Epithelial expression of HLA class II antigens and Fc gamma receptors in patients with adult periodontitis

The distribution of HLA class II (DR, DP, DQ) and Fc gamma R (I, II, III) was analyzed in the epithelia of patients with advanced marginal periodontitis using cryostat sections incubated with monoclonal antibodies (MoAb) against the Langerhans cell (LC) (CD1a) and various subtypes of HLA class II and Fc gamma R, and the indirect immunofluorescence technique. In the oral gingival epithelium (OGE), LC were concentrated subjacent to the connective tissue papillae, while in the pocket epithelium (PE), they were most abundant at the gingival margin. HLA-DP, DQ, and DR stained LC in both OGE and PE. HLA-DQ+ LC were significantly fewer than DP+ and DR+ LC. HLA-DR also stained keratinocytes (KC) in the whole extension of both OGE and PE. HLA-DP was also observed on KC, but not HLA-DQ. Fc gamma R II stained both LC and focal areas of KC. In PE FC gamma R II+ LC were concentrated near the bottom of the pocket, while in the OGE, they were concentrated at the gingival margin. Fc gamma R III was present only on KC, especially in the basal and suprabasal layer. The results indicate that the epithelial cells are actively involved in the development and maintenance of the inflammation of periodontal disease.

Mechanistic features associated with induction of metalloproteinases in human gingival fibroblasts by interleukin-1

Human gingival fibroblasts were treated with recombinant interleukin-1 (IL-1) to determine the effect of this stimulus on the relative expression of collagenase (MMP-1), stromelysin (MMP-3) and plasminogen activator (PA) mRNA. The steady-state mRNA levels for these genes were determined on Northern blots. IL-1 induced steady-state levels of these mRNAs to different extents. Nuclear run-on transcription studies showed that IL-1 induction of neutral metalloproteinase may be transcriptionally regulated. Actinomycin D and protein kinase inhibitors decreased the mRNA production for all three metalloproteinases, whereas cycloheximide decreased the production of collagenase and stromelysin mRNA. Protein kinase inhibitors (H7/H8) decreased production of the three mRNAs to different extents. This study demonstrates a potentially important role for IL-1 in the regulation of metalloproteinase expression in human gingival fibroblasts. The ability of IL-1 to induce the expression of stromelysin, collagenase and PA may define a pivotal role for this cytokine in the pathogenesis of periodontitis.

Views of cardiac-valve prosthesis patients and their dentists on anticoagulation therapy

By administering a questionnaire to 253 patients with cardiac-valve prostheses (89.3% responding), and another to 136 of their attending dentists (79% responding), the level of knowledge among both groups of anticoagulant therapy in connection with dental treatment was investigated. The cardiothoracic department monitored all anticoagulation therapies. Of the anticoagulated patients, 96.6% were able to state their medication (94.1% received phenprocoumon); and of 86 dentists with patients on anticoagulation treatment, 94% were aware of their patients' medication. All 20 dentists stating that their patients did not receive anticoagulants were correct. The great majority (98%) of the dentists employed a special measure to reduce the risk of bleeding associated with invasive dental procedures, most commonly (86%) referring patients to their general practitioner or hospital department for adjustment of the anticoagulant therapy. Around 60% of the dentists considered extractions and operations to require measures to reduce the risk of bleeding complications. We recommend referral of patients to the attending physician for adjustment of anticoagulation to a target International Normalized Ratio (INR) of 4.0 or possibly 3.0 before undergoing dental procedures involving the risk of bleeding. Additional reduction of the bleeding risk can be obtained by local application of an inhibitor of fibrinolysis (tranexamic acid).

Unique intronic variations of HLA-DQ beta gene in early-onset periodontitis

Human leukocyte antigen (HLA) class II beta chain plays an important role in the recognition of foreign antigens in immune reactions. Different forms of immune reaction may be concerned with initiation and progression of infectious diseases such as periodontitis. In this study we examined the frequency of HLA class II serotype and the variation of HLA class II beta gene in periodontitis patients. HLA serotypic frequencies in 70 Japanese patients with periodontitis and 26 individuals with periodontal health were examined. No HLA serotype specific to any type of periodontitis was observed. In order to detect differences among some HLA serotypes, restriction fragment length polymorphism (RFLP) analysis was undertaken with cDNA probes for HLA-DR beta and HLA-DQ beta genes in 20 subjects (15 patients and 5 healthy individuals). Atypical BamHI and EcoRI restriction sites were found in the HLA-DQ beta gene from 3 patients with early-onset periodontitis. In addition to these 20 subjects, an additional 80 subjects (40 patients and 40 healthy individuals) were screened for the atypical BamHI restriction site using the polymerase chain reaction method. It was detected in 7 patients with early-onset periodontitis, 1 patient with adult periodontitis, and 3 healthy subjects. No clinical differences except age were found between patients with this gene variation and other patients. Interestingly, all 3 healthy subjects with this gene variation were from subjects whose family members developed early-onset periodontitis with the gene variation. Atypical BamHI and EcoRI restriction sites and 41-nt repeated sequence were found in the intron before the third exon of HLA-DQB gene. These results suggest that these intronic gene variations may be useful as gene markers for a subpopulation of early-onset periodontitis and might affect immune reactions such as antigen recognition.

