Ultrastructure of the periodontal lesion in a case of Papillon-Lefèvre syndrome (PLS)

Diagnosis of Papillon-Lefèvre syndrome: review of the literature and a case report

Papillon-Lefëvre syndrome (PLS), classified as ectodermal dysplasia, is an autosomal recessive condition related to the cathepsin C (CTSC) gene mutation. The first clinical symptoms, occurring most commonly between the ages of 1 and 4, are palmoplantar hyperkeratosis and also periodontitis resulting in the loss of most or all teeth in the same sequence in which they erupted. Most often the redness of palms and soles precede the occurrence of keratoderma. Moreover, excessive sweating, moderate mental retardation, the tendency to purulent skin and internal organs infection may occur. Lack of cathepsin seems to have a crucial role in the intensity of symptoms. In most of the patients, there can be observed impairment of phagocytosis and chemotaxis of neutrophils, granulocytes, leukocytes and cytotoxic lesion of fibroblasts and macrophages. Also, functional impairment of lymphocytes, neutrophils, and monocytes is observed. The study, using flow cytometry, showed a decreased percentage of T cells CD8+ and increased CD4:CD8 ratio.

Você conhece esta síndrome?

A síndrome de Papillon-Lefèvre ou queratodermia transgressiva com periodontopatia é genodermatose rara, com acometimento cutâneo e dentário. As alterações aparecem por volta do primeiro ano de vida, com queratodermia transgressiva palmoplantar associada a periodontites, com perda precoce dos dentes decíduos e permanentes. É freqüentemente associada com infecções bacterianas da pele e de órgãos internos. A histopatologia é inespecífica, sendo o diagnóstico eminentemente clínico.

Structure of the periodontium in cathepsin C-deficient mice

Papillon-Lefevre syndrome is characterized by increased susceptibility to early-onset periodontitis and is caused by mutations in the cathepsin C gene. How deficiency of the enzyme relates to an increased periodontal infection risk is still not entirely clear. One possibility is that the deficiency leads to changes in the structure of the periodontal tissues as a result of which its barrier function to pathogens is compromised. We studied the structure of the periodontium in 9-month-old cathepsin C-deficient mice (cathepsin C(-/-)) and compared this with age-matched wild-type mice. Our observations showed that the overall structure of the gingiva, periodontal ligament, alveolar process, and cementum layer are normal in cathepsin C(-/-) mice, with one exception, namely that epithelial rests of Malassez in the periodontal ligament of the cathepsin C(-/-) mice are slightly enlarged. In both experimental and control animals, we noted cyst formation in rests of Malassez. No signs of periodontal infection were observed. It is concluded that cathepsin C deficiency does not lead to major changes in the structure of the periodontium.

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.

Severe gingival recession in trisomy 18 primary dentition. A clinicopathologic case report of self-inflicted injury associated with mental retardation

This clinicopathologic case report documents severe gingival recession in the primary dentition of a trisomy 18 patient. Primary molar and canine teeth exhibited recession extending beyond the midpoint of the buccal aspect of the root, occasionally reaching the root apex. Radiographic examination revealed taurodontism in both primary and permanent teeth. Clinical and histopathologic findings, along with case history, eliminated the possibility of prepubertal periodontitis and suggested a diagnosis of self-inflicted injury associated with mental retardation. Histologic examination of the primary teeth revealed normal cementum and dentin structure. Taurodontism, histologic structure of the dentition, and severe attachment loss in the primary dentition have not been described previously in trisomy 18.

Root resorption and signs of repair in Papillon-Lefèvre syndrome. A case study

The aim of this investigation was to describe some tooth-related histological features of prepubertal periodontitis. Teeth extracted during treatment of two Papillon-Lefevre syndrome patients were processed by means of the sawing and grinding technique. Light microscopy examination revealed little or no cementum in the coronal parts of the roots. Resorptions of various depths (0.02 to 1.5 mm) and to various extents (affecting up to 1/3 of the root surface) were observed in the 5 investigated teeth. Some resorptive defects on 1 of the examined incisors showed signs of spontaneous repair. Extrinsic fibers were inserted into the new cellular intrinsic fiber cementum which had formed directly on the bottom of the defect. Intact acellular extrinsic fiber cementum was found where fibers were still attached. Here, the characteristic of pristine cementum, a hyaline layer of peripheral dentin, could be identified. If resorption was not present, the cementum did not show any signs of hypoplasia. Thus, histological features of prepubertal periodontitis in the current material were (i) areas of extensive resorption, (ii) signs of spontaneous repair, and (iii) healthy cementum.

