Destructive membranous periodontal disease (Ligneous periodontitis)

Ligneous periodontitis exacerbated by Behçet's disease in a patient with plasminogen deficiency and a stop-gained variant PLG c.1468C > T: a case report

BACKGROUND

Plasminogen serves as the precursor to plasmin, an essential element in the fibrinolytic process, and is synthesized primarily in the liver. Plasminogen activation occurs through the action of plasminogen activator, converting it into plasmin. This conversion greatly enhances the fibrinolytic system within tissues and blood vessels, facilitating the dissolution of fibrin clots. Consequently, congenital deficiency of plasminogen results in impaired fibrin degradation. Patients with plasminogen deficiency typically exhibit fibrin deposits in various mucosal sites throughout the body, including the oral cavity, eyes, vagina, and digestive organs. Behcet's disease is a chronic recurrent systemic inflammatory disease with four main symptoms: aphthous ulcers of the oral mucosa, vulvar ulcers, skin symptoms, and eye symptoms, and has been reported worldwide. This disease is highly prevalent around the Silk Road from the Mediterranean to East Asia. We report a case of periodontitis in a patient with these two rare diseases that worsened quickly, leading to alveolar bone destruction. Genetic testing revealed a novel variant characterized by a stop-gain mutation, which may be a previously unidentified etiologic gene associated with decreased plasminogen activity.

CASE PRESENTATION

This case report depicts a patient diagnosed with ligneous gingivitis during childhood, originating from plasminogen deficiency and progressing to periodontitis. Genetic testing revealed a suspected association with the PLG c.1468C > T (p.Arg490*) stop-gain mutation. The patient's periodontal condition remained stable with brief intervals of supportive periodontal therapy. However, the emergence of Behçet's disease induced acute systemic inflammation, necessitating hospitalization and treatment with steroids. During hospitalization, the dental approach focused on maintaining oral hygiene and alleviating contact-related pain. The patient's overall health improved with inpatient care and the periodontal tissues deteriorated.

CONCLUSIONS

Collaborative efforts between medical and dental professionals are paramount in comprehensively evaluating and treating patients with intricate complications from rare diseases. Furthermore, the PLG c.1468C > T (p.Arg490*) stop-gain mutation could contribute to the association between plasminogen deficiency and related conditions.

Plasmin-Mediated Fibrinolysis in Periodontitis Pathogenesis

The hemostatic and inflammatory systems work hand in hand to maintain homeostasis at mucosal barrier sites. Among the factors of the hemostatic system, fibrin is well recognized for its role in mucosal homeostasis, wound healing, and inflammation. Here, we present a basic overview of the fibrinolytic system, discuss fibrin as an innate immune regulator, and provide recent work uncovering the role of fibrin-neutrophil activation as a regulator of mucosal/periodontal homeostasis. We reason that the role of fibrin in periodontitis becomes most evident in individuals with the Mendelian genetic defect, congenital plasminogen (PLG) deficiency, who are predisposed to severe periodontitis in childhood due to a defect in fibrinolysis. Consistent with plasminogen deficiency being a risk factor for periodontitis, recent genomics studies uncover genetic polymorphisms in PLG, encoding plasminogen, being significantly associated with periodontal disease, and suggesting PLG variants as candidate risk indicators for common forms of periodontitis.

Non-Plaque Induced Diffuse Gingival Overgrowth: An Overview

Non-plaque induced diffuse gingival overgrowth represents a broad class of conditions caused by several etiological factors. The aim of this review is to highlight the most recent updates and classifications of all the existent gingival overgrowths. In addition, we highlighted the diagnostic pathway that should be employed in patients affected by gingival overgrowth. Gingival overgrowth can be related to syndromic diseases including a wide spectrum of genetic and chromosomal alterations. However, thanks to scientific sharing and the availability of genetic panels it is possible to obtain an accurate phenotypic identification of well-known syndromes and also to identify new ones. This narrative review shows that through rigid, strict diagnostic protocols, the work of the clinician is greatly facilitated, despite the wide variety of pathologies considered. In conclusion, the exchange of specialists’ competencies and the multidisciplinary management of these patients, are crucial to reach diagnosis and the correct clinical-therapeutic management.