Head and neck manifestations of tumoral calcinosis

Intraoral facial and laryngeal features of tumoral calcinosis are reviewed in six patients of Jewish-Yemenite descent. Extraoral features included calcified masses, erythematous patches, and angular cheilitis. Oral soft tissue findings included papillary hyperplasia of the lip vermilion and velvety-red macules on the tongue, palate, and buccal mucosa. Gingival findings included advanced periodontitis and an erythematous marginal gingivitis. In all patients, orthognathic evaluation revealed a concave profile, retruded maxilla, and relative mandibular prognathism. Although previously reported clinical dental abnormalities were not present, extracted teeth demonstrated abnormal dentin. Hoarseness was present in all patients and was the earliest appearing feature in two patients. The appearance of these head and neck findings preceded the classical manifestations of tumoral calcinosis and may be helpful in the early diagnosis of this entity. The varied reported features of tumoral calcinosis support the notion that this disease may present multiple formes frustes with variable clinical expressivity.

Imaging of lymphoma manifestations in the extracranial head and neck region

CT and MRI are the most efficient imaging techniques for diagnosing lymphomas while Gallium-67 scintigraphy is used to assess treatment results. In this review, the imaging aspects of lymphoma are addressed according to anatomical subregions, from the orbit to the trachea, Waldeyer's ring being the most common site, in the head and neck. Lymphomas of this region are not easily distinguished from the more common squamous cell carcinomas; however, multiple extranodal sites, the presence of many non-necrotic lymph nodes and a large nasopharyngeal mass without significant bone destruction should alert one to the possibility of lymphoma.

Burning mouth syndrome: literature review and model for research and management

The literature on burning mouth syndrome (BMS) is reviewed with particular reference to its prevalence, local and systemic etiologic factors, psychogenic background and treatment. Research requirements are discussed, which focus on different clinical and psychological parameters and the necessity to evaluate BMS. Finally, a treatment protocol including oral, medical and psychological investigations is presented.

White lichenoid lesions of the buccal mucosa in patients with HIV infection

We report on eight patients who developed white lichenoid lesions of the buccal mucosa during the course of human immunodeficiency virus infection. In five patients the lesions appeared after the administration of zidovudine, in two after the intake of both zidovudine and ketoconazole, and in one after ketoconazole. In the majority of cases, lesions presented as bilateral reticular keratosis or atrophic changes of the buccal mucosa. Three patients manifested lichenoid atrophic changes of the dorsum of the tongue. The histopathologic features were hyperkeratosis, epithelial atrophy, basal cell liquefaction, and the presence in the lamina propria of either a patchy or diffuse lymphocytic infiltrate. All specimens tested negative for Epstein-Barr virus and human papillomavirus. Our study suggests that lichenoid lesions of the buccal mucosa, similar to what has been described as lichenoid drug reactions or idiopathic lichen planus, can be observed during human immunodeficiency virus infection and that administration of zidovudine and ketoconazole should be considered as a possible cause.

Lichenoid drug eruptions

Lichen planus-like or lichenoid eruptions from certain drugs and compounds can closely mimic idiopathic lichen planus. The patient's history and physical examination histopathologic criteria, and certain tests can assist in the differentiation between a lichenoid drug eruption and idiopathic lichen planus and in the identification of the offending drug.

A preliminary report on the Stone-Kaplan instrumentation for CO 2 laser periodontics. Phase I: periodontal pocket opening surgical procedure

A preliminary report on the Stone-Kaplan instrumentation for CO 2 laser periodontics is presented describing the instrumentation and introducing the first phase of its clinical usage. The design enables the introduction of a hollow fiber delivered CO 2 laser beam into the depth of a periodontal pocket enabling invasive surgical procedures to be carried out with exacting control of the laser beam as afforded by the design of the instrumentation. This design enables the performance of pocket-opening surgical procedures with ease of performance for the operator enhanced by the "instrument-in-hand" tactile-feedback and blind-visualization phenomena afforded by this unique design. The basic performance for a periodontal pocket opening procedure is presented here.