Subgingival microbial profile of Papillon-Lefèvre patients assessed by DNA-probes

The prevalence of 18 selected bacterial species was assessed by means of "checkerboard" DNA-DNA hybridisation in a group of 12 Saudi-Arabian adolescents with Papillon-Lefèvre syndrome. A total of 36 tooth sites were investigated. The patients exhibited severe periodontal disease with deep pockets. All 12 patients harboured the putative bacterial pathogens P. intermedia, F. nucleatum, P. micros and S. intermedius while T. denticola, B. forsythus, P. nigrescens, E. corrodens, S. noxia and C. rectus were recovered from 11 patients. P. gingivalis was recovered from 9 patients and 18 sites while corresponding figures for A. actinomycetemcomitans were 8 and 19, respectively. A number of the investigated species (B. forsythus, T. denticola, P. intermedia, C rectus) reached high levels (> or =10(6) cells) in more than 1/2 of the patients. On the other hand, bacteria such as A. actinomycetemcomitans and P. gingivalis were infrequently encountered at high levels in these subgingival samples. In conclusion, the analysis failed to demonstrate a PLS-specific profile of the subgingival infection, since the bacterial composition of the sampled sites closely resembled that characterising deep pockets in adult periodontitis patients.

The rationale for chemical adjuncts in plaque control

The rationale for the adjunctive use of chemical anti-plaque agents depends on many factors in addition to the inherent antimicrobial properties of those agents. What is indicated generally is a basic oral hygiene regimen, as simple as it can be, bearing in mind the practical difficulties of getting people to clean their teeth optimally. Chemical adjuncts in many cases have the potential to simplify plaque control regimens. The mode of delivery may be critical to the success or otherwise of an adjunct. Adjuncts may simplify and accelerate the work of hygienists as well as patients. They may also serve to control plaque in severe forms of infectious inflammatory periodontal disease, as well as providing practical means of plaque control in the handicapped, or in those unable to practice optimal conventional home care oral hygiene. Chemical anti-plaque adjuncts offer a prospect of re-establishing the homeostasis of oral microbial biofilms fully consonant with the aims of modern periodontal medicine.

Periodontal therapeutics--a viable option?

Research in recent years in periodontology has seen a shift from surgery towards medicine. While surgery, particularly regenerative, and including implants, continues to form an important element of periodontal treatment, the volume of treatment required and the results of recent and ongoing non-surgical studies clearly show that most future periodontics will be based on a physician-type approach. Improved diagnostics based on more precise periodontal disease classification, simplification of mechanical oral hygiene equipment and procedures, and the development of conventional and non-conventional chemical and physical adjuncts may be expected to reduce the rate of common periodontal disease advance, resulting in less complex treatments, and more of the latter coming to lie within the competence of the generalist and the hygienist working together. The rationale for non-surgical adjunctive therapy is extensive, far beyond the usual antimicrobial logic. It will also be important to control the oral microflora for systemic reasons, since increasingly strong links are being established between focal infection of oral origin, much of it periodontal, and a range of systemic diseases, including coronary heart disease, stroke, gastrointestinal disorders, and low birth weight, apart from severe, overt systemic infections. All these developments derive from a greatly improved understanding of the fundamentally ecological nature of the natural microbial biofilm that is dental plaque, and of its interactions with its human host.

Root surface characteristics of primary teeth from children with prepubertal periodontitis

This study describes the histologic characteristics of root surfaces of primary teeth from children with prepubertal periodontitis (PP). Fifteen primary teeth from 4 children with PP, and 2 control primary teeth from 2 healthy children were examined. Light microscopy revealed normal root surfaces in the control teeth. In contrast, the PP specimens revealed bacteria inside dentin tubules or covering cementum, a cuticle, or resorbed dentin; normal, wider than normal, or hypoplastic cementum; resorption lacunae with various depths; aplastic root resorption; alternate resorption and repair; and active repair. No cementoclasts were found in the resorption lacunae. Scanning electron microscopy revealed intrabony and suprabony root areas, and a "plaque free zone" (PFZ). Colonies of filaments were evident at the cemento-enamel junction (CEJ). The suprabony root surfaces had resorption lacunae, isolated short rods, calculus, colonies of filaments, or colonies composed by an heterogeneous bacterial population. The coronal boundary of the PFZ was the border of a sheet-like structure, which included isolated rods or filaments. At the PFZ, isolated filaments and rods, and a fibril matrix were evident. The apical boundary of the PFZ consisted of bundles of soft tissue remnants or the insertion of the periodontal fibers. The intrabony surfaces were mostly covered by soft tissue, which included isolated filaments and short rods. Resorption lacunae with or without soft tissue were also evident in this area. Crystals of calcium oxalate dihydrate and erythrocytes in distinct forms were found at various root areas. The present findings are different from those previously reported for hypophosphatasia specimens.