Oral lesions containing amyloid-like material

During oral pathology daily practice, true amyloid may be identified in oral amyloidosis and several odontogenic tumors. However, histologic examination often reveals other oral and perioral diseases with similar eosinophilic, acellular, amorphous substances. These include extensive areas of collagenous sclerosis, fibrin deposition, elastic fiber degeneration, and dentinoid material, which may resemble amyloid under light microscopic examination. These materials are often termed "amyloid-like" due to their close histologic resemblance to true amyloid. The rarity of most of these conditions and their strong histologic similarity may hamper an accurate diagnosis. Definitive diagnosis of these lesions may require clinical correlation; laboratory evaluation; histochemical or immunohistochemical reactions; and, in some cases, genetic investigation. In this review, we describe the main clinicopathologic features of this group of diseases that may manifest in the oral and/or perioral regions and that have in common the presence of amyloid-like material deposition.

Possible association between periodontitis and prostatitis: A pilot study

Introduction: Prostatitis is one of the most chronic diseases which is often associated with periodontitis. The serum Prostate Specific Antigen (PSA) levels can be elevated in a non-malignant condition such as symptomatic and asymptomatic prostatitis. Similarity in the inflammatory etiopathogenesis of these diseases is evident through the presence of Gram negative bacteremia, which in turn may be the possible link between these two conditions. Aim: To estimate the possible association between chronic periodontitis and prostatitis, evaluating the PSA levels in patients with moderate and severe periodontitis. Material and methods: 40 patients with prostatitis and elevated Prostate Specific Antigen (PSA) levels (≥ 4ng/ml) that participated in the study were hospitalized at the University Urology Clinic at the Faculty of Medicine in Skopje. Patients were divided into two groups on the basis of the levels of periodontal clinical attachment. First group of 20 patients with Clinical attachment level (CAL) ≥ 3mm, moderate periodontitis and other group of 20 patients with CAL ≥ 5mm, severe periodontitis. Dental plaque index (DPI), Index of gingival inflammation (IGI), Gingival bleeding index (GBI) and Clinical attachment level (CAL) were recorded and an assessment of PSA values was done and correlation to periodontal parameters, respectively. Differences in means, as statistically significant, were analyzed using Student's ttest. The relationship between PSA scores with all clinical parameters was done using Pearson's correlation coefficient technique. Results: Statistically significant differences were noted, (p<0.05) between periodontal index values (DPI, IGI, GBI, CAL) and PSA levels within the two examined groupsHigher PSA levels were recordedin patients with severe periodontitis than inthose with moderate periodontitis. Pearson coefficient test among these periodontal indices (DPI, IGI, GBI and CAL) and PSA levels in two examined groups showed no statistically significant correlation. Conclusion: Patients with severe periodontitis were found to have higher PSA levels than those with moderate periodontitis. The clinical parameters of periodontitis and elevated PSA levels indicated a probable link between the two diseases.

Porphyromonas gingivalis initiates coagulation and secretes polyphosphates - A mechanism for sustaining chronic inflammation?

BACKGROUND

Periodontitis is a chronic inflammation resulting in destruction of tooth-supporting bone. Chronic inflammation is characterized by extravascular fibrin deposition. Fibrin is central to destruction of bone; monocytes bind to fibrin and form osteoclasts, thus providing a link between coagulation and the tissue destructive processes in periodontitis. The oral microbiome is essential to oral health. However, local ecological changes, such as increased biofilm formation, result in a dysbiotic microbiome characterized by an increase of protease-producing species e.g. Porphyromonas gingivalis. Proteases initiate inflammation and may cleave coagulation factors. Polyphosphates (polyP) may also provide bacteria with procoagulant properties similar to platelet-released polyP. P. gingivalis has also been found in remote locations related to vascular pathology and Alzheimer's disease.

OBJECTIVES

The aim of this study was to investigate procoagulant activity of ten different species of oral bacteria present in oral health and disease as well as presence of polyP and fibrin formation in planktonic and biofilm bacteria.

METHODS

Oral bacteria were studied for protease production and procoagulant activity. The presence of polyP and formation of fibrin was observed using confocal microscopy.

RESULTS

P. gingivalis showed strong protease activity and was the only species exerting procoagulant activity. Confocal microscopy showed polyP intracellularly in planktonic bacteria and extracellularly after biofilm formation. Fibrin formation emanated from planktonic bacteria and from both bacteria and polyP in biofilm cultures.

CONCLUSIONS

The procoagulant activity of P. gingivalis could explain its role in chronic inflammation, locally in oral tissues as well as in remote locations.

