Stress and Nutritional Deficiencies on Periodontium

What is Stress

An inharmonious fit between the person and the

environment, one in which the person’s resources are taxed

or exceeded, forcing the person to struggle, usually in

complex ways to cope.”

Richard S. Lazarus. Puzzles in the study of daily hassles. J Behavioral Med. 1984; 7(4): 375-389

A reasonable amount of researches indicate the

association of psychosocial stress, financial

stress, occupational stress, distress, the negative

impact of life-events and depression with

Periodontitis

Linden GJ, Mullally BH, Freeman R. Stress and the progression ofperiodontal disease. J Clin Periodontol. 1996;

23(7): 675-680.

Stress can be viewed as a process with both

psychological and physiological components

Reners M, Brecx M. Stress and periodontal disease. Int J Dent Hyg.2007;5(4):199-204.

DIRECT Alteration of Resistance

of Periodontium to

infection

INDIRECT

Psychological aspect of a

person with health

impairing behaviour like

• Poor Oral Hygiene• Smoking• Alcohol Consumption• Poor Nutrition

Stress affects the periodontium directly or indirectly

• The most documented example between

stress and Periodontal disease is NUG

• NUG in soldiers during wartime in

trenches lead to diagnostic term Trench

mouth

Chronic or long term stress is more like be

associated with Periodontal destruction than

acute stress

Individual with Problem focussed (Practical

coping) skills fared better than individuals with

emotion-focussed (avoidance) coping skills

with respect to periodontal disease

Chronic stress and inadequate coping could

lead to changes in daily habits, such as

– Poor oral hygiene

– Clenching & Grinding

– Decreased salivary flow

– Suppressed Immunity

Stress induced Immunosuppression

• Stress and psychosomatic disorder impact the periodontal health

• Complex Interaction among

Stress Implications

Pshychiatric influence or Self induced injury

Self-induced or Factitious Injury

Neurotic Habits:

Grinding, Clenching Teeth, Nibbling on

Foreign Objects(pens etc),Nail Biting, excessive

use of tobacco

Self-inflicted injuries such as Gingival

Recession have been described both in children

and adults

Nutritional Influences

• No Nutritional defencies that by themselves may cause

Gingivitis or Periodontitis

• There are Nutritional defencies that produce changes in

oral cavity.

– Changes include alterations of tissue of lips, oral

mucosa,gingiva and bone

Vitamin Deficiency

• Fat soluble : A,D,E,K

• Water soluble: B,C

Vitamin A

• Major function is to maintain health of epithelial cells of skin & mucous membrane

• Prevent microbial invasion by maintaining epithelial integrity

• Deficiency in experimental animals– Hyperkeratosis, Hyperplasia of gingiva,

increased pocket formation, proliferation of Junctional epithelium, Retardation of wound healing

Vitamin D

• Essential for absorption of Ca from GIT and maintenance of Ca- P balance

• Deficiency Rickets in children, osteomalcia in adults

• Animals– Osteoporosis of alveolar bone

Vitamin E

• Serves an Antioxidant to prevent free radical

reactions

• Protect cells from Lipid Peroxidation

• Cell membranes which contain highest content of

Polyunsaturated Fatty Acids are major site of

Vitamin E deficiency

• No direct relation have been found between

Vitamin E deficiency and Oral Disease

• Systemic Vitamin E have been shown to

accelerate gingival wound healing in rats

Oral Changes associated Gingivitis Glossitis Glossodynia Angular Cheilitis Inflammation of entire oral mucosa

Oral disease is rarely caused by a deficiency

in just one component of the B-complex

group, the deficiency is generally multiple

Vitamin B Complex Deficiencies

Gingivitis in Vitamin Deficiencies is non-

specific because it is caused by bacterial

plaque rather than by deficiency but

deficiency can have modifying effect

B1 or Thiamine Deficiency

Characterised by• Paralysis• CVS symptoms including Edema• Loss of ApetiteOral symtoms-• Hypersenstivity of Oral Mucosa,• Minute vesicles on oral mucosa, buccal vesicles on buccal