Microbiological and immunohistological findings in a patient with Papillon-Lefèvre syndrome

The following communication is a case history of an 11 year-old female patient suffering from Papillon-Lefèvre syndrome. Since a massive occurrence of A. actinomycetemcomitans had been found in the subgingival microflora of the periodontal pockets, the patient was treated with repeated subgingival scaling, with an adjunct Amoxicillin and Metronidazol treatment. A bacteriological examination of the girl's family proved that several brothers and sisters as well as one parent also carried. A. actinomycetemcomitans, showing 3 different strains of this bacterium within the family. An immunohistological examination of the gingival tissue showed a massive inflammatory infiltrate which was dominated by plasma cells. The histological investigation of the first molars did not show morphological abnormalities of the root cementum. Posttreatment clinical and radiographical improvement of the periodontal conditions is reported despite the recurrent finding of A. actinomycetemcomitans.

Papillon-Lefèvre syndrome. Analysis of neutrophil chemotaxis

Papillon-lefèvre syndrome (PLS) is described as the association of palmar-plantar hyperkeratosis with precocious periodontal disease which results in exfoliation of primary and permanent dentitions. This study was planned to assess the chemotaxis of peripheral blood neutrophils in 7 patients (3 females and 4 males) with Papillon-Lefevre syndrome. The neutrophil chemotaxis was analyzed using the zymosan activated serum (ZAS) assay. Chemotaxis and spontaneous migration measurements were compared to those of the healthy control subjects. The peripheral blood neutrophil chemotaxis and spontaneous migration were depressed in all patients with Papillon-Lefèvre syndrome. The decreased chemotaxis of peripheral blood neutrophils strongly suggests that the neutrophils may act as one of the important key determinants in the pathogenesis of severe periodontal destruction in patients with PLS.

Papillon-Lefèvre syndrome: a review of the literature and report of 4 cases

This report describes 4 cases of Papillon-Lefèvre syndrome (PLS) affecting 2 Jordanian families with a total of 8 children. In family A, 3 girls out of 6 siblings were affected; and in family B, the eldest of 2 brothers. The patients were between 4 1/2 and 12 years old, and their parents, who are first cousins, were not affected. Diagnosis was determined by history, and clinical, laboratory, and radiographic examinations. All present cases exhibited the typical clinical features of PLS: hyperkeratosis of the palms and soles and the presence of advanced destructive periodontitis resulting in early loss of both the primary and permanent dentitions. In Case 4, cutaneous lesions were noticed at age 6 months and the child was edentulous by the age of 12 years. In all cases, there was a relationship between increased severity of skin lesions and seasonal variations and intensified periodontal destruction. There was an early eruption of the permanent teeth. The teeth were caries-free with no sign of root resorption. Dentists play a significant role in the diagnosis and management of PLS patients.

The apical border plaque in severe periodontitis. An ultrastructural study

This study concerns the apical border (AB) plaque in relation to severe forms of periodontitis (SP), including juvenile, post-juvenile, and rapidly progressing periodontitis. Twenty-four (24) teeth from 16 patients with SP were examined by transmission electron microscopy (TEM). The AB was not discrete, with islands of bacteria in the so-called plaque-free zone (PFZ). Coronal to the AB the established plaque consisted of a layer of Gram-positive cocci and ghost cells and a superficial layer mainly of Gram-negative morphotypes, including cocci, rods, filaments, fusiforms, and spirochetes. The most apical apparently intact organisms in the PFZ were in bacterial islands or in isolation and were predominantly Gram-negative cocci and rods, with ghost cells in abundance. Ruthenium red, alcian blue-lanthanum nitrate, and safranin O were used to label matrix polyanionic macromolecules, and periodic acid (thiosemicarbazide) silver proteinate for intracellular polysaccharide (IPS). The matrix components were mainly fibrillar. Many intact bacteria exhibited extracellular polysaccharides or glycocalyces associated with their cell wall, and cytoplasmic IPS granules. The latter varied in distribution and were evident even in the most apically advanced intact microorganisms. The results indicate that IPS and some matrix features of the apical border plaque in severe periodontitis in certain aspects resemble those of sub-contact area plaque on children's teeth, in health or associated with early chronic gingivitis, and with those in chronic adult periodontitis. They also suggest the establishment of acidic regions in the microniche at the bottom of the periodontal pocket in the various forms of periodontitis differing in rate of progression. It was concluded that there was a limited range of intact bacterial morphotypes in the apical border plaque in severe periodontitis, similar to those in chronic adult periodontitis.

