Immunological and metabolical studies in two siblings with Papillon-Lefevre syndrome

Diagnosis and initial management of children presenting with premature loss of primary teeth associated with a systemic condition: A scoping review and development of clinical aid

BACKGROUND

Premature loss of primary teeth (PLPT) can be a rare presentation of systemic medical conditions. Premature loss of primary teeth may present a diagnostic dilemma to paediatric dentists.

AIMS

To identify systemic conditions associated with PLPT and develop a clinical aid.

DESIGN

OVID Medline, Embase and Web of Science were searched up to March 2023. Citation searching of review publications occurred. Exclusion occurred for conference abstracts, absence of PLPT and absence of English-language full text.

RESULTS

Seven hundred and ninety-one publications were identified via databases and 476 by citation searching of review articles. Removal of 390 duplicates occurred. Following the exclusion of 466 records on abstract review, 411 publications were sought for retrieval, of which 142 met inclusion criteria. Thirty-one systemic conditions were identified. For 19 conditions, only one publication was identified. The majority of publications, 91% (n = 129), were case reports or series. Most publications, 44% (n = 62), were related to hypophosphatasia, and 25% (n = 35) were related to Papillon-Lefèvre. Diagnostic features were synthesised, and a clinical aid was produced by an iterative consensus approach.

CONCLUSIONS

A diverse range of systemic diseases are associated with PLPT. Evidence quality, however, is low, with most diseases having a low number of supporting cases. This clinical aid supports paediatric dentists in differential diagnosis and onward referral.

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.

Papillon-Lefèvre syndrome: Case report and review of the literature

Papillon-Lefèvre syndrome is a very rare syndrome of autosomal recessive inheritance characterized by palmar-plantar hyperkeratosis and early onset of a severe destructive periodontitis leading to premature loss of both primary and permanent dentitions. Various etiopathogenic factors are associated with the syndrome; but a recent report has suggested that the condition is linked to mutations of the cathepsin C gene. Two cases of Papillon-Lefèvre syndrome in the same family, having all of the characteristic features are presented. An 11-year-old girl, and her elder sister, a 13-year-old girl complained of loose teeth and discomfort in chewing along with recurrently swollen and friable gums. Both patients also had premature shedding of their deciduous teeth. The family history revealed consanguineous marriage of the parents. Both patients presented with persistent thickening, flaking and scaling of the skin of palms and soles. Severe generalized periodontal destruction with mobility of teeth was evident on intraoral examination; orthopantomograph examination showed severe generalized loss of alveolar bone in both the patients.

Papillon-Lefévre syndrome

The goal of periodontal therapy has always been regeneration of the lost tissues. However, conventional periodontal therapy has not always been successful in achieving regeneration, especially when it is part of a syndrome. This case report involves a 13-year old male patient with the chief complaint of mobile teeth for over 3 months. His dental history revealed early loss of primary dentition, around 3–4 years of age and that he noticed mobility of permanent incisors and molars at 9–10 years. Keratotic skin lesions on the palms and soles were present since the age of 3 years. Full mouth intra-oral periapical radiographs showed extensive bone loss upto apical thirds of the teeth and an orthopantamograph showed “floating in air” appearance. Further, a lateral cephalogram was taken to rule out any calcifications of the duramater. The case was provisionally diagnosed to be Papillon Lefévre syndrome. A conventional polymerase chain reaction assay was also done to assess the virulence genes in aggressive periodontitis. Though the management of PLS involves the regular phases of periodontal therapy, namely, etiotropic, surgical, restorative and maintenance phases, the complete esthetic and functional rehabilitation also involves other specialities especially prosthodontic and dermatologic and later an implantologist. After appropriate periodontal and prosthodontic management, the patient has been followed up for over a year and is maintaining in a stable condition.

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.

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.

Tissue plasminogen activator (t-PA) and placental plasminogen activator inhibitor (PAI-2) in gingival crevicular fluid from patients with Papillon-Lefevre syndrome

OBJECTIVES

Numerous patients with Papillon-Lefèvre syndrome (PLS) express a severe periodontal inflammation that results in premature loss of deciduous and permanent teeth. The plasminogen activating (PA) system is involved in physiological and pathological processes including epithelial healing, extracellular proteolysis and local inflammatory reactions. The aim of the study was to explore a possible role of the PA system in patients with PLS.

