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Periodontics is a vast subject by itself and a pediatric dentist is called upon to use the knowledge of the same while examining and planning the treatment of children and young adults. Contrasting forms of periodontal disease 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 to be able to identify and classify the disease correctly at the earliest applying the basic principles along with understanding of etiology and risk factors. A pediatric dentist is 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, however 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 etiologic 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.
Key Words: adolescents, aggressive, chronic, gingivitis periodontitis.
Clinical Relevance: Incorporation of periodontal screening in regular dental examination by pediatric dentist can help in early diagnosis and treatment of periodontal diseases. This would prevent further progression of disease and reduce the frequency of tooth loss.
Objective: The reader should understand the importance of periodontal screening, early diagnosis, proper treatment planning and effective maintenance plan to prevent the progression and recurrence of periodontal disease in children and adolescents.
Different forms of periodontal disease affect children and adolescents. The diseases affecting the periodontium can be limited to the gingival tissues or can be associated with destruction of the periodontal ligament and alveolar bone. There have been various attempts to classify periodontal diseases. Various classifications have been developed over a period of time.1-4
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Based on the World Workshop in Clinical Periodontics in 1989,3 the American Academy of Periodontology proposed a classification of periodontitis as a) adult periodontitis b) early-onset periodontitis c) Periodontitis associated with systemic disease d) necrotizing ulcerative periodontitis and e) refractory periodontitis. Early-onset periodontitis was further classified into a) pre-pubertal periodontitis (localized and generalized) b) juvenile periodontitis c) rapidly progressive periodontitis.(Table 1)
Problems associated with the 1989 classification led to 1999 international workshop on the classification of periodontal diseases.4 A new classification system was proposed in 1999 and is presently the most accepted classification system of periodontal diseases. The periodontal diseases are classified as: 1) gingival diseases (plaque induced and non plaque induced) 2) chronic periodontitis (localized and generalized) 3) aggressive periodontitis (localized and generalized 4) periodontitis as a manifestation of systemic disease 5) necrotizing periodontal disease 6) abscesses of periodontium 7) periodontitis associated with endodontic lesions and 8) developmental and acquired deformities and conditions.(Table 1)
In the new classification4 “adult periodontitis” was changed to chronic periodontitis and juvenile periodontitis to aggressive periodontitis. These changes were made to eliminate the age-dependent criteria. Chronic periodontitis was considered less age-dependent description than adult periodontitis. The term ”early-onset periodontitis” was discarded as this form of disease can occur in children, adolescents and adults. ”Localized aggressive periodontitis” replaced the older expression ”localized juvenile periodontitis” or ”localized early-onset periodontitis”. ”Generalized aggressive periodontitis” replaced ”generalized juvenile periodontitis” or ”generalized early-onset periodontitis.”(Table 2)
1989 Classification Of Periodontal Diseases
1999 Classification Of Periodontal Diseases
(Plaque induced and Non- Plaque Induced)
(Localized and Generalized)
(Localized and Generalized).
Periodontitis associated with systemic disease
Periodontitis as a manifestation of systemic disease
Necrotizing ulcerative periodontitis
Necrotizing periodontal disease
Abscesses of periodontium
Periodontitis associated with endodontic lesions
Developmental and acquired deformities and conditions
The categories of refractory periodontitis and rapidly progressive periodontitis were eliminated because of their heterogeneity. Prepubertal periodontitis was also eliminated as it was not perceived to be a single entity. Many severe periodontitis cases in children are caused due to presence of a systemic disease/s.5,6 (Table 2).
Various studies show that gingivitis is prevalent in children and adolescents.7-11 Studies have indicated that attachment loss and supporting bone loss is infrequent in the young but that the incidence increases in adolescents aged 12 to 17 when compared to children aged 5 to 11.11-13 A study conducted on schoolchildren demonstrated that the prevalence and extent of gingivitis increased with age.14 Gingivitis starts in the deciduous dentition and reaching a peak at puberty. Gingivitis reduced during adolescence and followed by a gradual rise throughout adult life.15 The increase in gingivitis levels may be ascribed to the increase in sites at risk, plaque accumulation and inflammatory changes related with tooth eruption and the influence of hormonal factors in puberty. The decline in gingivitis in adolescence may be due to improved social awareness and enhanced oral hygiene.16
Changes introduced in 1999 classification in comparison to 1989 Classification Of Periodontal Diseases
A category of Gingival diseases (Plaque induced and Non- Plaque Induced) was introduced. Gingival diseases were not represented in 1989 classification.
