Autoimmune Neutropenia as a Cause of Periodontal Disease in Preschool Children.

In autoimmune neutropenia, autoantibodies attack neutrophils resulting in their destruction or alteration of their function. Since neutrophils have important immunologic functions, aberrations in their homeostasis lead to increased susceptibility to diseases, such as periodontitis. Periodontitis as a manifestation of neutropenia can affect adults and children. In this paper, we describe the treatment of periodontal disease in a 2-year-old female with autoimmune neutropenia. The importance of an interdisciplinary approach, frequent recalls, and meticulous mechanical therapy in stabilizing her periodontal condition, despite ongoing systemic infections is emphasized.

Tumor necrosis factor-α and oral inflammation in patients with Crohn disease.

BACKGROUND: Crohn disease (CD) is a chronic inflammatory bowel disease often accompanied by periodontal symptoms. Based on its function in immune response, tumor necrosis factor (TNF)-α and its genetic variants have been discussed as risk indicators in inflammatory processes. Therefore, the aim of the present study is to investigate the impact of TNF-α polymorphisms on periodontal parameters and inflammatory lesions of oral mucosa as a characteristic of CD. METHODS: A total of 142 patients with CD were included in the study. Oral soft tissue alterations and periodontal parameters were assessed. Genotypes, alleles, and haplotypes of TNF-α polymorphisms (rs1800629, cDNA-308G > A; and rs361525, cDNA-238G > A) were determined by polymerase chain reaction with sequence-specific primers (PCR-SSP). RESULTS: Patients with CD who exhibit more severe oral soft tissue alterations were significantly more often A allele carriers of rs361525 than G allele carriers (14.2% versus 2.2%; P <0.001). Furthermore, A allele carriers had a higher mean periodontal probing depth (P <0.05), mean clinical attachment level (P <0.05), and sites with bleeding on probing (not significant). Similar results were obtained when evaluating A allele-containing genotypes (AG + AA) and haplotypes (GA). In multivariate analyses considering age, sex, smoking, and medication as confounders, the A allele was proven to be an independent risk indicator for oral soft tissue alterations in patients with CD. No genotype-dependent influence of rs1800629 was observed. CONCLUSION: The TNF-α A allele of rs361525 represents a significant risk indicator for oral soft tissue alterations in patients with CD.

Oral manifestations of allograft recipients before and after renal transplantation.

Renal transplantation is considered the best treatment option for patients with end-stage renal disease. In this study, the prevalence of oral lesions was studied in a cohort of renal transplant recipients before and after transplantation. Fifty-nine kidney transplant recipients were examined one week before and four months after transplantation. The information gathered included age, sex, smoking history, duration on dialysis, drugs and their doses. There were 41 males (69.5%) and 18 females (30.5%) with a mean age of 37 years. Before surgery, two patients had non-specific lesions and two other patients had leukoedema. Following transplantation, 24 patients (40.7%) did not have any specific lesion. In six patients, we observed non-specific erythematous lesions (10.2%). Other recorded observations are as follows: Gingival hyperplasia in five patients (8.5%), oral candidiasis of the erythematous type in five patients (8.5%), hairy leukoplakia in four patients (6.8%) and leukoedema in seven patients (11.9%). In our study patients, the prevalence of oral lesions increased after transplantation, although it was lower than that reported in other studies. This could be due to the differences in sample size, differences between Iranian race and other races and different pharmaceutical formulation of the drug produced in Iran.

Inflammatory environment induces gingival tissue-specific mesenchymal stem cells to differentiate towards a pro-fibrotic phenotype.

BACKGROUND INFORMATION: Human gingival tissues are prone to hyperplasia under inflammatory stimuli. We have identified gingival tissue-specific mesenchymal stem cells (GMSCs) and found their functional change being correlated with drug-induced gingival hyperplasia. However, whether these cells exhibit characteristics of pro-fibrotic phenotype under inflammatory condition remains unknown. RESULTS: GMSCs isolated from human normal gingival tissues (N-GMSC) and inflammatory gingival tissues (I-GMSC) were cultured in vitro, representative cytokines were added to simulate the in vivo inflammatory environment. Under the influence of the inflammatory cytokines, GMSCs exhibited higher rate of proliferation than those under normal condition, while their potential for osteogenic and adipogenic differentiation was suppressed. The expression of matrix metalloproteinases (MMP)-1, MMP-2, IL-1, IL-6, TNF-α and type 1 collagen was significantly higher in I-GMSCs than in N-GMSCs. Furthermore, compared with dental pulp stem cells, GMSCs showed different pattern of gene expression and extracellular matrix formation in inflammatory environment. CONCLUSIONS: Inflammatory microenvironment induces GMSCs to differentiate towards a pro-fibrotic phenotype, which could underlie the hyperplastic appearance of inflammatory gingiva.

