Microbiological features of Papillon-Lefèvre syndrome periodontitis

Herpesvirus-Bacteria pathogenic interaction in juvenile (aggressive) periodontitis. A novel etiologic concept of the disease

Localized juvenile (aggressive) periodontitis starts at puberty in otherwise healthy individuals and involves the proximal surfaces of permanent incisors and first molars. The disease destroys a sizeable amount of periodontal bone within a few months despite minimal dental plaque and gingival tissue inflammation. Cytomegalovirus and Epstein-Barr virus, as well as the two main periodontopathic bacteria Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis, are linked to juvenile periodontitis. Juvenile periodontitis-affected teeth show cementum hypoplasia. We hypothesize that an active herpesvirus infection, at the time of root formation, hampers cementum formation and, at puberty, herpesvirus reactivation triggers an upgrowth of bacterial pathogens which produce rapid periodontal destruction on teeth with a defective periodontium. A pathogenic interaction between active herpesviruses and bacterial pathogens can potentially explain the etiology and incisor-first molar destructive pattern of juvenile periodontitis. Effective treatment of juvenile periodontitis may target the herpesvirus-bacteria co-infection.

The oral microbiome of a family including Papillon-Lefèvre-syndrome patients and clinically healthy members

AIMS

The oral microbiota composition of patients diagnosed with Papillon-Lefèvre-syndrome and treated for several years were compared to those existing in the oral cavity of the clinically healthy family members and a cohort of patients having various stages of chronic periodontitis.

MATERIALS AND METHODS

A family with two sisters affected with severe periodontitis and with the typical skin symptoms of Papillon-Lefèvre-syndrome, and symptomless parents and third sibling were investigated. The Patients received periodontal treatment for several years and their oral microbiome was analysed by amplicon sequencing. Data were evaluated by microbial cluster analysis.

RESULTS

The microbiome of the patients with Papillon-Lefèvre-syndrome was predominated with Aggregatibacter actinomycetemcomitans and associated oral periodontopathogens. Although the clinically healthy family members showed no oral disorder, their microbiome resembled that of subjects having mild periodontitis.

CONCLUSIONS

Predominance of A. actinomycetemcomitans in the subgingival microbiome of patients with Papillon-Lefèvre-syndrome suggests that specific treatment strategies directed against this pathobiont may improve the oral health status of the affected individuals.

TRIAL REGISTRATION

The study was conducted in accordance with the Declaration of Helsinki and the ethical permission has been issued by the Human Investigation Review Board of the University of Szeged, Albert Szent-Györgyi Clinical Centre (Permission No. 63/2017-SZTE). September 19, 2017.  https://u-szeged.hu/klinikaikutatas/rkeb-altal-jovahagyott/rkeb-2017 .

Inherited diseases caused by mutations in cathepsin protease genes

Lysosomal cathepsins are proteolytic enzymes increasingly recognized as prognostic markers and potential therapeutic targets in a variety of diseases. In those conditions, the cathepsins are mostly overexpressed, thereby driving the respective pathogenic processes. Although less known, there are also diseases with a genetic deficiency of cathepsins. In fact, nowadays 6 of the 15 human proteases called 'cathepsins' have been linked to inherited syndromes. However, only three of these syndromes are typical lysosomal storage diseases, while the others are apparently caused by defective cleavage of specific protein substrates. Here, we will provide an introduction on lysosomal cathepsins, followed by a brief description of the clinical symptoms of the various genetic diseases. For each disease, we focus on the known mutations of which many have been only recently identified by modern genome sequencing approaches. We further discuss the effect of the respective mutation on protease structure and activity, the resulting pathogenesis, and possible therapeutic strategies.

Aggressive forms of periodontitis secondary to systemic disorders

A number of systemic disorders increase a patient's susceptibility to destructive periodontitis and have impacts on periodontal disease progression and severity. The underlying factors are usually genetic and are mainly related to alterations in the immune response and in certain endocrine functions, leading to various syndromes in which periodontitis and/or early tooth loss are secondary manifestations. Neutrophils are important immune defense cells that play a significant role in controlling the spread of microbial plaque infections in the dentogingival region. This review focuses on a selected group of systemic disorders that are associated with alterations in either neutrophil counts (quantitative disorders) or function (qualitative disorders), and defects in the mineralization of bone and dental tissues. In most of these diseases controlling the periodontal disease progression is very challenging. Proper diagnosis is a prerequisite for proper management of the periodontal problem. Future advances in research, including gene targeting and the resolution of enzyme deficiencies, may bring about remedies of the underlying systemic disorders and may significantly improve the outcome of periodontal treatment in these patients.

