ANUG (Acute Necrotizing Ulcerative Gingivitis)

• Signs: Punched – out crater depressions of interdental papilla
• Symptoms: Metallic foul taste, pasty saliva
• Treatment: 3 visits (2nd visit: 1 – 2 days after 1st; 3rd visit: 5 days after 2nd)

NUG/NUP

• No pocket formation (destroys junctional epithelium)

Primary Herpetic Gingivostomatitis

• Cellular change: Ballooning degeneration → Tzanck cells
• Treatment:
  • Within 3 days: Acyclovir 15 mg/kg × 5 times × 7 days
  • After 3 days: Supportive care with NSAIDs

Leukemic Gingivitis

• Most common in acute monocytic leukemia

Lead Intoxication

• Steel gray linear pigmentation (Burton's line)

Periodontal Diseases Associated with Neutrophil Disorders

1. Acute Necrotizing Ulcerative Gingivitis (ANUG)

   • Description: A severe form of gingivitis characterized by necrosis of the interdental papillae, pain, and foul odor.
   • Association: Neutrophil dysfunction can exacerbate the severity of ANUG, leading to rapid tissue destruction.

2. Localized Juvenile Periodontitis

   • Description: A form of periodontitis that typically affects adolescents and is characterized by localized bone loss around the permanent teeth.
   • Association: Impaired neutrophil function contributes to the pathogenesis of this condition.

3. Prepubertal Periodontitis

   • Description: A rare form of periodontitis that occurs in children before puberty, leading to rapid attachment loss and bone destruction.
   • Association: Neutrophil disorders can play a significant role in the development and progression of this disease.

4. Rapidly Progressive Periodontitis

   • Description: A form of periodontitis characterized by rapid attachment loss and bone destruction, often occurring in young adults.
   • Association: Neutrophil dysfunction may contribute to the aggressive nature of this disease.

5. Refractory Periodontitis

   • Description: A form of periodontitis that does not respond to conventional treatment and continues to progress despite therapy.
   • Association: Neutrophil disorders may be implicated in the persistent nature of this condition.

• Bence Jones Proteins: Mostly gamma chains
• Commonest lytic lesion site: Vertebral column
• Russell bodies: Found in plasma cells
• Bone scan not useful
• No ALP elevation
• High ESR: Often seen
• Prognostic marker: Beta-2 microglobulin

• Plaque & Bacteria:
  • Plaque: Mainly extracellular polysaccharides.
  • Pellicle: Thin film post-cleaning.
  • Bacteria in 1g plaque: 2 × 10¹¹.
  • Early plaque: Gram-positive.
  • Saliva: Streptococci dominate.
  • First oral colonizer: S. sanguis.
  • Secondary colonizer: S. mutans.
  • Red Complex: Most associated with periodontal disease.
  • Green Complex: A. actinomycetemcomitans, E. corrodens, Capnocytophaga.
• Tests & Toxins:
  • BANA test: Detects P. gingivalis, T. denticola, B. forsythia.
  • Leukotoxin (116-kDa): Secreted by A. actinomycetemcomitans.
  • Myeloperoxidase: Prevents A. viscosus attachment.
• Immunoglobulins:
  • Saliva: IgA.
  • GCF: IgG.
• GCF Lymphocyte Ratio: T:B = 1:3.
• TLRs: Absent on bacterial cells.

Cushing's Syndrome

• Earliest feature: Loss of diurnal variation of cortisol
• High-dose dexamethasone suppression test: Differentiates pituitary adenoma vs ectopic ACTH

Adrenal Insufficiency (Addison's Disease)

• Most common cause in India: Tuberculosis
• Most common primary tumor metastasizing to adrenals: Melanoma
• Most confirmatory test: ACTH stimulation test
• Diagnostic: Low plasma cortisol (<3 mg/dL) at 8 AM + elevated ACTH (>200 pg/mL)
• Most common symptom: Asthenia (due to hypotension & hypoglycemia)

Acquired Pellicle in the Oral Cavity

The acquired pellicle is a crucial component of oral health, serving as the first line of defense in the oral cavity and playing a significant role in the initial stages of biofilm formation on tooth surfaces. Understanding the composition, formation, and function of the acquired pellicle is essential for dental professionals in managing oral health.

Composition of the Acquired Pellicle

1. Definition:

   • The acquired pellicle is a thin, organic layer that coats all surfaces in the oral cavity, including both hard (tooth enamel) and soft tissues (gingiva, mucosa).

2. Components:

   • The pellicle consists of more than 180 peptides, proteins, and glycoproteins, which include:
     • Keratins: Structural proteins that provide strength.
     • Mucins: Glycoproteins that contribute to the viscosity and protective properties of saliva.
     • Proline-rich proteins: Involved in the binding of calcium and phosphate.
     • Phosphoproteins: Such as statherin, which helps in maintaining calcium levels and preventing mineral loss.
     • Histidine-rich proteins: May play a role in buffering and mineralization.
   • These components function as adhesion sites (receptors) for bacteria, facilitating the initial colonization of tooth surfaces.

Formation and Maturation of the Acquired Pellicle

1. Rapid Formation:

   • The salivary pellicle can be detected on clean enamel surfaces within 1 minute after exposure to saliva. This rapid formation is crucial for protecting the enamel and providing a substrate for bacterial adhesion.

2. Equilibrium State:

   • By 2 hours, the pellicle reaches a state of equilibrium between adsorption (the process of molecules adhering to the surface) and detachment. This dynamic balance allows for the continuous exchange of molecules within the pellicle.

3. Maturation:

   • Although the initial pellicle formation occurs quickly, further maturation can be observed over several hours. This maturation process involves the incorporation of additional salivary components and the establishment of a more complex structure.

Interaction with Bacteria

1. Bacterial Adhesion:

   • Bacteria that adhere to tooth surfaces do not contact the enamel directly; instead, they interact with the acquired enamel pellicle. This interaction is critical for the formation of dental biofilms (plaque).

2. Active Role of the Pellicle:

   • The acquired pellicle is not merely a passive adhesion matrix. Many proteins within the pellicle retain enzymatic activity when incorporated. Some of these enzymes include:
     • Peroxidases: Enzymes that can break down hydrogen peroxide and may have antimicrobial properties.
     • Lysozyme: An enzyme that can lyse bacterial cell walls, contributing to the antibacterial defense.
     • α-Amylase: An enzyme that breaks down starches and may influence the metabolism of adhering bacteria.

Clinical Significance

1. Role in Oral Health:

   • The acquired pellicle plays a protective role by providing a barrier against acids and bacteria, helping to maintain the integrity of tooth enamel and soft tissues.

2. Biofilm Formation:

   • Understanding the role of the pellicle in bacterial adhesion is essential for managing plaque-related diseases, such as dental caries and periodontal disease.

3. Preventive Strategies:

   • Dental professionals can use knowledge of the acquired pellicle to develop preventive strategies, such as promoting saliva flow and maintaining good oral hygiene practices to minimize plaque accumulation.

4. Therapeutic Applications:

   • The enzymatic activities of pellicle proteins can be targeted in the development of therapeutic agents aimed at enhancing oral health and preventing bacterial colonization.