PERIODONTAL DISEASE AS AN ETIOLOGY OF OROFACIAL AND MUSCULOSKELETAL PAINS IN WOMEN ( Case R € Port )

Orofacial pain includ€s Pain associated with tle hard and sofl fissues oflhe h€ad, face neck and all of the intadal structures Upon painful episod€s, consuming analgesics or lraditional medicine arc r;iatlely common. Il is aho a common s€ns€ that high choledercl and h)penensim ma),contrrb"ute !o .h. odi; Since mosr pain rufferers are $omen e\rtogen is proposcJ ro be a modulaLor ol pJrr Derc;ption. Neverlheless. the mechanism ofpain modulation in women is still in cunkorers) s)stemrc I'anii"'tatlons .r period.nlal diseas€ are widelv accepred Howe\er, the role ot pedodonral disease as an eriolos\ ol o;ofdciil and mdsculoslelelal parns i' rdrelv discu\sed Reenr srud) in medEr "tr"n"".ii.i.t-.r.gy ma) reveal fie possibilir) of periodonLal disete a" an eliolo€) of $ek iuinrut "r.ptoms. rt e oUj""i;ue ot rt'i. studl is to reteal rhe po's;b;lir) uf periodontal disedse a' an !ii"]""" '"r'"-i"" i"l dnd musculoskeletal parns. Periodontal treahents w€rc done to women who suner"J fron orolacial and nusculosk€letal pains, resulfing in the disappearing of the svnptoms n.eardine ro rne muirg re 'u l ls . rhe conclu. ron is rhar especia l lv in $omen perrodunral d smr-md) .,,1" *.ir. i,r -a t*"-"tuskeleLdl pd rns especiallv in s onen tnJaneriaa Jaut nal -t Dc {li'try 20t)6 [disi Khusus KPPJKG x1/:202'205


Introduction
The field of orofac;al pain includes pain condiiions that are associaled with th€ hard and soli tissues ofthe head, face, neck, and all oflhe intraoral slructures.The diagnostic range includes headacbei musculoskeletal, neurogenic, psychogenic painsi pains from major diseascs such as cancei and sleep disorders relatcd !o The sign and symploms of Pain in the general population have been found io occur more frequently in women than men, al ralio approximately 2 | l.How€ver, in populations $itn an a8e rdge of I5 -45.women are three lo nine times morc likel) to suffer from paintul symproms than men.: After the tifth d€cad€ of life.the diiTerence is declinihg; il is proPosed iha! estrogen is a possible etiology of th€se pain Researches on migraine shows !ha! women wilh great€r vulnerability to hormonal change shows improvemenl after menopause-However, only 60% of wom€n appear to be very hormonal sensilivq therefore, femal€ sexual hormones do not seem to be the only factor ;nfluencins headache."There was also a study lhat miSraine ;mproves in 55 -90 % of women during preSnanc) The eract pathophyrioloSical nlechanism underlying the relationship bct\een estrogen and pain remains ;n controversy' However.rhe possibility of periodontal disease as an etiologv of painful symptoms such as orofacial atd musculoskel€tal pains in women is mrelv A cas€ repo( by Utorno and Pmhasanti had been rcvealed lMt periodonlal lreatments w€re useful ;n eliminating paioful symptoms in women suffering from headache and dysmenorrhea " Nelertheless, this case report only reter lo ih€ lale puberry women.The obiectiv€ of this study Ar first visit, there were gingjlal is to propose periodontal disease as an €tiology of inflammarion ed r€dness in €very fegion, and orofacial and musculoskeletal pains especially in several fixed prosthesis.There was a cantilevef women.based on rhe evidencbbased case bridse wilhoul resL in 3T and &idle in 25 26 27 reports.
that mused food impaction and perjodonral

Case Operation Procedures
Case l: A 37 yees old femele suffered from beadach, shoulder neck and back muscles pain, especially i. the dght side of the body.Other symptoms were slepy in the aflemoon but sleeplessn€ss at nighi.The synptoms worsen about 6 months before the treahent was done, but the symptoms had alrcady staded abour 1 when h€r periods ca'ne, the pain b€came unbenrablei she could not sland and only lay down.She had dysm€norhea and all the pain symptoms worsen during that time.she has consulted s€veml docto.swithoul improlements.
