The introduction of highly active antiretroviral therapy (HAART) has decreased the incidence and prevalence of several oral manifestations such as oral candidiasis, hairy leukoplakia, and Kaposi's sarcoma in HIV-infected patients. Regarding periodontal disease the findings are not clear. This disease represents a group of chronic oral diseases characterized by infection and inflammation of the periodontal tissues. These tissues surround the teeth and provide periodontal protection (the gingival tissue) and periodontal support (periodontal ligament, root cementum, alveolar bone). Clinical, immunological, and microbiological aspects of these diseases, such as linear gingival erythema (LGE), necrotizing periodontal diseases (NPD) (necrotizing ulcerative gingivitis [NUG], necrotizing ulcerative periodontitis [NUP] and necrotizing stomatitis), and chronic periodontitis, have been widely studied in HIV-infected individuals, but without providing conclusive results. The purpose of this review was to contribute to a better overall understanding of the probable impact of HIV-infection on the characteristics of periodontal infections.

Necrotizing ulcerative gingivitis (NUG) can be a painful periodontal disease that can lead to loss of the interdental papillae. It is usually accompanied by systemic signs of fever, malaise and cervical and submandibular lymphadenopathy. It is caused by the profileration of anaerobic bacteria and has been linked to smoking and immunosuppression. This case series reports the occurrence of NUG in orthodontic patients and demonstrates that there is a varying scale of severity of the condition. Orthodontists should be aware of the clinical signs of NUG to ensure early detection and treatment of their patients in order to prevent irreversible loss of the interdental papillae and reduce the likelihood of recurrence. A treatment regime is suggested.

The general dental practitioner and paediatric dentist are in a unique position to identify and distinguish between a seemingly innocuous condition that may be a normal physiological aberration or an early sign of severe destructive periodontal disease. Although severe destructive periodontal conditions are uncommon in children, it is essential that children receive a periodontal screening as part of their regular dental examination. Early diagnosis ensures a high likelihood of a successful therapeutic outcome, primarily by reduction of aetiologic factors, remedial therapy and development of an effective maintenance protocol. This prevents the recurrence and progression of disease and reduces the incidence of tooth loss. In the first article, we discussed the classification, plaque-induced and non plaque-induced gingival diseases, localized and generalized forms of chronic as well as aggressive periodontitis. In this second article, we discuss periodontitis as a manifestation of systemic disease, necrotizing periodontal diseases, periodontal screening and basic periodontal examination, and treatment of periodontal diseases in children and adolescents.

CLINICAL RELEVANCE:

Incorporation of periodontal screening in regular dental examination by dentists can help in early diagnosis and treatment of periodontal diseases. This could prevent further progression of disease and reduce the frequency of tooth loss.

Contrasting forms of periodontal disease can affect children and adolescents with varying prevalence, severity and extent, leading to a diverse prognosis in these age groups. For an early diagnosis and treatment of periodontal conditions in young patients, it is essential for the dental practitioner to be able to identify and classify the disease correctly at the earliest opportunity, applying basic principles along with understanding of aetiology and risk factors. The first part of this article discusses the classification, plaque-induced and non-plaque-induced gingival diseases, localized and generalized forms of chronic, as well as aggressive, periodontitis.

CLINICAL RELEVANCE:

Knowledge of different forms of periodontal diseases affecting children and adolescents may help to distinguish between different forms of diseases and have value in screening and early diagnosis of the disease.

 To assess the prevalences and patterns of oral lesions occurring in human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). A cross-sectional study was conducted among 200 people living with HIV/AIDS (PlwHA) who regularly attended a counselling and treatment centre in Dar es Salaam, Tanzania. A questionnaire-guided interview and clinical oral assessment were used. Strict confidentiality and adherence to ethical codes were observed.The mean age of participants was 38.91 years (standard deviation: 10.424; mode: 35 years; median: 37.0 years; range: 15-76 years). Most participants (58.5%) were aware of predispositions towards the occurrence of oral lesions such as oral candidiasis (60.0%) in HIV/AIDS and most of these (72.0%) were aware that the lesions are treatable. Some participants reported occurrences of oral thrush (22.5%) and lip ulcerations (28.5%), although only 47.0% of these had sought medical advice. Examinations revealed that 29.0% of participants had at least one oral lesion associated with HIV/AIDS. Prevalences of the various types of lesion were: 11.5% for herpes simplex; 7.5% for oral candidiasis; 4.0% for oral hairy leukoplakia; 3.5% for Kaposi's sarcoma; 1.5% for dry mouth; 0.5% for angular cheilitis, and 0.5% for acute necrotising ulcerative gingivitis. Herpes simplex and Kaposi's sarcoma were more frequently observed in males (56.5% and 71.4%, respectively), whereas oral candidiasis and dry mouth were observed more often in females (86.7% and 66.7%, respectively) (χ(2) = 16.692, P = 0.016).  Prevalences of oral lesions associated with HIV/AIDS in PlwHA and using antiretroviral therapy are persistent, of moderate intensity and vary according to individual immune status. These patients' level of awareness about oral lesions was satisfactory, but formal medicodental lines of management were not prioritised. Contemporary protocol for the management of oral lesions should be understood and disseminated to the general public by dentists.