Papillon-Lefèvre syndrome: clinical presentation and management options

Papillon-Lefèvre syndrome (PLS) is a rare autosomal recessive disorder, characterized by diffuse palmoplantar keratoderma and precocious aggressive periodontitis, leading to premature loss of deciduous and permanent dentition at a very young age. Various etiopathogenic factors are associated with the syndrome, like immunologic alterations, genetic mutations, and the role of bacteria. Dentists play a significant role in the diagnosis and management of PLS as there are characteristic manifestations like periodontal destruction at an early age and an early eruption of permanent teeth. Here, we are presenting an elaborate review of PLS, its etiopathogenesis, clinical presentation, and management options.

The oral microbiome diversity and its relation to human diseases

As one of the most clinically relevant human habitats, the human mouth is colonized by a set of microorganisms, including bacteria, archaea, fungi, and viruses. Increasing evidence has supported that these microbiota contribute to the two commonest oral diseases of man (dental caries and periodontal diseases), presenting significant risk factors to human health conditions, such as tumor, diabetes mellitus, cardiovascular diseases, bacteremia, preterm birth, and low birth weight in infants. It is widely accepted that oral microorganisms cause diseases mainly by a synergistic or cooperative way, and the interspecies interactions within the oral community play a crucial role in determining whether oral microbiota elicit diseases or not. Since a comprehensive understanding of the complex interspecies interactions within a community needs the knowledge of its endogenous residents, a plenty of research have been carried out to explore the oral microbial diversity. In this review, we focus on the recent progress in this field, including the oral microbiome composition and its association with human diseases.

EBV-1 and HCMV in aggressive periodontitis in Brazilian patients

The purpose of the present investigation was to compare the presence of Epstein-Barr virus type 1 (EBV-1) and of Human Cytomegalovirus (HCMV) in crevicular fluid samples from deep and shallow periodontal pocket sites of Brazilian patients with aggressive periodontitis. A total of 30 systemically healthy patients with aggressive periodontitis participated in the study. Paper points were inserted into 2 gingivitis sites (< 3 mm) and into 2 periodontitis sites (> 5 mm) in each patient. PCR assay was used to identify genomic copies of HCMV and EBV-1. Twenty-three patients (77%) were positive for EBV-1, while only 2 patients (6%) were positive for HCMV. The McNemar test revealed a positive association between EBV-1 and periodontal lesions (p = 0.043). Thirty-four (57%) out of 60 periodontitis sites were positive for EBV-1, whereas 18 (30%) gingivitis sites were positive (p = 0.01). Only two sites (6.7%) were positive for HCMV. No positive association was found between HCMV and periodontitis or gingivitis (p = 0.479). The elevated occurrence of EBV-1 DNA in periodontal pockets of patients with aggressive periodontitis supports a possible periodontopathic role of this virus.

Aggressive periodontitis associated with Papillon-Lefèvre syndrome: Report of a 14-year follow-up

This case report describes the periodontal management, therapeutic approach, and 14-year follow-up of a patient diagnosed with Papillon-Lefevre syndrome (PLS). A female child, diagnosed with PLS-associated periodontitis at the age of 9 years and 11 months, presented with hyperkeratosis of the palms and soles, as well as generalized aggressive periodontitis. The dental treatment comprised standard periodontal debridement, scaling and root planing, instructions on oral hygiene, restorations, extraction of hopelessly affected teeth and a therapeutic use of antibiotics. The concomitant supportive periodontal therapy and antibiotic coverage could not stop the loss of periodontal attachment and destruction of the alveolar bone. Four years after treatment was initiated, the last remaining teeth were extracted and complete dentures were constructed. The dentures have been periodically replaced and the patient continues to return for follow-up once a year. The combination of intensive periodontal treatment and antibiotic regimen only temporarily delayed periodontal disease progression and did not prevent loss of both primary and permanent teeth. The outcome of this long-term follow-up case report shows that management of PLS-associated periodontitis is further complicated when the patient is first seen in the mixed dentition stage or later. In these situations, the chances of controlling the progression of periodontal breakdown and minimizing tooth loss are greatly reduced.

Role of polymorphonuclear leukocyte-derived serine proteinases in defense against Actinobacillus actinomycetemcomitans

Periodontitis is a chronic destructive infection of the tooth-supportive tissues, which is caused by pathogenic bacteria such as Actinobacillus actinomycetemcomitans. A severe form of periodontitis is found in Papillon-Lefèvre syndrome (PLS), an inheritable disease caused by loss-of-function mutations in the cathepsin C gene. Recently, we demonstrated that these patients lack the activity of the polymorphonuclear leukocyte (PMN)-derived serine proteinases elastase, cathepsin G, and proteinase 3. In the present study we identified possible pathways along which serine proteinases may be involved in the defense against A. actinomycetemcomitans. Serine proteinases are capable to convert the PMN-derived hCAP-18 into LL-37, an antimicrobial peptide with activity against A. actinomycetemcomitans. We found that the PMNs of PLS patients released lower levels of LL-37. Furthermore, because of their deficiency in serine proteases, the PMNs of PLS patients were incapable of neutralizing the leukotoxin produced by this pathogen, which resulted in increased cell damage. Finally, the capacity of PMNs from PLS patients to kill A. actinomycetemcomitans in an anaerobic environment, such as that found in the periodontal pocket, seemed to be reduced. Our report demonstrates a mechanism that suggests a direct link between an inheritable defect in PMN functioning and difficulty in coping with a periodontitis-associated pathogen.