MATERIAL AND METHODS

Samples of gingival crevicular fluid (GCF) were collected from areas with gingival infection in 20 patients with PLS and in 20 healthy controls. The concentration of tissue plasminogen activator (t-PA) and inhibitor (PAI-2) was measured with ELISA.

RESULTS

The median level of PAI-2 was significantly higher (p < 0.01) in PLS patients than in the controls, while the median value of t-PA did not differ between the groups. No difference in t-PA or PAI-2 levels was found regarding age, gender or presence of active periodontal disease.

CONCLUSION

The findings indicate an atypical activity of the PA system with a disturbed epithelial function in PLS patients, suggesting that the periodontal destruction seen in patients with PLS is secondary to a hereditary defect in the defense system.

Distribution of Bacteroides forsythus genotypes in a Japanese periodontitis population

Bacteroides forsythus is an important pathogen in periodontal diseases and has been associated with advanced and refractory periodontitis. The difficulties associated with culturing this species have meant that the distribution and pathogenic mechanisms of B. forsythus remain unclear. In this study, the arbitrarily primed polymerase chain reaction (AP-PCR) method was used to investigate the genotype distribution of B. forsythus in a Japanese periodontitis population, as well as the relationship between AP-PCR genotypes and periodontal status. B. forsythus reference strain, ATCC 43037T and 137 clinical bacterial isolates from 64 subjects were separated into 11 distinct AP-PCR genotypes using a single randomly-sequenced primer, 5'-CCGGCGGCG-3' (A-05). The majority (80.9%) of B. forsythus strains examined belonged to AP-PCR genotypes I, II, III and IV (accounting for 39.7%, 20.6%, 10.3% and 10.3%, respectively). Types I and III primarily consisted of isolates from chronic periodontitis subjects (80.8% and 85.7%, respectively), while Types II and IV consisted mainly of isolates from aggressive periodontitis subjects (85.7% and 100%, respectively). Except for three subjects who harbored two different B. forsythus genotypes in the oral cavity, all subjects only infected with one genotype intraindividually. These results demonstrate that the AP-PCR method is useful for genotypic analysis of B. forsythus. This species showed a genetic diversity among the investigated population. A clonal nature of B. forsythus infection is suggested. Furthermore, different AP-PCR genotypes of B. forsythus appear to be associated with different types of 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.

Genetic studies of syndromes with severe periodontitis and palmoplantar hyperkeratosis

The Papillon-Lefèvre and Haim Munk syndromes are characterized by the presence of both palmoplantar hyperkeratosis (PPK) and severe early onset periodontitis. It is the early onset periodontal disease component that distinguishes these from other more common forms of PPK. It has been proposed that the periodontal disease component may be a casual association in individuals with PPK. Genetic syndromes with palmoplantar keratosis and severe ealry onset periodontitis may be due to specific bacterial infections in individuals with PPK. Recently, keratin gene mutations have been identified in several conditions typified by palmoplantar keratosis. The present study sought to test the hypothesis that a keratin gene defect similar to those previously identified in other PPK conditions is responsible for the Haim Munk and the Papillon. Lefèvre syndromes. We have performed genetic linkage studies to test for linkage between polymorphic DNA loci within 2 cytokeratin gene families and the disease phenotype in Haim Munk syndrome and Papillon-Lefèvre syndrome. Families with individuals segregating for the Haim Munk syndrome and the Papillon-Lefèvre syndrome were examined to determine disease status, and genotyped for microsatellite DNA markers closely linked to the acidic (type I) and the basic (type II) cytokeratin genes on chromosomes 12 and 17. Genotype data were evaluated for microsatellite allele homozygosity in affected individuals. Results of these preliminary genetic studies suggest that the gene defect in Haim Munk syndrome is not due to a gene defect in either the type I or the type II keratin gene clusters. These findings suggest that Haim Munk syndrome may be genetically distinct from other more common forms of PPK that have been linked to the cytokeratin gene families, and suggest that mutations in genes other than keratin genes are responsible. Additional family studies are needed to confirm these preliminary findings.

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.