Ligneous Periodontitis in a Patient with Type 1 Plasminogen Deficiency: A Case Report and Review of the Literature

Background

Ligneous periodontitis or destructive membranous periodontal disease is a rare condition involving gingival tissues, which is due to plasminogen deficiency and fibrin deposition. Plasminogen deficiency is an ultrarare autosomal recessive disease. The disease is characterized by gingival enlargement and periodontal tissue destruction that leads to rapid tooth loss despite treatment attempts. A defect in fibrinolysis and abnormal wound healing are the main pathogenesis of this condition. It is caused by mutations in PLG, the gene coding for plasminogen, which results in decreased levels and functional activity. Case Presentation. In this case report, clinical and histopathological findings of a 26-year-old male patient who presented with generalized membranous gingival enlargement are presented. He was the third child of consanguineous parents and had multicystic congenital hydrocephalus at birth. Besides the gingival enlargement, he also presented ligneous conjunctivitis since childhood. The intraoral examination revealed generalized periodontal breakdown. Radiographs showed alveolar bone loss present in every quadrant. All blood investigations were normal except for plasminogen deficiency. A biopsy sample was excised from affected gingiva and a series of histopathological evaluation was performed. Based on clinical and histopathological evidence, a diagnosis of destructive membranous periodontal disease or ligneous periodontitis was made. A clinical exome assay for the PLG gene was also done. It was confirmed as Type 1 plasminogen deficiency.

Conclusion

Ligneous periodontitis has been rarely reported in India. The reasons could be because of the rarity of the disease or missed diagnosis. The need to take a proper history and perform a proper clinical examination and histopathologic evaluation has to be stressed when diagnosing and treating gingival enlargements. If a genetic condition is suspected, genetic screening is also needed. All these will help the clinician in correctly diagnosing the disease and formulating a proper treatment plan for managing the condition.

Ligneous gingivitis secondary to plasminogen deficiency: a multidisciplinary diagnostic challenge

Plasminogen deficiency is a genetic condition resulting in deposition of extravascular fibrin within mucosal tissues. Lesions associated with plasminogen deficiency most commonly affect the eyes, while intraoral lesions, when present, affect the marginal aspects of the gingiva. We report a diagnostically challenging case of ligneous gingivitis, which developed in a young male patient in the absence of other clinical lesions. Due to the rarity of this condition, it may fall under the radar of dentists and dental specialists, leading to missed or delayed diagnosis.

Proteolysis is the most fundamental property of malignancy and its inhibition may be used therapeutically (Review)

The mortality rates of cancer patients decreased by ~1.5% per year between 2001 and 2015, although the decrease depends on patient sex, ethnic group and type of malignancy. Cancer remains a significant global health problem, requiring a search for novel treatments. The most common property of malignant tumors is their capacity to invade adjacent tissue and to metastasize, and this cancer aggressiveness is contingent on overexpression of proteolytic enzymes. The components of the plasminogen activation system (PAS) and the metal-loproteinase family [mainly matrix metalloproteinases (MMPs)] are overexpressed in malignant tumors, driving the local invasion, metastasis and angiogenesis. This is the case for numerous types of cancer, such as breast, colon, prostate and oral carcinoma, among others. Present chemotherapeutics agents typically attack all dividing cells; however, for future therapeutic agents to be clinically successful, they need to be highly selective for a specific protein(s) and act on the cancerous tissues without adverse systemic effects. Inhibition of proteolysis in cancerous tissue has the ability to attenuate tumor invasion, angiogenesis and migration. For that purpose, inhibiting both PAS and MMPs may be another approach, since the two groups of enzymes are overexpressed in cancer. In the present review, the roles and new findings on PAS and MMP families in cancer formation, growth and possible treatments are discussed.

Unveiling the Link between Prostatitis and Periodontitis

Background:

One of the important tumor markers having critically important applications in every aspect of treating men with prostatic illness is prostate-specific antigen (PSA), formed by prostate acini's epithelial cells. Where prostate is affected by inflammation or malignancy, the PSA levels rise to/and above 4 ng/ml. This study analyzes the interlink between different severity of periodontitis and prostatitis by assessment of PSA antigen levels and periodontal clinical parameters.

