Endocrine+disorders

Three Take Away or Big ideas From Carranza on Endocrine Disorders and Periodontitis.  There is a relationship between endocrine disturbances and periodontal disease. "Endocrine disturbance and hormone fluctuations affect the periodontal tissues directly, modify the tissue response to local factor, and produce anatomic changes in the gingiva that may favor plaque accumulation and disease progression" (Carranza et al., 2006). The following are endocrinal disorders that could have direct affect or modifications on periodontal tissues:1. Diabetes Mellitus2. Hyperparathyroidism3. Sex hormones4. Gingiva during puberty5. Gingiva during menses6. Gingiva during pregnancy7. Gingiva during menopause8. Using corticosteroid hormones1. Diabetes Mellitus and Peridontal Disease Diabetes Mellitus is one of the most prevalent conditions in the Unites States, with over 15 million people affected (Carranza et al., 2006). This condition is characterized by long-term elevated blood sugar levels that ultimately can lead to numerous complications if not treated, such as micro and macro-vascular diseases, delayed healing, increased susceptibility to disease, and ultimately kidney disease (Carranza, et al., 2006). Diabetes is divided into two types, known as: Type 1 and Type 2 diabetes mellitus. Type 1 diabetes, formerly known as insulin dependent or juvenile onset diabetes, is an autoimmune condition in which the beta cells of the Islets of Langerhans in the pancreas are destroyed. These cells produce insulin, and their destruction causes an insufficient supply of insulin in the bloodstream. Patients must rely on injected insulin in order to manage their blood glucose levels. This condition can often be difficult to control, and patients may be at risk for ketosis and coma (Carranza et al., 2006). Type 2 diabetes is more common, accounting for nearly 95% of all cases. It is a condition in which sufficient insulin is produced, but the body has developed a resistance to its action. Both types of diabetes can have significant effects on the oral cavity.Periodontal changes associated with diabetes include enlarged gingiva, gingival polyps, abscesses,loose teeth, and periodontitis (Carranza et al., 2006). Other oral manifestations of diabetes mellitus are dry mucosa which is contributed by an inadequacy in salivary flow, angular chelitis due to the fact that there is an increased incidence for Candida infections, cracking and burning of the mouth and tongue, an increased incidence for caries and abscess, and longer time duration for gingival healing. Factors that are thought to contribute to the progression of peridontal disease in diabetic patients include the type of bacteria present in the oral microflora in these patients, as well as the theory that polymorphonuclear leukocyte (PMN) function is diminished causing an impairment in host response. In addition, it has been shown that collagen synthesis is decreased in individuals with uncontrolled diabetes, and that collagenase activity is increased, leading to a more rapid progression of the breakdown of periodontal tissues, a delayed tissue regeneration (Carranza et al., 2006).In addition, patients with poorly controlled diabetes have a higher content of glucose in their gingival fluid and blood. This increase of glucose may change the environment of the microflora, thereby contributing to the severity of periodontal disease (Carranza et al., 2006).Periodontal infection influences glycemia. Acute bacterial and viral infections have been shown to increase insulin resistance and aggravate glycemic control. This occurs in individuals with and without diabetes. In individual with type 2 diabetes, who already has significant insulin resistance, further tissue resistance to insulin induced by infection may considerably exacerbate poor glycemic control. In type 1 patients, normal insulin doses may be inadequate to maintain good glycemic control in the presence of infection-induced tissue resistance. It is possible that chronic gram-negative periodontal infections may also result in increased insulin resistance and poor glycemic control (Carranza et al., 2006).Patients that have uncontrolled diabetes tend to have more glucose in their system. This equates to more glucose excretion in the gingival fluid and blood. The extra glucose provides energy to specific bacteria depending on the type of diabetes. A.a is seen in both type 1 and 2. The nutrition provided to the bacteria allows growth and possible damaged to the periodontium if not controlled.Another reason why diabetic patients are more susceptible to disease is thought to be caused by poor PMNs chemotaxis, defective phagocytosis, or impaired adherence. The role of the PMN is important in controlling bacterial infection. If this line of defense does not operate correctly bacteria are free to cause damage.Patients with chronic diabetes have impaired collagen metabolism. The creation of different molecules in the body have to be precise. Hormone need to fit perfectly in the receptor that they are meant to attached to and proteins like collagen need to have a certain characteristic. Patients with diabetes have a higher concentration of //accumalated glycation end products (AGEs)// that bind to collagen and make it less likely to be repaired or replaced. **2- Female sex Hormone **Ginigval disease can be modified by female sex hormones during puberty, menstural cycles, and pregnancy. These hormaonal changes are characterized by non-specific inflammatory reactions with a predominant vascular component, which leads to increased bleeding. During puberty, the patient may experience an exaggerated response to gingival plaque. Because of the exaggerated response the gingival tissue will have pronounced inflammation in addition to bluish red discoloration, edema, and gingival enlargement due to local factors. As the child develops into an adult the severity of the response will decrease. This type of response will not occur an all patients during the puberty phase of life, and it can be prevented with proper oral hygiene. During a menstrual cycle, a patient may experience in occasional change in gingiva. These changes are attributed to hormonal imbalances and in some cases ovatian dysfunction. Notable changes do not occur to the gingiva because of menstruation.SR14.
 * Causes gingival alterations
 * Plans a role in puberty gingivitis, menopausal gingivitis, and pregnancy gingivitis
 * Gingiva may include these findings
 * Exudate
 * Bluish discoloration
 * Edema and slight enlargement
 * Hemorrhagic
 * Prior to the start of the females menstrual cycle the patient may present with:
 * Increased bleeding
 * Bloating
 * Tense feeling
 * Inflamed tissue
 * A change in the amount of bacteria can be seen during menstruation and ovulation up to 14 days earlier