Host defensive functions in a family manifesting early-onset periodontitis

Family case studies help us identify host risk factors in periodontal disease. In this study we examine a family consisting of a mother (40 years old, with rapidly progressive periodontitis), her elder daughter (14 years old, with localized juvenile periodontitis), and younger daughter (13 years old, with simple gingivitis). We examined 1) the peripheral neutrophil functions (chemotactic migration, phagocytosis, superoxide production); 2) lymphocyte functions (proliferative activity and cytokine productivity of T cells, immunoglobulin [Ig] M productivity of B cells when stimulated with pokeweed mitogen); 3) phenotypic analyses of peripheral lymphocyte subpopulations; 4) serum IgG antibody titers against periodontopathic bacteria; and 5) serological type of HLA class II. All the subjects exhibited high T4/T8 ratios due to high percentage of CD4-positive cells, showed high IgG titers to Actinobacillus actinomycetemcomitans, and had a HLA DQw1 in common. The mother showed a slight deficiency of neutrophil chemotactic migration to N-formyl methyonyl leucyl phenylalanin (fMLP), raised interleukin-2 productivity of T cell, and high levels of IgG titers to Porphyromonus gingivalis and Fusobacterium nucleatum. Both daughters showed weak T cell proliferative response to anti-CD3 monoclonal antibody and low IgM productivity. Low lymphocyte responsiveness may be involved in the pathogenesis of periodontal disease of these daughters; therefore, the lymphocyte dysfunctions shown should be considered in relation to the progression of periodontal disease.

Dental treatment of Papillon-Lefèvre syndrome: 15-year follow-up

A 9-year-old girl was initially treated for the periodontal component of Papillon-Lefèvre syndrome by extraction of all patient's erupted teeth, after unsuccessful clinical treatment with two different antibiotics. Follow-up dental records at age 24 showed the patient to have generalized gingivitis and poor oral hygiene; however, no additional teeth were lost or mobile. Radiographically, the alveolar crests, lamina dura, and periodontal ligament spaces appeared normal for a subject with missing teeth. Initially, the patient had depressed polymorphonuclear leukocyte (PMN) chemotaxis and adherence, as well as evidence of periodontal infection with Actinobacillus actinomycetemcomitans, (A.a.). The 6 and 15-year follow-ups showed normal PMN function and no detectable A.a. The improvement of the patient's PMN function was coincident with lack of detection of certain periodontopathic bacteria. If the PMN dysfunction of PLS is secondary to the infection, the reasons for the initiation of the disease still need to be clarified.

The hereditary palmoplantar keratoses: an updated review and classification

The palmoplantar keratoses (PPKs) comprise a heterogeneous group of disorders of keratinization, which can be subdivided into hereditary and acquired forms. Many authors have attempted to classify the hereditary forms, and most classifications have been based on the morphology, distribution, associated symptoms and mode of inheritance. Subsequently, many new forms have been recognized, and what were previously considered to be distinct types have been shown to be variants of a single type, both of which limit the usefulness of previous classifications. Hence, we propose a new, updated classification, which enables accurate diagnosis of these disorders.

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)

Late onset Papillon-Lefèvre syndrome? A chromosomic, neutrophil function and microbiological study

We had the opportunity to study a family with one of the most destructive forms of periodontal disease known, the Papillon-Lefèvre syndrome. The parents had no consanguinity and were not affected, and were therefore to be considered carriers of the disease. 2 sisters, the eldest and youngest, showed periodontal breakdown and hyperkeratotic skin lesions, but their deciduous dentition was not affected. 2 brothers had skin lesions only and another brother and sister were healthy. Furthermore, 2 babies died at birth one after a 9-month pregnancy and the other after a 6-month pregnancy, and the mother also suffered 3 miscarriages. For 4 years, we studied the family: in the case of both sisters, mechanical periodontal treatment and antibiotics were unable to control the disease. In the chromosomic study of the 2 sisters affected, the GTG banding technique found no trace of anomalies in the cells analyzed, whose chromosomic formation was 46,XX. Before treatment, the chemotaxis of the PMN, the phagocytosis of opsonized Staphylococcus aureus, and production of superoxide radicals by PMN was significantly impaired in both sisters. Despite scaling and root planing, the periodontal lesions still progressed, but the PMN functions evaluated were now normal in both sisters. An orally asymptomatic but dermatologically affected brother showed no significant defect in the phagocytic activity and the production of superoxide radicals.

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.

