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195]

Case Report

Dimorphic anemia and mental

depression as a result of systemic
manifestations of generalized
aggressive periodontitis: A pioneer
case report
Ajay Mahajan, Kanwarjit Asi, Nisha Thakur, Deepali Rasila

Department of Abstract:
Periodontology, Generalized aggressive periodontitis (GAP) is a rare form of periodontitis resulting in early loss of teeth. Most of
Himachal Pradesh the clinical evidence available in literature focuses on the diagnosis and management aspects of GAP. Systemic
Government Dental manifestations of GAP have been reported infrequently. To the best of our knowledge, the present case report
College and Hospital, is the first‑ever evidence providing a possible mechanism and link between GAP, dimorphic anemia, and mental
Shimla, Himachal depression suggesting that dimorphic anemia and mental depression are probable systemic manifestations of
GAP. A young female reported with her father to the hospital with a complaint of pain in her oral cavity and lack
Pradesh, India
of desire to eat. On thorough examination, GAP with dimorphic anemia and mental depression were diagnosed.
Periodontal treatment along with nutritional supplements was prescribed. An improvement was noticed in the
patient’s condition after a follow‑up period of 6 months. Systemic manifestations of GAP should include the
diagnoses of dimorphic anemia and mental depression and should be treated accordingly.
Key words:
Anemia, dimorphic anemia, generalized aggressive periodontitis, mental depression, systemic

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Website: INTRODUCTION GAP represents the most heterogeneous
www.jisponline.com group and includes the most severe forms of

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DOI:
10.4103/jisp.jisp_248_16 A ggressive periodontitis is a rare form of
periodontitis characterized by an early age
of manifestation and severe destruction of the
periodontal tissues. The disease manifests in
two forms – localized aggressive periodontitis
and generalized aggressive periodontitis (GAP)
based on the clinical and laboratory features.
According to the 1999 international classification
workshop, primary diagnostic features of
aggressive periodontitis include the following:[1]
• Noncontributory medical history
• Rapid attachment loss and bone destruction
• Familial aggregation of cases.
Address for
The secondary features that are considered to be
correspondence:
Dr. Ajay Mahajan, generally but not universally present are as follows:
Department of • Amount of microbial deposits inconsistent
Periodontology, Himachal with the severity of periodontal destruction
Pradesh Government • Elevated proportions of Aggregatibacter
Dental College and actinomycetemcomitans (Aa)
Hospital, Shimla, • Phagocyte abnormalities
Himachal Pradesh, India.
• Hyper‑responsive macrophages, producing
E‑mail: drajdent@yahoo.
co.in increased prostaglandin E2 and interleukin‑1
beta
Submission: 07‑07‑2016 • In some cases, self‑arresting disease
Accepted: 06‑12‑2017 progression.
periodontitis. Earlier described as generalized
juvenile periodontitis, GAP may be diagnosed
based on the following findings:[2]
• Usually affecting persons under 30 years of
age (however, may be older)
• Generalized interproximal attachment loss
affecting at least three permanent teeth other
than first molars and incisors
• Pronounced episodic nature of periodontal
destruction
• Poor serum antibody response to infecting
agents.
Most of the cases of GAP present with severe
clinical attachment loss and bleeding on
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How to cite this article: Mahajan A, Asi K,
Thakur N, Rasila D. Dimorphic anemia and mental
depression as a result of systemic manifestations of
generalized aggressive periodontitis: A pioneer case
report. J Indian Soc Periodontol 2017;21:412-6.