Characterization of mesenchymal stem cells from human normal and hyperplastic gingiva.

Human gingiva plays an important role in the maintenance of oral health and shows unique fetal-like scarless healing process after wounding. Here we isolate and characterize mesenchymal stem cells from human normal and hyperplastic gingival tissues (N-GMSC and H-GMSC, respectively). Immunocytochemical staining indicated that gingival lamina propria contained Stro-1 and SSEA-4 positive cells, implying existence of putative gingival MSC. Under attachment-based isolating and culturing condition, gingival MSC displayed highly clonogenic and long-term proliferative capability. By using single colony isolation and expansion approaches, we found both N-GMSC and H-GMSC possessed self-renewal and multipotent differentiation properties. N-GMSC and H-GMSC showed distinct immunoregulatory functions in a murine skin allograft setting via up-regulation of putative systemic regulatory T cells (Tregs). N-GMSC and H-GMSC were capable of regenerating collagenous tissue following in vivo transplantation, in which H-GMSC exhibited more robust regenerative capability. These findings suggest that gingival tissue contains tissue-specific mesenchymal stem cell population and is an ideal resource for immunoregulatory therapy due to its substantial availability and accessibility. In addition, gingival MSC over-activation may contribute to gingival hyperplastic phenotype.

Virulence of major periodontal pathogens and lack of humoral immune protection in a rat model of periodontal disease.

OBJECTIVE: This study was designed to test the hypothesis that periodontal pathogens Tannerella forsythia and Porphyromonas gingivalis are synergistic in terms of virulence potential using a model of mixed-microbial infection in rats. MATERIALS AND METHODS: Three groups of rats were infected orally with either T. forsythia or P. gingivalis in mono-bacterial infections or as mixed-microbial infections for 12 weeks and a sham-infected group were used as a control. This study examined bacterial infection, inflammation, immunity, and alveolar bone loss changes with disease progression. RESULTS: Tannerella forsythia and P. gingivalis genomic DNA was detected in microbial samples from infected rats by PCR indicating their colonization in the rat oral cavity. Primary infection induced significantly high IgG, IgG2b, IgG1, and IgG2a antibody levels indicating activation of mixed Th1 and Th2 immune responses. Rats infected with the mixed-microbial consortium exhibited significantly increased palatal horizontal and interproximal alveolar bone loss. Histological examinations indicated significant hyperplasia of the gingival epithelium with moderate inflammatory infiltration and apical migration of junctional epithelium. The results observed differ compared to uninfected controls. CONCLUSION: Our results indicated that T. forsythia and P. gingivalis exhibit virulence, but not virulence synergy, resulting in the immuno-inflammatory responses and lack of humoral immune protection during periodontitis in rats.

Detection of gingival crevicular fluid cytokines in children and adolescents with and without fixed orthodontic appliances.

OBJECTIVE: To study the expression of IL-1beta, IL-4, and IL-8 in the gingival crevicular fluid (GCF) of children, adolescents, and young adults with and without fixed orthodontic appliances. MATERIAL AND METHODS: Eighty systemically healthy children and adolescents participated in the study: 56 aged between 8 and 16 years without any orthodontic appliance (Group A) and 24 aged between 10 and 20 years having worn fixed orthodontic appliances for at least 12 months (Group B). Clinical examination included presence or absence of plaque, probing depth, bleeding on probing, and gingival overgrowth. GCF was collected by means of Durapore strips from four randomly selected sites per subject. The contents of interleukin-1 beta (IL-1beta), interleukin-4 (IL-4), and interleukin-8 (IL-8) were detected by ELISA, measured as total amounts (pg/30s) and expressed in log scale. RESULTS: Statistically significant differences were noted for the mean log IL-1beta, IL-4, and IL-8 between the two groups: Group B showed significantly higher mean levels in log IL-1beta and log IL-8 compared to Group A. Mean levels of log IL-4 were lower in Group B, although they did not reach statistical significance. Furthermore, mean levels of log IL-1beta and log IL-8 were associated with bleeding sites (p<0.001) and gingival overgrowth, while mean level of log IL-4 was associated with non-bleeding sites and no gingival overgrowth (p<0.001). CONCLUSION: Our findings suggest that fixed orthodontic appliances result in an increase in the expression of IL-1beta and IL-8. This may reflect biologic activity in the periodontium during orthodontic tooth movement.