Clinical, laboratory, and immunological studies of a family with a high prevalence of generalized prepubertal and juvenile periodontitis

A study of a consanguineous family with a high prevalence of localized juvenile periodontitis (LJP) and generalized prepubertal periodontitis (GPP) was done over a 7-and-a-half year period. The parents had adult periodontitis, while 2 daughters, aged 13 and 15, had LJP. Furthermore, 2 other daughters, ages 14 and 10, and a son, aged 9, were affected by GPP. Two remaining siblings were not affected. Clinical and radiographic examinations on all family members were done, and chemotaxis for blood neutrophils was assessed. Laboratory tests, immunological examinations, and evaluation for neutrophil functions were done on the GPP patients. Microbiological cultures were performed on 2 of the GPP patients, as well as in the mother. The mother, the 2 LJP patients, and 1 of the unaffected siblings had depressed PMN chemotaxis. The other family members, including the 3 GPP patients, had normal PMN chemotaxis. GPP patients did not have any systemic disease, and evidence of major defects in the immunological functions was not detected. LJP patients were successfully treated with root planing, subgingival curettage, and tetracycline therapy. Intensive periodontal therapy, combined with systemic administration of antibiotics, was not effective in halting periodontal tissue destruction in the 3 GPP patients. Results indicate that the underlying cause of GPP is not always related to leukocyte dysfunction. Since Actinobacillus actinomycetemcomitans was the most frequent pathogen found in subgingival microflora of 2 of the GPP patients, it is assumed that it may play a key role in the etiology of GPP.

Genetic approaches in the study of periodontal diseases

Periodontal diseases are essentially infectious in origin, their outcome depending on interaction between the pathogenic challenge and host response. Host genotype has been implicated in certain of the more unusual forms, but together these account for only a small proportion of periodontal patients. Nevertheless, the genes for these rarer conditions, some of which have already been located and/or cloned, are of considerable importance, since they may ultimately provide clues leading to a better understanding of the whole spectrum of periodontal disease. For the majority of periodontal patients, although inherited susceptibility is suspected, evidence of a significant genetic component is scanty. The priority here is therefore to establish the existence of contributing genes. This may be possible by using approaches designed to minimise the confounding effect of environmental variation that has probably been a source of confusion in the past.

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.

Papillon-Lefèvre syndrome in four siblings treated with etretinate. A nine-year evaluation

Four siblings with Papillon-Lefèvre syndrome (3 boys and 1 girl), aged 8 to 12 at time of first diagnosis in 1978 are reported. These four patients represent the second largest sibship reported in the literature, and the only familial cases treated with etretinate for 6 years with an additional 3 1/2 year follow-up evaluation. No long-term side effects of etretinate were found in the children. All four patients are the product of a second cousin marriage; all demonstrate the B5 locus on HLA typing.

Papillon-Lefèvre syndrome: a study of the long-term clinical course of recurrent pyogenic infections and the effects of etretinate treatment

A family with a clinical variant of Papillon-Lefèvre syndrome (PLS), associated with recurrent pyogenic infections, has been followed up for more than 20 years. Of the five living siblings, four were treated with etretinate for a period of at least 21 consecutive months. Clinical follow-up showed that the course of recurrent infections in susceptible PLS patients, although usually more severe in childhood, can be variable and unpredictable. The etretinate therapy resulted in marked improvement of the keratodermas, and was associated with complete remission of the pyodermas on both keratotic and non-keratotic skin. It is, therefore, suggested that etretinate may have a primary role in the prevention of recurrent pyogenic infections in susceptible PLS patients.

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

In this study, 11 permanent teeth and their associated soft tissues from an 11-year-old boy with PLS were examined. Plaque, cementum and periodontal tissues were examined by scanning (SEM) and transmission electron microscopy (TEM). Except for depressed lymphocyte transformation, there were no abnormal haematological data. Local findings included abnormally thin cementum, extensive destruction of the periodontal ligament were still attached to the root, and severe inflammation of the soft tissues. Few bacteria were found in any of the soft tissue layers. The apical border plaque was restricted to gram- cocci and rods. The features observed in this case of PLS may indicate primary defects of cementum or ligament attachment, or disruption of fibroblast and cementoblast function due to the rapid advance of the disease process. Lack of bacterial invasion in the pocket soft tissue casts doubt on its involvement in the present case of severe periodontitis. The restricted range of morphotypes observed suggests a limited range of associated organisms. Further research is required to clarify the rôle of the host response and to identify the organisms involved.

