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Gum Problems Amongst Medically Compromised Patient

Introduction

Periodontal disease, commonly referred to as gum disease / gum problem, is the single most common cause of tooth loss in adults. Gum disease, including gingivitis and periodontitis, are serious infections that left untreated, can lead to tooth loss. This inflammatory disease is a chronic bacterial infection that affects the gums, bones and other supporting structures of the teeth.

The impact of general health on oral health is well recognized. General health may affect the body defense response to oral bacteria. Some of these diseases increase the risk of gum problems which includes gingivitis and periodontitis or alter their presentation, progression and severity.

Individuals lacking adequate resistance to infection, in which the immune systems have been compromised by condition such as HIV-infection, Down Syndrom, autoimmune diseases, leukemia and several disorders of blood cells are vulnerable to gum problems.

AIDS and Gum Problems

Someone with human immunodeficiency virus (HIV), the virus that causes AIDS, is at increased risk for gum problems because his or her immune system is weakened and less able to withstand infection. In fact, studies have shown that oral infections are one of the earliest clinical signs that someone may have HIV. And about three quarters of people with HIV will develop some type of oral infection, whether it is gingivitis or oral thrush (candidiasis).


AIDS-related gingivitis; the gum are red and swollen

A HIV-positive person shows the same types of symptoms of gum problems as someone who is not HIV positive, including swollen or bleeding gums that are a dull red in color. But the symptoms may be more severe and more likely to recur in an immunocompromised person and the appearance of gum problems in people with HIV or AIDS also includes oral problems that are unique to this condition.

  • Necrotizing ulcerative periodontitis (NUP). NUP is a sign of severe suppression of the immune system, and patients who have it often complain of pain deep in the jaw. NUP causes pain, bleeding gums, and rapid destruction of the bone that supports the teeth. Someone with NUP will have ulcerated gum tissue surrounding the teeth, and the teeth may become loose. A dentist will treat this condition with a thorough cleaning and removal of infected tissue if necessary, followed by a course of antibiotics. NUP is very painful, and a patient’s dentist and doctor may work together to be sure that the patient is not in so much pain that he or she is unable to eat. If eating is too painful, nutritional supplements may be needed until the infection resolves.

Necrotizing ulcerative periodontitis with loss of attachement on the lower teeth causing receeding gums
  • Linear gingival erythema (LGE, also called red band gingivitis). The key sign of LGE is a red band along the base of the teeth where they meet the gingival tissue. This condition is less severe than NUP, but it should be treated with a professional dental cleaning. A mouth rinse; chlorhexidine gluconate is advisable for regular daily dental care routine for a few weeks.

Down syndrome and Gum Problems

Individuals with Down syndrome are likely to have a variety of illness including gum problems. In the deciduous dentition, gingivitis is almost always present and is often severe. A compromised immune system in these individuals contribute to a higher rate of infection even though they do not have a lot of plaque and tartar. These individuals also do not have some of the natural protection against gum disease like others. In addition, Down syndrome individuals have decrease ability to master adequate plaque control and consequently increase their susceptibility to gum problems. A study found that the first signs of periodontitis may be seen as early as 11 years of age with most lesions detected in the lower front teeth. Other affected teeth include the upper and lower first molars, and canines are the least affected.

The prevalence of gum problems in Down syndrome individuals is high (occurring in almost 100% of patients younger than 30 years) and is characterized by formation of deep pockets associated with substantial plaque accumulation. It is usually generalized, although they tend to be more severe in the lower front teeth region; marked recession is also sometimes seen in this region. The disease progresses rapidly. In localized form, affected sites exhibit rapid bone loss with minimal inflammation of the gum. Acute necrotizing lesions are a frequent finding.


Appearance of the gums in Down syndrome

The family is an important component in the treatment of gum problems in Down syndrome patients. Because many of these patients lack the comprehension or manual capacity to perform dental hygiene, family members should be entrusted with this responsibility. Treatment often can slow the disease process and should be followed with greater frequency and performed early in life.