Allergic disorders in systemic lupus erythematosus

Allergic disorders commonly occur in patients with systemic lupus erythematosus (SLE) and allergies to some drugs may occasionally be related to disease flares. We evaluated the prevalence of several types of allergy in 132 patients with SLE and their families and compared the SLE patients with a control group of 66 patients with non-lupus disorders. Total IgE levels were tested in 117 SLE patients and 61 controls. Eighty-three of the 132 SLE patients (63%) had a history of at least one type of allergic disorder. This prevalence was significantly higher (P < 0.0001) than that of the control group (20 of 66 controls). The prevalence of drug allergy (38% vs. 17%; P < 0.005), skin allergy (36% vs. 17%; P < 0.01) and insect allergy (14% vs. 2%; P < 0.02) were significantly higher in SLE patients when compared with controls. Family members of SLE patients had an increased prevalence of at least one type of allergy (55% vs. 24%; P < 0.0001), allergic rhinitis (30% vs. 14%; P < 0.02), asthma (25% vs. 9% P < 0.02), and both rhinitis or asthma (44% vs. 20%; P < or = 0.002). The presence of allergy both in the patient and in the family was more frequent in SLE patients than controls (42% vs. 15%; P < 0.001). We found no differences in total IgE levels between the two groups. Drug, skin and insect allergies were particularly frequent in SLE patients. We also found a high prevalence of rhinitis and asthma in their families.

Spirochaetes in oral infections

Oral spirochaetes, which are small-, medium- or large-sized, include species of the genus Treponema, many of which have not yet been cultured. They are found in root canal infections, pericoronitis, gingivitis and periodontitis, constituting up to 10% of the flora in endodontic abscesses, 30% in acute necrotizing ulcerative gingivitis, and 56% in advanced marginal periodontitis. The strong proteolytic activity of these organisms probably make them causes of infection rather than consequences. Being able to penetrate tissue, they bring their enzymes, metabolic products, and endotoxins, in direct contact with target cells. This may perturb essential functions of host cells and immunoglobulins. Enzyme activities may also help fulfil the complex growth requirements of spirochaetes in vivo. Reaction between infected periodontal tissue and monoclonal antibodies to Treponema pallidum has suggested that uncharacterized pathogen-related oral spirochaetes have surface structures and functions analogue to this well recognized pathogen. This warrants a more intensified search for the role of spirochaetes in oral infections.

Burning mouth in a Finnish adult population

Burning mouth syndrome is an oral pain disorder with a prevalence of 5-18% in patient materials. The aim of this study was to determine the prevalence of Burning mouth syndrome in a representative sample of the general adult population. Altogether 431 subjects (237 females, 194 males) participated in the study. Subjects were questioned about the experience of prolonged burning sensation; the site, severity, pattern, duration and possible associations of the onset of the burning sensation, and a thorough clinical examination was performed. In all, 15% of the subjects had experienced prolonged oral burning but a half of them had some clinically observable oral mucosal lesion or oral candidosis. The prevalence of the complaint was significantly higher in females than in males.

Burning mouth syndrome. Evaluation of multiple variables among 85 patients

The relationship between burning mouth syndrome and 48 variables was investigated in 241 patients, 45 years old and older, who had attended the Oral Medicine Clinic of the Faculty of Dentistry, University of Stellenbosch during a period of 4 years. A total of 85 cases of burning mouth syndrome were diagnosed in 65 women and 20 men. Statistically significant relationships (p < 0.05) were found with self-medication, xerostomia, and other salivary disturbances in both men and women with burning mouth syndrome when compared with their respective controls. Among the women with BMS, significant relationships were also found with anemia, inadequate diet, chronic infection, hormone therapy, ulcerative/erosive lesions, and atrophy. In contrast men with BMS showed statistically significant relationships between taking prescribed medication, central nervous system disturbances, gingivitis, and denture-related problems. In addition, significant associations were related to variables such as psychogenic factors, regurgitation, flatulence, and periodontitis.

In situ characterization of gingival mononuclear cells in rapidly progressive periodontitis

Rapidly progressive periodontitis (RPP) has been suggested as a distinct clinical entity within the spectrum of early onset periodontitis. Immunological mechanisms have been considered in the pathogenesis of RPP. This study was designed to evaluate the distribution and phenotypic properties of the lymphocyte populations within the affected gingival tissue of patients with RPP. Biopsies were obtained from 16 patients between 22 and 33 years of age. The tissue samples were processed for both histopathological and immunohistochemical examinations. Gingival tissue T lymphocytes (CD3+), helper T cells (CD4+), suppressor-cytotoxic T cells (CD8+), and cells positive for HLA-DR antigen were identified using monoclonal antibodies with an immunoperoxidase technique. Intracytoplasmic immunoglobulin-containing cells were also stained immunohistochemically with polyclonal antibodies. CD3+ cells were mainly located beneath the pocket epithelium. CD4+ and CD8+ cells were evenly distributed within this T-cell infiltrate with a CD4+/CD8+ ratio of 1:12. Numerous HLA-DR+ cells were also observed in the lymphocytic infiltrates. The majority of mononuclear cells located throughout the stroma were IgG+ plasma cells. Our results indicate that RPP patients present an IgG-bearing plasma cell dominated lesion with equal participation of both T-cell subpopulations. These findings suggest that activation and proliferation of B-cells play an important role in the pathogenesis of periodontal diseases.