Clinical management of prepubertal periodontitis in 2 siblings with Papillon-Lefèvre syndrome

The development of prepubertal periodontitis in Papillon-Lefévre syndrome (PLS) has been studied in 2 siblings, 12 and 8 years of age, since they were 5 and 3 years of age, respectively. Results of the treatment which comprised mechanical and chemical plaque control as well as systemic tetracycline medication, are reported. Extraction of temporary teeth, resulting in edentulousness prior to eruption of permanent teeth in the youngest child seemed to prevent destructive periodontitis from developing in the permanent dentition. After institution of continuous tetracycline medication in the oldest child at the age of 10 years, periodontitis with attachment loss did not occur in new sites. The possible rôle of specific micro-organisms in the progression of PLS-periodontitis is discussed.

In vitro studies of monocyte function in two siblings with Papillon-Lefèvre syndrome

Blood monocytes were isolated from two siblings with Papillon-Lefèvre syndrome (PLs) and compared to corresponding cells from their healthy cousin. The number of monocytes isolated were within normal limits in all three test participants. Aggregating tendency was increased when PLs monocytes were cultured in the presence of autologous sera. The monocyte ability of specific immune phagocytosis was decreased in PLs patients. The monocyte morphology, non-specific phagocytosis, lysosomal enzyme activities, and response to E. coli endotoxin were similar in patients and control.

Immunohistological study with peroxidase-antiperoxidase staining in a case of generalized prepubertal periodontitis

A case of prepubertal periodontitis was observed and examined immunohistologically with peroxidase-antiperoxidase staining. The patient was an 11-year and 7-month-old Japanese girl, well-developed and well-nourished. Her parents were first cousins. Her chief complaint was the loosening and loss of the permanent teeth. There was a similar history of primary dentition. Her remaining permanent teeth were loosened with severe alveolar bone loss, but calculus deposit was minimal. Significantly, there was no palmar-plantar hyperkeratosis. General examination showed normal data except for the increase of the immunoglobulin concentrations. In neutrophil function tests chemotaxis was depressed, although phagocytosis, random migration and superoxide production were within normal limits. Histologically, neutrophils were seen in the gingival tissue and other findings were also similar to those of adult periodontitis. In immunohistological examination, IgG-bearing cells which mostly consisted of plasma cells predominated in the lesion. Considering the past history, the immunodeficiency and the absence of palmar-plantar hyperkeratosis, the case was diagnosed as prepubertal periodontitis.

Histopathological and ultrastructural findings in a case of Papillon-Lefèvre syndrome

Gingiva from a 3-year-old Iranian boy suffering from Papillon-Lefèvre syndrome was examined by light and electron microscopy. Deep pockets associated with predominantly Gram-negative plaque were present. The gingival lesion was dominated by plasma cells, many of which were degenerate. Russell bodies were a prominent feature. No defect of epithelium was detected.

Behavior of neutrophilic granulocytes in a case of Papillon-Lefèvre syndrome

Recently we had the opportunity to examine and follow up over a period of 2 years an unusual case of Papillon-Lefèvre syndrome (PLS). A 10 year old boy exhibited all symptoms typical of PLS except periodontitis and premature loss of deciduous teeth. The present report aimed at studying the functional capacity of his neutrophilic granulocytes. It integrates clinical observations, histopathological findings and results of in vitro tests. The bioptic material examined included one gingival biopsy, extracted teeth, suppurative material discharged from periodontal pockets, pus emanating from a mucosal abscess, and peripheral blood leucocytes. The neutrophils were sampled on two separate occasions in two independent laboratories and tested for a variety of functions, i.e. motility, random and directional locomotion (chemotaxis), phagocytosis, membrane potential depolarization, oxygen consumption, NBT reduction, and intracellular killing of bacteria and fungi. Findings and test data indicated that in this case of PLS, neutrophilic granulocytes behaved normally with respect to all these functions including margination in blood vessels, emigration, phagocytosis of a broad range of bacteria, degranulation of lysosomes, and intracellular destruction. The data imply that factors other than neutrophil defects may be responsible for rapidly destructive periodontitis in cases where PLS is not associated with an increased susceptibility to infection.