Materials and Methods:

In this study, 100 chronic prostatitis patients diagnosed to also have periodontal diseases were divided into four batches on the basis of the nature of prostatitis and levels of periodontal clinical attachment. The grouping was as: group 1A – clinical attachment level (CAL) <3 mm and mild prostatitis, Group 2A – CAL ≥3 mm and mild prostatitis, and Group 1B – CAL <3 mm and moderate-to-severe prostatitis, Group 2B – CAL ≥3 mm and moderate-to-severe prostatitis. Readings of CAL, probing pocket depth, bleeding on probing, plaque index, and gingival index (PI and GI) were recorded, followed by calculation and assessment of PSA values and correlation of periodontal parameters, respectively.

Results:

An important and affirmative correlation (r = 0.5549, P < 0.05) was seen between PSA and CAL scores at significance level of 5%, and also between PSA and probing depths (PD) scores at 5% (r = 0.5315, P < 0.05), indicating that PSA and CAL scores, as also PSA and PD scores are mutually dependent. The similar positive correlation was seen between PSA with PI (r = 0.3231, P < 0.05) and GI (r = 0.3567, P < 0.05) scores, respectively, at 5% level of significance, which shows PSA is also mutually dependent on PI and GI scores.

Conclusion:

Patients with of grades, moderate-to-severe prostatitis as well as periodontitis were found having higher PSA levels. The clinical readings of periodontal parameters were significantly higher in patients with moderate-to-severe prostatitis which shows a pathological link between the above two.

Genes Critical for Developing Periodontitis: Lessons from Mouse Models

Since the etiology of periodontitis in humans is not fully understood, genetic mouse models may pinpoint indispensable genes for optimal immunological protection of the periodontium against tissue destruction. This review describes the current knowledge of genes that are involved for a proper maintenance of a healthy periodontium in mice. Null mutations of genes required for leukocyte cell–cell recognition and extravasation (e.g., Icam-1, P-selectin, Beta2-integrin/Cd18), for pathogen recognition and killing (e.g., Tlr2, Tlr4, Lamp-2), immune modulatory molecules (e.g., Cxcr2, Ccr4, IL-10, Opg, IL1RA, Tnf-α receptor, IL-17 receptor, Socs3, Foxo1), and proteolytic enzymes (e.g., Mmp8, Plasmin) cause periodontitis, most likely due to an inefficient clearance of bacteria and bacterial products. Several mechanisms resulting in periodontitis can be recognized: (1) inefficient bacterial control by the polymorphonuclear neutrophils (defective migration, killing), (2) inadequate antigen presentation by dendritic cells, or (3) exaggerated production of pro-inflammatory cytokines. In all these cases, the local immune reaction is skewed toward a Th1/Th17 (and insufficient activation of the Th2/Treg) with subsequent osteoclast activation. Finally, genotypes are described that protect the mice from periodontitis: the SCID mouse, and mice lacking Tlr2/Tlr4, the Ccr1/Ccr5, the Tnf-α receptor p55, and Cathepsin K by attenuating the inflammatory reaction and the osteoclastogenic response.

Periodontal and other oral manifestations of immunodeficiency diseases

The list of immunodeficiency diseases grows each year as novel disorders are discovered, classified, and sometimes reclassified due to our ever-increasing knowledge of immune system function. Although the number of patients with secondary immunodeficiencies (SIDs) greatly exceeds those with primary immunodeficiencies (PIDs), the prevalence of both appears to be on the rise probably because of scientific breakthroughs that facilitate earlier and more accurate diagnosis. Primary immunodeficiencies in adults are not as rare as once thought. Globally, the main causes of secondary immunodeficiency are HIV infection and nutritional insufficiencies. Persons with acquired immune disorders such as AIDS caused by the human immunodeficiency virus (HIV) are now living long and fulfilling lives as a result of highly active antiretroviral therapy (HAART). Irrespective of whether the patient's immune-deficient state is a consequence of a genetic defect or is secondary in nature, dental and medical practitioners must be aware of the constant potential for infections and/or expressions of autoimmunity in these individuals. The purpose of this review was to study the most common conditions resulting from primary and secondary immunodeficiency states, how they are classified, and the detrimental manifestations of these disorders on the periodontal and oral tissues.

Periodontitis associated with plasminogen deficiency: a case report

BACKGROUND

Plasminogen deficiency is a rare autosomal recessive disease, which is associated with aggressive periodontitis and gingival enlargement. Previously described treatments of plasminogen deficiency associated periodontitis have shown limited success. This is the first case report indicating a successful therapy approach consisting of a non-surgical supra- and subgingival debridement in combination with an adjunctive systemic antibiotic therapy and a strict supportive periodontal regimen over an observation period of 4 years.

