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Case Report
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
probing. Gingival enlargement and abscess although may be eat. Her father reported that the girl was not able to eat properly
associated with GAP are rare.[3] as she had mobile teeth and pain in her gums.
Although aggressive periodontitis has been the focus of many General physical examination
investigations aimed at understanding its etiopathogenesis, On examination, the girl looked absolutely normal except that
literature is deficient when it comes to assess the systemic she looked slightly younger than her reported age and had
manifestations of GAP. a pale appearance. To rule out any psychiatric abnormality,
consultation was taken from the Department of Psychiatry.
The present case report describes the first‑ever reported They diagnosed the patient with borderline mental depression
case of GAP possibly associated with generalized gingival based on Hamilton Depression Rating Scale but suggested
enlargement, multiple periodontal abscesses with dimorphic no treatment other than counseling (i.e., cognitive behavioral
anemia, and mental depression as systemic manifestations. therapy [CBT]). CBT is in fact an established treatment, and
majority of the cases of mental depression responded well to
CASE REPORT the same even in the absence of any antidepressant. Also to rule
out possibility of any syndrome and variation in her skeletal
A 21‑year‑old girl reported to the hospital along with her and mental age, full body radiographs of her right hand and
father with a chief complaint of enlarged gums and early loss wrist, right shoulder, right hip joint, right pelvis, right ankle,
of lower 1st molar along with pus discharge from various sites right elbow, and right knee were advised by her physician and
in the oral cavity [Figure 1]. the findings were negative [Figure 2].
Detailed history of the patient revealed that enlargement and pus A complete blood count was advised which revealed reduced
discharge started when the girl was 15 years and was preceded hemoglobin. The red blood cells which showed the presence
by mobility of her teeth. It was also revealed that the girl left of mild anisocytosis, normocytes, microcytes, pencil cells,
her school at the age of 17 years as she was not able to catch up hypochromia, and occasional polychromatic macrocytes were
with her peer group in her studies although she was normal but also seen. Hence, the patient was diagnosed with dimorphic
slightly sluggish in her other day‑to‑day activities. One peculiar anemia with neutrophilia.
finding which was reported was that the girl lacked the desire to
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 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 Figure 4: Posttreatment picture showing improvement in patient’s condition
Journal of Indian Society of Periodontology - Volume 21, Issue 5, September-October 2017 413
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abscesses were also noticed in the region of upper canines It was advised to undertake orthodontic therapy after the
and lower molars. Increased probing pocket depths and periodontal condition of the patient was stabilized. The patient
moderate‑to‑severe clinical attachment loss with vertical bone and her father were given detailed oral hygiene instructions
defects were present throughout the oral cavity at various and were motivated for better plaque control. Chlorhexidine
sites [Table 1]. A peculiar finding was that in addition to the digluconate mouthwash (0.12%) was prescribed to further
involvement of mandibular 1st molars and incisors, there was a aid in plaque control. Systemic antibiotics (amoxicillin and
severe loss of attachment and vertical bone defects in relation to metronidazole, 250 mg of each thrice daily) were prescribed for
various maxillary and mandibular teeth [Figure 3]. The amounts 8 days. After the initial periodontal treatment which consisted
of microbial deposits were inconsistent with the severity of of regular recalls every alternate day for the 1st week, the patient
periodontal tissue destruction. There was also pathological was recalled after 2 weeks for evaluation of the response to
mesial migration of mandibular left 2nd molar. A few carious treatment.
teeth were also present. On microbiological investigation, it
was revealed that there were elevated proportions of Aa but A re‑evaluation at 3rd week from the initial periodontal therapy
the Aa antibody titers were found to be normal. showed a reduction in probing depths and absence of gingival
abscesses and no bleeding on probing. There was marked
Based on the patient’s history, general physical and oral improvement in patient’s mental status and hematological
examination, a diagnosis of GAP associated with pubertal reports. Since the patient was improving and showing signs
gingival enlargement and periodontal abscesses was made, of gain in clinical attachment levels [Table 2 and Figure 4] and
with mental depression and dimorphic anemia as the systemic her father was inclined to avoid periodontal surgery, she was
manifestations of GAP. put on supportive periodontal therapy and was advised to
recall every month for the next 6 months.