mucosa, under the tongue or on palate

• Called Berberi

B2 Riboflavin Deficiency

• Glossitis-Magenta Discoloartion

• Angular Cheilitis

• Seborrheic Dermatitis

• Superficial Vascularising Keratitis

• Atrophy of Papillae

• Angular Chelitis-Perleche

B3 Niacin Deficiency

• Pellagra characterised by • 3Ds

– Dermatitis– Diarrhea– Dementia

• 3Gs– Glossitis– Gingivitis– Generalised Stomatitis

• Glossitis and Stomatitis are the earliest

signs of Niacin Deficiency

• Gingiva may be involved with or without

tongue changes

• MC finding is NUG in areas of

irritation

Folic acid Deficiency

• Results in Macrocytic Anemia with Megaloblastic Erythropoiesis

• Oral Changes

• GI lesions

• Diarrhea

• Intestinal Malabsorption

• Ulcerative stomatitis is an early indication of toxic

effect of Folic acid antagonist (Methotrexate) used

in treatment of leukemia

• Gingival changes associated with pregnancy and

OCP may be partly related to suboptimal levels of

Folic acid in Gingiva

• Phenytoin induced gingival growth and folic acid,

based on interference of folic acid absorption and

utilization of Phenytoin

Vitamin C or Ascorbic acid Deficiency

• Defective formation and maintenance of collagen

• Impairment or cessation of Osteoid formation

• Impaired Osteoblastic function

• Increased capillary permeabilty

• Susceptiblity to traumatic hemorrhages

• Hyporeactivity of contractile element of peripheral blood

vessels

Clinical Manifestation

• Hemorrhagic lesions into muscles & extremities,joints, nail beds

• Petechial hemorrhages around hair follicles

• Susceptibilty to infections

• Impaired healing

• Bleeding, swollen gums and loosened teeth

• Gingivitis in vitamin-C deficient patient is

caused by dental Plaque

• Vitamin C deficiency may aggravate the

gingival response to dental plaque and worsen

the edema, enlargement and bleeding

• Acute vitamin C deficiency does not cause or

increase the incidence of gingival inflammation,

but it does increases its severity

Vitamin C deficiency alone does not cause

periodontal destruction, local bacterial

factors are required for increased pocket

proding depth and attachment loss to occur

Protein Deficiency

• Protein depletion reults in Hypoprotienemia

• Protein deprivation has shown changes in Periodontium

of experimental animals

– Degeneration of gingival& Periodontal connective tissue

– Osteoporosis of Alveolar bone

– Impaired deposition of cementum

– Delayed wound Healing

– Atrophy of Tongue Epithelium

• Protein deficiency accentuates the destructive

effects of Bacterial plaque and occlusal trauma on

the periodontal tissue, but initiation of gingival

inflammation and its severity depend on

bacterial plaque

• Protein deprivation results in Periodontal tissue

that lack integrity and are more vulnerable to

breakdown when challanged by bacteria

Other Systemic Deficiency

HypophosphatasiaFamilial skeletal disease characterized by• Rickets,Poor Cranial Bone Formation, Premature

loss of primary teeth particularly incisors• Low level of Serum Alkaline Phosphatase• Phosphoethanolamine present in serum and urine

• Teeth are lost with no clinical evidence of gingival

inflamation• Reduced cementum formation

Early exfoliation of primary incisors in Hypophosphatasia

Congenital Heart Disease

• Cardiac defects involve heart and adjacent vessels or combination of both

• MC feature in CHD is Cyanosis

• Shunting of deoxygenated blood from Right to Left

• Poorly oxygenated blood in circulation

Chronic hypoxia causes

• Impaired development,

• Compensatory Polycythemia

• Clubbing of toes and Fingers

• Polycythemia can result in hemorrhagic or thrombotic tendencies

Oral manifestation

• Cyanosis of Lips & Oral Mucosa• Delayed eruption of both decidious and

permanent dentition• Increased positional abnormalities• Enamel Hypoplasia• Teeth color bluish white • Increased Pulp Vascular volume

• More severe caries & Periodontal disease in

Cyanotic Congenital Heart Disease patients

Teratology of Fallot

Characterised by four Cardiac Defects

1. Ventricular Septal Defect

2. Pulmonary Stenosis

3. Malposition of Aorta to Right

4. Compensatory Right Ventricular

enlargement

C/F:

Severe Cyanosis, audible Heart Murmurs and Breathlessness

ORAL CHANGES:• Purplish Discoloration of lips and Gingiva• Severe marginal Gingivitis and Periodontal Destruction• Tongue is coated or Fissured• Extreme reddening of of Fungiform or Filiform Pappilae• Number of Subepithelial Capillaries is increased after

Heart surgeries

Eisenmenger’s Syndrome

• VSD>1.5 cm in diameter• Greater blood flow from

stronger Left ventricle to Right Ventricle(Left to Right Shunt)

• Progressive Pulmonary Fibrosis

• Blood Flow reversed• Right to left flow (Right

to Left)

Oral Manifestations:

Cyanosis of Lips, Cheeks, Buccal Mucosa

Severe Generalised Periodontitis have been reported in

Eisenmengers syndrome

Metal Intoxication

• BISMUTH

• Narrow bluish black discoloration of gingival margin

in preexisting area of inflammation

• Precipiation of Bismuth Sulphide associated with

vascular inflammation

.

LEAD

• Salivation, coated tongue, peculiar

sweetish taste,

• Gingival pigmentation is linear

(Burtonian line),steel gray associated

with local inflammation

Mercury

• Headache, CVS symptoms, Pronounced salivation

and Metallic taste

• Gingival pigmentation deposition of mercuric

sulphide

• Phosphorous, Arsenic, Chromium can

lead to necrosis of alveolar bone with

loosening and exfoliation of the teeth

• Benzene intoxication lead to Gingival

Bleeding, ulceration and destruction of

underlying bone