412 © 2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow

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Mahajan, et al.: Systemic manifestations of generalized aggressive periodontitis
probing. Gingival enlargement and abscess although may be
associated with GAP are rare.[3]
Although aggressive periodontitis has been the focus of many
investigations aimed at understanding its etiopathogenesis,
literature is deficient when it comes to assess the systemic
manifestations of GAP.
The present case report describes the first‑ever reported
case of GAP possibly associated with generalized gingival
enlargement, multiple periodontal abscesses with dimorphic
anemia, and mental depression as systemic manifestations.
CASE REPORT
A 21‑year‑old girl  reported to the hospital along with her
father with a chief complaint of enlarged gums and early loss
of lower 1st molar along with pus discharge from various sites
in the oral cavity [Figure 1].
Detailed history of the patient revealed that enlargement and pus
discharge started when the girl was 15 years and was preceded
by mobility of her teeth. It was also revealed that the girl left
her school at the age of 17 years as she was not able to catch up
with her peer group in her studies although she was normal but
slightly sluggish in her other day‑to‑day activities. One peculiar
finding which was reported was that the girl lacked the desire to
Figure 1: Pretreatment picture of the patient showing gingival enlargement and
abscesses
Figure 3: Orthopantomogram showing severe bone loss at various sites other than
first molars and incisors
Journal of Indian Society of Periodontology - Volume 21, Issue 5, September-October 2017 413
eat. Her father reported that the girl was not able to eat properly
as she had mobile teeth and pain in her gums.
General physical examination
On examination, the girl looked absolutely normal except that
she looked slightly younger than her reported age and had
a pale appearance. To rule out any psychiatric abnormality,
consultation was taken from the Department of Psychiatry.
They diagnosed the patient with borderline mental depression
based on Hamilton Depression Rating Scale but suggested
no treatment other than counseling (i.e., cognitive behavioral
therapy [CBT]). CBT is in fact an established treatment, and
majority of the cases of mental depression responded well to
the same even in the absence of any antidepressant. Also to rule
out possibility of any syndrome and variation in her skeletal
and mental age, full body radiographs of her right hand and
wrist, right shoulder, right hip joint, right pelvis, right ankle,
right elbow, and right knee were advised by her physician and
the findings were negative [Figure 2].
A complete blood count was advised which revealed reduced
hemoglobin. The red blood cells which showed the presence
of mild anisocytosis, normocytes, microcytes, pencil cells,
hypochromia, and occasional polychromatic macrocytes were
also seen. Hence, the patient was diagnosed with dimorphic
anemia with neutrophilia.
Oral examination
Diffused gingival enlargement was present with superimposed
gingival inflammation, and multiple sites with periodontal
a b
Figure 2: Full body radiographs (a) and hand-wrist radiographs (b)
Figure 4: Posttreatment picture showing improvement in patient’s condition
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Mahajan, et al.: Systemic manifestations of generalized aggressive periodontitis
abscesses were also noticed in the region of upper canines
and lower molars. Increased probing pocket depths and
moderate‑to‑severe clinical attachment loss with vertical bone
defects were present throughout the oral cavity at various
sites [Table 1]. A peculiar finding was that in addition to the
involvement of mandibular 1st molars and incisors, there was a
severe loss of attachment and vertical bone defects in relation to
various maxillary and mandibular teeth [Figure 3]. The amounts
of microbial deposits were inconsistent with the severity of
periodontal tissue destruction. There was also pathological
mesial migration of mandibular left 2nd molar. A few carious
teeth were also present. On microbiological investigation, it
was revealed that there were elevated proportions of Aa but
the Aa antibody titers were found to be normal.
Based on the patient’s history, general physical and oral
examination, a diagnosis of GAP associated with pubertal
gingival enlargement and periodontal abscesses was made,
with mental depression and dimorphic anemia as the systemic
manifestations of GAP.
Case management
A detailed treatment plan was made which included restoration
of carious teeth, treatment of periodontal abscesses, and
thorough supra‑ and subgingival scaling. An orthodontic
consultation was also advised to restore the deranged occlusion.
Table 1: Pretreatment clinical attachment levels
