndrome (AIDS). Transmission occurs through the transfer of certain body fluids such as blood or semen. Transmission can also occur through sexual activity, through the sharing of contaminated needles by intravenous drug use, or from infected mothers to their newborns. 51 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

52 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) HIV infects and eventually kills a wide range of cells, in particular, CD4-positive helper T cells. The depletion of CD4-positive helper T cells can result in severe immunosuppression that renders the patient susceptible to many life-threatening fungal, bacterial, and viral infections. Infection with one or more of these opportunistic pathogens is the major cause of AIDS-related death. 52 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

53 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) The most frequently reported oral lesion in patients with AIDS is the fungal infection candidiasis. This infection is caused by the overgrowth of Candida albicans, a yeast commonly found in the normal oral microbiota. Lesions can develop on virtually any mucosal surface in the mouth and perioral tissues. Treatment usually involves the administration of topical or systemic antifungal agents. 53 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

54 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) The following figure demonstrates acute pseudomembranous candidiasis. The palate and buccal mucosa are covered with white patches that can be wiped off, leaving a reddened, ulcerated, and tender mucosal surface. 54 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

55 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) Patients who are infected with HIV often contract several viral infections of the oral cavity. A herpes virus, called the Epstein-Barr virus (EBV), is the most common of these viral infections. In patients who are positive for HIV, EBV has been strongly linked to a generally asymptomatic oral lesion called hairy leukoplakia. In some patients, hairy leukoplakia is the first sign of an HIV infection. 55 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

56 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) The corrugated white lesion of hairy leukoplakia usually occurs on the lateral border of the tongue as demonstrated in the following figure. 56 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

57 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) Some patients who are positive for HIV have severe forms of periodontal disease, such as necrotizing ulcerative gingivitis (NUG) or necrotizing ulcerative periodontitis (NUP), and rapidly progressing periodontitis. Bacteria associated with severe cases of periodontitis include, but are not limited to, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Campylobacter rectus, Prevotella intermedia, Micromonas (Peptostreptococcus) micros, Eikenella corrodens, and various Treponema species (spirochetes). 57 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

58 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) The following figure demonstrates the tissue destruction in patients with NUP. 58 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

59 I NFECTIOUS D ISEASES — A CQUIRED I MMUNODEFICIENCY S YNDROME (C ONT.) Treatment Considerations In patients who are immunosuppressed, recommending the use of an antimicrobial mouth rinse containing chlorhexidine is advisable to assist in reducing the plaque bacteria. Because patients with NUG or NUP frequently have tender gingival tissues, multiple visits and local anesthesia are usually required. 59 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

60 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS Herpes viruses are a group of DNA-containing viruses. One member of this group, known as herpes simplex virus-1 (HSV-1), primarily binds to nerve terminals within the epithelial tissues of the mouth and skin. A second virus, herpes simplex-2 (HSV-2), primarily affects the genitals. In a few patients, HSV-1 affects the genitals and HSV-2 can affect the oral tissues. 60 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

61 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS (C ONT.) After the initial infection of an epithelial surface, the virus migrates along the branches of the main sensory nerve of the face (trigeminal nerve) to the trigeminal ganglion, where it becomes latent or inactive. Later in life, a variety of stimuli can reactivate the virus, which then migrates to the original site of infection and causes mucosal or dermal ulcerations. This condition is called secondary or recurrent HSV infection. 61 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

62 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS (C ONT.) The following figure demonstrates the appearance of intraoral herpetic ulcerations on the tongue, buccal mucosa, and gingiva. 62 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

63 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS (C ONT.) The following figure demonstrates the appearance of Herpetic ulcerations of the buccal mucosa. 63 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

64 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS (C ONT.) The lesions are of rapid onset and painful, and the patient usually has a fever and does not feel well. Herpetic gingival lesions are sometimes confused with gingival changes associated with NUG; both diseases have rapid onset and are painful. One difference is that patients with NUG rarely exhibit ulcerations of the buccal mucosa or tongue. 64 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

65 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS (C ONT.) The gingival lesions of NUG are usually confined to the interproximal gingival tissues and have a cratered or “punched-out” appearance as demonstrated in the following figure. 65 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

66 I NFECTIOUS D ISEASES — H ERPES S IMPLEX I NFECTIONS (C ONT.) Herpetic lesions are usually self-limiting and resolve without therapy within 10 to 14 days as demonstrated in the following figure. 66 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