CASE PRESENTATION

The intraoral examination of a 17-year-old Turkish female with severe plasminogen deficiency revealed generalized increased pocket probing depths ranging from 6 to 9 mm, bleeding on probing over 30%, generalized tooth mobility, and gingival hyperplasia. Alveolar bone loss ranged from 30% to 50%. Clinical attachment loss corresponded to pocket probing depths. Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola, Prevotella intermedia, Prevotella nigrescens and Eikenella corrodens have been detected by realtime polymerase chain reaction. Periodontal treatment consisted of full mouth disinfection and adjunctive systemic administration of amoxicillin (500 mg tid) and metronidazole (400 mg tid). A strict supportive periodontal therapy regimen every three month in terms of supra- and subgingival debridement was rendered. The reported therapy has significantly improved periodontal health and arrested disease progression. Intraoral examination at the end of the observation period 3.5 years after non-surgical periodontal therapy showed generalized decreased pocket probing depths ranging from 1 to 6 mm, bleeding on probing lower 30%, and tooth mobility class I and II. Furthermore, microbiological analysis shows the absence of Porphyromonas gingivalis, Prevotella intermedia and Treponema denticola after therapy.

CONCLUSION

Adjunctive antibiotic treatment may alter the oral microbiome and thus, the inflammatory response of periodontal disease associated to plasminogen deficiency and diminishes the risk of pseudomembrane formation and progressive attachment loss. This case report indicates that patients with plasminogen deficiency may benefit from non-surgical periodontal treatment in combination with an adjunctive antibiotic therapy and a strict supportive periodontal therapy regimen.

Destructive membranous periodontal disease (ligneous gingivitis): a literature review

BACKGROUND

Destructive membranous periodontal disease, or ligneous gingivitis, is a rare condition involving nodular gingival enlargement with ulceration and periodontal tissue destruction. This review gives a brief account of the cases reported in the literature. An effort is also made to define the periodontal disease caused by plasminogen deficiency with a view to its potential inclusion in the classification of periodontal diseases.

METHODS

A MEDLINE/PubMed and manual search was conducted to find papers describing ≥1 case of ligneous disease involving the oral mucosa.

RESULTS

We identified 23 articles reporting 35 cases. For each patient, we analyzed various characteristics, including age, sex, age of onset, oral symptoms, histologic features, plasminogen levels (functional activity, plasma antigen), genetic features, treatment, and results of treatment during the reported follow-up.

CONCLUSIONS

Ligneous gingivitis is a rare periodontal disorder closely associated with ligneous conjunctivitis and plasminogen deficiency. Its diagnosis may be supported by the finding of genetic mutations responsible for the condition. Research is focusing on the future development of an effective therapy capable of arresting the destructive evolution of the disease. Additional studies, investigating features such as probing depth and attachment loss, are needed for the appropriate classification of this periodontal disease.

Plasmin is essential in preventing periodontitis in mice

Periodontitis involves bacterial infection, inflammation of the periodontium, degradation of gum tissue, and alveolar bone resorption, which eventually leads to loss of teeth. To study the role of the broad-spectrum protease plasmin in periodontitis, we examined the oral health of plasminogen (Plg)-deficient mice. In wild-type mice, the periodontium was unaffected at all time points studied; in Plg-deficient mice, periodontitis progressed rapidly, within 20 weeks. Morphological study results of Plg-deficient mice revealed detachment of gingival tissue, resorption of the cementum layer, formation of necrotic tissue, and severe alveolar bone degradation. IHC staining showed massive infiltration of neutrophils in the periodontal tissues. Interestingly, doubly deficient mice, lacking both tissue- and urokinase-type plasminogen activators, developed periodontal disease similar to that in Plg-deficient mice; however, mice lacking only tissue- or urokinase-type plasminogen activator remained healthy. Supplementation by injection of Plg-deficient mice with human plasminogen for 10 days led to necrotic tissue absorption, inflammation subsidence, and full regeneration of gum tissues. Notably, there was also partial regrowth of degraded alveolar bone. Taken together, our results show that plasminogen is essential for the maintenance of a healthy periodontium and plays an important role in combating the spontaneous development of chronic periodontitis. Moreover, reversal to healthy status after supplementation of Plg-deficient mice with plasminogen suggests the possibility of using plasminogen for therapy of periodontal diseases.