At first visit, €xlra oral condition looked normal, except for the fatigue appearance.Intra oml exmination found that there were gingival inflammation and redness in €very region.Pfobing revealed that p€riodontal pockets exisred in all regions and more pronounced in rhe post€rior regions and the gingiva ble€d easily.
Panoramic radiograph showed horizontal resoQfion in allregions, esp€cially in lower righl r€gion where she had a splinted crowns on 47 46.
The first thing to be done was reshaping the splint bridgq widen jt embrasure to favor food cleansing.Scaling was don€ and the reaction of scaling proc€dur€s made hef f€lt bett€r; headache and should€r pain subsides insrantly.
Ar second sit, one week lat€r, she said thar all the pain symptoms had disapp€ared!also sh€ had an undislr!.bed sleep at night.she was also taught how to clean he.splint bridge, and sugg€sted to make a new one if the symproms One month later, she was evalual€d and said lhat the pain symptoms did not exisr; and when she had h€r p€riod, the symprons retar€d to dysnenonh€a w€re gone.She was €valuated in April 2006, 6 monfts larer and the painful symptoms did not exisl.Cas€ 2: A 47 y€ars old f€mal€, suffered from several painful symptoms on the left sid€ of hel body such a! throbbing headach€, rcck, shoulder, back and leg muscles pains for abolrr 5 years.Other symptoms were dysregularion of blood $essure, heart palpitation!irribbility, and nasal She had already consulted many doctors in s€veral counlries uithout satisfying resulb_ Some doctors said that she had h)ertension and Panoramic radiograph showed a horizonlal r€sorption in all regions, €sp€cially under the fix€d p.ostheses of24 25 26 and 37 36.On J7. there was a frlrcation involvement and verical At that time, the treatment was initiared with elimination of retenaive ared of the fixed prostheses which might cause periodonhl problens especially distal of27 and buccal of37 which were tbe most retentive areas.Atief rshaping and scalin8, the patien!fetl better.Patient was scheduled to hav€ gingival curcltage 'n one week time; chlorhexelidine 0.1 0/o mouthwash and antibiol'c (ceffadoxil 500 mg) were prescrib€d.She was rold 10 take rhe antibiolic 2 hoors betbre th€ second visi!fo.
At second visit, on€ w€ek laler, ihe paticnt r€ported that after th€ fiBt rreah€nl headache and oiher painful symptoms in rhe shoulder.neck, arm and I€g were disappeared.Cure&ag€ was don€ in 24, 26 and 37; patienr was scheduled for the n€xt visit on€ week later.
Atthird vis;1, th€ patient had no complaints; at that time she had her period and all the painful symploms she used to sufier did nor exisl.The latesl evaluation was in February 2006, 5 monrhs later; and ihe symptoms did.otrecur_ Cas€ 3: A f€nale, aged 63, suf€red from hsdaches, pain in the neck and shoulder and spasm in the righr hand for abour on€ yed_ Especially ir rhe $umb, index and middle finger wer€ feltjus!like tied by a rope..She had already sought for tr€atm€nts by many docrors in sev€ral €ountd€s without satisfying result.
On erlra oralexanination ar firstvhii, rhere was an asymmetry on the right side of h€r face.lntra o.ally, lhe gingival wer€ inflam€d r€d and th€re wer€ a lot ofcalculus deposits in the lingual of the right lower post€rior reeth; and ako chronic pefiodontal absc€ss in 45 46.
Panoramic .adiographrevealed that there was severe periodontal disease in €very regions.Especially in 15 and 45, the horizontal and venical resorpaioruwere ext€nsive.
