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The influence of systemic conditions on the
oral environment and especially the periodontium has long been recognized and
supported by scientific evidence. However, an evidence base for the influence
of periodontal diseases on overall systemic health has only recently begun to
be established. There is growing evidence that a number of complex human
diseases are associated with opportunistic infections in periodontal medicine.
Asa consequence, there has been a resurgence of interest in oral microbial
ecology, mucosal immunity, and associations with systemic conditions, such as
prematurity and low birth weight, pulmonary diseases, cardiovascular diseases,
and cerebrovascular diseases. This review will highlight the many advances and
opportunities for improved health care in the 21st century.
Medical emergencies can occur in any patient; however, they are most prevalent in geriatric or medically compromised patients. There is a rapidly growing segment of the population who’s physical or psychosocial problems may complicate dental treatment. The elderly or medically compromised patient who is frequently taking one or more medications such as steroids, anticoagulants, cardiac drugs, or immunosuppressive agents may require special consideration before undergoing dental treatment. Asever-increasing numbers of such individuals seek dental care, it becomes the responsibility of the dentist to avoid adverse therapeutic interactions and to deal with medical emergencies when they occur [1-4] Periodontal diseases, now recognized as bacterial infections, are among the most common, chronic diseases of humans, affecting 5 to 30% of the adult population in the age group of 25 to 75+ years. Periodontal diseases are also among the most important causes of pain, discomfort, and tooth loss in adults[5-6] with an increasing likelihood of medical emergencies in this population, the practising dentist and auxiliary staffs are responsible for identifying patients with a potential for medical risk by obtaining a comprehensive pre-treatment physical evaluation[7-9].
The patient evaluation at dental office is
performed to determine patients’ physical and emotional status and how well
they will tolerate a specific dental procedure. Little and King, in 1971,
presented the reasons for an evaluation of general health in the dental office.
They concluded that it should be done
b) To identify patients who are taking drugs or
medications that could adversely interact with drugs prescribed, that would
complicate dental therapy, or that may serve as a clue to an underlying
systemic disease the patient has failed to mention
c) To provide information for the dentist to
modify the treatment plan for the patient in light of any systemic disease or
potential drug interactions.
d) To enable the dentist to select and
communicate with a medical consultant concerning the patient’s possible
systemic problems
e) To help establish a good patient-doctor relationship by showing patients the clinician’s interest in them as individuals and concern for their overall well-being
Information obtained from the medical evaluation may prevent a medical
emergency. Awell-conceived
evaluation of the patient includes, first the medical history which can be
obtain in form of questionnaire and the personal interview, second is Present
health status, that means The patient should be asked the date and results of
the last complete physical examination. (eg.Diabetes, Blood pressure). Third is
past medical history which includes whether patient is having any significant
past history that affects the present treatment plan, fourth is allergies means
The patient should be asked about allergies or reactions to any foods,
medications, or environmental factors. Specifically, aspirin, local
anaesthetics, antibiotics, and any other potential allergens that may be used
in dental therapy should be mentioned. Fifth is Medication, it is imperative to
determine the brand and/or generic name of the drug, why and by whom it was
prescribed, the dosage, and the length of time the medication has been taken.
Patients may not include medications used for allaying anxiety or for inducing
sleep, such as tranquilizers and sedative-hypnotic drugs. Sixth is family
history, which is taken to determine if there is a familial predisposition to
diseases or if there are diseases in which inheritance is an important factor.
Finally, Positive findings should be summarized
and recommendations recorded. This will enable the dentist and the dental staff
to quickly review a patient‘s medical status at each visit and facilitate the
diagnosis and treatment of any medical emergency that may arise. A
comprehensive medical history is an important procedure that dentists must
adopt and routinely use to ensure that their patients are receiving the optimum
benefit from all available health resources.
Genetics and Clinical perspective
It has long been
observed that unusual forms of periodontitis, such as disease affecting young
individuals (early onset periodontitis), “run in families.” The evidence for a
genetic influence on early onset periodontitis has been well reviewed in recent
year [10]. Genetic diseases can be divided into three major categories:
chromosomal disorders, Mendelian disorders, and non-Mendelian disorders.
