Prepubertal periodontitis. I. Definition of a clinical disease entity

Evaluation of microbiome in primary and permanent dentition in grade C periodontitis in young individuals

BACKGROUND

The aim of the present study was to evaluate the subgingival microbiome in patients with grade C molar-incisor pattern periodontitis (C-MIP) affecting the primary or permanent dentitions.

METHODS

DNA was isolated from subgingival biofilm samples from diseased and healthy sites from 45 C-MIP patients and subjected to phylogenetic microarray analysis. C-MIP sites were compared between children affected in the primary to those affected in the permanent dentitions. Within-subject differences between C-MIP-affected sites and dentition-matched healthy sites were also evaluated.

RESULTS

C-MIP sites of subjects affected in the primary dentition showed partially overlapping but distinct microbial communities from C-MIP permanent dentition sites (p < 0.05). Differences were due to increased levels in primary C-MIP sites of certain species of the genera Capnocytophaga and Leptotrichia, while C-MIP permanent dentition sites showed higher prevalence of Filifactor alocis. Aggregatibacter actinomycetemcomitans (Aa) was among species seen in high prevalence and levels in both primary and permanent C-MIP sites. Moreover, both permanent and primary C-MIP sites showed distinct microbial communities when compared to dentition-matched healthy sites in the same subject (p < 0.01).

CONCLUSIONS

Primary and permanent teeth with C-MIP showed a dysbiotic microbiome, with children affected in the primary dentition showing a distinct profile from those affected in the permanent dentition. However, Aa was enriched in both primary and permanent diseased sites, confirming that this microorganism is implicated in C-MIP in both dentitions.

Radiographic Description of the Distribution of Aggressive Periodontitis in Primary Teeth

OBJECTIVE

To describe the prevalence by site and tooth of aggressive periodontists (AP) in primary teeth of children with AP, that will facilitate the early diagnosis of AP.

STUDY DESIGN

Radiographic evidence of AP by tooth and site of primary teeth of 29 children with AP was analyzed by gender, ethnicity, type of dentition (primary or mixed), alveolar bone site and type of tooth.

RESULTS

The range and mean ± standard error of number of sites and teeth per patient with AP were 4 to 28, 13.1±1.2 and 4 to 12, 8.3±0.5 respectively. The differences in prevalence of AP by gender, ethnicity, dentition and homologous sites at both sides of the mouth were not statistically significant (Chi square). AP was mostly diagnosed at the distal area of the maxillary canine, the proximal areas of the first maxillary primary molars, and the distal area of the mandibular first primary molar. The most affected teeth with AP were the first primary molars followed by the maxillary cuspid, and the second molars.

CONCLUSIONS

Examination of children's primary teeth should include abnormal mobility, when found it should be followed by radiographic evaluation for the presence of AP, taking in consideration the present findings.

Clinical Characteristics of Localized Aggressive Periodontitis in Primary Dentition

OBJECTIVES

Due to the low prevalence of localized aggressive periodontitis (LAP), clinical characteristics of LAP in primary dentition are derived from a few case reports/series in the literature. The goal of this study was to determine common clinical characteristics such as bone and root resorption patterns, in a series of cases with LAP in primary dentition. We hypothesize these cases present aggressive periodontal bone destruction starting mostly around first primary molars and atypical root resorption patterns.

STUDY DESIGN

We have evaluated 33 LAP cases in primary dentition for pattern of bone destruction, root resorption and early exfoliation.

RESULTS

Cases evaluated were aged 5-12 (mean=8.7 years). Thirty cases presented more severe bone loss on first than second molars, with relatively fast progression to second molars, altered pattern of root resorption, mostly external (n=16) and early exfoliation of primary teeth due to periodontal bone loss, rather than physiologic root resorption (n=11).

CONCLUSIONS

This study showed common clinical characteristics found in LAP in primary molars, including possible initiation on first primary molars and abnormal root resorption patterns. These characteristics are important to be early identified and treated in order to prevent possible progression into the permanent dentition.

Nonsyndromic localized aggressive periodontitis of primary dentition: A rare case report

Periodontitis is an inflammatory disease of the gingiva and tissues of the periodontium. It is characterized by pocket formation and destruction of supporting alveolar bone. Periodontal diseases of aggressive nature are not very common in children. They are usually associated with systemic conditions. The present case report is of a 5-year-old male child who reported with rapid attachment loss and bony defects of the gingiva and supporting structures. His family and medical history gave no contribution for the diagnosis. Blood investigations did not reveal any abnormality. The microbial examination of culture revealed the presence of periodontal pathogen Aggregatibacter actinomycetemcomitans. The treatment objective in the present case was to prevent the further progress of the condition, restore esthetic and function in the child which would psychologically benefit the child.

