Papillon-Lefèvre syndrome associated early onset periodontitis: a review and case study

A case of Papillon-Lefèvre syndrome that has been managed successfully for six years is reported. Papillon-Lefèvre syndrome is a rare form of early onset periodontitis that occurs at a rate of 1-3 per million. Diagnostic features include palmar-plantar hyperkeratosis and rapid periodontal destruction. Although the etiology of this syndrome is unknown, current theories on the nature of the underlying defect fall into three main categories: anatomical, bacterial and host response. Historically, Papillon-Lefèvre syndrome was thought to lead to the inevitable loss of both the primary and permanent dentitions. However, a recently proposed treatment involving antibiotic coverage, extraction of the primary dentition and a period of edentulism has been shown to be effective in maintaining the permanent dentition. Since treatment may begin prior to the eruption of the permanent dentition, early recognition of Papillon-Lefèvre syndrome is critical. Any young patient who exhibits palmar hyperkeratosis should be examined carefully for periodontal breakdown. Since the number of cases available for study is limited, referral of such individuals to University dental clinics may allow for a more specific analysis of immune or bacterial factors that may lead to a better understanding of this disease.

In vitro endotoxin penetration of coronally unsealed endodontically treated teeth

The purpose of the study was to evaluate the penetration of bacterial endotoxin (L.P.S.) through obturated root canals. Twenty-four single-rooted teeth were instrumented in a uniform manner. The root canals of 16 teeth were obturated with guttapercha and Roth's sealer and 8 teeth were similarly obturated but without sealer. The teeth were then divided into three groups. Group 1-Positive control (4 teeth). Teeth obturated without sealer were used. Sticky wax was softened in an open flame and painted over the external root surface except the apical 2 mm and coronal canal orifice which were left free of the sticky wax. Group 2-Negative control (4 teeth). Again teeth without sealer comprised the teeth in this group. However, in this group the sticky wax covered the apical area of the root and the canal orifice coronally, in addition to the rest of the root. Group 3-Experimental (16 teeth). The teeth obturated in conjunction with sealer were used. Otherwise the teeth were treated as in group 1. The coronal root half was then hermetically sealed from the apical root half so that LPS placed coronally could move only through the obturated canal space to the apical segment. One ml of water containing 100 micrograms/ml endotoxin was placed in the upper chambers and pyrogen-free water in the lower chambers. The upper and lower chambers were then tested for endotoxin at different time periods upto 21 days. The upper chambers tested positive for endotoxin at all test times for all teeth. All 4 positive control teeth showed endotoxin in the lower chambers by 24 hrs.(ABSTRACT TRUNCATED AT 250 WORDS)

Ability of bacterial endotoxin to diffuse through human dentin

An in vitro system was developed to determine whether bacterial endotoxin is capable of diffusing through dentin without the use of filtration pressure. Cavities were prepared in five third molar teeth in order to produce a split chamber device consisting of occlusal and pulpal chambers with 0.5 mm of intervening dentin. Endotoxin was introduced into the occlusal chamber and the effluent in the pulpal chamber was sampled every 30 min for 5 h and at 24 h using the limulus lysate assay. In four specimens the initial appearance of endotoxin in the effluent ranged from 15 min to 4 1/2 h. In two specimens the concentration of endotoxin in the effluent leveled off in 4 1/2 and 5 h, respectively, whereas in another two the concentration continued to increase throughout the experiment. In one specimen no endotoxin was detected. The results indicate that endotoxin is capable of passing through 0.5 mm of dentin.