The therapy of oral lichen planus

Oral lichen planus is a chronic mucocutaneous disease that is relatively common. Although many patients are asymptomatic and require no therapy, those who exhibit atrophic and erosive lesions are often a challenge to treat. All therapies are palliative, and none is effective universally. Currently employed treatment modalities include corticosteroids administered topically, intralesionally, or systemically. Alternative therapies include topical and systemic retinoids, griseofulvin, Cyclosporine, and surgery. Other medical treatments and experimental modalities, including mouth PUVA, have been reported to be effective. Controversy concerning the efficacy of all these treatments suggests that oral lichen planus is a heterogeneous disorder. Eliminating lichenoid drug eruptions, candidiasis, trauma, contact mucositis, and emotional stress may play a role in the management of these patients. This article is a review of the many treatments and measures that have been employed in the management of patients with oral lichen planus.

Phenotypic and functional analysis of peripheral blood lymphocytes in oral lichen planus

To assess cellular immunity in oral lichen planus (OLP), peripheral blood mononuclear cells (PBMC) were obtained from 19 OLP patients and 30 control subjects. The proportions of circulating CD45RA+ and CD29+ lymphocyte subsets were determined. The proliferative activity of PBMC to the non-specific plant mitogens phytohemagglutinin (PHA) and concanavalin A (Con A) was examined together with the spontaneous proliferative response and the response in the autologous mixed lymphocyte reaction (AMLR). In the OLP group, the proportion of CD4+ CD45RA+ T lymphocytes was significantly less than control subjects and the proportion of CD4+ CD29+ T lymphocytes was increased significantly. The proliferative response to PHA was similar in OLP and controls subjects. Con A-stimulated PBMC proliferation was decreased significantly in the OLP group. Spontaneous PBMC proliferation in patients with non-reticular lesions was significantly less than control subjects. Despite a mildly depressed response in the AMLR in OLP patients, this result was not statistically significant. Results of the phenotypic analysis of peripheral blood lymphocytes indicate a decreased proportion of naive T cells and an increased proportion of primed memory T cells, although the antigen specificity of these memory cells remains to be determined. Results of the functional assays would seem to reflect this phenotypic shift, and as T cells responding to Con A stimulation and in the AMLR possess suppressor-inducer activity, these results may also suggest an association between OLP and defective innate T cell-mediated suppressor circuits.

Burning mouth syndrome. Critical review and proposed clinical management

Burning mouth syndrome is characterized by a burning sensation in one or several oral structures. Multiple causal factors have been proposed, and reports on their relative importance are conflicting. Lack of diagnostic criteria, differences in sampling procedures, incomplete workups, and lack of controlled studies make the reliable interpretation of the importance of proposed causal factors and the efficacy of specific treatment modalities difficult. This article summarizes the available data, critically analyzes their scientific merit, and proposes a protocol for clinical management.

An update on recent advances in the understanding of non-neoplastic diseases of the salivary glands

The recent advances in the understanding of the non-neoplastic disorders of salivary glands are summarised in this paper. The common infections are discussed and newer aspects of juvenile recurrent parotitis outlined. The benign lympho-epithelial lesion is reviewed in relation to Sjogren's syndrome and the salivary gland pathology seen in relation to infection with human immunodeficiency virus. A range of unusual conditions that may affect the minor salivary glands in particular, and can cause diagnosis dilemmas, is summarised.

Heterogeneity in the gingival fibromatoses

Forty-nine cases of isolated familial and idiopathic gingival fibromatoses, consisting of 12 cases from six families and 37 cases of idiopathic gingival fibromatosis, were reviewed. Pedigrees of five families revealed various penetrances and genetic heterogeneity as suggested by the presence of both autosomal dominant and autosomal recessive inheritances. Ultrastructurally, the lesions were composed of fibroblast-like cells and myofibroblast-like cells, with the former being the predominant cell type. The 267 cases of familial and idiopathic gingival fibromatoses were analyzed, and they with or without hypertrichosis, mental retardation, and/or epilepsy. These included 49 cases seen by the authors, 50 cases from the Japanese literature, and 168 cases from non-Japanese literature. Isolated gingival fibromatosis occurred more frequently after age of 12 years (P less than 0.0074). There was no significant difference in age of onset between generalized and localized forms of the idiopathic gingival fibromatosis. Gingival fibromatosis with hypertrichosis and mental retardation and/or epilepsy occurred frequently before 12 years (P less than 0.069). It has been shown that heterogeneity of the gingival fibromatosis is a result of either histologic heterogeneity, genetic heterogeneity, or a combination with other systemic disorders.