Gingival Inflammation and Aggressive Periodontitis in a Child with a Specific Antibody Deficiency

Exuberant gingival inflammation accompanied by periodontitis is a rare finding in a very young child and may indicate a defect in the host response. Affected children should be referred to appropriate specialists to establish a definitive diagnosis. A 5-year-old girl presented with persistent gingival inflammation and periodontal destruction. Immunological investigations identified specific polysaccharide antibody deficiency which, when treated, resulted in a significant improvement in the gingival condition. This case illustrates the need for integrated management by a wide range of dental and medical specialists. Antibody deficiency is rare but, if not identified and treated effectively, can be associated with chronic ill health and decreased life expectancy. CPD/Clinical Relevance: This article describes a rare case of gingival inflammation accompanied by periodontitis in a very young child secondary to an underlying host antibody deficiency and details the investigation, management and clinical outcomes.

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.

Learned and unlearned concepts in periodontal diagnostics: a 50-year perspective

In the past 50 years, conceptual changes in the field of periodontal diagnostics have paralleled those associated with a better scientific understanding of the full spectrum of processes that affect periodontal health and disease. Fifty years ago, concepts regarding the diagnosis of periodontal diseases followed the classical pathology paradigm. It was believed that the two basic forms of destructive periodontal disease were chronic inflammatory periodontitis and 'periodontosis'- a degenerative condition. In the subsequent 25 years it was shown that periodontosis was an infection. By 1987, major new concepts regarding the diagnosis and pathogenesis of periodontitis included: (i) all cases of untreated gingivitis do not inevitably progress to periodontitis; (ii) progression of untreated periodontitis is often episodic; (iii) some sites with untreated periodontitis do not progress; (iv) a rather small population of specific bacteria ('periodontal pathogens') appear to be the main etiologic agents of chronic inflammatory periodontitis; and (v) tissue damage in periodontitis is primarily caused by inflammatory and immunologic host responses to infecting agents. The concepts that were in place by 1987 are still largely intact in 2012. However, in the decades to come, it is likely that new information on the human microbiome will change our current concepts concerning the prevention, diagnosis and treatment of periodontal diseases.

A combination of clinical and microbiological management of generalized aggressive periodontitis in primary teeth. A case report

BACKGROUND

Generalized aggressive periodontitis (GAP) in primary teeth is a rare periodontal disease that occurs during or soon after eruption of the primary teeth. An association with systemic diseases is a possibility.

CASE REPORT

A 4-year-old Brazilian girl presented with GAP involving the entire primary dentition. The patient and her parents and sister were subjected to microbiological testing to identify the microorganisms involved in the disease. The patient underwent tooth extraction to eradicate the disease and received a prosthesis for the restoration of masticatory function. After the permanent teeth erupted, fixed orthodontic appliances were place to restore dental arch form and occlusion.

CONCLUSIONS

The results show the importance of an early diagnosis of GAP and of a multidisciplinary approach involving laboratory and clinical management to treat the disease and to restore masticatory function, providing a better quality of life for patients.

The interleukin-4 -34TT and -590TT genotype is correlated with increased expression and protein production in aggressive periodontitis

Aggressive periodontitis (AgP) is a severe periodontal disease characterized by rapid destruction of the tissues supporting the teeth in otherwise healthy individuals. The frequency of the interleukin-4 homozygous -34TT and -590TT genotype was increased in patients in comparison with controls. This study aimed to test the functional effect of this specific genotype in AgP patients by analyzing gene expression of IL-4 and STAT6, and protein concentration of IL-4, in activated CD4+ T cells. Results revealed an increased IL-4 and STAT6 expression and IL-4 production in the cells of the patients who were homozygous for the -34T and -590T alleles in comparison with the patients who were homozygous for the -34C and -590C alleles (p<0.05). These findings demonstrate that the IL-4 -34TT and -590TT genotype has a functional effect on T helper (Th) cells of patients with AgP, inducing increased expression of IL-4 and STAT6, and increased production of IL-4.

Periodontitis as a manifestation of chronic benign neutropenia

BACKGROUND

A subcategory of chronic neutropenia is chronic benign neutropenia, which is characterized by a prolonged non-cyclic neutropenia as the sole abnormality, with no underlying disease to which the neutropenia can be attributed. Chronic neutropenia is defined as a low absolute neutrophil count for >6 months. In this presentation, periodontitis seems to be the sole manifestation of a juvenile patient with chronic benign neutropenia. A 7-year-old white male presented with periodontitis of the primary dentition and early tooth loss. His medical and dental history was otherwise unremarkable. Suspecting some systemic illness as the underlying cause, the patient was referred for a medical consultation and a series of blood tests.

METHODS

Blood analyses included a complete blood count (CBC), sequential multiple analyzer 24 (SMA 24), glycated hemoglobin levels, and screening for anti-white blood cell antibodies. Blood levels of calcium, vitamin D, dihydroxyvitamin-D, phosphorus, and alkaline phosphatase were also measured. Liver function tests were performed.