At first visit wh€n abscess still present, scaling was don€ caretully, especially for the abundant calculus deposits in $eregion of45 46.Artibiotic, analgesic and chlorh€xeridin€ mouthwash w€re prescribed; the next visi!were scheduled in 5 days.
Ar second visi! the facial asymmetry did not exis.;she also said that the headache, pain and muscle spasd in the neck and shoulders subsides.At lhat lime, thc scaling procedure wd oontinued; aiter thc trealment was iinkhed.the parient said that ihe pain and spasm in h€r arm and fingers also ielt betcr' Padent was scheduled for the ncxt visit in sweek tine-At lhird vk;l.all lhe painlul symptooq includins hcadache and fin8er spasm were disappeared.The laiesl eralualion w$ in Februart 2006.6 months lateri fte palienl said that the symploms slill completely disappeared.

Discussion
Seleral peripheral md cenlral mechanism throirgh which estrogen could operale to increase pai.have been postulated for orofrcial pains, including enhanc€d inflammatory responses.actions olprcstaglandin release, and r€ceplors * Although in some situations prostaghnd;ns contribute to pain by dircctly activating nociceptors, they are Seremlly considered 10 be This case report and an article by Uromo and Prahasanti showed that, espccially in women who suffered from periodontal disede, the painful s)mptoms (headache and musculoskeletal paint occur from pub€rty unlil rnenoPause.Women in th€se case reports who slill have their menstrual period felt thai the painful syrnptoms were worsen durins their Period.'Migraine in women is attributed to abrupt withdrawal of estrogen rather lhan to susta;n high of low esrrogen levels.Abrupt wiihdrawal oi esrrogen occurs naturaliy in the menstrual cycle or artificially through cyclical inteN€nlion (e-9.during oral contracepl;ve), which causes the modulation of hyporhalamic beta endorphin and the dopamine and s€rolonin (5"HTl and 5-HT2) Anoiher cause of miSraine is the proinflammatory cytokine"s interleukin-lp (lL-19) and nitric oxide tNo).' lt has b€en Proposed thai NO plays a crucial role in the activation of the trlgeminovasculaf syslem by activating perivascular sensory affer€nt n€rve fib€n (via 5-HT feceptors) in the meninges.''According lo Nalbandian, low estrogen (17-B estradiol) as in menopause and phlsiological estroEen lev€ls as in pubefty tiu perimenopause, are stimulators of Thl inmune response that secreles pro;nflammalory cttokin€s such as IFNt, TNF-d and IL-12.In the other hand, high estrogen as in pregnancy, slimulat€ Th2 immune r€spo 3e rhat produce antiinflammatory cytokines IL-4, lL-t0 and TCF-P.'"Regarding to the existing painful symptoms that also occurred during the Iuteal phase which the female sexual hormones are in their peak concentralion,1'r ii seems plausible that no!only lemale sexual hormones nrodulate pain perception.The role of local inllammation such as chronic periodontal disease eliciled by endotoxin from gram negalive bactcfia (lipopolysaccharide.LPs)-\vhich nlay extcnd to sysemic inllammation'' should also be considered.l-ipopolysaccharide k a potent $inulalor of immunocompctent cells i e macropha8es and mast cells which rclease proinfl xmmatory mediators.'Tissue damage and inflammation as ir periodontal disease produce an aray ofchemical mediators such as bradykinin and prostanoids Other products are proinflammalor) c)'tokincs and neurop€ptides includins substance P {SP) and caloilonin Bene{elared peptide (CGRP) that can excite or sensnize nociceptofs !o elicit pain at thc s;ie of injury.r'raAmotg!hem.prostano;ds (i.e.prostaglandin E,, PGE,) werc shown 1o influence the inflammation.and their administ.ationwas found Io reproduce lhe maior signs of inflammation including augmentcd The inflammarory medialor PGE2 is thought to act direclly on lhe peripheral terminals of pdmdy afferent nociceptofs via