Peripheral blood reduction of memory (CD29+, CD45RO+, and "bright" CD2+ and LFA-1+) T lymphocytes in Papillon-Lefèvre syndrome

A Papillon-Lefèvre patient with characteristic chronic periodontal disease and palmoplantar keratoderma was studied over a 4-year period. An abnormal T-cell phenotype was steadily observed in peripheral blood; both low numbers of CD29+ and CD45RO+ cells and a low density surface expression of CD2 and LFA-1 molecules were found. T-cell activation through CD3, CD2 and ConA, PWM and IL-2 receptors was normal; however, there was impairment in the activation via CD28. CD2, LFA-1 and CD45 molecules were normal in charge and molecular weight. There was no tissue sequestering of T lymphocytes in periodontal lesions, but rather a relative T-cell reduction. It is suggested that an important decrease of the so-called "memory/hyperreactive" (CD45RO-positive) T cells does exist; therefore, hyperreactive T cells would not be available in sufficient numbers to leave the bloodstream through blood vessel endothelium, and the periodontium would be left without these important defenses and thus exposed to chronic infections. A disregulated factor affecting the transition from "naive" to "memory" T cells and the increase in certain surface molecules expression (i.e., CD2, LFA-1, CD29, and CD45RO) or the reversion from memory to naive T cells may be responsible for the disease pathogenesis. CD2 and LFA-1 molecule synthesis might be conjointly regulated on T lymphocytes.

Clinical, bacteriological, and immunological examinations and the treatment process of two Papillon-Lefèvre syndrome patients

Papillon-Lefèvre Syndrome (PLS) is a rare disease associated with the early onset of periodontal breakdown in deciduous and permanent dentition. The etiology of the destruction has not been completely clarified. Two female patients (ages 4 and 7 years) with severe destruction of the periodontal structures were examined. Except for palmar and plantar hyperkeratosis, dermatologic examination revealed no other medical disorders. On immunological analysis, measurement of serum antibody titers to 7 periodontopathic bacteria including Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans was performed by enzyme-linked immunosorbent assay (ELISA). Further immunoblot analysis of A. actinomycetemcomitans and microbial culture of samples collected from deep periodontal pockets and mouthrinse solution were performed. The serum of the two patients showed high IgG titer against A. actinomycetemcomitans. Immunoblot results of the two patients against sonicated extract of A. actinomycetemcomitans Y4 strain exhibited a similar pattern. The band pattern differed from that observed in other forms of early onset periodontitis patients or periodontally healthy subjects. Moreover, A. actinomycetemcomitans colonies were cultured in high percentages from the pocket samples. Antibiotic therapy was instituted in addition to conventional periodontal therapy. In the younger patient, all deciduous teeth were extracted as part of the treatment and A. actinomycetemcomitans was no longer detected. All four permanent first molars and 8 permanent incisors subsequently erupted with healthy periodontium. However, the older patient did not improve after periodontal and antibiotic (minocycline and erythromycin) treatments and A. actinomycetemcomitans was consistently detected. Ofloxacin medication finally eliminated A. actinomycetemcomitans from the periodontal pockets. This antibiotic was also associated with reduced gingival inflammation and probing depth.(ABSTRACT TRUNCATED AT 250 WORDS)

Papillon-Lefevre syndrome. Characterization of peripheral blood and gingival lymphocytes with monoclonal antibodies

A 14-year-old boy with typical features of Papillon-Lefevre syndrome (PLS) is presented. The purpose of this report was to study the immunopheno-typic features of the peripheral blood and gingival tissue lymphocytes with monoclonal antibodies in the patient. Peripheral blood T-cells, helper-T cells, suppressor-T cells, HLA-DR+ cells and IL-2R+ cells were determined using appropriate monoclonal antibodies and indirect immunofluorescence methods. B-cells were identified using the direct immunofluorescence technique. The gingival tissue was processed for both histopathological and immunohistological examinations. Gingival tissue lymphocytes were identified using monoclonal and polyclonal antibodies with the immunoperoxidase technique. Although we have not detected any significant alterations in the peripheral blood B-cell and T-cell populations, NK cells were significantly increased. HLA-DR+ cells and IL-2R+ cells were within normal limits. Histopathology of the diseased tissue revealed predominance of plasma cells in the lamina propria. The majority of the plasma cells were bearing IgG isotype. Most of the CD3+ T-cells were located beneath the pocket epithelium with an almost equal distribution of CD4+ and CD8+ T-lymphocytes, in situ. These findings indicate that PLS is a IgG+ plasma cell dominated lesion with the participation of T-lymphocytes, having similar distributions of both subsets. While the etiopathogenesis of the syndrome still has to be elucidated, these immunohistological findings could be used for further studies in this intriguing entity.