Clinical, genetic, and biochemical findings in two siblings with Papillon-Lefèvre Syndrome

BACKGROUND

Papillon-Lefèvre Syndrome (PLS) is an autosomal recessive disease characterized by palmoplantar hyperkeratosis and severe periodontitis affecting both primary and secondary dentitions. Cathepsin C (CTSC) gene mutations are etiologic for PLS. The resultant loss of CTSC function is responsible for the severe periodontal destruction seen clinically.

METHODS

A 4-year-old female (case 1) and her 10-year-old sister (case 2) presented with palmoplantar skin lesions, tooth mobility, and advanced periodontitis. Based on clinical findings, the cases were diagnosed with PLS. Mutational screening of the CTSC gene was conducted for the cases, and their clinically unaffected parents and brother. Biochemical analysis was performed for CTSC, cathepsin G (CTSG), and elastase activity in neutrophils for all members of the nuclear family. The initial treatment included oral hygiene instruction, scaling and root planing, and systemic amoxicillin-metronidazole therapy.

RESULTS

CTSC mutational screening identified a c.415G>A transition mutation. In the homozygous state, this mutation was associated with an almost complete loss of activity of CTSC, CTSG, and elastase. Although monthly visits, including scaling, polishing, and 0.2% chlorhexidine digluconate irrigation were performed to stabilize the periodontal condition, case 1 lost all her primary teeth. In case 2, some of the permanent teeth could be maintained.

CONCLUSIONS

This report describes two siblings with a cathepsin C gene mutation that is associated with the inactivity of cathepsin C and several neutrophil serine proteases. The failure of patients to respond to periodontal treatment is discussed in the context of these biological findings.

Cytomegalovirus-Associated Periodontitis and Guillain-Barré Syndrome

BACKGROUND

Guillain-Barré syndrome (GBS), an autoimmune disorder of the peripheral nervous system, is characterized by rapidly ascending neural paralysis, hyporeflexia, and areflexia. The polyneuropathy of the GBS affects one to four humans per 100,000 of the population annually throughout the world (adults and children). The pathogenesis of GBS remains unclear. However, there are increasing indications that the disease is triggered by a preceding well-established febrile infection by cytomegalovirus (CMV). The present report describes active CMV within the periodontium of a 37-year-old patient affected by GBS.

METHODS

Real-time reverse transcriptase-polymerase chain reaction (real-time RT-PCR) was performed to detect CMV, Epstein-Barr virus-1 (EBV-1), herpes simplex 1 (HSV-1) and 2 (HSV-2) virus, and enteroviruses (polio-, coxsackie-, echo-, and enteroviruses 68 and 71) from periodontal sites demonstrating advanced attachment loss. Healthy sites and sites with inflamed gingival tissue were not included in the study. Anaerobic bacterial culture determined the occurrence of potential major periodontal pathogens.

RESULTS

Real-time RT-PCR and microbiologic analysis revealed the presence of a dual infection of CMV and specific bacterial plaque. CMV, Porphyromonas gingivalis, Tannerella forsythensis, and Campylobacter species were associated with periodontitis active sites, loss of attachment, and gingival bleeding. Furthermore, periodontal sites infected by active CMV had no visible radiographic crestal lamina dura.

CONCLUSIONS

The periodontium may serve as a reservoir for CMV and a source of viral replication. However, further research is needed to test whether viral replication in the periodontium precedes the GBS symptoms.

Papillon-Lefèvre syndrome with albinism: A review of the literature and report of 2 brothers

BACKGROUND

Papillon-Lefèvre syndrome (PLS) is a very rare autosomal recessive disorder characterized by palmoplantar hyperkeratosis and severe early onset of destructive periodontitis leading to premature loss of both primary and permanent dentitions. The etiopathogenesis of the condition suggests that there is a genetic basis for susceptibility to specific virulent pathogens. Variation in the clinical presentation of PLS has recently been observed.