RESULTS

Following analysis of recent and previous blood test results, a diagnosis of chronic benign neutropenia was assigned. The patient's periodontal condition was treated with scaling and root planing, oral hygiene instruction, and antimicrobial mouthrinses. Three-month recall visits were recommended as a follow-up protocol.

CONCLUSIONS

This case represents the importance of diagnosing periodontal disease as a possible indicator of underlying systemic disease. When a patient presents with an unusual, generalized form of periodontal disease, screening for systemic disorders is required, as the oral condition may be the first or only manifestation of a systemic abnormality. This case also illustrates the reason for the change in classification of such a condition to periodontitis as a manifestation of systemic disease. This condition was previously classified as prepubertal periodontitis, a disease diagnosis that focused on the patient's age at the onset of the disease rather than the etiology.

Relationship Among Gender, Race, Age, Gingival Width, and Probing Depth in Primary Teeth

BACKGROUND

Limited information is available regarding the attached keratinized tissue, probing depth, and sociodemographic characteristics of primary teeth. This study was carried out to evaluate the relationship among age, gender, race, gingival width, and probing depth in each primary tooth type.

METHODS

The study population consisted of 300 children, aged 4 to 6 years, with clinically healthy gingiva, who were enrolled in an oral health program. Gingival width and probing depth were measured with a standard Williams periodontal probe in the middle of the keratinized gingiva and at six gingival sites (mesio-buccal, mid-buccal, disto-buccal, mesio-lingual, mid-lingual, and disto-lingual), respectively. Schiller's solution was used to establish the limits of keratinized gingiva.

RESULTS

The gingival width (mean +/- SD) on the buccal surfaces decreased from anterior to posterior positions in both arches; in the lower lingual surfaces, the inverse was observed. The gingival width (mean +/- SD) ranged from 2.95 +/- 0.15 mm to 6.16 +/- 0.20 mm and the probing depth from 1.03 +/- 0.91 mm to 2.08 +/- 0.07 mm. There was a tendency toward increased probing depth as age increased from 4 to 6 years. There was also an increase in the probing depth from anterior to posterior teeth.

CONCLUSIONS

In the majority of observations, it was concluded that there was a relationship among age, gingival width, and probing depth, but generally not among race and gender and these measurements, respectively. Furthermore, there is no relation between gender and gingival width and race and probing depth.

Evaluation of additional amine fluoride/stannous fluoride-containing mouthrinse during supportive therapy in patients with generalized aggressive periodontitis. A randomized, crossover, double-blind, controlled trial

OBJECTIVES

The objective of the present randomized controlled trial was to evaluate the efficacy of a mouthrinse containing a combination of AmF/SnF2 in controlling supragingival plaque accumulation and gingival inflammation during a 12-week period in patients affected by generalized aggressive periodontitis (GAP).

METHODS

Eighteen subjects, six males and 12 females, mean age: 32.2 years, were evaluated. One-half of the patients was either prescribed an AmF/SnF2-containing mouthrinse (test mouthrinse) or a control mouthrinse in addition to mechanical plaque control for 12 weeks. After a 2-week wash-out period, the patients received the alternative mouthrinse. Before and after treatment plaque index (PlI), gingival index (GI), angulated bleeding index (AngBI), tooth stain (GMSI), and tongue stain were recorded.

RESULTS

Test mouthrinse resulted in a statistically significant decrease in PlI (p = 0.029) and GI (p = 0.017). After treatment, PlI was significantly lower in test compared to control mouthrinse (p = 0.027). GMSI significantly increased post-treatment for both mouthrinse regimens (p < 0.001), a significantly higher score being observed for the test compared to control mouthrinse (p = 0.002).

CONCLUSIONS

The 12-week use of a AmF/SnF2-containing mouthrinse as an adjunct to conventional mechanical oral hygiene procedures in GAP patients was effective in controlling the amount of supragingival plaque deposits.

Position paper: periodontal diseases of children and adolescents

Children and adolescents are subject to several periodontal diseases. Although there is a much lower prevalence of destructive periodontal diseases in children than in adults, children can develop severe forms of periodontitis. In some cases, this destructive disease is a manifestation of a known underlying systemic disease. In other young patients, the underlying cause for increased susceptibility and early onset of disease is unknown. These diseases are often familial, suggesting a genetic predisposition for aggressive disease. Current modalities for managing periodontal diseases of children and adolescents may include antibiotic therapy in combination with non-surgical and/or surgical therapy. Since early diagnosis ensures the greatest chance for successful treatment, it is important that children receive a periodontal examination as part of their routine dental visits.

