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15GENERALIZED PARODONTAL DISEASES AND ANOREXIA NERVOSA: CLINIC - LABORATORY
PARALLELS
Reshetnyk L.
PhD student, Antonenko M.
PhD, doctor of Medicine, Zelinska N.
PhD, associate professor.
Department of Dentistry, Institute of Postgraduate Education Bogomolets National Medical University, Ukraine, Kiev.
ABSTRACT
The study was aimed to identify clinical and laboratory features of manifestation of generalized parodontal diseases in patients with anorexia nervosa. We used clinico-radiological, immunological, analytical and statistical methods. Thus, direct correlation and interdependence of generalized parodontal diseases in the format of basic characteristics of anorexia nervosa were established.
Keywords: generalized parodontal diseases, generalized parodontitis, hypersensibilisation, anorexia nervosa, osteoporosis.
Introduction. Generalized parodontal diseases (GPD) are one of the most common dental diseases, which occupy a significant place in the structure of human diseases [1]. Recently, there has been a steady tendency to increase the prevalence of GPD not only among able-bodied, but among young people with no gender preferences. According to WHO, the prevalence of GPD is 60-90% [2].
Despite the increase in dental culture of the population, which has been trending lately and prompts the early treatment of patients, the result of treatment of GPD is often unsatisfactory. This is due to some extent because of the complexity of understanding the etio-pathogenetic mechanisms of development of these diseases, and the high association of GPD with a number of diseases of the internal organs and systems with common points of contact between interdependence and mutual influence [3].
A great number of researchers point to the high probability of pathogenetic communication of GPD with endocrine pathology, systemic diseases of human connective tissue, infraction vitamin, protein and lipid metabolism, emphasizing the thesis of associativity, affiliation and, even, the comorbidity of these diseases in patients with such basic pathology [4, 5]. But in literature there are only fragmentary science articles that suggest a possible correlation of anorexia nervosa (AN) and GPD and offer a specific approach to the features of their treatment, which, in our opinion, is a major drawback [ 6, 7].
Recently, the incidence of AN has increased significantly and poses a serious state, social, psychological and medical problem. According to WHO in the general population, the prevalence of AN ranges from 0.37 to 1.0 per 100,000 population, with a frequency of 0.9- 4.3% in women and 0.3% in men and tends to increase significantly [8, 9, 10]. A particularly high risk of death was found with critically low body weight and later onset [11, 12, 13].
There are significant changes, associated with AN, in the neuro-endocrine system, including the axis of the hypothalamus - pituitary - amygdala - genital and thy-
roid gland. These changes are accompanied by a decrease in estrogen production, leading to pre-menar-cheal amenorrhea and potentiating cortisol levels, abnormal secretion of insulin-like growth factor-1 and decreased thyroid hormone metabolism. Hypoestrogenia can be a trigger for the development of osteopenia and osteoporosis, which leads to a decrease in bone mineral density. Emerging hypogonadism and secondary hy-perparathyroidism, as a result of disorganizing eating behavior in AN, low calcium intake, and vitamin D deficiency and hypercorticism, may also be one of the important components that predispose GPD in patients with AN.
Absence of clear ideas about interaction and interaction do not allow to develop adequate methods of treatment of GPD in patients with AN.
Aim: To identify clinical and laboratory features of manifestation of generalized parodontal diseases in patients with anorexia nervosa.
Materials and methods: to achieve this goal, clinical and radiological methods of parodontal assessment were used to verify the diagnosis (according to the systematics of parodontal diseases after M.F. Danilevsky, 1994) as well as immunological tests (inhibition of migrating leukocytes) by M. George method as a first type screening reaction and statistical methods (STATISTICA 6.0).
The object of our research, with informed consent, included 75 patients with AN, 18-36 years (average age 26 ± 3.8) - the main group (M), and 60 patients without AN of the same age - the comparison group (C). For a detailed analysis of the clinical manifestations of GPD all patients in the main (M) and comparative (C) groups were divided into several subgroups. M1 subgroup - patients with various forms of gingivitis. The M2 subgroup included patients with generalized parodontities (GP), associated with AN as the basic pathology.