Congenital
chromosomal disorders are caused by an abnormal dose of normal genes. Because
of a deficiency or excess of chromosomal material. Down syndrome (trisomy 21),
which is caused by the presence of an extra chromosome 21, is a classic example
of a chromosome abnormality.
Mendelian disorders are caused by a mutation in a single gene and, therefore, are also referred to as single-gene (or major gene effect) disorders. The inheritance patterns of Mendelian disorders may be described in terms of the classic patterns of how certain traits, such as autosomal dominant or autosomal recessive disorders, are transmitted through successive generations. In Non-Mendelian Disorders Most common adult-onset diseases have a genetic component that cannot be explained by either a chromosomal abnormality or a major gene effect. In particular, the genetic influence of non- Mendelian disorders does not fit the typical inheritance patterns within families. These disorders are undoubtedly multifactorial; they are caused by a combination of genetic and environmental factors.
The practical use of
genetic information offers the potential to change periodontitis treatment.
Genetic predisposition to the onset of periodontitis means that some patients
can be identified even before disease begins. This improves the chances of
successful prevention. Genetic heterogeneity associated with disease also
extends to treatment responsiveness. Distinguishing patients who are of good
responders from those who are poor responders will allow more precise
chemotherapeutic interventions because drug targets will be more precise.
The main barrier to
widespread use of current technology is its poor record in predicting the
patient’s future periodontal status. Clinical and biologic evaluations can tell
the clinician about the current status of the patient’s periodontium but these
signs, symptoms, and clinical judgments have relatively weak prognostic value.
By focusing attention on both the etiology and modifiers of periodontitis,
rather than on “furing” the results of disease, practitioners can anticipate,
manage, and prevent disease much more effectively.
Cardiovascular Diseases and Oral Infections
The relationship
between oral infections and cardiovascular disease is well known, particularly
with respect to orally derived bacteraemia as a source of organisms that infect
damaged heart valves causing bacterial endocarditis. Recently, evidence has
emerged relating periodontal infections to coronary artery disease and stroke.
Infective endocarditis (IE) is a microbial infection of a native or prosthetic cardiac valve or surrounding cardiac tissue. It may be caused by a variety of microorganisms, including bacteria, fungi, rickettsia, or chlamydia. Recent evidence linking severe, generalized periodontitis with coronary artery disease, suggests that the periodontics must be prepared to provide safe yet effective therapy to patients with various types of heart condition. [11-12] Dentists may provide dental care for patients with any of these disorders, most often they are called upon to manage patients at risk of IE.[13] Dental procedures that involve manipulation of soft tissue and result in bleeding can produce transient bacteraemia. For example, 43% of patients with periodontitis experienced transient bacteraemia following routine periodontal probing[14]. Transient bacteraemia may be induced by some surgical or nonsurgical periodontal treatment procedures. However, these bacteraemia rarely persist longer than 15 minutes and the majority dissipate within 3 to 5 minute [15-16]. The risk of IE derived from transient bacteraemia associated with manipulation of dental tissues must be weighed against the cost and risk of complications associated with administration of systemic antibiotics.
There is some
evidence that oral irrigation or use of air-abrasive polishing devices may
induce bacteraemia when used inappropriately or in patients with poor
periodontal health, and these devices are not recommended [17-20]. Rinsing with
antimicrobial agents containing chlorhexidinegluconate or providence iodine
prior to manipulation of dental tissues may reduce the overall bacterial bio load.
This may be especially important in high risk patients and in those with poor
oral hygiene.
The AHA
recommendations for specific prophylactic antibiotic regimens for dental
procedures are widely published. For most adults, oral administration of 2 g
of amoxicillin I hour before the dental procedure is recommended. Clindamycin
(600 mg I hour before the dental procedure), cephalexin/cefadroxil or
azithromycin/clarithromycin are recommended as alternatives in patients that
are allergic to penicillin. Intramuscular or intravascular antibiotic regimens
are prescribed for patients that cannot take oral medications. The
recommendations are considered adequate for patients that are at high risk from
IE, including those with cardiac valve prostheses[21].