[Infectious endocarditis induced by Actinobacillus actinomycetemcomitans. 8 new cases]

A commensal organism of the buccal cavity, Actinobacillus actinomycetemcomitans (AAC) has been responsible for at least four new cases of infectious endocarditis by year in France. This retrospective study was based on 90 new cases of infectious endocarditis by AAC, including 8 personal observations. One third of patients had no known cardiac disease before their infectious endocarditis, the portal of entry of which was usually dental. In cases of suspected infectious endocarditis, rapid and severe weight loss (43% of cases) and, less commonly, anicteric cholestasis (8%) should alert the physician for the possible pathological role of AAC. The echocardiographic appearances are non-specific. The diagnosis is confirmed on blood cultures but the organism grows slowly in CO2 enriched atmosphere. Initially, the course of the disease was favourable in one third of patients but, in two thirds of cases, complications were observed almost renal (26%), cardiac (24%) and neurological (18%). Two thirds of patients were cured by the time they were discharged whereas the remainder had sequellae, mainly valvular and neurological. The hospital mortality was 9%; late mortality was 6%. Therefore, the prognosis of AAC endocarditis, seems to be better than that of other bacteriological forms. A combination of cephalosporin and aminoside, or even a simple third generation cephalosporin antibiotic therapy for at least 4 weeks are usually effective. The complementary surgical indications are the same as for other forms of infectious endocarditis. Prophylaxis depends on strict prophylactic amoxicillin therapy for all cardiac patients at risk of infectious endocarditis before dental treatment and on good bucco-dental hygiene.

Prevalence and distribution of bacteriophage phi Aa DNA in strains of Actinobacillus actinomycetemcomitans

phi Aa is a bacteriophage that was originally isolated by induction of a lysogenic strain of the oral bacterium Actinobacillus actinomycetemcomitans. Since the discovery of phage phi Aa, additional phages infecting several other strains of A. actinomycetemcomitans have been identified. To determine the prevalence of phi Aa or phi Aa-related temperate phages in this species, a phi Aa-specific DNA probe was prepared to screen for homologous sequences among 42 strains of A. actinomycetemcomitans. Fourteen (33%) of the 42 strains examined contained DNA sequences that hybridized with the phage phi Aa probe. A bacteriophage designated phi Aa33384 was isolated by induction from one of the strains (ATCC 33384) that contained a sequence that hybridized with the phi Aa probe. The phi Aa probe hybridized with the DNA extracted from bacteriophage phi Aa33384. The distribution of the phage phi Aa sequence among A. actinomycetemcomitans serotypes was 5/13 (38%) of the serotype a strains, 0/16 (0%) of the serotype b strains, and 9/13 (69%) of the serotype c strains. The results of this investigation suggest that the target sequence prepared from the phage phi Aa genome is fairly common in the A. actinomycetemcomitans chromosome, and that the sequence is distributed among the A. actinomycetemcomitans serotypes in a seemingly nonrandom manner.

Clinical, microbiological, and histological factors which influence the success of regenerative periodontal therapy

The primary objectives of this double-blind, controlled clinical trial were to assess factor(s) which affect the success of guided tissue regeneration (GTR) procedures in mandibular Class II buccal furcation defects. Thirty subjects, with mandibular Class II furcation defects, were randomly assigned to one of two treatment groups; patients in Group A received oral hygiene instructions with scaling and root planing, while subjects in Group B received similar treatment but without subgingival scaling and root planing at the affected site. After initial oral hygiene instructions and scaling and root planing, GTR surgery was performed using ePTFE barrier membranes. Membranes were retrieved at 6 weeks and subjected to histological examination. Twelve months after regenerative therapy, clinical measurements and re-entry surgical measurements were repeated. Probing reduction (2.61 mm), horizontal probing attachment gain (2.59 mm), and vertical probing attachment gain (0.95 mm) were all significantly better compared to baseline. Likewise, significant improvements in furcation volume (8.0 microliters) and in bone measurements were observed at re-entry. There was no discernible difference between subjects for whom complete anti-infective therapy was deferred to the time of the surgery (Group B) compared to subjects in whom complete anti-infective therapy was performed as part of the hygienic phase of therapy (Group A). Pre-operative pocket depth was directly correlated with the magnitude of attachment gain as well as the amount of new bone formation in the furcation area. Subjects who maintained good oral hygiene and who had minimal gingival inflammation throughout the study demonstrated consistently better regenerative response.(ABSTRACT TRUNCATED AT 250 WORDS)