Genes and gene polymorphisms associated with periodontal disease

The scientific literature during the last ten years has seen an exponential increase in the number of reports claiming links for genetic polymorphisms with a variety of medical diseases, particularly chronic immune and inflammatory conditions. Recently, periodontal research has contributed to this growth area. This new research has coincided with an increased understanding of the genome which, in turn, has permitted the functional interrelationships of gene products with each other and with environmental agents to be understood. As a result of this knowledge explosion, it is evident that there is a genetic basis for most diseases, including periodontitis. This realization has fostered the idea that if we can understand the genetic basis of diseases, genetic tests to assess disease risk and to develop etiology-based treatments will soon be reality. Consequently, there has been great interest in identifying allelic variants of genes that can be used to assess disease risk for periodontal diseases. Reports of genetic polymorphisms associated with periodontal disease are increasing, but the limitations of such studies are not widely appreciated. While there have been dramatic successes in the identification of mutations responsible for rare genetic conditions, few genetic polymorphisms reported for complex genetic diseases have been demonstrated to be clinically valid, and fewer have been shown to have clinical utility. Although geneticists warn clinicians on the over-enthusiastic use and interpretation of their studies, there continues to be a disparity between the geneticists and the clinicians in the emphasis placed on genes and genetic polymorphism associations. This review critically reviews genetic associations claimed for periodontal disease. It reveals that, despite major advances in the awareness of genetic risk factors for periodontal disease (with the exception of periodontitis associated with certain monogenetic conditions), we are still some way from determining the genetic basis of both aggressive and chronic periodontitis. We have, however, gained considerable insight into the hereditary pattern for aggressive periodontitis. Related to our understanding that it is autosomal-dominant with reduced penetrance comes a major clinically relevant insight into the risk assessment and screening for this disease, in that we appreciate that parents, offspring, and siblings of patients affected with aggressive periodontitis have a 50% risk of this disease also. Nevertheless, we must exercise caution and proper scientific method in the pursuit of clinically valid and useful genetic diagnostic tests for chronic and aggressive periodontitis. We must plan our research using plausible biological arguments and carefully avoid the numerous bias and misinterpretation pitfalls inherent in researching genetic associations with disease.

Localized aggressive periodontitis in primary dentition: a case report

BACKGROUND

A 5-year-old Japanese boy presented with persistent gingival inflammation and severe mobility of the right lower primary incisors. Due to severe alveolar bone loss and a deep periodontal pocket (5 mm), the incisors were extracted at the second visit.

METHODS

Clinical, radiographic, histological, and microbiological examinations were carried out. Then, the polymerase chain reaction (PCR) technique was employed to detect specific periodontal pathogens. The chemotactic activity of polymorphonuclear neutrophils was also measured.

RESULTS

Tannerella, Capnocytophaga, Fusobacterium, and Eikenella sp. were recovered from the subgingival microflora around the right lower incisors, while A. actinomycetemcomitans, Tannerella forsythensis (formerly Bacteroides forsythus), Prevotella nigrescens, Campylobacter rectus, and Capnocytophaga gingivalis were detected using the PCR method. Further chemotaxis assay revealed that neutrophil function was depressed compared with that of healthy controls.

CONCLUSIONS

Although inflammation remained around the right primary second molars, the bone loss was controlled by periodic professional mechanical teeth cleaning (PMTC), subgingival irrigation, and local antibiotic application. The probing depths of all teeth, including permanent incisors and molars, were within 2.5 mm.

Accidentally induced periodontitis in primary dentition: longitudinal examinations of periodontal bacteria and clinical conditions

Periodontitis is very rare in the primary dentition although it can be accidentally induced in young children. The purpose of this study was to describe a case of periodontitis in a 4-year-old child, which was accidentally induced by insertion of small plastic tubes into the dental cervix of the primary incisors during play, and to discuss the clinical, radiographic, and microbiological findings. Removal of the plastic tubes resulted in resolution of the periodontal condition. Prevotella nigrescens and Campylobacter rectus were detected in subgingival plaque samples from the affected teeth at every examination, whereas Porphyromonas gingivalis, Treponema denticola, Prevotella intermedia, and Bacteroides forsythus were never found during the two-year observation period. The clinical and microbiological results suggest that the type of periodontitis caused by such an incidence is not progressive, unlike other periodontal diseases such as prepubertal and juvenile periodontitis.

Microbiological, immunological and genetic factors in family members with periodontitis as a manifestation of systemic disease, associated with hematological disorders