OBJECTIVE

The objective was to present the first report, which describes the concurrence of PLS and albinism. The etiology, pathology, and management of the condition were reviewed and genetic analysis was performed. SUBJECTS AND CLINICAL PRESENTATION: The probands are Jordanian brothers aged 13 and 20 years on their initial presentation. The parents were second cousins and not affected. The patients exhibited the typical clinical features of PLS with type 1 oculocutaneous albinism (OCA1). They also had increased susceptibility to infection manifested in recurrent tonsillitis, respiratory tract infection, pyoderma, onychogryphosis, and other pathosis. Skin biopsy demonstrated hyperkeratosis, focal parakeratosis, hypergranulosis, and acanthosis. Ectopic calcification of the dura was noticed in one of the probands. Hematological parameters tested were within the normal limits. The probands were tested for mutations in the causative genes of PLS and OCA1, cathepsin C (CTSC), and tyrosinase, respectively. Independent mutations (c.318-1G>A and c.817G>C/p.W272C) were identified in CTSC and tyrosinase, respectively. The probands were homozygous and their sister who had only PLS was homozygous for the same (CTSC) mutation but heterozygous for tyrosinase gene.

CONCLUSION

We hope that this report of coinheritance PLS and albinism will initiate further investigations to disclose other possible variations that may enhance our knowledge on gene mutations of this intriguing syndrome.

Periodontal treatment of patients with Papillon-Lefevre syndrome: a 3-year follow-up

BACKGROUND/AIM

Conventional mechanical periodontal treatment of Papillon-Lefevre syndrome (PLS) has often been reported to fail. This study describes the outcome of a non-surgical periodontal therapy including antimicrobial treatment of nine patients diagnosed with PLS. The patients originate from a total of 15 children and adolescents with PLS for which clinical characteristics are presented.

METHODS

Clinical examination including conventional periodontal measurements. Initial treatment including oral hygiene instruction, scaling and root planing and systemic amoxicillin-metronidazole therapy for 6 weeks. After that the patients were enrolled in a 3-month recall maintenance program. In addition to this mechanical supportive maintenance treatment, tetracycline was prescribed and used continuously for 1.5 years.

RESULTS/CONCLUSION

On five patients who were showing acceptable standard of oral hygiene and also compliance with the antibiotic medication, development of periodontitis on erupting teeth was prevented and disease activity on the previously periodontally involved teeth controlled during a 3-year period. Poor results of treatment were observed for three patients, all siblings. These patients failed to comply with the medication and also failed to improve their oral hygiene.

Update on human cytomegalovirus in destructive periodontal disease

AIM

Human cytomegalovirus (HCMV), a herpesvirus, is discussed in this review as it relates to destructive periodontal disease in humans.

RESULTS

HCMV genomic sequences, detected by polymerase chain reaction identification, occur with elevated frequency in severe adult periodontitis, localized and generalized aggressive (juvenile) periodontitis, Papillon-Lefèvre syndrome periodontitis, acute necrotizing ulcerative gingivitis, and periodontal abscesses.

DISCUSSION

Herpesviruses establish lifelong persistent infections. HCMV infection involves an asymptomatic latent phase interrupted by periods of recrudescence where viral replication and possibly clinical disease become manifest. HCMV reactivation is triggered by a number of immunosuppressive factors, some of which have been shown also to be risk factors/indicators of periodontitis. HCMV periodontal infection may cause release of tissue-destructive cytokines, overgrowth of pathogenic periodontal bacteria, and initiation of cytotoxic or immunopathologic events.

CONCLUSIONS

A growing body of data supports the concept that HCMV contributes to severe types of periodontal disease. HCMV infection of the periodontium may alter the immune control of resident microorganisms and be important in a multistage pathogenesis of periodontitis involving viral activation, periodontopathic bacteria, and host immune responses. Understanding the significance of HCMV and other herpesviruses in the development of periodontal disease may have important therapeutic implications. Vaccines against HCMV, which are in various stages of development, need to be evaluated for their ability to decrease the incidence of destructive periodontal disease.

Cytokines, matrix metalloproteinases and tissue inhibitor of metalloproteinases-1 in gingival crevicular fluid from patients with Papillon-Lefèvre syndrome

The aim of the present study was to compare concentrations of cytokines, matrix metalloproteinases (MMPs) and a metalloproteinase inhibitor (TIMP-1) in gingival crevicular fluids (GCF) from sites with gingival inflammation in 28 young patients with Papillon-Lefèvre syndrome (PLS), and in age- and gender-matched controls. Each group consisted of 17 females and 11 males with a mean age of 11.0 years (range 4-22 years). In both groups, anterior upper sites with a clinical diagnosis of gingival inflammation and with pockets < or = 3 mm were selected for sampling of GCF, which was carried out with filter disks inserted into the gingival crevice until saturated. The concentrations of cytokines (IL-1alpha, IL-1beta, TNF-alpha, and IL-8), matrix metalloproteinases (MMP-1, MMP-3, MMP-8, and MMP-9), and their tissue inhibitor (TIMP-1) were analysed using commercial ELISA kits. Significantly higher levels of IL-1beta (P < 0.001) and MMP-8 (P < 0.05) were disclosed among the PLS patients compared with their controls, while the opposite was found for IL-8 (P < 0.05) and MMP-1 (P < 0.001). The individual variations were considerable in both groups. When comparing the expression of cytokines, MMPs, and TIMP-1 in PLS patients with clinically active and non-active periodontitis, the non-active PLS patients showed significantly higher values of IL-1beta than the patients with active periodontal disease (ANOVA, P < 0.01). In conclusion, this study was unable to demonstrate a clear-cut pathognomonic expression of cytokines or MMPs in patients with PLS, but further studies on cytokine and MMP output are warranted.