Flow cytometric analysis of the cytotoxic effects of Actinobacillus actinomycetemcomitans leukotoxin on human natural killer cells

The goal of this investigation was to determine if human natural killer (NK) cells were susceptible to the cytolytic effects of the Actinobacillus actinomycetemcomitans leukotoxin (LTX). Following treatment with LTX (0-200 ng/ml), NK cell activation by interleukin-2 (IL-2) was evaluated. LTX inhibited the IL-2-induced expression of both CD69 and the IL-2 receptor. Furthermore, the up-regulation of CD56 was also impaired. To determine whether the observed functional deficits were the result of cell death, NK cell viability was evaluated by flow cytometry. Changes in forward and side light scatter patterns consistent with cell death were observed within 60 min. Direct analysis of cell viability by measuring propidium iodide exclusion, however, indicated little change in the viability of LTX-treated NK cells. Electron microscopic analysis of NK cells exposed to LTX revealed early nuclear alterations characterized by hyperchromaticity, nuclear fragmentation, and condensation of nucleoplasm. However, no change in membrane integrity was initially noted. Finally, LTX caused a rapid and sustained elevation in the intracellular levels of Ca2+. These morphological and biochemical changes are consistent with the notion of programmed cell death.

Bacteriology of dental infections

The most common dental diseases, periodontal disease and dental caries, are chronic infections caused by bacteria of normal oral flora. When these bacteria increase in number and irritation exceeds the host defence threshold, disease arises. The human oral flora comprises more than 300 different bacteria. During the last decade approximately 10 species, mainly Gram-negative anaerobes, have been noted as putative pathogens in periodontal disease. The Gram-positive and facultatively anaerobic mutans streptococci are aetiologically the most important bacteria in dental caries. Data have rapidly increased on the association of these bacteria with certain periodontal diseases or caries, on phenotypic and genotypic characteristics, pathogenic mechanisms, antibiotic susceptibility patterns and transmission among family members. Chronic dental infections have been the focus of renewed interest because of recent advances in oral microbiology as well as in medicine. We now know that in addition to oral streptococci, recently classified, fastidious periodontal anaerobes can be detected from various extra-oral infections. Oral bacteria may spread into the blood stream through ulcerated epithelium in diseased periodontal pockets and cause transient bacteraemias, which are regarded as increased risk, especially for immunocompromised patients or persons with endoprotheses. In these patients, routine antibiotic prophylaxis is recommended for invasive dental care procedures. Also the new association between dental infections and myocardial/cerebral infarction have offered new challenges for cooperation between dental and medical researchers.

Survival in transport media of Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia in human subgingival samples

The purpose of this study was to evaluate the survival in 3 transport media of 3 suspected periodontal pathogens, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis and Prevotella intermedia. Subgingival samples were taken from 10 patients with severe periodontitis, all harboring at least two of the above-mentioned species. The material was dispersed and aliquots were added to vials containing reduced transport fluid, reduced transport fluid containing 10% Fildes extract, or viability-maintaining microbiostatic medium, anaerobically prepared (VMGA III). Viable counts were determined after 1, 2, 4, 24 and 48 h of storage at 4 degrees C or at room temperature. The results showed that, for up to 4 h of storage, no significant differences existed for all parameters tested. A large increase of the total viable counts was found in VMGA III at room temperature after 24 and 48 h. This was due to an outgrowth of mainly streptococci. Incubation at 4 degrees C yielded often a significantly higher recovery compared to room temperature. After storage at room temperature, the tested bacteria were below detection level in some samples.