The microflora, immunological profiles of host defence functions, and human leukocyte antigen (HLA) findings are reported for a mother, son and daughter who were diagnosed as having 'periodontitis as a manifestation of systemic diseases, associated with hematological disorders'. Examinations were made of the bacterial flora from the periodontal pocket, neutrophil chemotaxis, neutrophil phagocytosis, and the genotypes (DQB1) and serotypes (DR locus) of HLA class II antigens. Phenotypic analyses of the peripheral lymphocytes were also conducted. The subgingival microflora from the mother was dominated by Gram-negative rods, especially Porphyromonas endodontalis, Prevotella intermedia/Prevotella nigrescens and Fusobacterium nucleatum. Subgingival microflora samples from the son and daughter were dominated by Gram-positive cocci and Gram-positive rods. Through the use of polymerase chain reaction, Campylobacter rectus and Capnocytophaga gingivalis were detected in all subjects, whereas Porphyromonas gingivalis, P. intermedia, and Treponema denticola were not detected in any subjects. All three subjects showed a remarkable level of depressed neutrophil chemotaxis to N-formyl-methionyl-leucyl-phenylalanine, although their phagocyte function levels were normal, in comparison to healthy control subjects. Each subject had the same genotype, HLA-DQB1*0601, while the mother had HLA-DR2 and HLA-DR8, and the son and daughter had HLA-DR2 only. In summary, the members of this family showed a similar predisposition to periodontitis with regard to certain host defence functions. It is suggested that the depressed neutrophil chemotaxis that was identified here could be a significant risk factor for periodontitis in this family.

Periodontal diseases in the child and adolescent

BACKGROUND

Periodontal diseases are among the most frequent diseases affecting children and adolescents. These include gingivitis, localized or generalized aggressive periodontitis (a.k.a., early onset periodontitis which includes generalized or localized prepubertal periodontitis and juvenile periodontitis) and periodontal diseases associated with systemic disorders. The best approach to managing periodontal diseases is prevention, followed by early detection and treatment.

METHODS

This paper reviews the current literature concerning the most common periodontal diseases affecting children: chronic gingivitis (or dental plaque-induced gingival diseases) and early onset periodontitis (or aggressive periodontitis), including prepubertal and juvenile periodontitis. In addition, systemic diseases that affect the periodontium and oral lesions commonly found in young children are addressed. The prevalence, diagnostic characteristics, microbiology, host-related factors, and therapeutic management of each of these disease entities are thoroughly discussed.

Prepubertal periodontitis associated with chronic granulomatous disease

BACKGROUND

Generalised prepubertal periodontitis is a rare entity that is usually a consequence of severe systemic diseases. Chronic granulomatous disease is one of the extremely rare inherited immunodeficiency diseases, which predisposes the patient to recurrent severe bacterial and fungal infections.

AIM

The purpose of this report is to describe a 5-year old male patient suffering from prepubertal periodontitis associated with chronic granulomatous disease, who was referred to the Department of Periodontology for treatment of severe gingival inflammation.

METHODS

A detailed past history was obtained and thorough clinical and laboratory examinations were performed.

RESULTS

Medical tests revealed the only immunodeficiency sign as the extremely low burst test result. The patient was diagnosed as having an autosomal recessive (AR) form of chronic granulomatous disease. He was put on prophylactic treatment with trimethoprim-sulfamethoxazole (TMP-SMX) and also a periodontal maintenance regimen with regular 1-month intervals.

CONCLUSION

This case report emphasises the importance of the differential diagnosis of severe immunodeficiency in the background of prepubertal periodontitis.

Influences of systemic diseases on periodontitis in children and adolescents

Systemic diseases affecting the host response as primary immunodeficiencies or secondary defects caused by lack of nutrients or changes in the local tissues are very often accompanied by early-onset prepubertal periodontitis. Local treatment in combination with systemic antibiotics may in milder forms improve the situation, but in many cases the success is questionable and premature loss of teeth occurs. Since the genetic basis of many of the diseases has been identified, future developments permit the correction of at least some of these defects by gene therapy.

Treatment of aggressive periodontitis by osseointegrated dental implants. A case report

BACKGROUND

Generalized aggressive periodontitis is described as a clinical entity affecting both deciduous and permanent dentition with extensive alveolar bone loss, mobility, and exfoliation of all or many teeth. Controversy exists on dental implant use to restore missing dentition in younger patients.

METHODS

This case report presents a patient diagnosed with aggressive periodontitis who has lost all but 4 of her teeth. Her personal and functional desires led us to include implant therapy in her treatment plan. The hematological data are presented with an analysis of the immunological profile.

RESULTS

Dental implants were placed, and following 3 months of osseointegration, an implant-supported prosthesis was completed. The patient was followed up for 36 months.

CONCLUSIONS

This case report presents an alternative treatment for rehabilitating dentition in a young patient treated for aggressive periodontitis. Similar case studies may help eliminate some of the controversy that exists regarding the use of dental implants in aggressive periodontitis patients.

Some local and systemic immunological features of prepubertal periodontitis

OBJECTIVES

The aim of the present investigation was to study local (gingival) and systemic host defense characteristics in a sample of children exhibiting local prepubertal periodontitis (LPP).

MATERIAL AND METHODS

2 groups of subjects were included in the present study. One group consisted of 11 children (9.5+/-2.0 years) with signs of periodontal disease (LPP group). A 2nd group comprised 21 adults (48.1+/-5.8 years) with advanced periodontal disease: adult periodontitis (AP) group. Gingival biopsies and a sample of peripheral blood were obtained in each individual of the AP group and in 7 out of the 11 subjects in the LPP group. The biopsies were prepared for morphometrical and immunohistochemical analysis and the blood samples prepared for immunohistochemical analysis.