The comparative (C) group consisted of two subgroups (C1), (C2) with different forms of gingivitis and GP, respectively. All patients with AN had a treatment in the neuropsychiatry department of Kiev Clinical Hospital on railway transport №1 (head of the Depart-
ment - O.V. Moskalenko). Note, that all examined patients had a restrictive form of AN. We did not have patients with the cleansing form of AN.
In the result of the research, independent parodontal soft tissue diseases of various forms and the course of gingivitis were diagnosed in 20±4.6% cases, while GP of different degrees and course was observed in 80±4.6% in the main group.
Analyzing the data of patients of the subgroup M2, catarrhal gingivitis prevailed among the independent diseases of the soft parodontal tissues, while other forms of gingivitis were not diagnosed.
It was found that the majority of patients had catarrhal gingivitis in 86.7±8.8% cases, which had exclusively chronic course, and exacerbation of the process was observed only in 13.8±8.8% cases.
It is fair to note that the collection of a detailed anamnesis in patients of the main group and the identification of complaints was difficult due to the lack of a psychological alliance, which was accompanied by a lack of willingness to participate in voluntary contact during the examination. This is due to the fact that people with AN are unreliable "informants". Only a further structured interview helped gather information to evaluate anamnestic features and complaints.
While examination patients of the (C) group collection of anamnesis and complaints had no difficulties. Such patients were ready for dialogue. There was an open desire to participate in a therapeutic alliance.
Results of own research. The research, as a whole, established a high incidence of GPD in patients with AN, including both independent soft parodontal tissue diseases and diseases of the entire parodontal
It should be noted that patients of the comparative group without manifestations of anorexia nervosa had a higher incidence of independent forms of gingivitis -80 ± 5,2%, while GP of different degrees and course was diagnosed less frequently and was observed in 20
We believe that the absence of any connotative dental complaints in patients of (M) group, in our opinion, could be due to the full focus only on the paradigm of their appearance, pathological concern about their own weight, figure and low level of all components of compliance. But in 20±10.3% of cases there was a so-called symptom of aeration, manifested by complaints of the inability to chew food, unbearable pain when trying to bite off a piece of fresh bread, "pathological tooth mobility" and a feeling of tooth loss that did not respond to clinical changes.
It should be noted that in the majority of patients of Mi subgroup chronic gingivitis was characterized by involvement in the pathological process of only the marginal part of the gums. In most cases (66.7±12.2%) with a background of stagnant hyperemic and dense gums, a marked narrow band of stagnant hyperemia was noted in the area of the cervical teeth. In 20±10.3% cases areas of congestive gum hyperemia were replaced by zones with marked pallor. It was found that only 13.8±8.8% cases of chronic inflammation covered all components of the soft tissues of the periodontium.
complex (fig. 1).
Main characteristics of generalized parodontal diseases in
patients with anorexia nervosa (the main group) „ „ . . ..
Independent forms of gingivitis
15 (without detailing the form and
a course of disease)
60 Generalized parodontities
(without detailing the degree and a course of disease)
± 5,2% of cases (fig. 2).
Patients in M1 subgroup had typically supragingi-val dental calculus, and in 26.7 ± 11.4% cases it appeared as a whole layer.
In all patients of the M1 subgroup according to the radiological examination, the extension of periodontal fissures was established throughout, while maintaining the cortical plate. They noted osteoporosis of the apex of the alveolar bone ridge and bone components of the periodontal complex.
It can be assumed that the enlargement of the per-iodontal cleft and osteoporosis, on the one hand, was due to chronic inflammatory process in the soft tissues of the parodontum, and on the other - the existing osteoporosis could be a manifestation of systemic osteoporosis caused by a decrease in estrogen production, abnormal secretion of insulin secretory factor and decreased thyroid hormone metabolism, resulting hypogonadism, and secondary hyperparathyroidism.
Patients of the C1 subgroup, unlike pations of the M1 subgroup, were diagnosed with all forms of gingivitis, including catarrhal, atrophic, desquamative, ul-
77.1±6.1% cases, 4,2±2.9% cases, 6.3±3.5% cases, 2.1±2.1% cases, 10.4±4.4% cases, respectively.
It should be noted that, unlike the patients in the (M) group, in the (C) group, a high motivational component was observed, which indicated a willingness to take part in full treatment.