Infections in patients with inherited defects in phagocytic function

Patients with defects in phagocytic function are predisposed to intracellular microorganisms and typically have early dissemination of the infection. Recognition of the underlying disorder and aggressive antimicrobial therapy has been beneficial for the patients. Improved understanding of the pathophysiology has also affected patient management by allowing specific, targeted immunomodulatory intervention. The disorders described in this review are not common but have had a significant impact on our understanding of the role of phagocytic cells in host defense. Conversely, understanding the role of the neutrophil and macrophage in infection has benefited not just the patients described in this review but also other patients with similar disease processes.

Herpesviral-bacterial interactions in aggressive periodontitis

BACKGROUND

Human cytomegalovirus, Epstein-Barr virus and herpesvirus co-infections occur with significantly higher frequency in actively progressing than in stable periodontitis sites of adolescents and young adults. Also, periodontal presence of cytomegalovirus and Epstein-Barr virus is associated with increased occurrence of subgingival Porphyromonas gingivalis, Bacteroides forsythus, Dialister pneumosintes, Prevotella intermedia, Prevotella nigrescens, Treponema denticola and Actinobacillus actinomycetemcomitans.

AIM

This article reviews the evidence linking herpesviruses to the development of aggressive periodontitis and suggests a potential mechanism for herpesviral acceleration of the periodontal disease process.

CONCLUSIONS

It seems to be a reasonable supposition that the etiopathogenesis of various types of aggressive periodontitis includes the combined action of herpesviruses and specific bacterial species. New vaccines and vaccination technologies that are being developed against herpesviruses warrant testing for their ability to induce a protective immune response against destructive periodontal disease. Clearly, the importance of combined herpesviral-bacterial infections and associated host responses in the development of periodontitis needs to be studied further.

Activation of interleukin 1beta gene transcription by human cytomegalovirus: molecular mechanisms and relevance to periodontitis

In recent years, studies have demonstrated an association between human cytomegalovirus (HCMV) and destructive periodontal disease. It has been shown that reactivation of HCMV in periodontitis lesions may be related to progressing periodontal disease. Several possible mechanisms by which HCMV exerts periodontopathic potential have been previously proposed. These are reviewed and include the upregulation of bone resorptive cytokines such as interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) by active HCMV infection at the periodontitis site. This review focuses on the molecular basis of IL-1beta gene activation by HCMV immediate early (IE) gene products. A novel hypothesis is also described whereby HCMV plays a significant role in the pathogenesis of periodontal disease by the ability of its IE proteins to strongly transactivate IL-1beta gene expression. More studies are needed to further explore this hypothesis and clarify the association between HCMV and periodontitis.

Detection of human viruses in patients with chronic periodontitis and the relationship between viruses and clinical parameters

BACKGROUND

Recent studies have demonstrated that various human viruses, especially cytomegalovirus (HCMV), Epstein-Barr virus type-1 (EBV-1), and herpes simplex virus (HSV), seem to play a part in the pathogenesis of human periodontitis. Little information is available on the relationship between these viruses and clinical periodontal parameters in patients with chronic periodontitis. This study examined the occurrence of HCMV, EBV-1, and HSV in patients with chronic periodontitis and the relationship between these viruses and clinical parameters.

METHODS

A nested polymerase chain reaction (PCR) method determined the presence of HCMV, EBV-1, and HSV. Subgingival plaque samples from 30 patients with chronic periodontitis and 21 randomly selected healthy controls were collected by paper points, and clinical measurements were recorded from both sampling sites and entire dentition. The following indices were measured: plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment loss (CAL).

RESULTS

HCMV was detected in 44.3% of chronic periodontitis patients and 14.3% of healthy persons (P < 0.05); EBV-1 in 16.7% of chronic periodontitis patients and 14.3% of healthy persons (P = 1.00); and HSV in 6.7% of chronic periodontitis patients and in no healthy persons. HCMV and EBV-1 detected and undetected sites in patients with periodontitis showed statistically significant differences in sampling clinical depth (SPD) and sampling clinical attachment loss (SCAL). Differences in the measurements of PI of entire dentition and GI of entire dentition between HSV detected and undetected sites were statistically significant.