RESULTS

The cellular infiltrates in the biopsies of the LPP group contained a larger proportion of lymphocytes and, in particular B cells, than was the case in the AP group. The TCR Valpha/Vbeta gene expression in the lesions in the AP group was dominated by Vbeta 17 and in the LPP group by Valpha2. The content in peripheral blood of various lymphocyte sub-populations and TCR Valpha/Vbeta gene expression in the 2 groups was almost similar.

CONCLUSION

It is suggested that (i) the systemic host response in children with prepubertal periodontitis has many features in common with that seen in adult patients but that (II) local defense mechanisms in the periodontitis lesion of LPP differ from those in adult periodontitis.

Localisation of a gene for prepubertal periodontitis to chromosome 11q14 and identification of a cathepsin C gene mutation

Prepubertal periodontitis (PPP) is a rare and rapidly progressive disease of young children that results in destruction of the periodontal support of the primary dentition. The condition may occur as part of a recognised syndrome or may occur as an isolated finding. Both autosomal dominant and recessive forms of Mendelian transmission have been reported for PPP. We report a consanguineous Jordanian family with four members affected by PPP in two nuclear sibships. The parents of the affected subjects are first cousins. We have localised a gene of major effect for PPP in this kindred (Zmax=3.55 for D11S901 at theta=0.00) to a 14 cM genetic interval on chromosome 11q14 flanked by D11S916 and D11S1367. This PPP candidate interval overlaps the region of chromosome 11q14 that contains the cathepsin C gene responsible for Papillon-Lefèvre and Haim-Munk syndromes. Sequence analysis of the cathepsin C gene from PPP affected subjects from this Jordanian family indicated that all were homozygous for a missense mutation (1040A-->G) that changes a tyrosine to a cysteine. All four parents were heterozygous carriers of this Tyr347Cys cathepsin C mutation. None of the family members who were heterozygous carriers for this mutation showed any clinical findings of PPP. None of the 50 controls tested were found to have this Tyr347Cys mutation. This is the first reported gene mutation for non-syndromic periodontitis and shows that non-syndromic PPP is an allelic variant of the type IV palmoplantar ectodermal dysplasias.

Early-onset periodontitis

In 1993, the 1st European Workshop on Periodontology explicitly recognized that there was insufficient knowledge to differentiate truly different forms of periodontal disease from differences in the presentation/severity of the same disease. In spite of recent progress in our understanding of periodontal diseases, the issue is far from having been resolved. Classification of periodontal diseases, therefore, remains based upon the definition of specific clinical syndromes. Early-onset periodontitis (EOP) is one such syndrome and comprises a group of pathological conditions leading to loss of periodontal tissues early in life. The notion that classifies periodontitis syndromes as "early-onset" or "adult" is primarily epidemiological in nature and is based on the observation that periodontitis is rather infrequent in children and young adults. Nevertheless, considerable epidemiological evidence indicates that periodontitis does affect children and young adults to a level of severity that may lead to premature exfoliation of primary and/or permanent teeth. Clinical presentation of periodontitis early in the life of an individual is thought to indicate that the etiologic agents have been able to cause considerable tissue damage over a relatively short period of time. It also implies either infection with highly virulent bacteria and/or a highly susceptible subject. The purpose of this review is to discuss the criteria generally utilized to classify EOP, provide the rationale to designate EOP as a distinct disease entity, and to review the evidence justifying a subclassification into particular subgroups of EOP.

Periapical inflammatory responses and their modulation

Periapical inflammatory responses occur as a consequence of bacterial infection of the dental pulp, as a result of caries, trauma, or iatrogenic insult. Periapical inflammation stimulates the formation of granulomas and cysts, with the destruction of bone. These inflammatory responses are complex and consist of diverse elements. Immediate-type responses--including vasodilatation, increased vascular permeability, and leukocyte extravasation--are mediated by endogenous mediators, including prostanoids, kinins, and neuropeptides. Non-specific immune responses--including polymorphonuclear leukocyte and monocyte migration and activation, and cytokine production--are elicited in response to bacteria and their products. Interleukin-1 and prostaglandins in particular have been implicated as central mediators of periapical bone resorption. Chronic periapical inflammation further involves specific T- and B-cell-mediated anti-bacterial responses, and activates a network of regulatory cytokines which are produced by Th1- and Th2-type T-lymphocytes. Various naturally occurring and genetically engineered models of immunodeficiency are beginning to help elucidate those components of the immune system which protect the pulpal/periapical complex. Both specific and non-specific responses interface with and are regulated by the neural system. The modulation of these responses by immune response modifies, cytokine antagonists, and other novel therapeutic agents is discussed. As an experimental model, periapical inflammation has many advantages which permit it to be used in studies of microbial ecology and pathogenesis, host response, neuroimmunology, and bone resorption and regeneration.