Finalizing the analysis of subjective and clinical manifestations of lesions of parodontal soft tissues affiliated with AN, the patients of the (M) group were characterized by: no complaints; low degree of psychological alliance with the doctor; had catarrhal gingivitis with a predominant lesion of the marginal gums with chronic course; extension of the periodontal cleft and osteoporosis of the bone component of the periodontal complex.
In 60 patients (80,0±4,6%) (out of 75) of the (M2) subgroup on the basis of clinical and radiological examination was diagnosed GP from the initial to the second degree, chronic course with the predominant absence of complaints (fig. 3).
The distribution of parodontal lesion in patients of the main
group
12
GP, initial-I degree, chronic
course
GP, I-II degree, chronic
course
48
It should be noted that among the examined patients of the M2 subgroup, GP had a chronic course, and only 3.3± 2.3% cases had exacerbation of the process as a result of the recently transmitted infectious process. Symptomatic catarrhal marginal gingivitis was observed in soft periodontal tissues. We believe that mainly chronic course of GP in patients of M2 subgroup, in our opinion, could be caused by significant changes in the general immunological reactivity of the organism due to AN, which did not allow to trigger an active inflammatory response.
As a result of radiological examination of patients of M2 subgroup with primary -I degree GP, the extension of the periodontal fissure and osteoporosis of the bone component of the periodontal complex was revealed, the horizontal type of resorption in all patients, as well as the cortical plate dislocation in the segment of the primary degree, and 1/3 reduced in the segment I degree. The advantages and priorities of different segments of the periodontal complex in patients with NA were not observed.
In determining the hypersensitivity of the delayed action to the bone antigen in this group, all patients showed a high degree of tissue sensitization, which showed significant changes in the bone component of the parodontal complex. This could be a predictor and an indicative factor that simplifies the diagnosis of primary-stage GP when the radiographic picture is not yet clearly expressed.
Some peculiarities were established in the study of the interdependence of GPD and AN with the gender of patients, age and their peculiarities of duration, form and stage of the main disease.
Thus, no influence of gender on the peculiarities of manifestation of GPD, associated with AN was noted (fig. 4).
The impact of patient's gender with anorexia nervosa on the features of the course of generalized parodontal diseases
60 50 40 30 20 10
33
27
Women Men
Independent forms of gingivitis (without detailing the form and a course of disease)
Generalized parodontities (without detailing the degree and a course of disease)
It was found that high frequency of GPD was defined to all age categories of patients with AN, and the course of GP increased with age (table i). It should be noted that since the exacerbated course of both ca-
tarrhal gingivitis and GP was observed in 2 persons, respectively, we considered it expedient to analyze the effect of patients' age on the frequency of GPD only among persons with GPD chronic course, associated with AN.
Table i
Influence of age on frequency of generalized parodontal diseases in patients with anorexia nervosa
Age of patients, years Catarrhal gingivitis, chronic course Generalized parodontal diseases
Main disease GP, initial-I degree, chronic course GP, I-II degree, chronic course
Anorexia ner- 7 8 11
vosa 18-25 9,9+3,5% 11,3+3,8% 15,5+4,3%
p> 0,05 p > 0,05 p > 0,05
4 4 16
25-30 5,6+2,7% 5,6+2,7% 22,5+5%
p> 0,05 p> 0,05 p > 0,05
2 1 18
31-36 2,8+ 2% 1,4+1,4% 25,4+5,2%
p < 0,01 p > 0,05 p > 0,05
Total 13 13 45
18,3+4,6% 18,3+4,6% 63,4+5,7%
*p - confidence indicator
It is established that as the stages of AN progress, in particular primary, anorectic and cachectic, the proportion of people with GP increases. Thus, if it was
14.7% at the initial stage of AN, and reached 20% at the anorectic stage, then it was already 42.7% at the cachectic stage (fig. 5).
