Table of Contents

Title Page

Copyright Page

Foreword

Preface

Acknowledgements

Chapter 1 Establishing a Differential Diagnosis for Periodontal Manifestations of Systemic Diseases

Aim

Outcome

Terminology

Guiding Principles Behind Establishing a Diagnosis

The Diagnostic Pathway

The Complaint

The History of the Complaint

The Medical History

Social History

Family History

Sexual History

The extra-oral examination

The intra-oral examination

The Lesion

Location

Lesion size

Lesion shape

Attachment

Colour

Surface

Base

Consistency

Associated pathology

Localisation

The ‘surgical sieve’

Special Investigations

The Differential Diagnosis

The Working Diagnosis

Definitive Diagnosis

Key Points

Further Reading

Chapter 2 The Role of Clinical Investigations

Aim

Outcome

Introduction

General Considerations

Indications for Investigation

Interpretation of Investigations

Specificity and Sensitivity of Tests

Biopsy

Microbiology

Identification of Bacteria

Identification of Fungal Organisms

Identification of Viruses

Blood and Serological Tests

Radiology and Imaging

Further Reading

Chapter 3 Gingival Colour Changes – Localised

Aim

Outcome

Red Lesions

Kaposi’s Sarcoma

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Vascular Lesions

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Telangiectasia

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Erythroplakia (Erythroplasia)

Clinical features (Reichart 2005)

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

White Lesions

Trauma

Leukoplakia

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Leukokeratosis Mucosae Oris (White Sponge Naevus of Cannon)

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Squamous Cell Carcinoma

Lichen Planus

Candidosis

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Pigmented Lesions

Amalgam Tattoo

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Melanotic Macule (Ephelis)

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Naevi

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Malignant Melanoma

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Further Reading

Chapter 4 Gingival Colour Changes – Generalised

Aim

Outcome

Red Lesions

Desquamative Gingivitis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Primary Herpetic Gingivostomatitis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Streptococcal Gingivostomatitis

Orofacial Granulomatosis

Plasma Cell Gingivitis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Other hypersensitivity reactions of the gingivae

Sturge Weber Syndrome

Clinical features

Differential diagnosis

Clinical investigation

Management options

White Lesions

Lichen Planus (see also Chapter 8)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Other Generalised White Lesions

Pigmented Lesions

Extrinsic Staining

Racial Pigmentation

Clinical Features

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Drug-Induced and Heavy Metal Pigmentation

Addison’s Disease

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Further Reading

Chapter 5 Gingival Enlargements – Localised

Aim

Outcome

The Epulides

The Fibrous Epulis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

The Vascular Epulis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Multiple/Disseminated Pyogenic Granulomata

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

The Giant Cell Epulis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Congenital Epulis

Viral ‘Wart-like’ Lesions

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Neurofibroma

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Dental Appliance-Induced Hyperplasia

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Lateral Periodontal Abscess

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Gingival Abscess

Stitch Abscess

Localised Trauma (see also Chapter 7)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival Sites

Differential diagnosis

Clinical investigation

Management options

Histiocytosis X

Haemangioma/AV Malformations

Kaposi’s Sarcoma (KS)

Squamous Cell Carcinoma (SCC)

Metastatic Tumours

Lymphoma

Reactive Osteoma

Lesions Associated with PTEN-Hamartoma Tumour Syndromes

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Footnote

Further Reading

Chapter 6 Gingival Enlargements – Generalised

Aim

Outcome

Terminology

Fibrous Swellings

Hereditary Gingival Fibromatosis (HGF)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Drug-induced Gingival Overgrowth (DIGO)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Dental Appliance-induced Enlargement

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Delayed Gingival Retreat

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Oedematous Enlargements

Inflammatory Gingival Enlargement

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Angioedema (C1-Esterase Inhibitor Deficiency/Dysfunction)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Granulomatous Enlargements

Orofacial Granulomatosis (OFG)

Clinical appearance

Aetiology

Involvement of non-gingival sites

Clinical investigation

Management options

Sarcoidosis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Crohn’s Disease

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Exophytic Swellings

Leukaemia

Pyostomatitis Vegetans

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Wegener’s Granulomatosis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Bony Swellings