A comparison of two transport media for saliva and subgingival samples

This study has shown that microorganisms associated with caries (mutans streptococci, lactobacilli) and marginal periodontitis (Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus actinomycetemcomitans) in pure culture can be stored in VMGA or reduced transport fluid and be recovered sufficiently after 24 h. Sufficient recovery after 24 h of mail transport was also obtained in 37 saliva samples obtained from adults and 80 subgingival samples from a group of patients before and 3, 6 and 15 months after periodontal treatment. The samples transported in VMGA III showed in comparison to the samples transported in reduced transport fluid a higher recovery rate as well as a higher percentage of the total viable count for investigated anaerobic species. This was explained by the different composition of the two media and also by the gel consistency of VMGA III, which maintains a low redox-potential even during transport after transferring a sample into the medium. In a few samples aerobic bacteria increased in both media.

Postoperative bleeding tendency as a risk factor in Actinobacillus actinomycetemcomitans-associated periodontitis

Frequent bleeding on probing (BOP) has been considered a risk factor for recurrence of periodontitis. In the present study, 29 patients with Actinobacillus actinomycetemcomitans-associated periodontitis were enrolled in a carefully performed recall system. At 6 sites per tooth, periodontal probing depth (PPD), gingival index (GI), plaque index (PlI) and BOP was assessed 6 weeks, 6 months, 1 and 2 years after comprehensive therapy. Professional toothcleaning and subgingival scaling at sites with PPD > or = 5 mm and BOP was carried out every 2nd or 3rd month. Subgingival samples from 2 sites, a pooled subgingival sample, cheek mucosa, saliva and tongue samples were selectively cultivated for A. actinomycetemcomitans after 2 years. Following active therapy, 8% sites had a PPD of > or = 4 mm, whereas 21% sites bled on probing. After 2 years, respective figures were 12 and 27%. During maintenance, frequent BOP (> or = 3 times at 4 visits) had a predictive value of 0.133 to indicate an increase in PPD of > or = 2 mm and a negative predictive value of 0.947. The predictive value of no bleeding to indicate a stable site was 0.972, the negative predictive value 0.078. There was evidence for heterogeneity of associations between increase in PPD of > or = 2 mm and > or = 3 times BOP among patients (chi 2(28) = 41.45, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Configural frequency analysis for exploring bacterial sets in periodontal health and disease

Periodontal research has been concerned with identifying bacterial sets in oral health and disease. Configural frequency analysis (CFA) is a taxonomical method used to test the statistical significance of patterns of elementary cell frequencies in cross-tabulated data, and may therefore be used to evaluate interactions among occurrences and non-occurrences of periodontal microorganisms. CFA patterns may exist as configural types or anti-types depending on whether observed cell frequencies are greater or less than expected frequencies, respectively, based on table marginals. CFA was applied to two published data sets. In the first, the occurrence of Bacteroides (Porphyromonas) gingivalis (Bg) and Treponema denticola (Td) was studied in military subjects. Analysis of individual cells of the resultant two-by-two contingency table revealed the existence of a single anti-type (Td in the absence of Bg) suggesting a sequential phenomenon. The second, more complex, data set was based on reported occurrence of Actinobacillus actinomycetemcomitans (Aa), Bg, and Bacteroides (Prevotella) intermedius (Bi) in sites with and without progressive periodontitis. CFA based on all data identified three statistically significant configural types and two anti-types. However, a somewhat different configurational picture emerged when disease progression status was considered a stratification variable for separate analysis. All these analyses, which were undertaken for expository purposes, assumed independence of observations. Methodological procedures are suggested for CFA when observations are not independent.

Characterization and physical mapping of the genome of bacteriophage phi Aa from Actinobacillus actinomycetemcomitans

The size, configuration and restriction map of Actinobacillus actinomycetemcomitans bacteriophage phi Aa DNA was determined by means of restriction endonuclease analysis. Digestion of the phi Aa DNA with restriction enzymes Hind III, Eco RI and Sal I produced 6, 5, and 4 fragments, respectively. Based upon the sum of the sizes of the restriction fragments of these enzymes, the DNA was estimated to be 47.2 kilobase pairs in length. A restriction map was constructed using Hind III and Sal I. Incubation with exonuclease Bal 31 for increasing lengths of time resulted in progressive hydrolysis of the DNA, as expected for a linear molecule. No sub-molar fragments or diffuse bands were observed in the agarose gels of the restriction endonuclease digests of the phi Aa DNA. Attempts at ligating the ends of the DNA were consistently unsuccessful. Therefore, we found no evidence for cohesive ends, a circular permutation of the genome or for headful packaging mechanism from a concatameric DNA precursor.