Lichen planus

Lichen planus, a papulosquamous disease, in its classical presentation is characterized by pruritic violaceous papules most commonly on the extremities of middle-aged adults. It may or may not be accompanied by oral and genital mucous membrane involvement. Its course is generally self-limited for a period of several months to years, but it may last indefinitely. There are many clinical variants described, ranging from lichenoid drug eruptions to association with other diseases such as diabetes mellitus, autoimmune disease, and the graft-versus-host reaction. The relationship of these, if any, to classical lichen planus is questionable. Multiple therapeutic options exist including corticosteroids, retinoids, griseofulvin, PUVA, and cyclosporine.

Prevention of infective endocarditis: a review of the medical and dental literature

This paper is a review of what is presently known about the cause and prevention of infective endocarditis. Systemic antibiotics alone are not always enough for an effective prevention of infective endocarditis. Non-streptococcus bacteria frequently found in the periodontal pocket are now reported as causing infective endocarditis; these bacteria are not uniformly susceptible to the antibiotics recommended for prophylaxis. Animal studies indicate that periodontal disease does increase the incidence of infective endocarditis and that the number of microbes entering the blood stream may not be as important in the production of infective endocarditis as other qualities, such as the microbe's ability to adhere. Antibiotics may affect the ability of a microorganism to adhere to tissues of the heart, but this association is yet unclear and may vary with the antibiotic and species of bacteria. Reduction of inflammation of the periodontal tissues is of the utmost importance in the prevention of infective endocarditis; however, mouthrinses have a very limited effect in a periodontal pocket of more than 3 mm in depth and irrigation of a periodontal pocket may create a dangerous bacteremia. Nevertheless, in addition to systemic antibiotics, local antimicrobial agents followed by routine dental treatment and maintenance show promise as an effective means for the prevention of infective endocarditis. Future research in the prevention of infective endocarditis should include placement of antimicrobials in the periodontal pocket and systemic agents that reduce platelet adhesion. The suggestions presented in this review are only recommendations for further research and are not to be construed as a substitute for the current guidelines.

Clinical characteristics and management outcome in the burning mouth syndrome. An open study of 130 patients

Clinical characteristics and treatment responses were studied in 130 patients with burning mouth syndrome (BMS). Most patients were postmenopausal women, and the tongue was the most frequently afflicted site. Although 39% of the patients complained of dry mouth, no causative factors were evident. Therefore BMS is assumed to be a functional disorder. This was at least partially confirmed because the most effective management was in response to mood-altering drugs. From our data BMS appears to be a chronic condition with variations in symptoms among patients and without a predictable endpoint.

The cause and management of burning mouth condition

This paper reviews the clinical presentation and many causes of burning mouth condition. A diagnostic approach and some management procedures that include eliminating all oral irritants, correcting predisposing systemic disease, and most important of all, allaying anxiety that induces parafunctional mouth habits. The term "burning mouth condition" (BMC) is considered more appropriate than the word "syndrome" for this common and troublesome complaint.

Periodontal findings in adult twins

Gingivitis and periodontitis are among the most common diseases known to man. Although bacterial plaque is generally accepted as the primary etiologic agent, little information is available concerning the influence that host genetic factors have on these diseases. The purpose of the present study was to examine the relative contribution of environmental and host genetic factors to clinical measures of periodontal disease through the study of both reared-together twins and monozygous twins reared apart. Probing depth, clinical attachment loss, gingivitis, and plaque were assessed from the Ramfjord teeth in 110 pairs of adult twins (mean age 40.3 years), including 63 monozygous and 33 dizygous twin pairs reared together and 14 monozygous twin pairs reared apart. Bootstrap sampling was used to estimate and provide confidence limits of between-pair and within-pair variances, intraclass correlations and heritability. Based on ratios of within-pair variances or heritability estimates, a significant (P less than 0.05) genetic component was identified for gingivitis, probing depth, attachment loss and plaque. Heritability estimates indicated that between 38% to 82% of the population variance for these periodontal measures of disease may be attributed to genetic factors. While there is general agreement that bacteria are important in the pathogenesis of the periodontal diseases, future etiologic studies should consider the role of host genetic influences.