Prior to cardiac
surgery, dental procedures associated with a high risk of significant
bacteraemia should be accompanied by appropriate prophylactic antibiotic
support. When possible, dental extractions should be accomplished at least 2
weeks prior to the heart surgery to allow adequate wound healing. Patients
those are on anticoagulant regimen i.e. Aspirin which is often used as an
antithrombotic agent because of its inhibition of platelet aggregation, most
cardiologists prescribe very small daily dosages (80 to 325 mg). At these dose
levels, the medication will not significantly alter bleeding time[22]. On
occasion, however, patients on higher aspirin levels are at a slight risk for
prolonged postoperative haemorrhage following periodontal therapy. For these
individuals, the medication should be discontinued for 4 to 7 days
prior to the scheduled procedure with the concurrence of the cardiologist[23].
DE Stefano and colleagues[24] found that periodontal disease and poor oral hygiene are stronger indicators of risk of total mortality and of coronary heart disease. They suggest that oral hygiene may be an indicator or a surrogate for lifestyle affecting personal hygiene and health care and might explain the relationship between periodontal disease and heart disease. Multiple studies showing the relationship between periodontal disease and heart disease, after adjusting for many factors associated with lifestyle, such as smoking and weight, suggest that the relationship is not simply explained by lifestyle. Also, the finding that the graded exposure of periodontal disease leads to an increased cumulative index of coronary heart disease argues against lifestyle as a simple explanation for this association[25].
The association
between periodontal disease and cardiovascular disease or stroke could be due
to residual confounders or incomplete control of confounders. As with most
studies that adjust for possible confounders, the adjustments may not be
complete, so associations of this magnitude may be due to residual confounders.
Further research will
be needed to determine which, and to what extent, factors act singly or in
concert to contribute to the formation of athermanous plaques. It is important
to know the mechanisms, however, since they add evidence to support the association
between periodontal infection and atherosclerosis. In addition, knowing the
mechanisms may well lead to simple, cost-effective interventions that would
moderate, in part, the contribution of infection to atherosclerosis.
Relationship between Periodontal and
Respiratory Diseases
Respiratory diseases
are responsible for a significant number of deaths and considerable suffering
in humans. Accumulating evidence suggests that oral disorders, particularly
periodontal disease, may influence the course of respiratory infection. It is
possible that the teeth can serve as a reservoir for respiratory infection.
Indeed, the notion that the oral cavity may influence the bacterial flora of
the lower bronchi is not new. Oral bacteria can be released from the dental plaque
into the salivary secretions, which are then aspirated into the lower
respiratory tract to cause pneumonia. It has long been known that severe
anaerobic lung infections can occur following aspiration of salivary
secretions, especially in patients with periodontal disease[26].
Oral bacteria may
also have a role in the exacerbations of Chronic Obstructive Pulmonary Disease
(COPD). Laboratory studies suggest that oral anaerobes such as p. gingivuliscan
cause marked inflammation when instilled into the lungs of laboratory
animals[27]. Lack of attention to oral hygiene results in an increase in the
mass and complexity of dental plaque, which may foster bacterial interactions
between indigenous plaque bacteria and acknowledged respiratory pathogens such as
P.aueruginosuand enteric bacilli[28]. Dental plaque may therefore
provide a reservoir for colonization of respiratory pathogens that can be shed
into saliva. More recently, a prospective study of 57 consecutive
patients admitted to medical ICU during a 3-month period assessed the
colonization of dental plaque by respiratory pathogens[29]. The amount of
dental plaque on the teeth of inpatients increased over time, as did the
proportion of respiratory pathogens in their dental plaque.