0
The results of the study showed no correlation be- disease and GP was found more with accentuation for tween the duration of NA and the independent forms of the duration of 9-12 years (table 2). gingivitis, but a direct dependence of the underlying
Table 2
Influence of the duration of anorexia nervosa on the manifestation of generalized periodontal diseases
25
20
15
10
23
Primary stage Anorectic stage Cachectic stage
Catarrhal gingivitis, chronic course
GP, initial-I degree, chronic course
GP, I-II degree, chronic course
Fig. 5. Influence of stages of anorexia nervosa on the frequency of generalized parodontal diseases
Duration of anorexia nervosa, years The number of patients Catarrhal gingivitis, chronic course Generalized parodontal diseases
GP, initial-I degree, chronic course GP, I-II degree, chronic course
4 3 8
1-3 15 5,6+2,7% 4,2+2,4% 11,3+3,8%
p > 0,05 p > 0,05 p > 0,05
5 3 11
4-8 19 7+3% 4,2+2,4% 15,5+4,3%
p > 0,05 p> 0,05 p > 0,05
4 7 26
9-12 37 5,6+2,7% 9,9+3,5% 36,6+5,7%
p < 0,01 p > 0,05 p> 0,05
Total 13 13 45
18,3+4,6% 18,3+4,6% 63,4+5,7%
*p - confidence indicator
5
0
Conclusions:
1. A high incidence of periodontal disease was established, reaching 100% in patients with anorexia nervosa.
2. Among the independent forms of gingivitis, the most common was chronic catarrhal gingivitis with an emphasis on the marginal gums in patients with anorexia nervosa.
3. It is established that generalized parodontitis prevails over other forms of GPD (80 ± 4.6%), mainly I-II degrees, chronic course in patients with anorexia nervosa.
4. The influence of age on the frequency of generalized periodontal diseases has been established. The severity of GP was directly dependent on the age of patients with AN.
5. The course of GP was directly dependent on the age of patients with AN.
6. The relationship between the main clinical and radiological manifestations of generalized parodontitis
from the the duration and stage of nerve anorexia (primary ^ anorectic ^ cachectic) was established.
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DIABETES MELLITUS AND CHRONIC HEART FAILURE: CURRENT VIEWS ON THE PROBLEM
Salimova G.
Independent researcher, Tashkent medical academy
Najmutdinova D.
Doctor of Science, professor, Tashkent medical academy
Razakova F.
Independent researcher, National University of Uzbekistan
ABSTRACT
This article presents modern views on type 2 diabetes mellitus with its association with chronic heart failure. Keywords: type 2 diabetes mellitus, chronic heart failure, diabetic cardiomyopathy.
Currently, despite the development of high technologies, problems associated with type 2 diabetes mellitus (DM) remain, since the steady increase in this disease and the frequency of its serious consequences is of great concern to the global medical community. Thus, according to the World Diabetes Federation (IDF), there were more than 150 million patients in the world at the end of the 20th century, and according to WHO forecasts, the number of patients with type 2 diabetes will reach 333 million by 2025. Unfortunately, by the time of diagnosis of type 2 diabetes, half of the patients already have complications leading to a decrease in the quality of life, early disability and premature death [1]. This is due to consequences such as loss of vision, the development of terminal stages of renal failure, non-traumatic amputations, as well as complications associated with cardiovascular disease (CVD). It should be noted, according to numerous data in the literature [2], in diabetes cardiovascular disease occur 2-5 times more often than those without the disease. At the same time, there is a high risk of developing conditions such as coronary heart disease (CHD), myocardial infarction (MI), arterial hypertension (AH), and acute cerebrovascular accident (stroke). So, 69% of patients
with diabetes have dyslipidemia, 80% have hypertension, and 50-75% have diastolic dysfunction. Thus, today type 2 diabetes is regarded as the equivalent of the presence of a clinically pronounced cardiovascular disease in a patient, which indicates the need to pay special attention to this problem. As it is known, the main cause of deaths in 52% of patients with diabetes is chronic heart failure (CHF) [3].
It has now been proven that there is a two-way relationship between heart failure and type 2 diabetes, confirmed by pathogenetic studies, as well as a significantly worsening prognosis for the patient with a combination of these nosologies [4]. The Framingham study proved an increase in the risk of developing heart failure in patients with type 2 diabetes, compared with the general population, 2 times for men and 5 times for women [5]. As a result of epidemiological studies, it was found that the prevalence of heart failure among patients with diabetes is approximately 2.5 times higher than in the general population. It is noteworthy that according to the results of population studies, type 2 diabetes is a risk factor for developing heart failure, since the risk increases with increasing severity of type 2 diabetes [6,7]. Moreover, in diabetes, the predictors of