Table 2: Posttreatment (6 months) clinical attachment levels
414 Journal of Indian Society of Periodontology - Volume 21, Issue 5, September-October 2017
It was advised to undertake orthodontic therapy after the
periodontal condition of the patient was stabilized. The patient
and her father were given detailed oral hygiene instructions
and were motivated for better plaque control. Chlorhexidine
digluconate mouthwash (0.12%) was prescribed to further
aid in plaque control. Systemic antibiotics (amoxicillin and
metronidazole, 250 mg of each thrice daily) were prescribed for
8 days. After the initial periodontal treatment which consisted
of regular recalls every alternate day for the 1st week, the patient
was recalled after 2 weeks for evaluation of the response to
treatment.
A re‑evaluation at 3rd week from the initial periodontal therapy
showed a reduction in probing depths and absence of gingival
abscesses and no bleeding on probing. There was marked
improvement in patient’s mental status and hematological
reports. Since the patient was improving and showing signs
of gain in clinical attachment levels [Table 2 and Figure 4] and
her father was inclined to avoid periodontal surgery, she was
put on supportive periodontal therapy and was advised to
recall every month for the next 6 months.
DISCUSSION
The present case report is the first‑ever clinical evidence which
describes a case of GAP associated with gingival enlargement
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Mahajan, et al.: Systemic manifestations of generalized aggressive periodontitis
GAP
Pain and discomfort Mental Depression
ANAEMIA
Difficulty in eating Loss of appetit e
Malnutrition
Figure 5: Flowchart showing the probable link between generalized aggressive
periodontitis, mental depression, and anemia, GAP – Generalised aggresssive
periodontitis
and multiple gingival abscesses resulting in dimorphic anemia
and mental depression. GAP is characterized by generalized
interproximal attachment loss affecting at least three permanent
teeth other than first molars and incisors.[1] The diagnosis of
GAP is made on the basis of clinical examination, radiographic
and microbiological evaluation, and the historical evidence
being provided by the patient. However, it is not necessary
for the presence of all the above‑mentioned factors to
assign a diagnosis of GAP.[4] In our case, two of the primary
diagnostic clinical features were present along with increased
number of Aa.
Gingival enlargement is a common gingival finding, and
multiple causes have been associated with it varying from
chronic inflammatory gingival enlargement (acute/chronic),
drug‑induced, leukemic, granulomatous, neoplastic, and
idiopathic gingival enlargement.[5] Gingival enlargement is
also associated with many conditions including pregnancy,
puberty, Vitamin C deficiency, plasma cell gingivitis, and
nonconditioned gingival enlargement (pyogenic granuloma).
[5]
The differential diagnosis is based on the history of the
patient, clinical features, and histopathological examination
of the enlarged gingival tissue. In the present case, the patient
was a teenager who had a history of recurrent episodes of
gingival enlargement in the previous year. Based on the
clinical presentation of the enlarged tissue along with age,
negative medical, familial, drug history of the patient, the
case was diagnosed as gingival enlargement associated with
puberty. Although gingival enlargement during puberty
has all the clinical features generally associated with chronic
inflammatory gingival enlargement, it is the degree of
enlargement and the tendency to develop massive recurrence in
the presence of relatively scant plaque deposits that distinguish
pubertal gingival enlargement from uncomplicated chronic
inflammatory enlargement.[4,5]
Periodontal abscess is localized purulent infections within the
tissue which is adjacent to the periodontal pocket that may
lead to the destruction of the periodontal ligaments and the
alveolar bone. These are also known as lateral periodontal
abscesses or parietal abscesses. Periodontal abscesses may arise
from a variety of sources, including microbial plaque infection,
trauma, and foreign body impaction. It is also associated with
systemic diseases such as diabetes.[6] Severe attachment loss
and active progression of GAP may be responsible for these
Journal of Indian Society of Periodontology - Volume 21, Issue 5, September-October 2017 415
abscesses in our case since gingival and periodontal abscesses
are common in patients with periodontitis during active phases
of the disease.[7] Other probable cause could be reduced host
immunity due to anemia causing fulminant gingival infections
and hence abscesses.[8,9]
Anemia is a condition in which the number of red blood
cells (and consequently their oxygen‑carrying capacity) is
insufficient to meet the body’s physiologic needs. In dimorphic