67 I NFECTIOUS D ISEASES — H UMAN P APILLOMAVIRUS I NFECTIONS The human papillomavirus (HPV) targets epithelial cells. Certain subtypes of HPVs cause skin (cutaneous) warts. The most common oral lesion associated with the HPV is a benign epithelial tumor called an oral squamous cell papilloma. These tumors can appear on any soft-tissue surface in the mouth, but most are observed on the soft palate. 67 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

68 I NFECTIOUS D ISEASES — H UMAN P APILLOMAVIRUS I NFECTIONS (C ONT.) Gingival lesions occasionally occur as demonstrated in the following figure. 68 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

69 I NFECTIOUS D ISEASES — H UMAN P APILLOMAVIRUS I NFECTIONS (C ONT.) HPV infections have a characteristic cauliflower- like appearance and a white or pink exterior. Surgical removal is usually a successful treatment. Direct contact with a lesion that is actively shedding viral particles is believed to be the mode of transmission. 69 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

70 I NFECTIOUS D ISEASES — H UMAN P APILLOMAVIRUS I NFECTIONS (C ONT.) Some HPV (primarily subtype 16), in conjunction with other risk factors such as tobacco and alcohol use, are believed to have an association with squamous cell carcinoma, a type of oral cancer. Most papilloma-like lesions do not lead to oral cancer. 70 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

71 D ERMATOLOGIC D ISEASES Many diseases that involve the skin can also affect the soft tissues of the mouth including: Malignant melanoma Squamous cell carcinoma Kaposi sarcoma Candidiasis HPV infection Psoriasis Vesiculobullous diseases such as erythema multiforme, pemphigus vulgaris, pemphigoid, and lichen planus 71 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

72 D ERMATOLOGIC D ISEASES (C ONT.) Dental hygienists may treat patients who have painful oral lesions associated with certain dermatologic diseases. These lesions can prevent the patient from performing adequate oral hygiene procedures or make subgingival instrumentation more difficult. Lichen planus is probably the most common dermatologic disease. 72 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

73 D ERMATOLOGIC D ISEASES — L ICHEN P LANUS Lichen planus is a chronic inflammatory skin and mucosal disease. The causes of lichen planus are unknown, but cell-mediated autoimmune reactions against basal epithelial cells are involved. 73 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

74 D ERMATOLOGIC D ISEASES — L ICHEN P LANUS (C ONT.) The following figure demonstrates the most common type of lichen planus, the reticular form, which is characterized by the presence of lacelike white lesions on the buccal mucosa. 74 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

75 D ERMATOLOGIC D ISEASES — L ICHEN P LANUS (C ONT.) The tongue and gingiva are also frequently involved. The lesions usually produce no symptoms. Two other less common types of lichen planus are: Atrophic Erosive Both types frequently cause painful gingival lesions. 75 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

76 D ERMATOLOGIC D ISEASES — L ICHEN P LANUS (C ONT.) Gingival lesions in the atrophic form usually consist of fiery red tissues that are sore and tender, as demonstrated in the following figure. 76 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

77 D ERMATOLOGIC D ISEASES — L ICHEN P LANUS (C ONT.) The topical or systemic administration of steroids can reduce the pain associated with oral lichen planus lesions. Some success has also been reported with an intensive program of oral hygiene instruction in which an antimicrobial mouth rinse (0.2% chlorhexidine) is used. 77 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

78 O RAL C ANCER Cancer is a general term for a large group of diseases in which genetically altered abnormal cells experience uncontrolled growth. Such cells are generally referred to as malignant because, if not eliminated, they can lead to death. Certain cancers are sometimes referred to as malignant neoplasms (new growths) or malignant tumors (swellings). 78 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

79 O RAL C ANCER (C ONT.) Important risk factors that predispose an individual to the development of oral cancer include: Smoking or other tobacco use Excessive alcohol intake Exposure to ionizing radiation Ingestion of environmental toxins and chemicals Infection with certain viruses 79 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

80 O RAL C ANCER (C ONT.) Oral cancer is any malignant growth that originates from tissues of the mouth. Cancer cells can spread in two basic ways: Local invasion of adjacent tissues Metastasis Metastasis is the process in which malignant cells are carried away from the site of origin to another part of the body. 80 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