CONCLUSIONS

Findings of the present study confirm the frequent presence of HCMV in crevicular samples of chronic periodontitis lesions, and suggest a strong relationship between the presence of HCMV and EBV-1 in subgingival areas and the measurements of probing depth and probing attachment loss.

Treatment of Papillon-Lefèvre syndrome periodontitis

BACKGROUND, AIMS

Conventional mechanical treatment of Papillon-Lefèvre syndrome periodontitis has a poor prognosis. This report describes an effective antimicrobial treatment of rapidly progressing periodontitis in an 11-year old girl having Papillon-Lefèvre syndrome.

METHOD

Clinical examination included conventional periodontal measurements and radiographic analysis. Occurrence of major suspected periodontopathic bacteria was determined by selective and non-selective culture and by polymerase chain reaction (PCR) identification. Presence of cytomegalovirus and Epstein-Barr type 1 virus was determined by a nested-PCR detection method. Therapy included scaling and root planing, oral hygiene instruction, and systemic amoxicillin-metronidazole therapy (250 mg of each/3 times daily/10 days) which, based on follow-up microbiological testing, was repeated after 4 months. Supportive periodontal therapy took place at 2 visits during a 16-month period.

RESULTS

At baseline, 10 of 22 available teeth demonstrated severe periodontal breakdown. At 16 months, probing and radiographic measurements revealed no teeth with additional attachment loss, and several teeth exhibited significant reduction in gingivitis and pocket depth, increase in radiographic alveolar bone height and clinical attachment level, and radiographic evidence of crestal lamina dura. Baseline subgingival microbiota included Actinobacillus actinomycetemcomitans (3.4% of total isolates), Prevotella nigrescens (16.4%), Fusobacteriumnucleatum (14.3%) and Peptostreptococcus micros (10.6%), as well as cytomegalovirus and Epstein-Barr type 1 virus. At termination of the study, culture and PCR examinations showed absence of A. actinomycetemcomitans, P. micros and herpesviruses, and P. nigrescens and F.nucleatum each comprised less than 0.1 % of subgingival isolates.

CONCLUSION

This study suggests that controlling the periodontopathic microbiota by appropriate antibiotic and conventional periodontal therapy can arrest Papillon-Lefèvre syndrome periodontitis.

Papillon-Lefèvre syndrome: serum immunoglobulin G (IgG) subclass antibody response to periodontopathic bacteria. A case report

BACKGROUND

Papillon-Lefevre syndrome (PLS) is a rare autosomal recessive disorder which is characterized by palmar-plantar hyperkeratosis and rapid periodontal destruction of both primary and permanent dentitions. In this case report, we present clinical features, and microbiological and immunological findings of 40 month-old Thai male PLS patient.

METHODS

Microbiological examinations consisted of bacterial culture methods utilizing selective media, morphological identification, and biochemical tests. In addition, the specific serum IgG subclass antibody titers reactive with etiologic periodontal bacteria were determined by the dot-blot immunological analysis and enzyme linked immunosorbent assay (ELISA).

RESULTS

The examinations revealed that the patient harbored 3 major suspected periodontopathic microorganisms, A. actinomycetemcomitans, P. gingivalis, and P. intermedia. The patient's serum IgG1, IgG2, and IgG3, but not IgG4, titers against A. actinomycetemcomitans were dramatically increased. The predominant IgG subclass was IgG1. In contrast, the IgG titers against other tested bacteria, P. gingivalis, P. intermedia, and F. nucleatum, appeared to be similar to those of a healthy control.

CONCLUSIONS

A. actinomycetemcomitans seems to play a pivotal role in the bacteria-host interaction in PLS periodontal pathogenesis. Response of the specific serum IgG subclass antibody titers against the A. actinomycetemcomitans antigen has been demonstrated. This association warrants further investigation.

Aggressive periodontitis associated with Fanconi's anemia. A case report

BACKGROUND

Fanconi's anemia is an autosomal recessive disease associated with chromosomal breakage as well as pancytopenia, skin pigmentation, renal hypoplasia, cardiac defects, microcephaly, congenital malformations of the skeleton, hypogonadism, and increased risk of leukemia. The present report describes the periodontal clinical and microbiological status of an 11-year old male having Fanconi's anemia.

METHODS

Polymerase chain reaction analysis to detect human cytomegalovirus (HCMV), Epstein-Barr type 1 virus, and herpes simplex virus (HSV) was performed on paper-point samples pooled from either 3 periodontal sites with advanced attachment loss or 3 gingivitis sites with no clinical attachment loss. Anaerobic bacterial culture examination was performed on the pooled periodontitis sample.