Treatment of prepubertal periodontitis. A case report and discussion

This paper reports the treatment of prepubertal periodontitis in a 3-year-old girl with Papillon-Lefèvre Syndrome. Initially, the patient was found to have a myeloperoxidase deficiency and microbiological tests have identified Bacteroides and Fusobacterium, in 60% and 25%, respectively of the total number of microbial flora cultivated. The initial treatment was extraction of all the primary teeth with grade 3 mobility, scaling, root planing and daily subgingival irrigation with a 0.2% solution of chlorhexidine. Several months before the eruption of the first permanent molars, the rest of the primary teeth were extracted. The patient was treated with daily subgingival irrigation of chlorhexidine and weekly professional oral hygiene. At the age 6 1/2 years, the permanent teeth have normal gingiva and crevice depths; microbiological investigation reveals a prevalence of the coccoid forms, and radiographs show no evidence of periodontal pathology.

A case report of chronic neutropenia: clinical and ultrastructural findings

This case report of severe periodontitis concerns a young male patient with chronic idiopathic neutropenia seen between 1981 and 1983 by the School of Dental Medicine of Geneva and from 1984 to 1988 by the Eastman Dental Hospital of London. The patient was maintained by intermittent systemic antibiotics, subgingival chlorhexidine irrigation, conventional debridement, brushing, and wire-mesh and composite splinting of loose teeth. After leaving school, at the patient's express wish, the extreme downhill pattern of the periodontitis resulted in removal of affected teeth and overdenture construction. The extracted teeth and associated soft tissues were examined for relevant plaque and host response features. The intact morphotypes associated with the advancing front of the lesion were invariably Gram-negative or positive coccoid cells, or less commonly short rods, as in all documented forms of periodotitis. Connective tissue destruction was associated with a leucocyte accumulation comprising mainly polymorphonuclear neutrophils (PMN) and plasma cells. Both were observed degenerated more deeply than in routine adult periodontitis, including PMN lysosome loss and lymphocyte maturation within peripheral blood vessels. Only in one instance, one part of the superficial connective tissue of one block contained bacteria. It was concluded that the features of plaque and the lesion suggest a typical first line of defence response as in other forms of periodontitis. From the consideration of the 10 years clinical history of the patient, it is clear that non-surgical management is possible even in extreme cases, without any compromise of the patient's oral or systemic health, and in accord with the patient's wishes.

Prepubertal periodontitis: a review of diagnostic criteria, pathogenesis, and differential diagnosis

This paper reviews the literature on prepubertal periodontitis (PP) according to the definition and the classification of PP by Page. The generalized form of PP (G-PP) defined by Page was identified as the oral manifestation of a systemic disease called leukocyte adhesion deficiency (LAD) and thus the pathogenesis is known at the molecular level. On the other hand, the localized form of PP (L-PP) is a disease defined by clinical criteria and its pathogenesis is not known at the molecular level. The reported prevalence of L-PP differs widely in reports, according to the methodology and population studied. However, it seems to be at least 0.84% or greater. Potential periodontal pathogens that have been associated with L-PP include the following bacteria: Actinobacillus actinomycetemcomitans (A.a.), Bacteroides intermedius, Bacteroides gingivalis, Capnocytophaga sputigena, and Eikenella corrodens. Suggested contributing factors have included PMN or monocyte chemotactic defects and cementum defects. There is no unique pattern of bone loss in L-PP; however, there may be a type of periodontitis that affects all deciduous teeth, in the absence of LAD. L-PP may lead to localized juvenile periodontitis (LJP) or generalized juvenile periodontitis (GJP). Histiocytosis X, hypophosphatasia and mild forms of blood dyscrasias may have minimal or no clinical signs and symptoms except for alveolar bone loss. Therefore diseases known to be associated with alveolar bone loss must be definitively excluded in prepubertal children until the pathogenesis of L-PP at the cellular and molecular levels is understood and L-PP can be definitively diagnosed either as a distinct disease entity or entities.