MEDICAL CONDITIONS AFFECTING THE PERIODONTAL TISSUES
forming a periodontal diagnosis, it is important to be aware of underlying
medical conditions that can alter the response of the peiodontal tissues
to plaque accumulation, or act independently of plaque on the periodontal
A thorough medical
history is an integral part of the dental examination for new patients,
and should be updated at each recall appointment. A number of medical conditions,
or their related drug therapy, can lead to gingival hyperplasia. Of the
ten or more drugs that have been found to cause gingival overgrowth, the
three most common types of drugs that have been associated with hyperplasia
1. Phenytoin (Dilantin),
an anticonvulsant drug used in the management of epilepsy.
2. Cyclosporin A
(Sandimmun), used to prevent rejection in organ transplantation, and for
treatment of some aut~immune diseases.
3. Nifedipine (Adalat),
a calciumchannel blocker used in the prophylaxis and treatment of angina,
and in the control of mild hypertension.
Hormonal effects due
to pregnancy, puberty and the contraceptive pill have also been related
to gingival hyperplasia. Increased progesterone secretion alters the gingival
vasculature and the inflammatory response to accumulated plaque.
is also associated with some granulomatous disorders, such as Crohn's disease,
sarcoidosis and Wegener's granulomatosis. Crohn's disease is the most common
of this group. The characteristic gingival lesion associated with this
disease is a diffuse erythematous, granular enlargement of the attached
gingiva. Severe periodontal destruction has been reported for some patients
with Crohn's disease.
It is always necessary
to eliminate local causes of gingivalovergrowth. Plaque and ill-fitting
dentures are also major causes of this response, and need to be corrected
as part of periodontal management. Defects in the host response may lead
to more rapid periodontal breakdown. Insuliniiependent diabetes mellitus,
particularly if undiagnosed or poorly controlled, is related to increased
periodontal destruction and susceptibility to periodontal abscesses. Neutrophil
defects related to cyclic neutropenia and leukemia result in severe destructive
periodontitis. The periodontal manifestations of genetic conditions, such
as Down's syndrome, Papillon-Lefevre syndrome and Chediak-Higashi syndrome,
also occur through defects affecting neutrophils. HIV infection dramatically
suppresses normal host response, and HIV-related gingivitis and periodontitis
have been defined as distinct clinical entities.
There are a few rare
connective tissue disorders that result in accelerated periodontal destruction,
including scurvy, kwashiorkor (protein deficiency), hypophosphatasia, and
Ehlers-Danlos syndrome. Neoplastic disorders, such as squamous cell carcinoma,
multiple myeloma, and eosinophilic granuloma, can affect the gingival tissues
or the deeper periodontal tissues leading to bone loss. A medical history
should not only uncover illnesses that directly affect the periodontal
tissues, but should also reveal conditions that may affect your management
of the patient. Many common medications result in decreased salivary flow.
A history of radiation therapy to the head or neck area can also be related
to dry mouth. Disabling conditions such as arthritis can limit the patient's
ability to clean their teeth, and oral hygiene devices may need to be adapted
to the patient's needs. The need for antibiotic prophylaxis, (for example,
due to rheumatic fever, cardiac valvular surgery, prosthetic replacement
of hip joints), should be recorded and included as part of a periodontal
treatment plan. Allergies to any medication should also be noted.
Smoking has been associated
with increased periodontal destruction in some studies, and therefore details
of this habit should be recorded. Advice on smoking cessation can form
part of your overall treatment plan.
An excellent reference
for the relationship between medically related conditions and the periodontium
is: Seymour RA, Heasman PA. Drugs, diseases and the periodontium. Oxford
University Press, 1992.