Mechanisms of Action of Oral Bacteria in the Pathogenesis of Respiratory Infection
Several mechanisms
can be envisioned to help explain how oral bacteria can participate in the
pathogenesis of respiratory infection:
- oral pathogens (such as P. gingivulis, A. actinomycetemcomituns)
may be aspirated into the lung to cause infection
- periodontal disease-associated enzymes in saliva may modify mucosal
surfaces to promote adhesion and colonization by respiratory pathogens
- periodontal disease-associated enzymes may destroy salivary pellicles
on pathogenic bacteria
- Cytokines originating from periodontal tissues may alter respiratory
epithelium to promote infection by respiratory pathogens.
Several reports have documented a strong
association between periodontal disease and an increased frequency of oral
infections in nursing home resident[30]. However, there are no studies that
have identified an association between poor oral hygiene and the increased
incidence of pneumonia in such subjects. A possible link between poor oral
hygiene and the increased incidence of pneumonia in nursing home residents has
been suggested but no supporting evidence was provided[31].
The key role that is orpharyngeal bacterial
colonization plays important role in the pathogenesis of bacterial pneumonia,
several methods have been proposed to reduce or eliminate colonization in
susceptible patients, such as those on mechanical ventilation. It is
hypothesize that improved oral hygiene in the hospital setting may decrease the
occurrence of oropharyngeal colonization by respiratory pathogens and thus
decrease the risk of nosocomial pneumonia. One method, called selective
digestive decontamination (SDD), uses antibiotics topically applied to the
surfaces of the gastrointestinal tract (including the oral cavity) to reduce
the carriage of pathogenic bacteria and thus to prevent respiratory
infection[32-33]. However, while diminishing the colonization rate of
pathogenic bacteria in the hospital setting, SDD does not appear to have an
effect on the mortality rate and seems to foster the selection of
antibiotic-resistant bacteria and cross-infection[34-35]. These findings have
raised doubts about the widespread use of SDD. Other approaches to reduce
colonization of these pathogens certainly deserve more study.
Chlorhexidine appears to be a reasonable choice for this as it has been shown to reduce plaque and salivary levels of bacteria by up to 85%[36].Interestingly, chlorhexidinegluconate has been shown to reduce transfer of group B streptococci from mother to infant during parturition[37]. An interesting report by DeRiso and colleagues[38] suggests that a 0.12% chlorhexidinegluconate oral rinse reduced the overall nosocomial infection rate by 65% in 353 patients admitted to a cardiovascular ICU, and the incidence of total respiratory tract infections by 69%. These investigators also noted a 43% reduction in the use of no prophylactic antibiotics in chlorhexidine-treated patients. Finally, overall mortality was reduced to I. 16% in the chlorhexidine-treated group versus 5.56% in the placebo group.
Variety of recommendations has been made to
reduce the incidence of nosocomial pneumonia. Surveillance of potential
pathogens, identification of high-risk patients, staff education, hand washing,
and the proper use of gloves and gowns, all have a positive impact on reducing
nosocomial pneumonia. Additional attention paid to oral hygiene may even
further reduce the risk of nosocomial pneumonia. Unfortunately, little
information is available concerning the effect of improved oral hygiene on
infection rates in the hospital or nursing home setting. It would, therefore,
seem reasonable to perform appropriate studies to evaluate the effect of
improved oral hygiene on respiratory pathogen colonization in high-risk
subjects.
Periodontal
Disease and Diabetes
Oral complications of
diabetes may include alterations in salivary flow and constituents, increased
incidence of infection, burning mouth, altered wound healing, and increased
prevalence and severity of periodontal disease. Xerostomia and parotid gland
enlargement may occur in the diabetic individual. Diabetes patients may
complain of burning mouth syndrome associated with decreased salivary flow. Dry
mucosal surfaces are easily irritated and often provide a favourable substrate
for the growth of fungal organisms. The incidence of candidiasis may be
increased in patients with diabetes[39].
