Nutrition and Oral Medicine (Nutrition and Health)

66 Part II / Oral and General Health2.1.4. PUBERTY-ASSOCIATED GINGIVITISPuberty is a stage in the development of human beings characterized by sexual maturation.Studies suggest that the prevalence, severity, and extent of gingivitis increase inchildren reaches a peak around the age of 12–14 and decreasing thereafter, with significantlylower values by the age of 16–17 (14). The increase in the severity and extent ofgingivitis appear to parallel sexual maturation rather than plaque index, suggesting anenhanced response of gingival tissues to the presence of dental plaque and supporting therole of puberty in the pathogenesis of gingivitis (15).One of the most significant changes occurring during pregnancy, menstrual cycle, andpuberty are major hormonal shifts, and these hormonal changes have been proposed asone of the mechanisms responsible for the increase in the expression of gingivitis duringthese physiological states (10,16). During pregnancy, there is a significant increase ingonadotropins in the first trimester and progesterone and estrogens in the second and thirdtrimesters. The menstrual cycle is also associated with significant surges in progesteroneand estrogen, although these changes are less dramatic than those seen in pregnancy.During puberty, the changes in the hormonal makeup vary between girls and boys. Ingirls, there is a significant increase in estrogen and progesterone; in boys, testosteronereaches significantly high values. The main mechanisms by which sex hormones affectperiodontal tissues are the effects on the elements of the host response such as increasedblood vessel permeability, vasodilation, decreased epithelial keratinization, reduction inneutrophil chemotaxis, and changes in T cells and signal transduction molecules (4,17).Studies have shown that the bacterial makeup changes during pregnancy and puberty,with a significant increase in the proportion of anaerobic to aerobic bacteria, particularlythe periodontopathogen Provotella intermidia, probably because of the ability of thesebacteria to use progesterone and estrogen as growth factors (9).2.1.5. DIABETES-ASSOCIATED GINGIVITISThe relationship between diabetes and periodontal disease is also discussed in Chapter11; the topic is reviewed here in the context of diabetes risk factors for periodontaldisease. Diabetes mellitus (DM) is an endocrine disorder with significant metabolicdisturbances. Type 1 diabetes (T1DM) is characterized by destruction of the pancreatic-cells through autoimmune mechanisms with consequent decrement or complete depletionof the insulin. Type 2 DM (T2DM) is characterized by the inability of insulin toexert its functions on target tissues because of deficiencies in its transduction system.T1DM constitutes 5–10% of all diagnosed diabetes, generally has its onset before theage of 21, and affects approx 1 in 400–500 children and adolescents. T2DM constitutes90–95% of all diagnosed cases of diabetes and has its onset in adulthood, although it hasbecome increasingly diagnosed in children and adolescents (18).Although gingivitis is prevalent in children, adolescents, and adults, DM adds anadditional risk to its development (3,19). In adults, the prevalence of people with diabeteshaving gingival inflammation is higher than in people without diabetes, whereas inchildren and adolescents with diabetes, the prevalence of gingivitis may almost doublecompared to healthy children and adolescents (20,21). When evaluated in children, theseverity and extent of gingivitis may also be significantly increased (22–27) and maydepend on glycemic control (25,28). Moderate to severe gingivitis is twice as extensivein subjects with diabetes compared to subjects without diabetes (24).