the E-prostanoid rcceplors.'alhe efec$ are to produce hyperalges;a (tenderness); m sensrtrze nociceptorsr'*, and to enhance telodotoxin resislanl voltag€-gated-sodium currcni (TTX_RI Na).''Prostaglandin E, and nitric oxide (NO) sensitize primary afferenl heurons to bradykinin and other mediaro.sand are likely 10 be involved at mulliple sites along the nociceptive pathway " Comparing the characteristics of panl modulating subslances behreen men and women coincidenlally, basal NO serum concentrahon rn women is high€r tlan nen." ln addition" the anti oxidant propefies of €strogen ma) prelen$ NO degradalion and consequendy increasinS No availab;lity.b the presence ofNO, the sialc ol hypenlgesia and sensitization prcduced by PGEr When macrcphag€s are strongly aclivated.th€y can iniur€ nomalhost tissues by the release of NO which is a non-selective microbicidal.wh;ch do not distinguish between sclflissue and microbes.rrDanraged tissue creates more prostaslandins and bmdykinin, thus may induces mo.e pain md hYperalsesia.'Estrog€n ud Proges!€rone have disadvantag€ous effects to g;ngiva, as ihey ma) cause the susceplibility of women to periodontal disease.Estrogen decreases gingival keratinization, whereas progesterone increas€s lasodilalalion and permeabiljty.Add;lionally, esfoSen and proSesterone 6ay act as gowth facrots ol Ptevotella .intefnediath.t is gram negative periodontal paihogenic bacicria " In lhe pres€nce of LPS and IFN-T.macrophaS€s that primed wilh physiological le\el.l7-0esbadiol increae lhe producrion of NO." Interferonl, a Thl cytokine which is stimulated by low or physiolodcal €strogen level activates macrophages which then produce morc prcinfl ammatory clokines.'"Therefore.as h€adache mav €aused bv excess of IL-I, TNF-oe, and NOrp, women wirir low and physiological estrog€n lev€l may suffe.edfrom headache in fte presence of LPS.Coincidentally, 55-90% mig.aiheurs improve during pre€nancy, $pecially during the last two semesters;r it could be relaled to rhe high estrogen lev€l which acll as a stimlrlator of Thz cytokines which is anti-inflammatory.ruM€dical psychoneurdmmunology is focuses on tie intemctions among the C€ntral Nervous Syst€m (CNS), th€ neuroendocrine syst€m, and the immun€ system.The bypothalamic-pituilaly-adrenal (HPA) axis h a major pathway-through which immune function Proinflammatory c)lokines may stimulate the HPA axis which lead !o d|e Slucocodicoid (i.e.cortisol) synlh€sis.''The inc.ease ofcoiisol synthesis may decrease prog€slerone level in sev€ral ways: (l) as mnisol itself is a derivate of progesterone, increase of corthol synthesis may I€ad to d€crease of progesterone level", (2) by comp€titiv€ binding; as co.tisol and progesteron€ has the same affinity both to corticoid and progesterone receptors,^ cortisol may binds to progesterone r€ceptors,rv these mechanisms may r€du€€ th€ circulating prog€sl€rone lev€I.

Conclusion
Periodontal dis€ase, which is a chronic inf€c.ion;may cause orofacial and musculoskeletd pains in wom€n al lsst by two ways.First, chronic infection is a source of proinflammatory mediators which stimulat€ th€ production of codsol and decrease of progestercne level.This condition may lead to estrogen domin.nceand abrupr withdrawal of estmgen during the menstrual p€riod.Second, in women wilh low and physiological €sirog€n lev€|, LPS induc€d macrophages rel€ase mof€ proinflammatmy cytokines, prostaglandin Er, nitric oxide, and bradykinin which cause painful As a result, in the presenc€ of periodontal dis€as€ th€ slate of hyperalgesia orofacial and musculoskelelal pains may become chronic in women fiom pubeny-until meropaus€.Since periodonLal uearmenrs in *ese care repoas retief lhese painful symptoms, il is concluded thal p€riodontal disease has an important role in the etiology of orofacial and musculoskele&l pains in R€Ierences