Diabetes is often
associated with increased gingival inflammation in response to bacterial
plaque[40]. This response may be related to the level of glycaemic control,
with subjects with well-controlled diabetes having a similar degree of
gingivitis as no diabetic individuals and poorly controlled diabetic subjects
having significantly increased inflammation Increased gingival
inflammation[41-42] may be seen in diabetic subjects even though plaque levels
are similar to no diabetic controls.
Diabetic patients
must be examined individually to assess their potential response to periodontal
therapy. The mere presence of diabetes does not condemn the person to a less
favourable periodontal outcome. A diabetic patient with good glycaemic control
can be expected to respond in a fashion similar to the no diabetic subject. The
presence of poor glycaemic control may place the patient at risk of a less
favourable response. In addition, other factors such as smoking or poor plaque
control may adversely affect the response to periodontal therapy in diabetic
individuals, just as they may in a no diabetic person.
Patients who present to the dental office with intraoral findings suggestive of a previously undiagnosed diabetic condition should be questioned closely. Questions should be targeted toward eliciting a clear history of polydipsia, polyuria, polyphagia, or recent unexplained weight loss. Patients should also be asked about family history of diabetes.
In patients with
suspected poorly controlled diabetes, dental treatment should be limited
initially to provision of emergency care[43]. Referral to the patient’s
physician should include a description of intraoral findings and a brief
outline of the patient’s dental treatment needs. The dental practitioner should
request evaluation of the patient’s glycaemic control and appropriate medical
management prior to elective dental treatment. In known diabetic patients, it
is important to establish the level of glycaemic control early in the
examination process. This can be done through physician referral or review of
medical records. Key considerations related to dental treatment of the diabetic
patient include stress reduction, diet modification, inpatient versus
outpatient care, antibiotic use, changes in medication regimens, and
appointment timing[44-45].
At one time, a
general recommendation was made for diabetic patients to have their dental
appointments in the morning. This recommendation was also made for many other
medically compromised patients. While morning appointments may be preferable
for some diabetic patients, others may be better treated in the afternoon.
Appointment timing often depends on the particular medication regimen used by
each individual patient. When possible, it is best to plan dental treatment
either before or after periods of peak insulin activity because hypoglycaemic
reactions are more likely to occur when insulin levels are high[45].
Ensuring oral health
in patients with diabetes requires an expanded scope of medical and dental
knowledge. There is undoubtedly a close relationship between diabetes and
periodontal disease, a relationship requiring further study and exploration.
Diabetes increases the risk of periodontal destruction, especially in patients
whose glycaemic control is poor. These same patients are most likely to report
to the dental office with significant periodontal treatment needs. All diabetic
patients should have routine dental evaluation and preventive therapy. The
practitioner who understands the role of diabetes in the etiology of oral
diseases, the potential for oral infections to influence glycaemic control, the
current medical therapeutic approaches to diabetes, and the implications of
diabetes on dental care provides the patient with the best chances of
successful treatment outcomes.
Periodontal Medicine and Female Patients
Women's life cycle changes present unique challenges to the oral health care profession. Hormonal influences associated with the reproductive process alter periodontal and oral-tissue responses to local factors creating diagnostic and therapeutic dilemmas. It is imperative, therefore, that the clinician recognize, customize, and vary periodontal therapy according to the individual female and the stage of her life cycle.
Puberty
During puberty, the
female experiences an increase in the production of sex hormones (estrogen and
progesterone) that remains relatively constant following puberty throughout the
normal female lifetime reproductive phase. There is also an increase in the
prevalence of gingivitis without an increase in the amount of plaque[46]. Recent
studies associated with puberty gingivitis indicate proportionately elevated
motile rods, spirochetes, and Prevotelluintermediu. Statistically
significant increases in gingival inflammation and in the proportion of Prevotellaintermediuand
Prevotellanigrescenswere seen in puberty gingivitis[47].
Preventive care,
including a vigorous program of oral hygiene, is vital. Milder gingivitis cases
respond well to scaling and root planning with frequent oral hygiene
instruction. Severe cases of gingivitis may require microbial culturing,
antimicrobial mouthwashes and local site delivery, or antibiotic therapy.