Decision making in dentistry. Part II: Clinical applications of decision methods

The study of clinical decision making provides a common model on which to base dental practice and thus promotes standardization of care and treatment. Decision analysis can assist in identifying missing data in clinical problems and thus generate clinically relevant research agendas. Part II reviews the current literature focusing on three areas of decision making in dentistry: diagnosis, treatment planning, and disease prediction. The growing body of literature indicates that wide variation exists among the treatment plans made by dentists. Considerable bias arises from many sources of uncertainty in decision making, including the limitations of human memory and judgment. Literature pertaining to computer application of decision analysis in dentistry and to policy making are reviewed.

Serum zinc levels in patients with burning mouth syndrome

The serum zinc levels were measured by atomic absorption spectrophotometry in 30 patients with burning mouth syndrome, (BMS) and in 30 control subjects with clinically healthy oral mucosa. The mean value of serum zinc levels in the patient group was found to be significantly lower (mean +/- SD = 12.13 +/- 1.40 mumol/L) than the mean value of serum zinc levels in the control group (mean +/- SD = 12.89 +/- 1.62 mumol/L; p less than 0.05). The number of subjects with serum zinc levels less than the minimum normal value (less than 11 mumol/L) was higher in the patients with BMS (30%) than in the control subjects (10%). These results suggest that in some patients low serum zinc levels may be associated with BMS. However, the number of patients with BMS was too small to allow definite conclusions.

Autoimmunity in periodontal disease

Periodontal disease in characterized by the loss of the normal supporting tissues of the teeth and a humoral and cellular immune response to bacterial antigen of dental plaque which accumulates at the dento-gingival junction. This review considers the evidence for the existence of an autoimmune component of the host immune response, the possible origin of such a response and the way in which such a host response may contribute to the changes observed in the periodontium in the disease.

Antibiotic prophylaxis for medical-risk patients

The three current regimens for the prevention of infective endocarditis are discussed and compared along, with at-risk patients and dentally-induced bacteremias. The principles of antibiotic prophylaxis, and other medical conditions where antibiotic prophylaxis is controversial or inadequately documented is critically analyzed.

A family study of a mother and daughter with increased susceptibility to early-onset periodontitis: microbiological, immunological, host defensive, and genetic analyses

Microbiological, immunological, host-defensive, and genetic analyses were performed on a mother and daughter, both of whom had early-onset periodontitis (rapidly progressive periodontitis in the mother; localized juvenile periodontitis in the daughter). Microscopic examination revealed a greatly elevated percentage of rod-form bacteria in both subjects. Fusobacterium sp. and Porphyromonas gingivalis (formerly Bacteroides gingivalis) were the predominant microorganisms cultured. The humoral immune responses to F. nucleatum, P. gingivalis, and Actinobacillus actinomycetemcomitans were much higher in both subjects than those to any other periodontal bacteria examined. Functional and phenotypic analysis of the peripheral lymphocytes showed no significant abnormalities. However, investigation of neutrophil function showed that the mother had depressed neutrophil chemotaxis and superoxide production. The daughter had depression not only of chemotaxis and superoxide production, but also of neutrophil phagocytosis. Serological typing of HLA antigens revealed the same Class II HLA profile in both subjects. It was concluded that both subjects very probably had an identical condition and that these patients provided a unique model for improving our understanding of the host factors involved in periodontal disease.

Immunopathogenesis of oral lichen planus

Oral lichen planus (LP) is a common mucosal disorder in which cell mediated immunity is thought to play a major role. In this paper, a unifying hypothesis which attempts to integrate cellular and molecular signals in the local immune response in oral LP is presented. In this model, modified keratinocyte surface antigens are the target for the cytotoxic cell response which characterizes oral LP, whereas mast cells and antigen presenting Langerhans cells are key cellular elements in the evolving lesion. It has been established that mast cell degranulation induces adhesion molecule expression on endothelium which facilitates lymphocyte homing to the tissues. These adhesive interactions between lymphocytes and keratinocytes are postulated to be important determinants in the effector phase of the lesion. Cytokines produced by both lymphocytes and keratinocytes which influence the local immune response could promote chronicity. Accordingly, modulation of immunologic events is a potential therapeutic approach for oral LP.

Dental extraction for patients on oral anticoagulant therapy

Dental extraction in patients receiving long-term oral anticoagulant therapy is a controversial issue. Continuation of anticoagulation exposes the patient to serious hemorrhage, whereas cessation of therapy increases the risk of thromboembolism. Forty patients treated by coumarin underwent 63 tooth extractions, without a change in the therapeutic protocol of anticoagulation. The biologic adhesive Beriplast was used successfully to achieve local hemostasis at the site of the surgical wound. Apart from one patient who had mild oozing, there were no incidences of postsurgical hemorrhage.