RESULTS

The patient suffered from pancytopenia, allergy, asthma, hearing impairment, and mental retardation. Dentition consisted of 7 primary teeth, 11 erupted permanent teeth, and 14 unerupted permanent teeth. Most erupted teeth showed severe gingival inflammation with some gingival overgrowth and various degrees of periodontal attachment loss. Genomes of HCMV and HSV were detected in the pooled periodontitis sample and HCMV in the pooled gingivitis sample. The periodontitis sample but not the gingivitis sample revealed HCMV mRNA of major capsid protein, suggestive of active viral infection. The periodontitis sample also yielded Actinobacillus actinomycetemcomitans (1.1% of total isolates), FusobActerium species (7.9%), Campylobacter species (2.2%), Peptostreptococcus micros (3.4%), and Candida albicans (0.3%).

CONCLUSIONS

Oral features of Fanconi's anemia may include increased susceptibility to periodontitis. It is likely that underlying host defense impairment coupled with periodontal infection by HCMV and A. actinomycetemcomitans contribute to the severe type of periodontitis associated with Fanconi's anemia.

Herpes viruses and periodontopathic bacteria in early-onset periodontitis

OBJECTIVES

This study examined the occurrence of human herpes viruses and suspected periodontopathic bacteria in early-onset periodontitis patients who experienced progressive disease in at least 2 periodontal sites during the maintenance phase of therapy.

MATERIAL AND METHODS

In each of 16 individuals (9 male and 7 female; mean age 33.1+/-2.6 years), subgingival plaque samples were collected from 2 deteriorating and 2 stable periodontitis sites. A nested polymerase chain reaction method determined the presence of human cytomegalovirus (HCMV), Epstein-Barr virus type 1 (EBV-1) and herpes simplex virus (HSV). A 16s rRNA polymerase chain reaction method identified Porphyromonas gingivalis, Dialister pneumosintes, Bacteroides forsythus and Actinobacillus actinomycetemcomitans.

RESULTS

HCMV was detected in 59.4% of active and in 12.5% of stable sites (p<0.001), EBV-1 in 43.8% of active and in 12.5 % of stable sites (p=0.01), HSV in 34.5% of active and in 9.4% of stable sites (p=0.03), and co-infection with any of the 3 test herpesviruses in 43.8% of active and in 3.1% of stable sites (p<0.001). P. gingivalis was detected in 71.9% of active and in 37.5% of stable sites (p=0.01), D. pneumosintes in 62.5% of active and in 18.8% of stable sites (p=0.04), co-infection with P. gingivalis and D. pneumosintes in 50% of active and in 0% of stable sites (p<0.001), and co-infection with any 3 or 4 of the test bacteria in 40.6% of active and in 0% of stable sites (p=0.001). All periodontitis sites showing herpesvirus co-infection and all but one site showing P. gingivalis and D. pneumosintes co-infection revealed bleeding upon probing.

CONCLUSIONS

HCMV, EBV-1, HSV and herpesvirus co-infection, as well as P. gingivalis, D. pneumosintes and P. gingivalis-D. pneumosintes co-infection were statistically associated with active periodontitis. Herpesviruses are immunosuppressive and may set the stage for overgrowth of subgingival P. gingivalis, D. pneumosintes and other periodontopathic bacteria. Understanding the significance of herpesviruses in human periodontitis may allow for improved diagnosis, more specific therapy and, ultimately, disease prevention.

Successful periodontal maintenance of a case with Papillon-Lefèvre syndrome: 12-year follow-up and review of the literature

BACKGROUND

Various approaches to treating the periodontal condition associated with Papillon-Lefèvre syndrome have been reported. These include oral hygiene instruction, use of mouthrinses, frequent debridement, multiple antibiotic regimens, periodontal surgery, extraction of hopeless teeth, and extraction of all deciduous teeth. Because Papillon-Lefèvre syndrome is rare, most publications are case reports, and very few document long-term successful treatment of the periodontal condition.

METHODS

In 1986, a 3.5-year-old Indo-Canadian male was diagnosed with Papillon-Lefèvre syndrome and began periodontal treatment. Initial therapy consisted of debridement every 3 weeks, a 0.12% chlorhexidine mouthrinse, 2 regimens of metronidazole, and oral hygiene instruction for his parents. After 10 months it became apparent that the treatment was having little beneficial effect, since the periodontal destruction continued and teeth 51 and 61 exfoliated. At age 4, all remaining deciduous teeth were extracted and complete dentures inserted for the following 2-year edentulous period; then a 3-month maintenance schedule was maintained.

RESULTS

The patient is now 17 years old and all his adult teeth are present with the exception of the third molars. His oral hygiene varies between moderate and good, with his most recent plaque score at 80% effectiveness. There are no probing depths greater than 4 mm, with the exception of the distal of the lower second molars where opercula are present.