The gingival inflammatory infiltrate in cardiac patients treated with calcium antagonists.

OBJECTIVES: To analyse the periodontal inflammatory infiltrates in patients with cardiac disease, some of these patients were treated with calcium antagonists (nifedipine and diltiazem) and some were not, to compare them with a healthy control group, and to evaluate the changes in the inflammatory infiltrate after periodontal treatment. MATERIAL AND METHODS: A "healthy group" (HG, n=12), a "cardiac group" (CG, n=12) without treatment with calcium antagonists, a "nifedipine group" (NG, n=18) and a "diltiazem group" (DG, n=13) were analysed. Biopsies were taken from a zone 2-3 mm below the upper part of the interproximal papillae 12-13 and 33-32 before causal periodontal treatment and after 1 year. Using haematoxylin-eosin staining, the plasma cells (P), lymphocytes (L), histiocytes (H) and polymorphonuclear cells (PMN) were counted. T and B lymphocytes were evaluated using the monoclonal antibodies anti-CD20 and anti-CD45RO. Statistical tests used: chi2 for study of the sample composition; ANOVA for comparison between groups; Student t-test and Wilcoxon test for comparison between visits; post-hoc test Bonferroni. RESULTS: When the cells were compared statistically, differences were established for L at the first visit (p<0.00001) and at the last visit (p<0.02), for the B lymphocytes (first visit p<0.0021, last visit p<0.022) and for the T lymphocytes (first visit p<0.0042, last visit p<0.0021). Between the 2 visits, HG showed significant reductions for P (p<0.01), L (p<0.045) and H (p<0.033); and the NG for L (p<0.0001). Lymphocytes showed differences in the NG with respect to the B lymphocytes (p<0.008). CONCLUSIONS: Nifedipine affects the inflammatory infiltrate with a greater number of lymphocytes (especially B) and these cells fell significantly in number after periodontal treatment.

Risk factors in the development of cyclosporine-induced gingival overgrowth.

BACKGROUND: Severe gingival hyperplasia (GH) is one of the most frequent side-effects associated with the prescription of cyclosporine-A (CsA). Using the largest group of renal allograft recipients assembled for this purpose, in this study, we statistically modeled the genetic (HLA), medical, and dental risk factors for the development of GH subsequent to administration of CsA. METHODS: Two hundred thirty-six renal transplant patients underwent full dental examination to quantify the extent and distribution of hyperplasia and dental disease (gingivitis, plaque, and calculus). Computerized data from all patients included pre-transplant medical history and dosage of nifedipine and azathioprine, as well as dose and serum levels of CsA and CsA microemulsion. Donor and host HLA haplotype were studied to investigate potential association of haplotype and donor-host mismatching with the development of GH. We evaluated the data by multivariate regression analysis, using Statistical Package for Social Sciences (SPSS). RESULTS: There was no association with age, sex, duration of renal replacement therapy, or interval since transplantation or pre-transplant disease (P>0.05). There also was no association of disease with host HLA haplotype, but degree of HLA-A mismatching was protective for GH development (P<0.002). GH was associated with the dose and serum levels of CsA (P<0.001) and the last dose of CsA microemulsion (P=0.009) but not nifedipine (P=0.10). Gingival inflammation and plaque were also strongly associated with GH (P<0.0003). In multivariate analysis, however, the last recorded dose of CsA (P<0.0001), presence of local gingival inflammation (P<0.0001), and gingivitis (P<0.003) were the independent predictors of the extent and severity of GH. CONCLUSIONS: Inter-patient variation in the extent and severity of GH is related to CsA dose and serum levels. Differences in host HLA phenotype do not explain individual susceptibility to GH, but donor-host HLA-A mismatching may be important. Inter-site variation in the extent and severity of the disease is related to local gingival inflammation.

Relationship between gingival hyperplasia and class II histocompatibility antigens in renal transplant recipients.

Gingival hyperplasia, a well-known side effect of ciclosporin A (CS-A), is much more prominent when CS-A is used in combination with calcium channel blockers, especially dihydropyridines. On the other hand, it is interesting to note that this complication is not observed in all patients using this drug combination. This study was conducted in order to investigate the relationship (if any) between major histocompatibility complex antigens and gingival hyperplasia. Seventy-six renal transplantation patients were evaluated by an experienced dentist for gingival hyperplasia. The patients were then divided into two groups according to the presence (group 1, n = 18) or absence (group 2, n = 58) of gingival hyperplasia. There was no significant difference between the two groups regarding age, sex, transplant age, donor type, antihypertensive and immunosuppressive therapy protocols, and CS-A levels. HLA-DR2 antigen was present in 63% of the patients with gingival hyperplasia and in 34% of the patients without gingival hyperplasia. However, the HLA-DR1 antigen frequencies were found to be 11 and 22% in group 1 and group 2, respectively. In patients receiving nifedipine as an antihypertensive therapy, gingival hyperplasia developed more often than in patients receiving verapamil or diltiazem. As a result, in renal allograft recipients with HLA-DR1 antigen, gingival hyperplasia was seen less frequently than in HLA-DR2-positive patients. It is believed that the presence of these antigens regulates the response of the patients to either CS-A and/or calcium channel blockers.