Successful treatment of ligneous gingivitis with warfarin

Ligneous gingivitis is a rare condition characterized by inflammation and nodular gingival enlargement secondary to fibrin deposits in the gingival that results from plasminogen deficiency. Several therapeutic approaches have been used with limited success. We report a case of a patient with homozygous plasminogen deficiency and ligneous gingivitis that was initially refractory to local care and systemic antibiotics, but later improved with the addition of warfarin.

Hypoplasminogenemia with ligneous periodontitis: a failed local therapeutic approach

BACKGROUND

Hypoplasminogenemia is a rare condition that is associated with ligneous conjunctivitis, a form of chronic conjunctivitis characterized by firm, fibrin-rich, pseudomembranous lesions on the tarsal conjunctivae and oral lesions. Pseudomembranes may develop on the gingivae, and there may be periodontal involvement.

METHODS

Several therapeutic approaches have been developed to treat such patients, but they have had limited effect. We used gingivectomies, topical heparin, and corticosteroids to treat periodontal lesions in an 18-year-old girl.

RESULTS

This approach had no benefit.

CONCLUSION

The question remains about how best to manage patients with hypoplasminogenemia.

Ligneous conjunctivitis: a clinicopathological, immunohistochemical, and genetic study including the treatment of two sisters with multiorgan involvement

Ligneous conjunctivitis (LC) is a rare disease characterized by wood-like pseudomembranes developing on the ocular and extraocular mucosae secondary to plasminogen (PLG) deficiency. In this paper, we report two cases of LC in two sisters of 57 and 62 years of age that presented with recurrent, bilateral pseudomembranes on conjunctiva and a history of consanguinity and deafness. Pseudomembranes showed superficial and/or subepithelial deposits of eosinophilic amorphous hyaline, amyloid-like material with a variable proportion of granulation tissue, and inflammatory cells. The eosinophilic deposits were negative for Congo red stain, immunoreactive for fibrinogen, and consistently negative for amyloid A component, transthyretin, beta(2)-microglobulin, albumin, fibronectin, collagen type IV, vimentin, and cytokeratins. Among inflammatory cells, a percentage of positivity of roughly 60% for lymphocytes T (CD3+) and 40% for lymphocytes B (CD8+), with a relation of cytotoxic/helper (CD8/4) T cells of 3:2, was found. In one case, nasal polyps and recurrent gastric peptic ulcer were also characterized by the same subepithelial hyaline deposits. A novel homozygous point mutation c.1856 C>T was found in exon 15 of the PLG gene in both patients. Amniotic membrane transplantation was done in one case with promising results.

A ligneous periodontitis and conjunctival lesions in a patient with plasminogen deficiency

Destructive membranous periodontal disease is a rare and poorly defined entity that is a part of a systemic disease due to accumulation of fibrin material. The disease is characterized by gingival enlargement and periodontal tissue destruction that leads to rapid bone loss despite treatment efforts. We present a case with ligneous periodontitis and conjunctivitis.

Ligneous periodontitis and gingival antioxidant status: report of two cases

Ligneous periodontitis (LP) is a rare periodontal disease in which plasminogen deficiency and fibrin deposition both play a part, resulting in characteristic gingival enlargement and periodontal breakdown. Recent data suggest that oxidant/antioxidant changes are significant in the pathology of oral diseases. This study examines the gingival histopathology in 2 cases with LP. To examine the antioxidant (AO) status, the activity of the major AOs glutathione (GSH), catalase (CAT), and glutathione S-transferase (GST) and the malondialdehyde (MDA) levels, a product of lipid peroxidation, were measured and compared with healthy control subjects. The histopathologic examination of the gingiva revealed subepithelial fibrin accumulation and irregular extensive downward proliferation of the epithelium. Biochemical analysis showed that the CAT, GST, and MDA levels were higher in LP patients than in the control subjects, and the GSH level was lower. Our preliminary findings show that in LP, the AO capacity of the gingiva changes or decreases and lipid peroxidation increases, which suggests that oxidative stress is involved in the pathology of the periodontal breakdown observed in this disease.