The term Adult periodontitis changed to Chronic periodontitis to eliminate the age-dependent criteria.
The term Early-onset periodontitis was replaced by Aggressive Periodontitis to eliminate the age-dependent criteria.
Localized juvenile periodontitis or localized early-onset periodontitis was replaced by Localized aggressive periodontitis.
Generalized juvenile periodontitis or generalized early-onset periodontitis was replaced by Generalized aggressive periodontitis.
Refractory periodontitis and rapidly progressive periodontitis eliminated because of their heterogeneity
Prepubertal periodontitis was also eliminated as severe periodontitis cases in children are caused due to presence of a systemic disease/s.
Prevalence of periodontitis in the deciduous dentition is difficult to estimate because of scarcity of data. Exfoliation and eruption can lead to undependable information. A low prevalence of marginal bone loss in the deciduous dentition is found in children of European origin in comparison to Asian children.17,18 The prevalence of early onset periodontitis in blacks was 2.1% 19- 2.6%.20 The prevalence rate for whites was 0.17%.20 In a survey in the United States, no significant difference was found in prevalence rates between males and females.20 Black males and white females were approximately three times more likely to have localized early-onset periodontitis than black females and white males respectively.20
Periodontitis in the deciduous dentition is generally clinically insignificant, severe generalized periodontitis may be found in young children with rare systemic diseases, such as Papillon-Lefevre syndrome, cyclic neutropenia, agranulocytosis, Down’s syndrome, hypophosphatasia and leukocyte adhesion deficiency.21
Periodontal diseases that can affect young individuals include: 1) dental plaque-induced gingival diseases; 2) chronic periodontitis; 3) aggressive periodontitis; 4) periodontitis as a manifestation of systemic diseases; and 5) necrotizing periodontal diseases.22 However few other diseases like primary herpetic gingivostomatitis may also affect children.(Table 3)
Periodontal diseases affecting children and adolescents
Dental plaque-induced gingival diseases
Periodontitis as a manifestation of systemic diseases
Necrotizing periodontal diseases
Dental plaque-induced gingival diseases:
Definition: Plaque-induced gingivitis is defined as inflammation of the gingiva in the absence of clinical attachment loss.23
Gingivitis associated with dental plaque only: Chronic marginal gingivitis is the most prevalent type of gingival change in childhood. Dental plaque causes inflammation within the gingival tissues which manifests as clinical signs of gingivitis.
The gingival diseases associated with plaque, endogenous hormonal fluctuations, drugs, systemic diseases, and malnutrition have numerous universal characteristics. The universal features of these gingival diseases include clinical signs of inflammation, signs and symptoms that are restricted to the gingiva, reversibility of the diseases by removing the etiology, the presence of bacterial plaque to initiate and intensify the severity of the lesion, and a potential role as a precursor to attachment loss.24 (Table 4).
Universal features of gingival diseases
Clinical signs of inflammation
Signs and symptoms that are restricted to the gingiva,
Reversibility of the diseases by removing the etiology.
Presence of bacterial plaque to initiate and intensify the severity of the lesion.
A potential role as a precursor to attachment loss
The features of plaque-induced gingivitis24 are 1) plaque present at gingival margin; 2) disease begins at the gingival margin; 3) change in gingival color;25,26 4) change in gingival contour;25,26 5) sulcular temperature change;27 6) increased gingival exudate;28 7) bleeding upon probing;25 8) absence of attachment loss; 9) absence of bone loss; 10) histological changes including an inflammatory lesion; 11) reversible with plaque removal. Subgingival levels of Actinomyces sp., Capnocytophaga sp., Leptotrichia sp., and Selenomonas sp. have been found to be increased in experimental gingivitis in children when compared to gingivitis in adults.29
Gingival Diseases Modified by Systemic Factors Associated with the Endocrine System: Hormonal changes affect the periodontal diseases, although bacterial plaque is essential to initiate gingival disease.