Supportive periodontal therapy visits may need increased frequency. Whenever
possible, involvement of a parent or caregiver with home care procedures is
recommended.
Menses
During the
reproductive years, there are on-going changes in the concentration of the
gonadotrophins and ovarian hormones during the monthly menstrual cycle.
Estrogen and progesterone are steroid hormones produced by the ovaries during
the menstrual cycle. The gonadotrophins follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) influence estrogen and progesterone to prepare the
uterus for implantation of the egg. The concept that ovarian hormones may
increase inflammation in gingival tissues and exaggerate the response to local
irritants has been postulated by several studies. Gingival inflammation seems
to be aggravated by an imbalance and/or increase in sex hormones[48].
Progesterone has been associated with increased permeability of the microvasculature, altering the rate and pattern of collagen production in the gingiva, increasing folate metabolism[49-50], altering the immune response. Gingival tissues have been reported to be more edematous and erythematous preceding the onset of menses in some individuals. In addition, an increase of gingival exudate has been observed during the menstrual period and is sometimes associated with a minor increase in tooth mobility[51]. Intraoral recurrent aphthous ulcers[52], herpes labialis lesions, and Candidae infections occur in some women as a cyclic pattern associated with the luteal phase of their cycle when progesterone is the highest. During the peak level of progesterone (about 7 to 10 days prior to menstruation), premenstrual syndrome (PMS) also occurs. There appears to be no significant differences in estrogen and progesterone levels between women who suffer from PMS and women who do not. Yet, women with PMS seem to have lower levels of certain neurotransmitters such as encephalin, endorphins, gamma amino butyric acid (GABA) and serotonin. Depression, irritability, mood swings, and difficulty with memory and concentration may be symptoms of neurotransmitter reduction.
For the women who
have increased gingival bleeding and tenderness associated with the menstrual
cycle, adherence to 3 to 4-month supportive periodontal therapy appointments is
recommended. Antimicrobial mouth rinses prior to cyclic inflammation may be
indicated. Particular emphasis should be placed on oral hygiene. Care should be
taken during dental treatment to prevent stimulating the more sensitive gag
reflex. The clinician should be aware that nonsteroidal anti-inflammatory
medication, infection, and acidic foods exacerbate GERD. Fluoride rinses and/or
trays, frequent periodontal debridement, and avoidance of mouthwashes with high
alcohol content may reduce the associated gingival and caries sequelae.
The PMS patient may
be difficult to treat due to emotional and physiologic sensitivity. Treat the
gingival and oral mucosal tissues gently. Moisten gauzes or cotton rolls with a
lubricant, chlorhexidine rinse, or water before placing them in the aphthous
prone patient. Careful retraction of the oral mucosa, cheeks, and lips will be
necessary in both the aphthous and herpetic prone patient. Since the
hypoglycemic threshold is elevated, advise the patient to have a light snack
prior to her appointment.
PREGNANCY
Pregnancy provides
unique diagnostic and treatment challenges to the periodontal clinician. It is
an opportunity to individualize care at a time when the patient may experience
the most profound physiologic and psychologic changes in her life. Awareness
exists regarding pregnancy and its effect on periodontal disease; however,
recent evidence indicates an inverse relationship to systemic disease. Current
research implies that periodontal disease may alter the systemic health of the
patient as well as adversely affect the well-being of the foetus by elevating
the risk of low-birth-weight, preterm infants.
In 1877, Pinard recorded the first case of “pregnancy gingivitis[53]. Pregnancy gingivitis is extremely common, occurring in approximately 30 to 75 percent of all pregnant women[54-55]. It is characterized by erythema, edema, hyperplasia, and increased bleeding. Histologically, the description is the same as gingivitis. The etiologic factors, however, are different despite clinical and histologic similarities. Pyogenic granulomas occur during pregnancy at a prevalence of 0.2 to 9.6 percent. The “pregnancy tumor” or “pregnancy epulis” are clinically and histologically indistinguishable from pyogenic granulomas occurring in women who are not pregnant or in men. They appear most commonly during the second or third month of pregnancy. The gingiva is the most common site involved (approximately 70% of all cases), followed by tongue and lips, buccal mucosa, and palate[56]. They usually grow rapidly, bleed easily, and become hyperplastic and nodular. They may be sessile or pedunculated and may be ulcerated. Colour ranges from purplish red to deep blue, depending on the vascularity of the lesion and the degree of venous stasis. The lesion classically occurs in an area of gingivitis and is associated with poor oral hygiene. Often calculus is present. Osseous destruction is not usually associated with pyogenic granulomas of pregnancy.
