1. Stress and Nutritional
Deficiencies on Periodontium

2. 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

3. 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.

4. 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.

5. 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

6. • The most documented example between
stress and Periodontal disease is NUG
• NUG in soldiers during wartime in
trenches lead to diagnostic term Trench
mouth

7.  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

8. Chronic stress and inadequate coping could
lead to changes in daily habits, such as
– Poor oral hygiene
– Clenching & Grinding
– Decreased salivary flow
– Suppressed Immunity

9. Stress induced Immunosuppression
• Stress and psychosomatic disorder impact the
periodontal health
• Complex Interaction among

10. Stress Implications

15. 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

16. Nutritional Influences

17. • 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

18. Vitamin Deficiency
• Fat soluble : A,D,E,K
• Water soluble: B,C

19. 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

20. 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

21. 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

22. • 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

24. 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

25. Gingivitis in Vitamin Deficiencies is non-
specific because it is caused by bacterial
plaque rather than by deficiency but
deficiency can have modifying effect

26. B1 or Thiamine Deficiency
Characterised by
• Paralysis
• CVS symptoms including Edema
• Loss of Apetite
Oral symtoms-
• Hypersenstivity of Oral Mucosa,
• Minute vesicles on oral mucosa, buccal vesicles
on buccal mucosa, under the tongue or on palate

27. B2 Riboflavin Deficiency
• Glossitis-Magenta Discoloartion
• Angular Cheilitis
• Seborrheic Dermatitis
• Superficial Vascularising Keratitis
• Atrophy of Papillae
• Angular Chelitis-Perleche

28. B3 Niacin Deficiency
• Pellagra characterised by
• 3Ds
– Dermatitis
– Diarrhea
– Dementia
• 3Gs
– Glossitis
– Gingivitis
– Generalised Stomatitis

29. • 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

30. Folic acid Deficiency
• Results in Macrocytic Anemia with
Megaloblastic Erythropoiesis
• Oral Changes
• GI lesions
• Diarrhea
• Intestinal Malabsorption

31. • 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

32. 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

33. 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

34. • 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

35. Vitamin C deficiency alone does not cause
periodontal destruction, local bacterial
factors are required for increased pocket
proding depth and attachment loss to occur

36. 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

37. • 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

38. Other Systemic Deficiency
Hypophosphatasia
Familial 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

39. Early exfoliation of primary incisors in
Hypophosphatasia

40. 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

41. Chronic hypoxia causes
• Impaired development,
• Compensatory Polycythemia
• Clubbing of toes and Fingers
• Polycythemia can result in hemorrhagic or
thrombotic tendencies

42. 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

43. 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

44. 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

45. 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)

46. Oral Manifestations:
Cyanosis of Lips, Cheeks, Buccal
Mucosa
Severe Generalised Periodontitis have
been reported in
Eisenmengers syndrome

47. Metal Intoxication
• BISMUTH
• Narrow bluish black discoloration of gingival margin
in preexisting area of inflammation
• Precipiation of Bismuth Sulphide associated with
vascular inflammation
.

48. LEAD
• Salivation, coated tongue, peculiar
sweetish taste,
• Gingival pigmentation is linear
(Burtonian line),steel gray associated
with local inflammation

49. Mercury
• Headache, CVS symptoms, Pronounced salivation
and Metallic taste
• Gingival pigmentation deposition of mercuric
sulphide

50. • 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