Microbiological findings in prepubertal periodontitis. A case report

Generalized pre-pubertal periodontitis (GPP) is a rare entity that usually affects children with severe systemic diseases. We report the case of a 7-year-old male patient diagnosed with GPP, with no apparent systemic condition, who lost all his primary teeth to periodontal disease. Before extractions, while he was still in mixed dentition the subgingival plaque was collected and analyzed using DNA probes to 40 different microorganisms. Putative periodontopathogens such as Prevotella intermedia, Selenomonas noxia, Fusobacterium nucleatum, and Actinobacillus actinomycetemcomitans could be identified throughout the mouth. More intriguing was the colonization of the sulcus of some secondary teeth by potentially harmful microorganisms found in pockets of diseased adjacent primary teeth.

Subgingival microflora and treatment in prepubertal periodontitis associated with chronic idiopathic neutropenia

Prepubertal periodontitis affects both primary and permanent dentition. The purpose of this study was to examine the composition of subgingival microflora of the permanent dentition in an 11-year-old Caucasian female, who had premature exfoliation of her deciduous teeth on her 5th year of age, and the response of this condition to the antibiotic therapy and supportive periodontal care. Gingival tissues were highly inflamed and alveolar bone loss was detected radiographically. The girl had experienced frequent upper respiratory tract infections, tonsilitis and recurrent otitis media. Her mother had history of early onset periodontitis associated with chronic idiopathic neutropenia. Blood chemistry tests and immunological examinations were also performed. Subgingival plaque samples were collected from the proximal sites of permanent molars, incisors, canines and maxillary premolars. 27 different microbial species were isolated from the subgingival microflora. Among the predominant species were Porphyromonas gingivalis (17.6%-7.3%), Prevotella intermedia (12.4%-4.7%), Capnocytophaga sputigena (14.4%-10.4%), Capnocytophaga ochracea (13.2%-6.9%) and Actinobacillus actinomycetemcomitans (9.3%-5.5%). Periodontal treatment consisted of scaling, root planing in conjunction with antibiotic administration of Augmentin 312.5 mg and Flagyl 200 mg, each t.i.d. for 10 days. 3 weeks after the antibiotic therapy, bacterial samples were collected from the same sites. All the periodontal pathogens were recovered in lower levels and A.actinomycetemcomitans was almost eliminated in the 3-week period. The evaluation of clinical indices at 3, 6 and 12 months showed that periodontal treatment in conjunction with antibiotics was effective and rapidly followed by marked clinical improvement. The microbiological monitoring at 3, 6 and 12 months after antibiotic treatment and each time prior to supportive periodontal care, revealed that the periodontal pathogens fluctuated in low levels even 12 months after treatment and could be maintained at low level by supportive periodontal care at 3-month intervals.

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.

A case of chronic severe neutropenia: oral findings and consequences of short-term granulocyte colony-stimulating factor treatment

Neutropenia is an absolute decrease in the number of circulating neutrophils in the blood which results in susceptibility to severe pyogenic infections. Various oral findings such as periodontitis, alveolar bone loss and ulceration may be seen in neutropenic patients. A case is presented of a 6 year old girl with chronic, probably congenital, severe neutropenia with frequent respiratory tract infections, recurrent oral ulcerations and significant periodontal break-down resembling prepubertal periodontitis. She was given granulocyte-colony stimulating factor (G-CSF) treatment which resulted in an increase in granulocyte count within two weeks and resolution of the neutropenic ulceration. It is suggested that G-CSF together with dental care regimens is a promising treatment model in chronic severe neutropenia cases presenting with oral manifestations.

Loss of deciduous teeth and germs of permanent incisors in a 4-year-old child. An atypic prepubertal periodontitis? A clinical, microbiological, immunological and ultrastructural study

A 4-year-old child was referred, in April 1988, to Rennes Dental School (France) for deciduous tooth mobility with premature loss of 4 deciduous teeth and germs of 2 permanent incisors. Microbiological examinations by culture revealed the presence of the periodontal pathogen Actinobacillus actinomycetemcomitans. Immunofluorescence of plaque samples revealed the presence of Porphyromonas gingivalis that had not been isolated by culture. Neutrophil functions were within normal ranges. Transmission electron microscopy of gingiva showed a disorganised epithelium. The connective tissue was infiltrated by inflammatory cells. The basement membranes were normal, but the connective tissue-epithelium interface was mainly composed of short rete pegs. Scanning electron microscopy of extracted deciduous teeth revealed lack of cementum, lacunae in the cementum and lack of fibrillar insertion on the middle part of the root. Skin lesions, mainly situated on face, were observed. Treatment was by extraction of mobile deciduous teeth combined with 3-week courses of metronidazole. Clinical and microbiological follow-up was continued over a 7-year period. No periodontal lesions have been detected since eruption of the permanent teeth. The present subgingival and lingual microflora (December 1995) is composed of bacteria associated with periodontal health. However, the future appearance of a hitherto undetected systemic disease is still possible.

