Prepubertal Periodontitis



Fig. 12-23 Thrombocytopenic purpura. A, Hemorrhagic gingivitis in patient with thrombocytopenic purpura B, Marked reduction in severity of gingival disease alter removal of surface debris and careful scaling

Periodontal Disease Panoramic Radiograph
Fig 1 ? 74 Prepubertal periodontitis (A), clinical picture and panoramic radiograph (B). The palient is a 10-year-old boy with cyclic neutropenia and agammaglobulinemia.

the oral cavity, oropharynx, and throat is characteristic. The mucosa exhibits isolated necrotic patches that are black and gray and arc sharply demarcated from the adjacent uninvolved areas.104-1 *2 The absence of a notable inflammatory reaction due to lack of granulocytes is a striking feature. The gingival margin may or may riot be involved. Gingival hemorrhage, necrosis, increased salivation, and fetid odor are accompanying clinical features. The occurrence of rapidly destructive periodontitis has been described in cyclic neutropenia d ig. 12-24>.1x1

The following microscopic changes have been described in the periodontium11:

• Hemorrhage into the periodontal ligament with destruction of the principal fibers

• Osteoporosis of lite cancellous bone with osteoclastic resorption

• Small fragments of necrotic bone in the hemorrhagic periodontal ligament

• Hemorrhage in the marrow adjacent to the teeth, areas in which the periodontal ligament is widened and consists of dense fibrous tissue with fibers parallel to the tooth surface

• Formation of new bony trabeculae

In cyclic neutropenia the gingival changes recur with recurrent exacerbation of the disease.4"

Experimentally, neutropenia has been produced in dogs with heterologous antineutrophil serum. Neutrophilic granulocytes disappeared from the tissues, but ulcerative lesions and bacterial invasion were not observed, probably owing to the short duration of the experiment (4 days).1 { Because infection is a common feature of agranulocytosis, differential diagnosis involves consideration of such conditions as acute necrotizing ulcerative gingivitis, diphtheria, noma, and acute necrotizing inflammation of the tonsils. Definitive diagnosis depends on the hematologic findings of pronounced leukopenia and almost complete absence of neutrophils.

Chediak-Higashi Syndrome. < hediak-lligashi syndrome is a rare disease that affects the production of organelles found in almost every cell. It affects mostly the melanocytes, platelets, and phagocytes and produces partial albinism, mild bleeding disorders, and recurrent bacterial infections, including rapidly destructive periodontitis. It has been described as a genetically transmitted disease in ranch-raised mink (see Chapter l()).8,,S4

Antibody Deficiency Disorders

Agammaglobulinemia. Agammaglobulinemia results from a deficiency in B cells; T-cell function remains normal. It can be congenital (X-linked or Bruton's agammaglobulinemia) or acquired. The disease is characterized by recurrent infections, including destructive periodontitis in children (see l ig. 12-24).

Acquired Immunodeficiency Syndrome. Acquired immunodeficiency syndrome (AIDS) is caused by the human immunodeficiency virus (HIV) and is characterized by destruction of lymphocytes, rendering the patient susceptible to opportunistic infections, including destructive periodontal lesions and malignancies (see Chapter 2<)).


In aged individuals, arteriosclerotic c hanges characterized by intimal thickening, narrowing of the lumen, thickening of the media, and hyalinization ot the media and adventitia, with or without calcification, are common in vessels throughout the jaws, as well as in areas of periodontal inflammation d ig. 12-25).841617,1 Both periodontal disease and arteriosclerosis increase with age, and it has been hypothesized that the circulatory impairment induced by vascular changes may increase the patient's susceptibility to periodontal disease.Conversely, there is recent evidence to suggest that individuals with periodontal disease may be at greater risk for heart disease as a result of chronic periodontal infections and inflammation. See Chapter 13 for a detailed discussion of the relationship between periodontal inflammatory disease and the risk for systemic diseases.

Periodontal Systemic Disease
Fig. 12-25 Vascular changes in an aged individual with periodontal disease. A, periodontitis, showing inflammation extending from the gingiva into the interdental septum B, Detailed view, showing arterioles with thickened walls in the marrow space ol the interdental septum

In experimental animals, partial ischemic: of more than 10 hours' duration created by arteriolar occlusion produces changes in the oxidative enzymes and acid phosphatase activity and in the glycogen and lipid content of the gingival epithelium.98 local necrosis, followed by ulceration, occurs in the epithelium, with the junctional epithelium least affected.u,s DMA duplication is depressed. Changes typical of periodontal disease do not occur. Ischemia is followed by hyperemia, which is accompanied by metabolic changes and increased DNA synthesis in the epithelium. The gingival response to arteriolar occlusion is epithelial proliferation and thickening.

Congenital Heart Disease

Gingival disease and other oral symptoms may occur in children with congenital heart disease.'"10 In cases of tetralogy of Fallot, which is characterized by pulmonary stenosis, right ventricular enlargement, a defect in the Interventricular septum, and malposition of the aorta to the right, the oral changes include a purplish-red discoloration of the lips and gingiva and sometimes severe marginal gingivitis and periodontal destruction d igs. 12-26 and 12-27). Hie discoloration of the lips and gingivae corresponds to the general degree of cyanosis and returns to normal after corrective heart surgery. Ihe tongue appears coated, fissured, and edematous, and there is extreme reddening of the fungiform and filiform papillae. I he number of subepithelial capillaries is increased but will return to normal after heart surgery.11*

In cases ol tetralogy of lliseiimeiiger, there is pul-nfonar\ insufficiency and a diastolic murmur; the lips, cheeks, and buccal mucous membranes are cyanotic, but markedly less so than in tetralogy of I allot. Severe generalized marginal gingivitis may be found. In cases in which there is transposition of the aorta ami superior vetia cava, cyanotic discoloration and marginal gingivitis of a lesser degree are noted. In coarctation ot the aorta, there is narrowing of the vessel in the region where it is joined by the ductus arteriosus. Patients with this problem show marked inflammation of the gingiva in the anterior part of the mouth.

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