Analysis of peripheral blood leukocytes in patients with cyclosporine A-induced gingival hyperplasia.

BACKGROUND: Gingival overgrowth is one of the major adverse effects of the immunosuppressive drug cyclosporine A (CsA). Although several studies have attempted to determine the immunological mechanisms of gingival hyperplasia (GO) due to CsA therapy, the pathogenesis remains unclear. In this study, the distribution of the peripheral blood leukocytes in a group of renal transplant patients undergoing CsA therapy was analyzed and possible correlations of periodontal and pharmacological variables to lymphocyte subpopulations, natural killer cells, and monocytes investigated. METHODS: Thirty-six patients were classified into 2 groups of 18 each according to the degree of gingival overgrowth. The periodontal evaluation included plaque index (PI), gingival index (GI), gingival overgrowth (GO), calculus index (CI), and probing depth (PD). The pharmacological variables of current doses of the therapeutic serum levels of CsA were investigated. The peripheral blood leukocytes were studied by 2-color flow cytometric analysis using anti-human CD2, CD3, CD4, CD8, CD11b, CD11c, CD16, CD19, HLA-DR, and CD3+HLA-DR+ monoclonal antibodies. RESULTS: Statistical evaluation revealed that none of the pharmacological variables varied between the 2 groups. Responders (GO >30%) had significantly higher GI, PD, and GO scores compared to nonresponders (GO < or =30%). Of the immunological parameters studied, only CD2 was higher in the responder group. None of the clinical parameters correlated to the immunological values. CONCLUSIONS: The results of this study may be useful in explaining the underlying mechanisms of drug-induced gingival overgrowth. Several previously unsuspected cells and accessory activation mechanisms for T lymphocytes could play a role in the pathogenesis.

Determinants of gingival overgrowth severity in organ transplant patients. An examination of the rôle of HLA phenotype.

The role of HLA phenotype as a risk factor for drug-induced gingival overgrowth was investigated in a cohort of 172 transplant recipients. Clinically significant overgrowth warranting surgical correction was observed in 72 patients (42%). Using stepwise regression modelling, 6 clinical parameters were identified as significant risk factors for the severity of gingival overgrowth. These were; age, sex, creatinine plasma level, duration of therapy, papilla bleeding index and concomitant medication with a calcium channel blocking drug. 3 HLA alleles were also identified as risk factors when adjusted for other clinically significant risk factors (HLA -DR2, A24, B37). However, when the p-values for the HLA variables were corrected to compensate for the use of multiple significance testing, only HLA-B37 remained statistically significant at the 5% level. Organ transplant patients are at risk of developing gingival overgrowth, with approximately 25% medicated with cyclosporin alone requiring corrective gingival surgery. This figure more than doubles in patients concomitantly medicated with a calcium blocking drug. The data at present available would suggest that the severity of gingival overgrowth is also significantly associated with the HLA-B37 phenotype.

Cyclosporine A upregulates interleukin-6 gene expression in human gingiva: possible mechanism for gingival overgrowth.

Cyclosporine A (CsA) is a widely used immunosuppressant for transplant patients and is also used for the treatment of a wide variety of systemic diseases with immunologic components. A prominent side effect of CsA administration is gingival overgrowth. It has been postulated that CsA alters fibroblast activity through effects on various cytokines such as the interleukins, however, as yet, data concerning the molecular mechanisms involved in connective tissue proliferation are still preliminary in nature. The purpose of this study was to evaluate interleukin-6 (IL-6) gene expression in gingival tissues of patients receiving CsA therapy and exhibiting gingival overgrowth. Radioimmunoassay (RIA) demonstrated a significant difference in tissue levels of IL-6 as mean +/- SEM. IL-6 content in CsA-stimulated tissue was 184.3 +/- 30.2 ng/mg total protein versus 23.3 +/- 6.5 ng/mg total protein in control tissue. In situ hybridization indicated that overgrown gingival tissues from patients taking CsA had a significantly higher content of IL-6 mRNA when compared to control tissues. Expressing IL-6 mRNA levels as silver grains/cell, CsA-stimulated tissue had 166.9 +/- 12.0 grains of IL-6 mRNA/cell while control tissue had 12.8 +/- 3.0 grains of IL-6 mRNA/cell. These results demonstrate that CsA therapy results in increased levels of IL-6 protein and IL-6 mRNA in overgrown human gingival tissues. This is the first report of CsA-upregulated IL-6 gene expression in vivo, and may explain in part the molecular mechanisms responsible for CsA-induced gingival overgrowth.