Effect of dental plaque control on gingival lichen planus

Eleven patients, all women, aged 43 to 76 years, with atrophic or ulcerative lichen planus lesions of gingiva were included in this preliminary study. After initial examination, the patients received an intensive individual hygiene treatment. The patients continued using the most appropriate, atraumatic method resulting in the best possible oral hygiene over a 1 year period during which they were seen for follow-up examinations at 3-month intervals. The mean plaque scores decreased after the initial treatment followed by an increase. The mean scores for severity of subjective symptoms and for type and extension of lesions initially decreased with the plaque scores and remained lower throughout the study. It is concluded that in some cases both subjective and objective improvement of atrophic and ulcerative gingival lichen planus may be obtained by means of intensive oral hygiene procedures although such procedures do not remove the basic cause of lichen planus. However, further studies are needed to examine the role of dental plaque control in patients with oral lichen planus.

Juvenile and rapidly progressive periodontitis. Peripheral blood lymphocyte subpopulations

Juvenile and rapidly progressive periodontitis are grouped under the heading of early-onset periodontitis. In recent years, much attention has been devoted to studying immunologic factors in early-onset periodontitis. This study was designed to investigate peripheral blood lymphocyte subpopulations, natural killer cells and interleukin-2 receptor positive (IL-2R +) cells in patients with juvenile and rapidly progressive periodontitis. 38 patients with juvenile and 30 patients with rapidly progressive periodontitis, plus 30 normal healthy control subjects were included in the study. Peripheral blood T-lymphocytes, helper T-cells, suppressor T-cells, HLA-DR+ cells, and IL-2R + cells were determined using appropriate monoclonal antibodies and the indirect immunofluorescence method. B-lymphocytes were identified using the direct immunofluorescence technique. Both groups of patients had normal number of total CD3+ T-cells, CD4+ helper T-cells, CD8+ suppressor T-cells, HLA-DR+ cells and IL-2R+ cells. Natural killer cells were found to be significantly elevated in both groups. These findings could contribute to the immunopathogenesis of early-onset periodontitis.

Long-term use of oral anticoagulants. Current recommendations

In many patients receiving long-term oral anticoagulation therapy, hemorrhagic complications occur less often when prothrombin time is maintained within a lower range than that required by a traditional regimen. A target prothrombin time ratio of 1.3 to 1.5 has been recommended for all circumstances except (1) prevention of thromboembolism in patients with mechanical heart valves and (2) prevention of recurrent systemic embolism. Because primary care physicians often monitor the overall treatment program of patients receiving oral anticoagulants, they need to be familiar with the indications, contraindications, and practical considerations that are associated with the use of these drugs.

Comparison of NK-cell (Leu-7+ and Leu-11b+) populations in clinically healthy gingiva, chronic gingivitis and chronic adult periodontitis

Various investigations have reported the presence of cytotoxic lymphocyte activity in inflammatory periodontal disease. The collective evidence indicates that the inflammatory infiltrates of gingivitis and periodontitis should feature a major component of large granular lymphocytes (NK-cells) possessing cytotoxic potential. Thus, the purpose of this study was to determine and compare, by use of immunohistochemical methods, the numbers of NK-cells in biopsies of clinically healthy gingiva, chronic gingivitis and chronic adult periodontitis and their relationship, if any, to the T- and B-lymphocyte populations. Gingival biopsies were obtained from 8 patients in each of three disease groups selected on the basis of predetermined clinical criteria. Using the avidin-biotin immunoperoxidase technique, four consecutive serial sections from each biopsy specimen were stained with a panel of antihuman monoclonal antibodies for T-lymphocytes (UCHL-1) B-lymphocytes (CD-45R), and NK-cells (Leu-7 and Leu-11b). Analyses of variance yielded a statistically significant main effect for each cell immunophenotype. The Newman-Keuls Sequential Range Test showed statistically significant differences for all but two mean comparisons (p less than 0.01). The comparisons for UCHL-1 and Leu-7 between chronic gingivitis and periodontitis specimens did not demonstrate significance. Although T- and B-lymphocyte populations increased approximately 20 x progressing from healthy to gingivitis to periodontitis specimens, the NK-cell population showed only a 3 x increase which represented 19%, 6.6% and 7% of the total of all positively stained lymphocytes across biopsy groups.

Diversity of IgG antibody responses in the patients with various types of periodontitis

Serum IgG antibodies to seven periodontopathic bacteria were assessed with an enzyme-linked immunosorbent assay (ELISA) in 56 patients with periodontitis. Patients were selected according to the severity of bone loss, and were also classified into three categories by age: juvenile periodontitis (JP), advanced destructive periodontitis (ADP), and adult periodontitis (AP). Bacteroides gingivalis, B. loescheii, Fusobacterium nucleatum, Actinobacillus actinomycetemcomitans, Eikenella corrodens, B. intermedius, and Capnocytophaga ochracea were the bacterial strains of interest. Antigens were prepared by cold ultrasonication of washed bacterial cells. Association of high- or low-IgG antibody titer to the bacteria was evaluated. High or low titers of IgG were based on ELISA measurements in 28 healthy subjects. Values exceeding 100% above or below the normal standard deviation were classified as high or low titers, respectively.