Case management
A detailed treatment plan was made which included restoration DISCUSSION
of carious teeth, treatment of periodontal abscesses, and
thorough supra‑ and subgingival scaling. An orthodontic The present case report is the first‑ever clinical evidence which
consultation was also advised to restore the deranged occlusion. describes a case of GAP associated with gingival enlargement
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literature on GAP is available in the forms of case reports and Periodontol 1999;4:39‑53.
case series due to difficulties in gathering sufficiently large 3. Padmanabhan S, Dwarakanath CD. Severe gingival enlargement
populations to assess the diagnostic features, pathogenesis, and associated with aggressive periodontitis. J Indian Soc Periodontol
systemic effects of the condition. The literature is scarcer for 2013;17:115‑9.
assessing the systemic effects of GAP. In addition, as most of the 4. Mahajan A, Dixit J, Verma U. An intriguing case of gingival
enlargement associated with generalized aggressive periodontitis.
current reported evidence is focused on the etiopathogenesis
Periodontal Pract Today 2007;4:295‑9.
of GAP and its treatment, the systemic manifestations of GAP
5. Carranza FA, Hogon EL. Gingival enlargement. In: Newman MG,
are often neglected. Hence, our case report underscores the fact Takei H, Klokkevold P, Carranza FA, editors. Carranza’s Clinical
that GAP may result in dimorphic anemia, other nutritional Periodontology. 10th ed. St. Louis, MO: Saunders Elsevier; 2006.
deficiencies, and mental depression. It is recommended that p. 374‑88.
the clinicians must assess these systemic manifestations while 6. Singh AK, Saxena A. The periodontal abscess: A review. J Dent
preparing their treatment plan for GAP. Med Sci 2015;14:81‑6.
7. Roshna T, Nandakumar K. Generalized aggressive periodontitis
CONCLUSION and its treatment options: Case reports and review of the
literature. Case Rep Med 2012;2012:535321.
Dimorphic anemia and mental depression are possible systemic 8. Page RC, Altman LC, Ebersole JL, Vandesteen GE, Dahlberg WH,
manifestations of GAP. The treatment regimen for GAP must Williams BL, et al. Rapidly progressive periodontitis. A distinct
clinical condition. J Periodontol 1983;54:197‑209.
take into account the associated systemic manifestations of
9. Gross RL, Reid JV, Newberne PM, Burgess B, Marston R, Hift W,
GAP, and nutritional supplements may also be added during
et al. Depressed cell‑mediated immunity in megaloblastic anemia
the course of treatment to improve the patient’s condition. The due to folic acid deficiency. Am J Clin Nutr 1975;28:225‑32.
possibility of patient having mental depression along with 10. Bain BJ. Blood cell morphology in health & disease. In: Lewis SM,
GAP should also be taken into account and dealt accordingly. Bain BJ, Imelda Bates. Dacie & Lewis Practical haematology.
It is also worth mentioning that as this was a case report of a 10th ed. Philadelphia: Churchill Livingstone; 2006. p. 79‑113.
single patient, it is not possible to establish/rule out a cause 11. Velez H, Restrepo A, Vitale JJ, Hellerstein EE. Folic acid deficiency
and effect relation between GAP and the two conditions until secondary to iron deficiency in man. Remission with iron therapy
future studies on a larger group of population are performed. and a diet low in folic acid. Am J Clin Nutr 1966;19:27‑36.
12. Pradeep AR, Anuj S. Anemia of chronic disease and chronic
Financial support and sponsorship periodontitis: Does periodontal therapy have an effect on anemic
Nil. status? J Periodontol 2011;82:388‑94.
13. Yu SL, Eng HL. Dramatic recovery from severe anaemia by
resolution of severe periodontitis. J Dent Sci 2010;5:41‑6.
Conflicts of interest
14. Hegde S, Riyas, Kashyap R, Kumar A. Comparative evaluation
There are no conflicts of interest.
of blood parameters in chronic periodontitis patients and healthy
patients for signs of anaemia. J Dent Med Sci 2014;13:30‑6.
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