81 O RAL C ANCER (C ONT.) Oral cancers can cause a variety of signs and symptoms. White or red lesions of the oral mucosa may be cancerous. Unexplained lumps or swellings of the mouth or face can be the first sign of certain cancers. 81 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

82 O RAL C ANCER (C ONT.) The following figure demonstrates long- standing ulcerations or unhealed sores of the mouth or lips that should be particularly suspected of being cancerous. 82 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

83 O RAL C ANCER (C ONT.) Even common signs of periodontitis, such as loose teeth and radiographically visible bone loss, as demonstrated in the following figure, can be signs of a malignant lesion. 83 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

84 O RAL C ANCER (C ONT.) The most frequent type of oral cancer is squamous cell carcinoma, a malignancy that develops from epithelial cells. The formation of oral squamous cell carcinoma is strongly linked to pipe and cigarette smoking. The chronic use of smokeless tobacco (snuff) has also been linked to squamous cell carcinoma. Most snuff users habitually place the tobacco between the gingiva and cheek and leave it in place for prolonged periods. 84 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

85 O RAL C ANCER (C ONT.) Heavy smokers frequently have visible changes in their palatal tissues as demonstrated in the following figure. 85 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

86 O RAL C ANCER (C ONT.) In almost all cases, the oral mucosa has dramatic and clinically obvious changes as demonstrated in the following figure. 86 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

87 O RAL C ANCER (C ONT.) Treatment of cancer usually involves a combination of approaches, all of which are aimed at eradicating the malignancy. Basic cancer therapy techniques involve the following: Surgical excision of the lesion Administration of anticancer drugs (chemotherapy) Irradiation of the malignancy 87 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

88 O RAL C ANCER (C ONT.) Treatment Considerations Oral health care practitioners may provide dental and periodontal services before or during cancer treatment. Chemotherapeutic treatment of cancer uses toxic drugs that kill malignant cells, but these drugs also kill normal cells, creating a variety of severe side effects. The patient’s oral diseases should be brought under control before anticancer drugs are administered. 88 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

89 O RAL C ANCER (C ONT.) Some cancer-fighting drugs cause painful oral ulcerations that make routine plaque control procedures impossible, as demonstrated in the following figure. 89 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

90 O RAL C ANCER (C ONT.) Radiation therapy is sometimes used to treat some cancers of the head and neck. Damage to the salivary glands can occur with the patient experiencing a temporary, or possibly a permanent, reduction in salivary flow. The resulting xerostomia can promote plaque retention and increase the patient’s risk of severe dental caries. 90 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

91 O RAL C ANCER (C ONT.) Another possible side effect of radiation therapy is temporary damage to the oral mucosa. Mucosal tissues lining the oral cavity may receive radiation burns. This condition is sometimes called radiation-induced mucositis. 91 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

92 B LOOD D YSCRASIAS Blood dyscrasias refer to a large group of disorders that affect cellular elements of the red or white blood cells. The functioning of white blood cells, such as polymorphonuclear neutrophils (PMNs) or polymorphonuclear leukocytes (PMLs) may be impaired. As a result, periodontal diseases and other oral infections can worsen in patients who have either impaired PMN function or a significant decrease in the normal numbers of PMNs (leukopenia). 92 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

93 B LOOD D YSCRASIAS (C ONT.) Commonly encountered blood disorders that affect white blood cell populations include: Aplastic anemia Agranulocytosis Cyclic neutropenia Several forms of leukemia 93 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

94 B LOOD D YSCRASIAS (C ONT.) Aplastic Anemia Aplastic anemia refers to a dramatic reduction in the ability of bone marrow to produce most of the cellular components of blood. A variety of factors, such as toxic chemicals or certain drugs, can cause aplastic anemia. In some patients, no cause can be identified, which is termed idiopathic aplastic anemia. 94 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

95 B LOOD D YSCRASIAS (C ONT.) Patients with a blood dyscrasia experience a rapidly progressing form of periodontitis as demonstrated in the following figure. 95 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

96 B LOOD D YSCRASIAS (C ONT.) Agranulocytosis Agranulocytosis is the depletion of the granulocyte precursors in the bone marrow. Because PMNs are one type of granulocyte, severe periodontal infections are frequently a feature of this disease. Oral ulcerations also occur. A reaction to certain medications can cause agranulocytosis. 96 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