CONCLUSIONS

Extraction of all the deciduous teeth followed by a period of edentulousness may partially explain the fact that there has been no recurrent attachment loss in the permanent teeth up to age 17. Other explanations are discussed as part of the literature review of Papillon-Lefèvre syndrome.

A microbiological study of Papillon-Lefévre syndrome in two patients

AIM

To analyse the microflora of subgingival plaque from patients with Papillon-Lefévre syndrome (PLS), which is a very rare disease characterised by palmar-plantar hyperkeratosis with precocious periodontal destruction.

METHODS

Bacterial isolates were identified using a combination of commercial identification kits, traditional laboratory tests, and gas liquid chromatography. Some isolates were also subjected to partial 16S rDNA sequencing. Plaque samples were also assayed for the presence of Porphyromonas gingivalis, Prevotella intermedia, and Actinobacillus actinomycetemcomitans in a quantitative enzyme linked immunosorbent assay (ELISA) using monoclonal antibodies.

RESULTS

The culture results showed that most isolates were capnophilic and facultatively anaerobic species-mainly Capnocytophaga spp and Streptococcus spp. The latter included S. constellatus, S. oralis, and S. sanguis. Other facultative bacteria belonged to the genera gemella, kingella, leuconostoc, and stomatococcus. The aerobic bacteria isolated were species of neisseria and bacillus. Anaerobic species included Prevotella intermedia, P. melaninogenica, and P. nigrescens, as well as Peptostreptococcus spp. ELISA detected P gingivalis in one patient in all sites sampled, whereas A. actinomycetemcomitans was detected in only one site from the other patient. Prevotella intermedia was present in low numbers.

CONCLUSIONS

Patients with PLS have a very complex subgingival flora including recognised periodontal pathogens. However, no particular periodontopathogen is invariably associated with PLS.

Herpesviruses in HIV-periodontitis

BACKGROUND/AIMS

Human herpesvirus-associated diseases exhibit elevated morbidity and mortality in patients infected with human immunodeficiency virus (HIV). This study aimed to investigate the occurrence of herpesviruses in HIV-periodontitis.

METHOD

Gingival biopsies from periodontitis lesions of 21 HIV-patients and 14 non HIV-patients were studied. Nested-polymerase chain reaction methods were employed to detect human cytomegalovirus, Epstein-Barr virus type 1 and 2 (EBV-1, EBV-2), herpes simplex virus, human herpes virus (HHV)-6, HHV-7 and HHV-8.

RESULTS

Gingival biopsies from HIV-periodontitis lesions showed on average 4.0 herpesvirus species and gingival biopsies from HIV periodontitis lesions of non-HIV patients revealed an average of 1.9 herpesvirus species (p<0.001). Occurrence of 4 to 6 different herpesviruses was more common in HIV- than in non HIV-gingival biopsies (71% vs. 7%) (p<0.001). EVB-2 was detected in 12 (57%) biopsies from HIV-periodontitis but was absent in non HIV-periodontitis biopsies (p= 0.002). HHV-6 also occurred in significantly higher frequency in HIV-periodontitis (71%) than in non HIV-periodontitis (21%) (p=0.01). HHV-8 was detected only in biopsies from HIV-periodontitis lesions..

CONCLUSION

HIV-periodontitis seems to be associated with elevated occurrence of EBV-2, HHV-6 and herpesvirus co-infections compared to periodontitis in non-HIV-patients. The periodontopathic significance of herpesviruses in HIV-periodontitis constitutes a research topic of considerable interest.

Herpesviruses: a unifying causative factor in periodontitis?

Human cytomegalovirus and Epstein-Barr virus type 1 are discussed in this review as they relate to destructive periodontal disease in humans. Genomes of the two herpesviruses occur frequently in severe adult periodontitis, localized and generalized juvenile periodontitis, Papillon-Lefèvre syndrome periodontitis, Down's syndrome periodontitis, HIV-associated periodontitis and acute necrotizing ulcerative gingivitis. Herpesvirus infections generally involve a mild or asymptomatic primary phase followed by an asymptomatic latent phase interrupted sporadically by periods of activation, where viral replication and possibly clinical disease become manifest. Herpesvirus reactivation is triggered by a number of immunosuppressing factors, some of which have also been shown to be risk indicators of periodontal disease. Available evidence argues for the involvement of active cytomegalovirus infection in the initiation and progression of localized juvenile periodontitis and possibly other types of periodontal disease. In periodontal disease, herpesviruses may cause release of tissue-destructive cytokines, overgrowth of pathogenic periodontal bacteria, and initiation of cytotoxic or immunopathogenic events. Understanding the significance of herpesviruses in the causation and pathogenesis of destructive periodontal diseases may have important implications in future prevention and treatment of the diseases.