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
Quintessentials of Dental Practice – 43/44
Periodontology – 5/6
British Library Cataloguing-in Publication Data
Chapple, Iain L. (Iain Leslie)
Periodontal medecine; a window on the body. - (Quintessentials of dental practice; 43/44. Periodontology; 5 )
1. Periodontics
I. Title II. Hamburger, John
617.6′32
ISBN: 1850973075
Copyright © 2006 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN 1-85097-307-5
This text is dedicated to my second daughter, Natasha Sophie Chapple, born 17th August 2004
Iain L C Chapple
‘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
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.
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:
Recognise the broader scope of clinical periodontology and the importance of medical management in addition to the traditional surgical focus of the discipline.
Recognise the importance of close liaison with colleagues in oral medicine and pathology.
Take a systematic approach to medical history-taking that extends routine questions into certain relevant areas of enquiry that involve the body in general.
Examine oral lesions systematically and use the findings of specific features of the lesion and associated signs and symptoms, to start formulating differential diagnoses.
Identify non-periodontal sites that may be affected by the presenting condition and what features to note at those sites.
Return to the verbal enquiry and identify relevant follow-up questions that may further clarify the findings of the clinical examination – re-focus the history.
Understand when additional clinical investigations are indicated, which are appropriate and how to perform them.
Be able to interpret the findings of routine clinical investigations (e.g. blood test results) and develop a sense of the potential implications for the patient.
Advise the patient about the aetiology of non-plaque-induced periodontal lesions.
Identify the need to refer for advice or treatment by dental or medical specialists.
Understand how the routine treatment he or she provides may impact, either positively or negatively, upon the condition.
Identify a range of therapeutic options for the patient and understand the need for regular review and re-appraisal of the condition as appropriate.
Iain L C Chapple
John Hamburger
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.
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.
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.
A variety of clinical, procedural and pathological terms and descriptors are used throughout this chapter, and Table 1-1 defines these by category.