Further Reading

Chapter 7 Localised Gingival Ulceration

Aim

Outcome

Definition

Traumatic Ulceration

Clinical appearance

Clinical symptoms

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Bacterial Infections

Necrotising Ulcerative Gingivitis (NUG)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Tuberculosis

Syphilis

Viral Infections

Hand, Foot and Mouth Disease

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Varicella Zoster

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Cytomegalovirus

Deep Mycoses

Recurrent Aphthous Stomatitis

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Neoplastic Ulceration

Oral Squamous Cell Carcinoma

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Metastatic Disease

Further Reading

Chapter 8 Generalised Gingival Ulceration

Aim

Outcome

Vesicles and Bullae

Mucocutaneous Disease

Pemphigoid

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Pemphigus

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Lichen Planus

Haematological Disease

The Leukaemias

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

The Lymphomas

Clinical features

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Other Haematological Conditions

Further Reading

Chapter 9 Localised Gingival Recession

Aim

Outcome

Classification of Localised Recession Defects

Developmental Conditions

Dehiscence and Fenestration

Anatomical Tooth Position

Traumatic Defects

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Conscious Self-Mutilation (see also Chapter 7)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Subconscious Self-Mutilation

Inflammatory/Infective Conditions

Defects Associated with Underlying Systemic Disease

Linear Morphoea (Localised Scleroderma)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Histiocytosis-X

Eosinophilic Granuloma

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Necrotising Ulcerative Periodontitis (NUP) – see also Chapter 7

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Necrotising Ulcerative Stomatitis (NUS)

Drug-Induced Recession

References

Further Reading

Chapter 10 Generalised Gingival Recession

Aim

Outcome

Background

Aetiology of Gingival Recession

Systemic Disease with Generalised Recession as Manifestation Due to Destructive Periodontitis

Down Syndrome

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Papillon-Lefèvre Syndrome

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Hypophosphatasia

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Chronic Granulomatous Disease (CGD)

Chèdiak-Higashi Syndrome

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Ehlers-Danlos Syndrome

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Leukocyte Adhesion Deficiency (LAD)

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management options

Acatalasia

Infantile Genetic Agranulocytosis

Cohen Syndrome

Glycogen Storage Disease

DiGeorge Syndrome

Wiskott-Aldrich Syndrome

Histiocytosis X

Systemic Disease with Generalised Recession as Manifestation Independent of Periodontitis

Progressive Systemic Sclerosis (Scleroderma)

Clinical appearance

Clinical symptoms

Involvement of non-gingival sites

Differential diagnosis

Aetiology

Clinical investigation

Management options

Drug-Induced Gingival Recession

Cytotoxic chemotherapy drugs

Recreational drugs

Cytotoxic antimicrobials

Further Reading

Chapter 11 Miscellaneous Lesions

Aim

Outcome

Introduction

Uncontrolled/Unexplained Gingival Bleeding

Myelodysplasia

Clotting Factor Deficiencies

Idiopathic Thrombocytopenic Purpura (ITP)

Platelet Pool Storage Disease

Acute Leukaemia

Chronic Leukaemia

Thrombocytopaenia

Aplastic Anaemia

Thrombasthenia

Patients on Warfarin

Para-Gingival Swellings

Osteomas

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Gardner’s Syndrome

Mandibular Tori

Annular Lesions

Erythema Migrans

Clinical appearance

Clinical symptoms

Aetiology

Involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Erythema Multiforme

Radiological Conditions or Lesions Associated with the Roots

1. Root Resorption

2. Inter- and Peri-radicular Radiolucencies

Systemic Sclerosis (scleroderma)

Periapical Cemental Dysplasia

Lateral Periodontal Cyst (Developmental)