Immunohistochemical study of 30 cases of cyclosporin A-induced gingival overgrowth.

Immunohistochemical techniques were used to study the presence of cyclosporin A (CsA) and leukocyte subsets in 30 gingival biopsies of renal transplant subjects with gingival overgrowth (GO). Statistical analysis revealed significant differences in the total number of inflammatory cells determined by monoclonal antibody CD45, the monocyte/macrophage (CD68) subset, the plasmatic cells (EMA), and the total of T-lymphocytes (CD3) (P < 0.001, Student t test) between the treated subjects and the healthy control group. Differences were found in the helper/inducer T lymphocytes CD4 (P < 0.001 Student t test) and cytotoxic/suppressor T lymphocyte (CD8) (P < 0.01, Student t test) subsets between both groups. The CD4/CD8 ratio was greater in the transplant subjects than in the control group (1.82 +/- 0.16 versus 1.35 +/- 0.05 respectively) (P < 0.05 Student t test). There was no significant difference in the populations CD16+, CD57+, and CD20+. The CD45+ CD4+, and CD68+ cells increased in number along with the degree of GO. The number of epithelial cells/mm2 which displayed a deposit of CsA increased in accordance with the degree of GO (P < 0.05, Kruskal-Wallis's test). Likewise, the intraepithelial deposit of CsA in the GO region was found to be related to the inflammatory infiltrate CD4+, CD8+, and CD68+ (r = 0.7432; r = 0.7346; r = 0.77005, respectively). Our findings suggest that the intraepithelial deposit of CsA and the inflammatory infiltrate play a predominantly pathogenic role and are both related to the degree of GO.

Immunoglobulin A levels in serum and saliva of patients treated with phenytoin.

A study was conducted to compare IgA levels in serum and saliva obtained from phenytoin-treated epileptic patients (PHT-TEPs) and a control group and to examine the correlation between IgA levels and clinical parameters. Eighteen epileptic patients treated with phenytoin and 18 periodontally healthy individuals with no systemic disease were included in the study. Clinical parameters were recorded, and samples of serum and saliva were obtained from each individual. IgA levels were determined by the radial immunodiffusion technique. Serum IgA levels were significantly lower in PHT-TEPs. No difference was found in salivary IgA levels between the PHT-TEP and control groups. Weak negative correlations were found between serum IgA level and gingival overgrowth index (GOI), and between salivary IgA level and GOI. None of the clinical parameters was significantly correlated with IgA level in the PHT-TEP group.

Wegener's granulomatosis. A distinct gingival lesion.

A hyperplastic (strawberry) gingivitis is a feature of Wegener's granulomatosis. A further case is described in which the only manifestations to date have been the gingival lesion. The diagnostic value of the ANCA test is discussed for patients who present with an unusual hyperplastic gingivitis.

Changes in the number and distribution of Langerhans cells in the hydantoin hyperplasic gingiva as compared with the clinically normal one.

A study was made of the number of Langerhan's cells (LCs) per mm2 of section which express the antigens T6 and/or HLA-DR in seriated gingival sections of diphenylhydantoine-induced hyperplasia (HG) and clinically normal gingivae (NG). NG showed histological correlation with its macroscopic appearance. In HG the classical histopathological findings were verified, as well as the epithelial maturation irregularities, conductive to the development of epithelial gaps. In the immunostained samples, LCs appear amply distributed in the epithelium in greater numbers than in NG and more branched except in the immature areas, where they mostly express HLA-DR. In HG keratinocytes, HLA-DR+ are observed in the basal layer, except in developing epithelial gap zones. The Wilcoxon test for the NG-T6/NG-DR and HG-T6/HG-DR was not significant; but the Mann Whitney test for NG-T6/HG-T6 and NG-DR/HG-DR was significant to p less than 0.05. It is understood that the increase in LC numbers in HG is a manifestation of their active participation in local immune reactions. The presence of DR+/T6- LCs in the less keratinized areas seems to indicate the relationship of LCs with epithelial proliferation and/or differentiation.