During pregnancy, gingivitis is casued by bacterial plaque. Pregnancy increases the gingival response to plaque. Changes in healthy gingiva are not normally noted when there are no local factors present. However, pregnancy does affect the severity of previously inflammed areas. The severity of gingivitis increases during the second and third month of pregnancy. The previously inflammed areas become enlarged, edematous, have noticable color change, and increased bleeding. It has been suggested that the accentuation of gingivitis occurs during the first and third trimesters. Because during the first trimester, there is an over production of gonadotropins, and during the third trimester the levels of estrogen and progesterone are at there highest (Carranza et al., 2006). The gingiva will begin to return to its original state as soon as 2 months postpartum and after a year the gingiva will return to its normal state. SR Changes to the gingiva are bleeding, bright red to blueish red in appearance, the marginal and interdetnal gingivae are edematous, pit on pressure, smooth, shiny, soft, and may have a raspberry like appearance (Carranza et al., 2006). No changes occur in the gingiva during pregnancy in the absence of local factors, such as plaque. Important to note that that pregnancy itself does not cause gingivitis. GE But it does change the microflora in the body which may be the cause of inflammation. The bacteria that is most common seen due to hormonal interaction is //P. intermedia.//

**3-Corticosteroid Hormones **ACTH appears to have no effect on the incidence and severity of gingival and periodontal disease. However, exogenous cortisone may have an adverse effect on bone quality and physiology. Studies in animals have shown that introducing systemic cortisone into the test subjects resulted in osteoporosis of the alveolar bone, hemorrhaging of the PDL, and destruction of the collagen fibers and connective tissue of the periodontium (Carranza, 2006).It is believed that circulating cortisol in the system can decrease the immune response with increased exposure, resulting in an increased pathologic response to the bacteria present in the mouth (Carranza, 2006). This can lead to a periodontal response in the host.Renal transplant patients who are receiving immunosuppressive therapy have less gingival inflammation than control subject with similar amounts of plaque. (Carranza, 2006)Gingiva during pregnacy: During pregnanct, there is an increased tooth mobility, pocket depth, and bleeding. This is due to the increase in estrogen and progesterone. **Hyperparathyroidism** results in demineralization of the skeleton, increased osteoclasis with proliferation of the connective tissue in the enlarged marrow spaces, and formation of bone cysts and giant cell tumors" (Carranza et al., 2006). Changes to the oral cavity are increased mobility, malocclusion, decreased bone density, widening of the PDL space, no lamina dura and radiolucent cyst like spaces. When these cyst like spaces are filled with connective tissue, giant cells, and hemosiderinladen macrophages it is then known as a brown tumor (Carranza et al., 2006). Radiographically the clinician will see a ground glass appearance, with connective tissue bone cysts. Patient will generally have malocclusion and tooth mobility.