Leukemia and Gum Problems

In leukemic individual, even when aggressively undergoing chemotherapy, there is marked decline in immune system. When this suppression of immune system occurs, the leukemia patient is at mark risk for development of gum problems. These conditions develop in response to microbial components in the mouth for which the leukemia patient is not able to defend against. The presence of gum problems can result in complication associated with eating and keeping a proper diet.

Gum bleeding is a common finding in leukemic individuals, even in the absence of inflammation of the gum. In leukemic individual the inflamed gum is bluish red in colour, markedly spongelike and friable, and bleeds persistently on the slightest provocation or even spontaneously. This markedly altered and degenerated tissue is extremely susceptible to bacterial infection, which can be so severe as to cause acute gum necrosis.

Study showed that leukemic cells can infiltrate the gum and less frequently the bone that support the teeth. Infiltration of these cells often result in leukemic gum enlargement, commonly found on the gum in between teeth and sometimes in severe condition the gum may partially cover the crowns of the teeth.


Appearance of mild gum enlargement

Thrombocytopenia and Gum Problems

Thrombocytopenic purpura is a blood dyscrasia associated with a decrease in circulating platelets, prolonged clot retraction and bleeding time. Individual who suffers from thrombocytopenia usually bleeds spontaneously or on the slightest provocation and is difficult to control. The gums are swollen, soft and friable. The gum changes represent an abnormal response to local irritation.

Diabetes and Gum Problems

Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Gum disease is one of the lesser-known complications that can affect patients with diabetes. Individuals with diabetes had a greater level of gum disease than individuals who do not have the disease. Diabetic patients have a decreased ability to fight bacteria that invade the gums. When a body is suffering from diabetes, the structure of the blood vessels is altered. This may affect the efficiency of the blood flow and in turn may weaken the bone and the gums leaving them more prone to infection. Like all infection, serious gum disease may be a factor in causing blood sugar to rise and may make diabetes harder to control. The symptom of gum disease as a result of diabetes however may manifest themselves individually.

Treatment

Treatment of gum problems is the same in immunocompromised individuals. A thorough cleaning to remove plaque and tartar followed by regular routine of twice-daily tooth brushing and daily flossing is recommended. However these group of individuals must be especially deligent about the oral health and visit dentist at the first sign of irritation or infection of the gums. Gum problem is best treated at an early stage.

Conclusion

The mouth is a readily accessible and visible part of the body which can sense and response to the external world and at the same time reflects what is happening deep inside the body. The mouth may show sign of nutritional deficiencies and early warning sign for disease such as HIV infection, stress and other immune system problems. Although gum problems are mainly an infectious disease, environmental, physical, social and body defense mechanism may affect and modify disease expression. In other words the immune response to bacteria in the mouth is very important and is likely to explain the differences in disease severity from individual to another. These alterations may manifest clinically early onset of gum disease or a more rapid rate of destruction than would occur in the absence of such disorders.

References

  1. Almas K & Awartani FA. Prevalence of medically compromised patients referred for periodontal treatment to a leading hospital in Central Saudi Arabia. Saudi Med J (2003); 24(11); 1242.
  2. American Academy of Periodontology. Parameter on Periodontitis Associated with Systemic Conditions. J Periodontol (2000); 71: 876-879
  3. Louise F Rose, Barbara J, Steinberg & Steven L.Atlas. periodontal management of the medically compromised patient. Periodontol 2000 (1995); vol 9: 165-178
  4. Mealey BL. Periodontal implications ; Medically compromised patients. Ann Periodontol (1996); 1: 256-321
  5. Mealey BL, Reses TD, Louise F Rose & Sara GG. Systemic factor impacting the periodontium in Periodontics: Medicine, Surgery & Implant (2004) , Elsevier Mosby.
  6. Perry RK, Mealey BL & Carranza FA. Influence of Systemic Disease and Disorders of Periodontium in Clinical Periodontology (2007). Elsevier Mosby 9th edition
  7. Ryder MI. Periodontal management if HIV-infected patients. Periodontol 2000 (2000);23; 85-93
Last reviewed : 25 April 2014
Writer : Dr. Khamiza bt. Zainol Abidin
Accreditor / Reviewer : Dr. Uma Subramaniam