The clinical manifestation of necrotizing ulcerative gingivitis (NUG) is distinct from that of common gingivitis in that it is characterized by local necrosis of the gingival tissues, rapid onset, pain and extensive bleeding. The phylum Synergistetes is a novel bacterial phylum consisting of Gram-negative anaerobes, with evidence of presence in biofilms associated with periodontal and endodontic infections. To date, the involvement of members of this phylum in NUG has not been investigated. This study aimed to evaluate the presence and levels of known human oral Synergistetes bacterial clusters in dental plaque from patients with NUG and compare them with those found in gingivitis. Marginal dental plaque samples from 21 NUG and 21 gingivitis patients were analysed quantitatively by fluorescent in situ hybridization and microscopy for members of two oral Synergistetes clusters (A and B) and for Jonquetella anthropi. Synergistetes cluster A bacteria were detected in all samples but at higher levels (9.4-fold) and proportions (2.5-fold) in NUG patients than in gingivitis patients. However, with regard to Synergistetes cluster B bacteria, there were no differences between NUG and gingivitis patients. J. anthropi was detected in only half of the samples and at lower levels than the other taxa. In conclusion, these data demonstrate that Synergistetes cluster A bacteria, but not cluster B bacteria or J. anthropi, are more strongly associated with NUG than with gingivitis.

To describe the clinical signs, major laboratory findings, diagnostic procedures and outcome in dogs with erythema multiforme or epitheliotropic T-cell lymphoma of the oral cavity.Retrospective analysis identified 14 client-owned dogs with erythema multiforme or epitheliotropic T-cell lymphoma of the oral cavity. Histological changes were combined with immunohistochemistry and clonality testing data in selected cases, and a clinical follow-up was acquired.Ulcerative stomatitis with no significant or only minor abnormalities on haematology and serum biochemistry panels was common. Histological features were diagnostic in seven cases. The use of immunohistochemistry distinguished the two diseases in an additional three cases. In four cases, the diagnosis remained questionable, and clonality testing for T-cell receptor gamma gene rearrangement helped confirm erythema multiforme in one case. Clinical follow-up revealed erythema multiforme in two and epitheliotropic T-cell lymphoma in one of the remaining questionable cases.Erythema multiforme and epitheliotropic T-cell lymphoma may affect, but are rarely limited to the oral cavity of dogs, and they usually present as stomatitis. Histological features alone are not always diagnostic. Immunohistochemistry and clonality testing may assist in the differentiation between the two, but in ambiguous cases, repeated biopsy and clinical follow-up are essential.

Necrotizing ulcerative gingivitis is the most common clinical syndrome preceding noma. It is found in developing countries and in malnourished children and especially in deprived groups such as children at Koranic boarding schools. The objective of this study was to determine the prevalence of necrotizing ulcerative gingivitis and factors associated with its occurrence in a boarding school population.This was a cross-sectional study of children in Koranic boarding schools in the city of Touba, Senegal. A multistage sampling strategy was used and 8 out of 17 schools were selected. The variables collected were gender, age, oral hygiene habits, duration of residence, presence of ulcerative gingivitis and plaque, and gingival bleeding index. A logistic regression analysis with R software using the manual procedure down was used to identify factors associated with the dependent variables.There were 501 participants and boys made up 92% of the study group. The mean age was 9.3 (sd 4.0) years. The mean of duration residence was 3.4 (sd 1.5) years. The prevalence of necrotizing ulcerative gingivitis was 37% and 81% of children did not use a toothbrush or a chewing-stick. The length of residence, school size, hygiene habits and plaque and bleeding indices were significantly associated with necrotizing gingivitis after adjustment for other variables.It is necessary to develop oral hygiene programs, to establish policies to manage the oral health of children and to improve health and nutrition at Koranic boarding-schools.

There is emerging evidence that oral mucositis/stomatitis is a common adverse effect of sunitininb antiangiogenic therapy in patients with metastatic renal cell carcinoma (mRCC). In addition, a case of sunitinib-related jaw osteonecrosis was recently described. We report on 2 patients with mRCC treated with sunitinib. The first patient, a 19-year-old woman, treated with cisplatin and sunitinib, presented with oral pain, malodor, spontaneous and continuous gingival bleeding, and painful necrotic ulcerations clinically resembling necrotizing ulcerative gingivitis (NUG). Suntinib-related stomatitis and bleeding were considered cumulative to NUG symptoms. The second patient, a 64-year-old woman, treated with sunitinib only, complained of mandibular pain. Sunitinib-related jaw osteonecrosis was diagnosed. Gingival bleeding and soft tissue necrosis, as well as jaw osteonecrosis may develop as adverse events of sunitinib use. Antiangiogenic therapies are increasingly used in the treatment of cancers. The presented cases are aimed to alert health care professionals on adverse oral events.