Ligneous alveolar gingivitis in the absence of plasminogen deficiency

A case of localized, longstanding, asymptomatic ligneous gingivitis affecting the crest of the edentulous lower left posterior alveolar ridge (ligneous alveolar gingivitis) of a middle-aged Caucasian woman is presented. This patient did not have any associated ophthalmic lesions (ligneous conjunctivitis) and did not have a plasminogen deficiency.

Ligneous Periodontitis and Ehlers-Danlos Syndrome

BACKGROUND

Generalized membranous gingival enlargement due to an accumulation of fibrin deposits associated with severe alveolar bone loss (ligneous periodontitis) is a rare condition, and plasminogen deficiency seems to play a central role in its pathogenesis. However, this condition has not been described in association with syndromes. This article reports a case of ligneous periodontitis in a boy with the classic type of Ehlers-Danlos syndrome (EDS).

METHODS

A 12-year-old white male presented with generalized gingival overgrowth and severe alveolar bone loss. A physical examination revealed clinical signs of EDS (velvety skin with mild hyperextensibility, marked hypermobility of the limb joints, atrophic scars on his knees, and easy bruising), which is associated with a positive family history for joint hypermobility. A biopsy of gingival tissues was submitted for routine histology, hematoxylin and eosin (H&E), and direct immunofluorescence (antifibrinogen). An evaluation of plasminogen activity was also performed.

RESULTS

Histopathology revealed chronic periodontitis with fibrinoid material deposition, and direct immunofluorescence proved to be positive for fibrin. Functional plasminogen was reduced. A conclusive diagnosis of ligneous periodontitis due to plasminogen deficiency associated with the classic type of EDS was rendered.

CONCLUSIONS

Ehlers-Danlos syndrome can be associated with ligneous periodontitis. In the present case, the histologic examination represented an important tool in the differential diagnosis, because it ruled out EDS type VIII as the associated systemic factor to periodontal breakdown.

Non-Hodgkin's lymphoma and auricular hypoplasia: associated with juvenile colloid milium or ligneous conjunctivitis?

The exact nature of amyloid-like hyaline material deposits in the skin is not well understood in some disorders. Three of those--ligneous conjunctivitis, ligneous periodontitis and colloid milium--have been rarely reported in a same patient. We report a case of mucosal and skin deposits of an amyloid-like homogeneous material associated with non-Hodgkin's lymphoma and congenital auricular hypoplasia. We discussed and reviewed the literature on these unique associations to determine whether these are the same pathological process. We also noted whether this case represents a new syndrome or a coincidental association.

Destructive membranous periodontal disease (ligneous periodontitis): a case report and 3 years follow-up

Destructive membranous periodontal disease is a rare, destructive and poorly defined entity, which is the part of a systemic disease due to plasminogen deficiency and fibrin deposition. The disease is characterised by gingival enlargement and periodontal tissue destruction that leads to rapid tooth loss despite treatment attempts. Biopsy is essential to rule out other periodontal disease in the differential diagnosis.

Juvenile colloid milium associated with conjunctival and gingival involvement

Juvenile colloid milium is an uncommon cutaneous disease characterized by translucent papules distributed on sun-exposed areas with early onset. Association of juvenile colloid milium with conjunctival and gingival deposits is uncommon and interesting. We report a case of juvenile colloid milium associated with conjunctival and gingivai deposits of an amyloid-like homogeneous eosinophilic material. It seems that all 3 of these in our patient may be different expressions of the same pathologic disease.

Recurrent Recalcitrant Gingival Hyperplasia and Plasminogen Deficiency: A Case Report

BACKGROUND

Recurrent gingival hyperplasia due to plasminogen deficiency is a rare condition due to fibrin deposition in the connective tissue. Only eight cases have previously been reported in the English literature, and all cases were diagnosed before the age of 35 years. This paper presents an older patient with recurrent gingival hyperplasia due to plasminogen deficiency (hypoplasminogenemia).

METHODS

A 59-year-old woman presented with recurrent gingival swelling of 6 years' duration. Multiple biopsies performed at various time periods were histologically reported to be gingival hyperplasia with chronic inflammation. Routine hematoxylin and eosin (H & E) staining and direct immunofluorescence were performed.

RESULTS

H & E-stained sections showed subepithelial, eosinophilic, amorphous, acellular deposits. Direct immunofluorescence showed positive staining for fibrin, immunoglobulin (Ig) G, IgA, and IgM. Functional plasminogen and plasminogen activator inhibitor-1 assays were done and found to be deficient. A diagnosis of gingival hyperplasia due to plasminogen deficiency (hypoplasminogenemia) was rendered.