Gingival Cyst

Incisive (Naso-palatine) Canal Cyst

Patent Nasopalatine Ducts

Aneurysmal Bone Cyst

Squamous Odontogenic Tumour

Ameloblastoma

Ameloblastic Fibroma

Histiocytosis-X

3. Inter- and Peri-radicular Radiopacities

Periapical Osteosclerosis

Condensing Osteitis

Hypercementosis

Cementomas

Cementicles

Cementoblastoma

Ossifying Fibroma

4. Radiolucent Lesions – Well Circumscribed Radiolucencies

Odontogenic Keratocyst

Radiological appearance

Clinical symptoms

Aetiology and involvement of non-gingival sites

Differential diagnosis

Clinical investigation

Management

Inflammatory Cyst

Neural Sheath Tumours

Multi-locular Radiolucencies

Odontogenic Keratocyst and Gorlin-Goltz Syndrome

Botyroid Cyst

Ameloblastoma

Odontogenic Myxoma

Giant Cell Tumour of Bone

Aneurysmal Bone Cyst

Arterio-venous Malformations (AVMs)

Sturge Weber Syndrome

Cherubism

Ossifying Fibroma

Poorly Defined Radiolucent Lesions

Osteomyelitis

Osteoradionecrosis

Intraosseous Carcinoma

Gingival Carcinoma

Ameloblastic Carcinoma

Radiolucent Lesions as Presentations of Systemic Disease

Histiocytosis-X

Multiple Myeloma

Non-Hodgkins Lymphoma (see Chapter 8)

Leukaemia

Generalised Radiolucencies

Hypophosphatasia

Hyperparathyroidism

Sickle Cell Anaemia

5. Radiolucent Lesions with Radiopacities

Periapical Cemental Dysplasia

Calcifying Odontogenic Cyst

Calcifying Epithelial Odontogenic Tumour (CEOT)

Adenomatoid Odontogenic Tumour

Odontomes

6. Radiopaque Lesions – Focal Radiopacities

Osteoma

Osteosarcoma

Generalised Radiopacities

Gardner’s Syndrome

Sclerosing Osteomyelitis

Fibrous Dysplasia

Albright’s Syndrome

Paget’s Disease of Bone

Osteopetrosis

Hyperostosis

Further Reading

Cover

Quintessentials of Dental Practice – 43/44
Periodontology – 5/6

Periodontal Medicine — A Window on the Body

Authors:

Iain L C Chapple

John Hamburger

Editors:

Nairn H F Wilson

Iain L C Chapple

cover
Quintessence Publishing Co. Ltd.

London, Berlin, Chicago, Paris, Milan, Barcelona, Istanbul, São Paulo, Tokyo, New Delhi, Moscow, Prague, Warsaw

This text is dedicated to my second daughter, Natasha Sophie Chapple, born 17th August 2004

Iain L C Chapple

Foreword

‘Periodontal Medicine’ is an intriguing title for the latest addition to the rapidly expanding, widely acclaimed Quintessentials in Dental Practice series. Building on differential diagnoses for periodontal manifestations of systemic diseases and the role of relevant special investigations, this compact text of immediate practical relevance provides a unique consideration of gingival colour changes, enlargements, ulcerations and recession, not to forget a concluding miscellany of other gingival lesions.

This book is novel and therefore another pleasing first for the timely Quintessentials in Dental Practice series. In common with all the other volumes in the Series, ‘Periodontal Medicine’ can be read and easily digested over a matter of a few hours. This time will be well spent, with a lasting legacy of enhanced insight and understanding of conditions of the periodontium. Once read, this book should not be put on a shelf to gather dust. In contrast, it should become a well-used aide-memoire to keep to hand in everyday clinical practice. Excellent clinical pictures generously illustrate the carefully crafted text, making this attractive volume another jewel in the Quintessentials crown. The authors are to be congratulated on the special qualities of this book.

