Hematologic Condition Associated with Periodontal Disease in Children

Dian Puspita Sari

Introduction

• Soft tissue lesions of the oral cavity are common in children

• Distinguishing between findings that are normal and those that are indicative of gingivitis, periodontal disease, local or systemic infection, and potentially lifethreatening systemic conditions is important

• The loss of periodontal attachment in children, manifest by tooth mobility or premature loss, can be a symptom of neoplasia, immunodeficiency, or metabolic defects

• The early detection and treatment of these conditions can be life-saving.

HISTIOCYTOSIS

• A rare disorder• Histiocytic infiltration of the bones, skin, liver,

or other organs• Langerhans cell histiocytosis (LCH) presents

with single or multiple-site involvement• The skin, oral mucosa, bone, and lymph nodes

are typical locations for single-site involvement

• Multisite involvement occurs in the liver, spleen, lungs, bone marrow, and gastrointestinal and central nervous systems

• Between 10 and 20 percent of patients present with infiltration of the oral cavity, usually the posterior mandible

• The typical dental presentation of LCH is eruption of the primary molars at or soon after birth

• Additional oral manifestations include pain; ulceration; enlargement, inflammation, or recession of the gingiva; and mobility of teeth because of expansion of the alveolar bone

• Dental radiographs may show discreet, destructive bone lesions that make the teeth appear to be "floating on air"

• Periosteal new bone formation and slight root resorption also may be present

• Cases may present as aggressive periodontitis lesions that do not respond to routine periodontal therapy, despite the presence of periodontal flora typically associated with periodontitis

• When periodontal involvement is suspected to be a manifestation of LCH, biopsy of the gingiva or periodontal tissues is needed

• The diagnostic evaluation for children in whom a diagnosis of LCH is being considered is extensive and should be performed in consultation with a pediatric hematologist

LEUKEMIA

• Leukemia, particularly the monocytic type, can cause gingival enlargement because of infiltration of the gingival tissues

• Leukemic gingival enlargement is typically painless, shiny, red, and edematous

• Bleeding is common and can make it difficult to maintain oral hygiene

• Necrotic ulceration and involvement of the underlying bone also can occur

• The inflammation that results may act as a stimulus for further gingival swelling

• Additional symptoms include fever, malaise, easy bruising or bleeding, and bone or joint pain.

• The diagnosis of leukemia should be considered in patients who have hemorrhagic gingival edema and anemia, thrombocytopenia, or abnormal leukocyte and differential counts on complete blood count

• The treatment of leukemia (both lymphocytic and myelogenous leukemia) can have oral complications, including:- Mucositis- Oral infection with candida, herpes simplex virus, or other opportunistic organisms- Gingival inflammation

- Spontaneous gingival bleeding (because of thrombocytopenia)- Gingival squamous cell carcinoma (as a complication of graft versus host disease in bone marrow transplant recipients)

• The chemotherapy-induced oral complications in patients with leukemia are more prevalent immediately after administration of chemotherapy

• The oral complications of chemotherapy can be diminished by aggressive preventive care

• Comprehensive oral examination before the initiation of cancer therapy

• The oral cavity is a reservoir for many microorganisms with the potential to cause systemic infection in the immunocompromised host

• In addition, dental plaque causes gingivitis and gingival bleeding

• Careful brushing with a soft toothbrush should be continued throughout therapy• Although it has been recommended that toothbrushing

be suspended or replaced by cleaning with sponge-tipped brushes ("toothettes") when platelet counts are low, these approaches are not adequate for plaque removal, and available evidence suggests problems are more likely to arise when oral hygiene is poor

NEUTROPENIA

• Neutropenia is a hematologic disorder characterized by reduced numbers of circulating neutrophils.

• It is diagnosed when the absolute neutrophil count (ANC) is less than 1500/microL

• Neutrophils are an important component of the host response to pathogenic dental plaque in the gingival sulcus, and patients with neutropenia are at risk for severe gingivitis and pronounced alveolar bone loss.

• Periodontal disease occurs in the following types of childhood neutropenia:– Congenital neutropenia– Autoimmune neutropenia– Cyclic neutropenia

Congenital

• Congenital neutropenia occurs in several conditions where there is a marked decrease in (or lack of) circulating neutrophils from the time of birth

• an estimated frequency of two cases per million population

• Children with congenital neutropenia are susceptible to recurrent infection, often due to staphylococci and streptococci

• Oral lesions, otitis media, respiratory infection, cellulitis, and skin abscesses are the most common.

• These infections heal slowly and may be fatal

• Oral manifestations of congenital neutropenia include ulcers, severe gingivitis, alveolar bone loss, gingival recession, tooth mobility, and premature tooth exfoliation.

• The treatment of congenital neutropenia usually involves the administration of granulocyte colony-stimulating factor (G-CSF)

Autoimmune

• Autoimmune neutropenia (AIN) is caused by granulocyte-specific antibodies.

• AIN has been associated with a variety of underlying diseases, including viral infection, collagen vascular disease, primary abnormalities of B or T lymphocytes or natural killer (NK) cells, idiopathic thrombocytopenic purpura (ITP), and autoimmune hemolytic anemia

• Benign neutropenia of infancy and childhood typically occurs in infants between the ages of 5 to 15 months, but the range extends from one month to adulthood

• Severe gingivitis and periodontal disease may result without preventive measures.

Cyclic neutropenia

• Cyclic neutropenia is characterized by regular oscillations in the numbers of circulating neutrophils, monocytes, eosinophils, lymphocytes, and reticulocytes

• The cycles typically occur at 21-day intervals, but the intervals can range from 15 to 35 days

• Cyclic neutropenia can have onset in childhood or adulthood

• Childhood onset is more common and appears to be a genetic condition with autosomal dominant inheritance

Dental management

• Early dental referral and highly motivated parents are the keys to successful dental management of children with neutropenia

• Neutropenia predisposes the child to hemorrhagic gingivitis and periodontal disease, but the progression of bone loss is because of the host response to pathogenic subgingival plaque

• Thus, scrupulous oral hygiene, antimicrobial rinses, frequent professional tooth cleaning, and targeted antibiotic therapy can delay or halt periodontal bone loss.

• Antibiotic therapy for neutropenic children with periodontal disease is determined by microbial cultures of the gingival sulcus

• The organisms most commonly cultured in children with periodontal disease include Prevotella intermedia, Actinobacillus actinomycetemcomitans, Eikenella corrodens, and Capnocytophaga sputigena

• Eradication and control of these pathogens is essential in the treatment of periodontal disease.

• Periodic surveillance cultures will help to determine the need for repetition of antibiotic therapy.

• The treatment of neutropenic children with periodontal disease is usually more successful in children with localized than with generalized periodontal disease; generalized periodontal disease may be refractory to antibiotic therapy without correction of the underlying neutrophil defect.

• Treatment of the underlying disorder with administration of G-CSF, and normalization of neutrophil counts, may not be sufficient to maintain oral health because of possible associated functional neutrophil defects; this underscores the significance of professional dental care for such patients

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