CONCLUSIONS

Recurrent gingival hyperplasia due to plasminogen deficiency (hypoplasminogenemia) is a newly recognized and rare condition. H & E staining, direct immunofluorescence, and assessment of functional plasminogen levels are essential to differentiate this condition from other conditions in which subepithelial, eosinophilic, amorphous materials are deposited.

Ligneous conjunctivitis

Ligneous conjunctivitis (McKusick 217090) is a rare form of chronic conjunctivitis characterized by the development of firm fibrin-rich, woody-like pseudomembraneous lesions mainly on the tarsal conjunctivae. Less frequently, similar lesions may occur on other mucous membranes of the body indicating that these manifestations are part of a systemic disease. Histopathological findings from affected humans and (plasminogen-deficient) mice indicate that wound healing, mainly of injured mucosal tissue, is impaired due to markedly decreased (plasmin-mediated) extracellular fibrinolysis. Pseudomembraneous lesions of the eyes and other mucosal tissue mainly contain clotted fibrin(ogen). Actually, systemic plasminogen deficiency has been linked to ligneous conjunctivitis in humans and mice. In one case, ligneous conjunctivitis has been induced by antifibrinolytic treatment with tranexamic acid. Further rare associated disorders of ligneous conjunctivitis are congenital occlusive hydrocephalus and juvenile colloid milium. This review outlines the historical background, clinical characteristics of ligneous conjunctivitis and its associated complications, histological abnormalities of pseudomembraneous lesions, inheritance, hemostasiologic and molecular genetic findings in affected patients, current treatment approaches, and the plasminogen-deficient mouse as an animal model.

Ligneous conjunctivitis, hydrocephalus, hydrocele, and pulmonary involvement in a child with homozygous type I plasminogen deficiency

Ligneous conjunctivitis is a rare and unusual form of chronic pseudomembranous conjunctivitis which usually starts in early infancy. Plasminogen deficiency has recently been associated with ligneous conjunctivitis. The disease may be associated with pseudomembranous lesions of other mucous membranes in the mouth, nasopharynx, trachea, and female genital tract and also with congenital hydrocephalus. In this report, a 1-month-old Turkish boy who had pseudomembranous conjunctivitis, occlusive hydrocephalus, and hydrocele is presented. After surgery for ventriculo-peritoneal shunt establishment, he developed inspiratory stridor, respiratory distress, and pulmonary atelectasis. Tracheal pseudomembranes were also demonstrated by bronchoscopy. Plasminogen antigen level and plasminogen activity were very low. Genomic DNA from the patient was screened for mutations in the plasminogen gene and a homozygous L650fsX652 mutation (deletion of 2081C) was detected. Both of his parents were heterozygous for this mutation. He died due to respiratory failure during follow-up.

CONCLUSION

Ligneous conjunctivitis related to type I plasminogen deficiency is relatively common in the Turkish population, however, mutations are heterogeneous and a common founder is unlikely.

Oral lesions indicative of plasminogen deficiency (hypoplasminogenemia)

BACKGROUND

Gingival overgrowth with ulceration has recently been recorded in 4 reports: (1) our report of a British patient with ligneous conjunctivitis in whom the gingival lesions appeared to be related to tranexamic acid-an antifibrinolytic agent; (2) a report of 2 Turkish patients and an Italian patient with mainly gingival lesions; (3) our report of 5 Turkish patients with mainly gingival lesions; and (4) a report of 3 new Turkish cases, which also were associated with gingival lesions and alveolar bone loss. These patients all had gingival swellings, and a minority had conjunctival involvement similar to ligneous conjunctivitis, although the etiology was unclear in all. Nevertheless, fibrin exudation was fundamental because the hyaline or amyloidaceous material seen on the gingival biopsy stained for fibrin but failed to stain for amyloid.

METHODS

We have examined 6 more patients who exhibited gingival swelling caused by amyloidaceous deposits that stained only for fibrin, and we assayed their plasminogen levels.

RESULTS

The plasminogen functional activity assayed in these 6 additional patients, and in 2 of the 5 patients previously reported by us, was significantly reduced.

CONCLUSIONS

Gingival overgrowth with ulceration appears to be a new complication caused by plasminogen deficiency; it also appears to be related to ligneous conjunctivitis in some cases.