anemia, two distinct forms of red cell populations exist. It
can occur when iron deficiency anemia responds to iron
therapy, after the transfusion of normal blood to a patient
with a hypochromic anemia and in sideroblastic anemia.[10] It
shows signs of folic acid deficiency and severe iron deficiency
anemia.[11]
One of the most astonishing findings in the present case was
the fact that the patient was diagnosed with dimorphic anemia
based on her hematological reports. The cause of anemia
could be GAP in this case as the patient was not able to eat
properly for the past 1 year due to pain and discomfort caused
by severe periodontal destruction. In addition, the patient’s
lack of desire to eat due to mental depression could have
contributed to the loss of appetite and reduced hemoglobin
levels. An interesting correlation could be established between
GAP, mental depression, and anemia in the form that GAP
resulted in depression and malnutrition and depression
further contributed to lack of desire to eat and hence anemia
Figure 5. Previous studies have in fact suggested that GAP
leads to mental depression, weight loss, malaise, and loss of
appetite.[8] The fact that there was a significant improvement in
patients’ blood picture which correlated with the improvement
in her periodontal condition again supports the diagnosis of
dimorphic anemia as a consequence of GAP. The incidence
of anemia as a consequence of chronic periodontitis cases has
also been reported earlier.[12,13] The difference between anemia
caused by chronic periodontitis and GAP lies in the fact that
while chronic periodontitis results in anemia of chronic diseases
with normal mean red cell volume (MCV) values and reduced
hematocrit,[12‑14] the anemia caused by GAP is of dimorphic
type and nutritional deficiency related with normal red blood
cell count and altered MCV values. Although a polymerase
chain reaction  (PCR) analysis for confirming genetic aspect
and neutrophilic activity would have definitely helped but as
the patient was poor and in majority of the cases of GAP, the
diagnosis is made according to the criteria set by the American
Academy of periodontology, 1999 classification of periodontal
diseases and conditions (i.e., using history, clinical features,
and radiographic features aided by microbial examination if
needed. Family history may reveal a history of early tooth loss
in the parents or immediate blood relatives of the patient);[15]
these were not recommended. In addition, the utility of PCR
is limited as it adds immensely to the cost of treatment for the
patient. The enormous cost of the very accurate PCR technique
is deterrent to its widespread application in routine diagnostic
procedures.[16]
After a period of 6 months, there was a significant improvement
in the patient’s condition although a dietary supplement
containing iron and folic acid and other trace elements was
prescribed in consultation with her physician for a period of
3 months as a part of maintenance therapy. Majority of the
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Mahajan, et al.: Systemic manifestations of generalized aggressive periodontitis
literature on GAP is available in the forms of case reports and
case series due to difficulties in gathering sufficiently large
populations to assess the diagnostic features, pathogenesis, and
systemic effects of the condition. The literature is scarcer for
assessing the systemic effects of GAP. In addition, as most of the
current reported evidence is focused on the etiopathogenesis
of GAP and its treatment, the systemic manifestations of GAP
are often neglected. Hence, our case report underscores the fact
that GAP may result in dimorphic anemia, other nutritional
deficiencies, and mental depression. It is recommended that
the clinicians must assess these systemic manifestations while
preparing their treatment plan for GAP.
CONCLUSION
Dimorphic anemia and mental depression are possible systemic
manifestations of GAP. The treatment regimen for GAP must
take into account the associated systemic manifestations of
GAP, and nutritional supplements may also be added during
the course of treatment to improve the patient’s condition. The
possibility of patient having mental depression along with
GAP should also be taken into account and dealt accordingly.
It is also worth mentioning that as this was a case report of a
single patient, it is not possible to establish/rule out a cause
and effect relation between GAP and the two conditions until
future studies on a larger group of population are performed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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16. Valones MA, Guimarães RL, Brandão LA, de Souza PR,
de Albuquerque Tavares Carvalho A, Crovela S, et al. Principles
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