Alterations in
immunocompetency during pregnancy may create an exaggerated response in
periodontal supporting structures. Periodontal status prior to pregnancy may
influence the progression or severity as the circulating hormones fluctuate.
The anterior region of the mouth is more commonly affected, and interproximal
sites tend to be most involved[57]. Increased tissue edema may lead to
increased pocket depths and relate to a transient tooth mobility[58] Anterior
site inflammation may be exacerbated by increased mouth breathing, primarily in
the third trimester from “pregnancy rhinitis.”
Periodontal Disease And Preterm Low-Birth
weight Births
Due to the pioneering
research ofOffenbach and co-workers, evidence exists thatuntreated periodontal
disease in pregnant womenmay be a significant risk factor for preterm (<37weeks)
low-birth-weight (< 2,500 g) babies[59]. The relationship with
genito-urinary tract infection and preterm low birth weight (PLBW) is well documented
in human and animal studies. Periodontal researchers suspecting periodontal
disease as another source of infection found that mothers of low-birth-weight
infants, otherwise having low risk, had significantly more periodontal
attachment loss than control mothers having normal-weight infants at birth. The
current opinion is that PLBW occurs as a result of infection and is mediated
indirectly, principally by the translocation of bacterial products such as
endotoxin (lipopolysaccharide [LPS]) and by the action of maternally produced
inflammatory mediators[60].
Perimylolysis or acid
erosion of teeth may occur if “morning sickness” or esophageal reflux is severe
and involves repeated vomiting of gastric contents. Severe reflux may cause
scarring of the esophageal sphincter, and the patient may become a more likely
candidate for GERD later in life.
Xerostomia is a frequent complaint among pregnant women. One study found this persistent dryness in 44 percent of pregnant participant[61].
A rare finding in pregnancy
is ptyalism, or sialorrhea. This excessive secretion of saliva usually begins
at 2 to 3 weeks of gestation and may abate at the end of the
first trimester. While its etiology has not been identified, ptyalism may
result from the inability of nauseated gravid women to swallow normal amounts
of saliva rather than from a true increase in the production of saliva[62].
Because pregnancy
places the woman in an immunocompromised state, the clinician must be aware of
the total health of the patient. Gestational diabetes, leukemia, and
other medical conditions may appear during pregnancy.
The periodontal
evaluation of the pregnant patient begins with a thorough medical history. This
history should note any complications the patient has encountered in the pregnancy
and record any previous previous miscarriages, recent cramping, spotting, or
pernicious vomiting. If possible, the next step is to contact the obstetrician
to discuss the patient’s medical status, dental needs, and proposed treatment
plan. The most important objectives in planning dental treatment for the
pregnant patient are to establish a healthy oral environment and to obtain
optimum oral hygiene levels. These are achieved by means of a good preventive
dental program, consisting of nutritional counselling and rigorous plaque
control measures in the dental office and at home.
It is prudent to
avoid elective dental care other than good plaque control during the first
trimester and the last half of the third trimester if possible. The first
trimester is the period of organogenesis, when the foetus is highly susceptible
to environmental influences. In the last half of the third trimester, there is
a hazard of premature delivery because the uterus is very sensitive to external
stimuli. Prolonged chair time may need to be avoided because the woman is most
uncomfortable at this time. Further, there is a possibility that supine
hypotensive syndrome may occur. In a semi-reclining or supine position, the
great vessels, particularly the inferior vena cava, are compressed by the
gravid uterus. By interfering with venous return, this compression will cause
maternal hypotension, decreased cardiac output, and eventual loss of
consciousness. Supine hypotensive syndrome can usually be reversed by turning
the patient on her left side, thereby removing pressure on the vena cava and
allowing blood to return from the lower extremities and pelvic area.