97 B LOOD D YSCRASIAS (C ONT.) Cyclic Neutropenia Cyclic neutropenia is a blood dyscrasia of an unknown cause during which periodic reductions in the neutrophil populations in the blood and bone marrow occur. Patients with this disease experience flare-ups of any existing periodontal infections during the period of PMN depletion. 97 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

98 B LOOD D YSCRASIAS (C ONT.) Treatment Considerations Patients with blood dyscrasias are at increased risk for periodontal infections. A rigorous program designed to prevent gingivitis and periodontitis should be provided to this patient population. 98 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

99 L EUKEMIAS Leukemias are a group of cell malignancies of the bone marrow. Abnormal white blood cells replace and suppress the differentiation of normal bone marrow tissue. Normal white blood cells are depleted, and the production of platelets is reduced. As a result, patients with leukemia (particularly those with acute forms) are at an increased risk for infections and bleeding problems. 99 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

100 L EUKEMIAS (C ONT.) The major types of leukemia are acute lymphoblastic leukemia, acute myeloblastic leukemia, chronic myeloid leukemia, and chronic lymphocytic leukemia. The acute forms have a sudden onset and lead to death in a few months unless treated. Chronic forms develop slowly and usually have a relatively long clinical course. In all types of leukemia, increased susceptibility to infection (including periodontal diseases) can occur as a result of immunosuppression. 100 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

101 L EUKEMIAS (C ONT.) In some forms of leukemia, particularly acute myeloblastic leukemia, gingival enlargement occurs as a result of the accumulation of leukemic cells in the gingival tissues and swelling caused by plaque-induced inflammation. This oral manifestation of leukemia is relatively rare and is usually observed only in patients who are extremely sick and hospitalized. 101 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

102 L EUKEMIAS (C ONT.) Some patients with acute leukemia are treated with bone marrow transplantation. This treatment involves the intentional destruction of the abnormal marrow before inserting normal marrow cells. Because severe immunosuppression occurs with this treatment, eliminating all sources of oral infection before the patient’s malignant bone marrow is destroyed is advised. 102 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

103 N EUROLOGIC D ISORDERS Diseases affecting the nervous system are termed neurologic disorders. Patients with neurologic disorders exhibit three basic problems: 1. Physical inability to perform adequate oral hygiene procedures because of difficulties with hand movement and coordination 2. Mental and/or physical inabilities to cooperate with the practitioner 3. Changes in oral tissues that increase the risk for dental diseases 103 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

104 N EUROLOGIC D ISORDERS (C ONT.) Phenytoin-Influenced Gingival Enlargement Phenytoin is often prescribed to control cerebral seizures (epilepsy). A side effect of phenytoin is gingival enlargement. Approximately 50% of patients who take phenytoin for an extended time experience this side effect. Plaque control problems associated with gingival enlargement can lead to periodontitis and tooth loss. In cases of severe enlargement, surgical excision of the gingival tissue is required. 104 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

105 N EUROLOGIC D ISORDERS (C ONT.) The following figure demonstrates phenytoin- induced gingival enlargement. 105 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

106 N EUROLOGIC D ISORDERS (C ONT.) Treatment Considerations Evidence suggests that plaque-induced inflammation plays an important role in the gingival enlargement process. Patients who have this side effect should practice meticulous oral hygiene procedures. Frequent visits for professionally administered cleaning of the teeth are also advisable. 106 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

107 N EUROLOGIC D ISORDERS (C ONT.) Drug-influenced gingival enlargement is also a side effect of other drugs: Immunosuppressive medications (cyclosporine) are used to combat the rejection of transplanted organs. Medications such as verapamil and nifedipine are prescribed to treat cardiovascular problems. 107 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

108 N EUROLOGIC D ISORDERS (C ONT.) As demonstrated in the following figure, gingival enlargement can also occur in patients who have a rare condition known as hereditary gingival fibromatosis. 108 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.

109 T OBACCO U SE AND P ERIODONTAL D ISEASES Strong evidence suggests that tobacco use is an important risk factor for periodontal diseases. Smoking likely suppresses certain components of the immune system. Impaired neutrophil function induced by products of tobacco smoke appear to be particularly important. Informing a patient that periodontal diseases are infections and that smoking reduces the patient’s resistance to such infections and reduces his or her ability to control periodontal disease is more difficult if the patient continues to smoke. 109 Copyright © 2014, 2007, 2001, 1996 by Saunders, an imprint of Elsevier Inc.


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