Possible autosomal-dominant inheritance of prepubertal periodontitis in an extended kindred

This study presents the clinical findings and the distribution of prepubertal periodontitis in an extended family with high prevalence of this entity. The expression of surface markers and adhesion molecules on peripheral lymphocytes were also studied. Approximately 50% of the children in this family suffered from prepubertal periodontitis. All the affected children were otherwise healthy. 2 identical twins were similarly, but not identically, affected. Detailed laboratory tests and analysis of lymphocyte surface marker expression, including CD18, were all within the normal levels. Both localized and generalized forms of prepubertal periodontitis were found. The high prevalence of prepubertal periodontitis in the 2 branches of this family, and the fact that identical twins were similarly affected, suggest a strong genetic predisposition for prepubertal periodontitis. The family pedigree is consistent with an autosomal-dominant mode of transmission. The coexistence of localized and generalized forms of the disease in sibs suggests the same genetic etiology for both entities with variability in disease expression. This variability in disease expression is further supported by the fact that 2 identical twins were not identically affected.

Absence of adult dental anomalies in familial hypophosphatasia

This paper is a supplemental report on 3 previous publications about a family in which 3 male children manifested gingival recession, alveolar bone resorption and premature exfoliation of their deciduous teeth without apical root resorption and without clinical signs of inflammation. Laboratory blood and urine studies in conjunction with an analysis of periodontal microflora and family pedigrees established a diagnosis of hypophosphatasia in these 3 children, as well as their father, the paternal grandmother and paternal great-uncle. Clinical data also revealed that a son of the paternal great-uncle and his daughter were similarly affected. The family pedigree is consistent with an autosomal dominant mode of transmission. The 3 brothers are now between the ages of 18 and 22 yr and all have complete permanent dentitions. Aside from some periodontal manifestations of prior dentoalveolar trauma, most of the findings of the periodontal assessment are within normal limits. All 3 exhibit moderate to severe caries and some degree of gingival inflammation, but minimal periodontal pathosis.

Children, adolescents and periodontal diseases

OBJECTIVES

This manuscript attempts to critically review current literature regarding the natural history, aetiology and pathogenesis of the common periodontal diseases to affect children and adolescents. The logic behind the emergence of a new classification in the early 1990s is explained and potential problems with the interpretation of such systems outlined.

DATA SOURCES

The manuscript focuses upon recent developments, reported in the international periodontal literature, aimed at unraveling the molecular basis for this group of diseases. The concept of one disease type progressing with time to another disease within the same individual is discussed, and early data presented that indicate the possibility of microbial transmission from deciduous to permanent dentition's within a subject.

CONCLUSIONS

It is concluded that differing classification systems for adolescent and childhood periodontal diseases may lead to confusion within the dental profession, unless the clinical and molecular basis for such diseases is fully understood. Further advances in basic research using molecular biology tools should assist in our understanding of the aetiopathology at a molecular level and hopefully lead to the development of new treatment strategies.

Generalized prepubertal periodontitis. A report of 4 cases with the immunological findings

The clinical and immunological data from 4 patients with generalized prepubertal periodontitis are presented. The peripheral blood neutrophil chemotaxis was measured using zymosan activated sera as the chemoattractant. All of the 4 patients have shown depressed neutrophil chemotaxis compared to those of the healthy controls. Peripheral blood lymphocyte subpopulations were analysed by double-coloured flow cytometry using monoclonal antibodies for the receptors CD2, CD3, CD4, CD8, CD19, CD29, CD45RA+, 34,29dK, CD56. CD11b/CD18. Lymphocytes bearing CD3 receptors showed a significant decrease compared to those of the controls. Natural killer cells were lowered in 3 of the 4 cases. All of the patients showed a higher increase in CD11b/CD18 expression. The evaluation of CD11b/CD18 receptor in peripheral blood leukocytes may be of help explaining the rôle of neutrophils in the pathogenesis of the disease.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

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 peripheral blood lymphocyte subsets

We have studied the peripheral blood lymphocyte populations in our 6 patients (2 female and 4 male) with a mean age of 11.19 with Papillon-Lèfevre Syndrome (PLS) using adequate monoclonal antibodies and double coloured flow cytometry. Total B, T, CD4, CD8, CD29, CD45RA, NK, HLA-DR cells were studied. Total B, T, CD4 and CD8 lymphocytes were within normal limits. We have observed an increase in the CD29 lymphocytes and NK cells and a decrease in CD45RA lymphocytes. We think that these findings are important in explaining B lymphocyte activation and in the pathogenesis of the PLS.