The second trimester is the safest period for providing routine dental care. The emphasis at this time is on controlling active disease and eliminating potential problems that could arise in late pregnancy. Extensive reconstruction procedures and major oral or periodontal surgery should be postponed until after delivery. Pregnancy tumors that are painful, interfere with mastication, or continue to bleed or suppurate after mechanical debridement may require excision and biopsy prior to delivery. Dental radiography is one of the more controversial areas in the management of a pregnant patient. It is most desirable not to have any irradiation during pregnancy, especially during the first trimester, because the developing fetus is particularly susceptible to radiation damage[63]. However, the safety of dental radiography has been well established, provided features such as high-speed film, filtration, collimation, and lead aprons are used. Of all aids, the most important for the patient is the protective lead apron. Studies have shown that when an apron is used during contemporary dental radiography, gonadal and fetal radiation is virtually unmeasurable[64].
Another area of controversy involves drug
therapy because drugs given to a pregnant woman can affect the fetus by
diffusion across the placenta. A conservative approach is prudent, the dentist
prescribing only the minimum effective dose and duration absolutely essential
for the pregnant patient’s well-being and only after careful consideration of
potential side effects. The dentist may need to be familiar with the
classification system established by the Food and Drug Administration (FDA) in
1979 to rate fetal risk levels associated with many prescription drugs. In
periodontal therapy, the use of antimicrobial agents is common. During
pregnancy, the clinician must weigh the benefits and the risks to both mother
and fetus. Antibiotics with systemic effects cross the placenta and reach the
fetus. The effect of a particular medication on the fetus depends on the type of
antimicrobial, the dosage, the trimester, and the duration of the course of
therapy[65]. At this date, there is inadequate research in relation to
subgingival irrigation and local site delivery in relation to the developing
fetus.
Oral
contraceptives
Gingival tissues may have an exaggerated
response to local irritants. Inflammation ranges from mild edema and erythema
to severe inflammation with haemorrhagic or hyperplastic gingival tissues. It
has been reported that there is more exudates in inflamed gingival tissues of
OC users than in those of pregnant women[66]. Investigators have reported
several mechanisms for the heightened response in gingival tissues. Kalkwarf
reported that the response may be due to alteration of the microvasculature,
increased gingival permeability, and increasing synthesis of prostaglandin[67].
Prostaglandin E is a potent mediator of inflammation. Jensen and colleagues
found dramatic microbial changes in pregnant and OC user groups as compared
with a no pregnant group[68].
A comprehensive medical history and an assessment of vital signs (particularly blood pressure) are extremely important in this group of patients. Treatment of gingival inflammation exaggerated by oral contraceptives should include establishing an oral hygiene program and eliminating local predisposing factors. It is also imperative that the patient be informed of their heightened risks and the need for meticulous home care and compliance with supportive periodontal therapy visits. Periodontal surgery may be indicated if there is inadequate resolution after initial therapy (scaling and root planning). Antimicrobial mouthwashes may be indicated as part of the home care regimen. It may be advisable to perform extraction of teeth (especially of third molars) on non-estrogenic days (days 23 to 28) of the pill cycle, to reduce the risk of a postoperative localized ostitis[69].
CONCLUSION
Transmissible and opportunistic microorganisms are
responsible for dental caries. Transmissible and opportunistic microorganisms
are also responsible for periodontal diseases. In the case of periodontal
diseases, the microbial-induced infection presents a substantial infectious
burden to the entire body. Further, specific microorganisms within the
microbial ecology associated with the disease process release toxins that
invoke an inflammatory response. Bacteria, bacterial toxins, localized tissue
response cytokines, and other inflammatory mediators enter the vascular
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