Effects of root planing on the distribution of microorganisms adult periodontitis sites

The aims of this study were to identify the microbial species present in subgingival plaque in patients with adult periodontitis, and to investigate the effects of root planing upon the microbial flora for 12 months following root planing. Microorganisms from samples of subgingival plaque obtained from adult periodontitis sites in 15 patients were cultured, both aerobically and anaerobically, on a variety of media and identified. Prevotella intermedia and Porphyromonas asaccharolytica were the most frequently identified species before treatment. Bacteroides ureolyticus, the Prevotella veroralis/buccalis complex and other microorganisms including Capnocytophaga ochracea, species of streptococci, staphylococci and diphtheroids were also frequently isolated. Root planing improved periodontal health, and was accompanied by reductions in the frequencies with which P. intermedia, P. asaccharolytica, the P. veroralis/buccalis complex and C. ochracea were isolated. Regular scaling and oral hygiene reviews maintained the clinical improvements and balance in favour of beneficial microbial species during the study.

Pericarditis, pneumonia and brain abscess due to a combined Actinomyces--Actinobacillus actinomycetemcomitans infection

A patient is described in whom there developed a pulmonary infiltrate and constrictive pericarditis caused by a combined Actinomyces and Actinobacillus actinomycetemcomitans infection, presumably originating from his poor dentition. The diagnosis was only made following repeated thoracotomy. After surgery, long-term treatment with antibiotics led to complete clinical recovery. None the less, some months later he was found to have a brain abscess which resolved during a further course of antibiotics. The variable clinical picture of actinomycosis is discussed, as well as the role of other bacteria frequently associated with actinomycotic infection, in particular Actinobacillus actinomycetemcomitans. The therapeutic implications are described.

Actinobacillus actinomycetemcomitans pneumonia with chest wall involvement and rib destruction

There are four cases of Actinobacillus actinomycetemcomitans pulmonary infections reported in the English literature prior to 1990. We report a case of A actinomycetemcomitans pulmonary infection with invasion of overlying soft tissue, rib, and sternum. This manifestation has not been previously reported. The clinical manifestation is similar to that of Actinomyces israelii, which may be misinterpreted as malignancy initially. The portal of entry of A actinomycetemcomitans may be via hematogenous spread or aspiration. The diagnosis depends on culture after prolonged incubation of the involved tissue obtained by aspiration or biopsy. Elevated serum antibody is helpful for diagnosis of active infection. A actinomycetemcomitans is susceptible to most antibiotics, but is frequently resistant to penicillin, vancomycin, clindamycin, and erythromycin. Isolation of the organism and an in vitro drug sensitivity testing are important in managing the patient. Our patient recovered after a three-month regimen of penicillin.

Microbial etiology of periodontal diseases. Where are we? Where are we going?

Many studies indicate a strong association of Actinobacillus actinomycetemcomitans with localized juvenile periodontitis. Species associated with adult periodontitis include Bacteroides forsythus, Porphyromonas gingivalis, Prevotella intermedia, A. actinomycetemcomitans, and Wolinella recta. Capnocytophaga species may be important in pubertal gingivitis. An unnamed spirochete related to Treponema pallidum has been identified in acute necrotizing ulcerative gingivitis lesions. Species isolated from prepubertal periodontitis, peri-implantitis, pericoronitis, and human immunodeficiency virus gingivitis and periodontitis are similar to those isolated from periodontal and gingival infections. Species identification in combination with clinical characteristics facilitates periodontal diagnosis. DNA probes, immunoassays, and benzoyl-arginine naphthylamide reactivity methods can be used to indicate putative pathogens in plaque samples. Microbial identification aids in antibiotic selection and planning a treatment regimen.