Nairn Wilson
Editor-in-Chief

Preface

Periodontal Medicine is a term used for different purposes in different parts of the world. In North America, it relates to the study of the dynamic relationship between periodontal diseases and systemic conditions, such as cardiovascular and cerebrovascular disease, pre-term labour and low-birth-weight babies, diabetes mellitus, osteoporosis and disorders of the respiratory tract. Such studies investigate the peripheral impacts of periodontal inflammation on systemic health and also the influence of systemic diseases on the progression of chronic periodontitis, such as type 2 diabetes mellitus, where evidence exists for a bi-directional relationship with periodontitis. However, in the UK and parts of Europe ‘periodontal medicine’ is a term used to describe the periodontal (and gingival) manifestations of medical conditions. This includes their investigation, diagnosis and therapeutic management and how management of the oral condition integrates with the patient’s medical management as part of a holistic approach within defined care pathways. My own periodontal practice (ILC) relies heavily upon close working relationships with medical and surgical colleagues and joint patient management with bi-directional feedback, discussion and decision-making. In order of frequency, joint care is provided with Oral Medicine, Dermatology, Genito-Urinary Medicine, Cardiology, Clinical Immunology, Paediatric Medicine, Nephrology, Haematology, Gastroenterology, Geriatric Medicine, Ear/Nose/Throat and Maxillofacial Surgery.

This text therefore aims to provide the reader with an illustrated approach to managing the oral consequences of systemic diseases that present within and around the periodontal tissues. We have used the clinical appearance of the lesions as the starting point for discussion so that practitioners can follow a logical step-wise approach to differential and definitive diagnosis and subsequent management, either themselves, or through referral for secondary care. Some lesions are extremely common and others rare, and therefore each chapter tabulates the lesions that fall within its boundaries at the beginning of the chapter, but only discusses in detail the more common conditions. The final chapter discusses the less common non-plaque-induced conditions outwith their natural visual grouping.

Outcomes of Reading This Text

This text will not deal with plaque-induced periodontal conditions, but will focus on non-plaque-induced lesions and their management. It is hoped that having read this text the reader will be able to:

Iain L C Chapple
John Hamburger

Acknowledgements

Iain Chapple wishes to thank his wife Liz and daughters Jessica and Natasha for their unconditional support and forbearance during the preparation of this book.

John Hamburger would like to thank his wife Ros and daughter Rachel for all their support and understanding during the preparation of this book.

The authors would also like to thank their colleagues within Periodontology and Oral Medicine. In particular Mrs Lorraine Williams and her staff who have approached the changes of the last 10-years so positively with enthusiasm, vigour and open minds. In addition, we are most grateful to our colleagues across a diverse range of medical specialties who offered their valued advice generously during the multidisciplinary management of our more complex patients.

We are indebted to Ms Jan Poller for her skillful proof reading of the manuscript and to Mr Michael Sharland and Ms Marina Tipton (Multi-media Services, Birmingham Dental School), Mr Paul England and Mr Jason Pike and colleagues (Clinical Illustration, Birmingham Dental Hospital). Thanks are also due to Mrs A Richards for permission to use Fig 2-2; Drs Barboza and Cunha and the British Dental Journal for the use of Fig 5-13; to Mr Mo Sandhar for the use of Fig 11-11; Mr D Glenwright for Figs 1-6, 1-10, 5-1, 5-8, 5-9, 5-15, 5-18, 10-10 and 10-21; Dr M Saxby for Figs 6-13a and b, Mr A Roberts for Figs 10-18 and 10-19; Mr M Milward for Fig 10-22; Mr J Rout for Figs 11-5a-e, 11-11, 11-12, 11-14, 11-15, 11-16, 11-18, 11-19, 11-24, 11-27a and b, 11-28, 11-29, 11-30, 11-31 and 11-32; Professor P Heasman for Figs 11-25a and b and Professor R Seymour for use of Fig 6-22.

Chapter 1

Establishing a Differential Diagnosis for Periodontal Manifestations of Systemic Diseases

Aim

This chapter aims to provide the reader with a step-by-step guide to history-taking, examination and further investigation of non-plaque-induced lesions that arise withithe periodontal tissues, including the free and/or attached gingiva and associated oral mucosa, to help establish a differential diagnosis.

Outcome

Having read this chapter the reader should appreciate the need for a forensic and systematic approach to establish differential diagnoses for oral and medical conditions that manifest within the periodontal and associated tissues.

Terminology

A variety of clinical, procedural and pathological terms and descriptors are used throughout this chapter, and Table 1-1 defines these by category.