Most patients with three types of periodontitis (76.8%) exhibited high-IgG antibody titers against various periodontopathic bacteria. The sera mostly included high-IgG titer against one or some of B. gingivalis, E. corrodens, F. nucleatum, and/or A. actinomycetemcomitans. B. gingivalis was predominantly associated with three categories of periodontitis (60.7%). However, high-IgG antibody titer against B. gingivalis alone was found in relatively low percentage (21.4%). Most of the cases were associated with one or more of the other periodontopathic bacteria. High-IgG titer against A. actinomycetemcomitans was found in a few patients (12.5%), who showed severe and more rapid bone loss. Nine patients (16.1%) showed lower IgG antibody titer than did the healthy control subjects. Of the nine, three patients who belonged to the JP category showed the chemotaxis dysfunction of their PMNs. Some immunodepression was suspected in these patients.

Lichen planus evoked by periodontal surgery

A case of Lichen Planus (LP) following periodontal surgery in a patient previously free of the disease is described. Genetic predisposition and lymphokine secretion stimulated by local trauma are suggested as a possible mechanism of the phenomenon. It is recommended that LP patients, especially those suffering from the erosive type, should be treated as conservatively as possible, minimizing the possibility of trauma to the oral tissues where local immunity may have been altered by a pathological process.

Response to anticoagulant drug withdrawal

This study evaluated 44 separate medication withdrawal periods in 17 subjects who were attending a hospital anticoagulation clinic for management of anticoagulation medication. The data suggest that when anticoagulant withdrawal is needed for particular dental procedures, a 2-day hold is an effective period of medication withdrawal. No thromboembolic events were observed after any of the withdrawal periods. Further, no posttreatment hemorrhagic episodes were observed when the anticoagulant medication was reinstituted after dental treatment. Prothrombin time blood levels should be determined in the immediate pretreatment period, however, because the prothrombin time can fluctuate even in the best maintained patients.

Infectious flare-ups and serious sequelae following endodontic treatment: a prospective randomized trial on efficacy of antibiotic prophylaxis in cases of asymptomatic pulpal-periapical lesions

Without peritreatment antibiotics, infectious flare-ups (about 15% incidence) and serious sequelae follow endodontic treatment of asymptomatic teeth with necrotic pulps and associated periapical lesions. Antibiotics administered after endodontic treatment (4-day regimen) reduce the flare-up incidence to about 2%, but hypersensitivity responses, sensitization, resistant microbes, and drug-taking compliance are potential problems. To ascertain whether a specific prophylactic antibiotic (high-dose, 1-day regimen) would preferentially maintain this low flare-up incidence while overcoming antibiotic-related problems, 315 patients with quiescent pulpal necrosis and an associated periapical lesion were randomly given either penicillin V or erythromycin (base or stearate). Evaluations of flare-up after endodontic treatment were done at 1 day, 1 week, and 2 months. A 2.2% flare-up incidence was found, with no statistically significant differences for penicillin (0.0%), base (2.9%), and stearate (3.8%). No hypersensitivity responses occurred. Gastrointestinal side effects were found primarily with the erythromycins (12.4%). A comparative analysis of the data from our first study (no peritreatment antibiotics) and the pooled data from our last two investigations (including the current trial) showed that peritreatment antibiotic coverage significantly reduced flare-ups and serious sequelae after endodontic treatment (p less than 0.001).

Psychological aspects of patients with burning mouth syndrome

This article reports the results of a psychological questionnaire survey of 184 patients who have burning mouth syndrome. The results are compared with normative data obtained in the Netherlands. In general, it may be concluded that in a large number of patients with glossodynia, psychological aspects such as anxiety, depression, and neurotic tendencies are of great importance. However, it must be emphasized that this conclusion may not be interpreted as support for a psychogenic cause of the syndrome or for a strong psychological factor in the etiology of glossodynia.

Prevention of infective endocarditis: not by antibiotics alone. A 7-year follow-up of 90 dental patients

Ninety patients (thirty-nine men, fifty-one women with a mean age of 45.4 years with rheumatic heart disease or prosthetic heart valves, were subjected to a total of 1617 dental procedures, which required about 3400 patient/dentist encounters. All treatments were performed according to the protocol described in the present article. Although theory expects three to six cases of infective endocarditis cases in the described population, none of the patients have encountered the disease (p = 0.0013). A conceptual approach, as well as the protocol, is presented. Properly applied, the protocol will reduce the probability of iatrogenic and self-inflicted bacteremia, thus elevating the efficacy of the preventive process.