Puberty-Associated Gingivitis: The rise in steroid hormone levels during puberty in both sexes has a transitory effect on gingivitis.30 There is an increase in gingival inflammation in circumpubertal age individuals of both sexes without a simultaneous increase in plaque levels.31-33 The predilection to develop candid signs of gingival inflammation in the presence of relatively small amounts of plaque during the circumpubertal period differentiates the disease. The incidence and severity of gingivitis in adolescents are also influenced by dental caries, mouth breathing, crowding of the teeth, and tooth eruption.34
Diabetes Mellitus-Associated Gingivitis: Diabetes mellitus-associated gingivitis is found in children with poorly controlled Type 1 diabetes mellitus (insulin-dependent diabetes mellitus or juvenile onset).35,36 The features of gingivitis associated with diabetes mellitus are similar to plaque-induced gingivitis. The level of diabetic management is an significant characteristic than plaque control in the severity of the gingival inflammation.35,36
Gingivitis is frequently associated with tooth eruption. Tooth eruption by itself does not cause gingivitis. The inflammation results from plaque accumulation around erupting teeth. Partially exfoliated, loose deciduous teeth often cause gingivitis due to plaque accumulation. The incidence and severity of gingivitis is more around malpositioned teeth because of their increased tendency to accumulate plaque.37
Periodontitis irrespective of the specific classification show irreversible loss of connective tissue attachment and apical migration of the junctional epithelium and true pocket formation. The correct diagnosis of the different types of periodontitis is important as the management of periodontitis depends on the correct diagnosis.
Incipient and incidental attachment loss – A precursor to periodontitis:
The terms “incipient” attachment loss38,39 and incidental attachment loss38,39 have been used to describe loss of support in adolescents. A loss of attachment >1 mm and early alveolar bone loss are prevalent and can affect a sizable proportion of adolescents.40-41 The term “incipient” is used to describe the initial stage of adult type periodontitis (chronic periodontitis) and a working definition is the presence of loss of attachment >2 mm that is not related to gingival recession.39
The term “incidental” attachment loss was used by Löe & Brown in relation to early-onset (aggressive) periodontitis in adolescents.20 It was suggested that it may correspond to an initial phase of an early-onset ”juvenile” periodontitis or even be incidental to other factors. There is prevalence of attachment loss in adolescents that does not fit the categorization of localized early-onset periodontitis and/or generalized early onset periodontitis.38,42
The category of incidental attachment loss includes individuals who do not fit the criteria for diagnosis of either localized early-onset periodontitis or generalized early-onset periodontitis, but show â‰¥4 mm of attachment loss on one or more teeth.39 An epidemiological survey of early-onset periodontitis in 14 to 17 years old adolescents used attachment loss of â‰¥3 mm as the cut-off for diagnosis and found that 71% of the incidental early-onset periodontitis group had one site affected and 97% had three or less affected sites.42 The definition of incidental attachment loss can be used to classify individuals with few sites affected by abnormal attachment loss, not associated with local causes such as proximal caries or overhanging restorations.
Definition: Chronic periodontitis is defined as inflammation of the gingiva extending into the adjacent attachment apparatus. The disease is characterized by loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone.43
Clinical Features:44(Table 5)
1. Chronic periodontitis is the most common form of periodontal disease in adults but can be found in children and adolescents affecting both the primary and secondary dentitions.
2. The amount of periodontal destruction is proportionate to local factors.
3. The composition of microbial plaque is complex and varies to a great extent within and between patients and subgingival calculus is a frequent finding.
4. Chronic periodontitis can be classified on the basis of extent of disease as localized when fewer than 30% of sites are affected, and generalized when this level is exceeded.
5. Chronic periodontitis can also be classified on the basis of the severity of the periodontal destruction. Disease is mild (1 to 2 mm clinical attachment loss), moderate (3 to 4 mm clinical attachment loss), or severe (â‰¥5 mm clinical attachment loss)
6. Although chronic periodontitis is initiated by microbial plaque, factors such as systemic risk factors including smoking, stress, diabetes, HIV and host factors influence the pathogenesis and progression of the disease.
7. Progression can only be confirmed by repeated clinical examinations and is considered likely to occur in diseased sites that are left untreated. It usually has slow to moderate rates of progression, but may have periods of rapid progression.
Clinical Features of Chronic periodontitis
Most common form of periodontal disease in adults but children and adolescents also affected.
The amount of periodontal destruction is proportionate to local factors.
The composition of microbial plaque is complex and variable.
Slow to moderate rates of progression with periods of rapid progression.
Initiated by plaque but modified by systemic factors such as smoking, stress, diabetes, HIV and host factors.
Extent of disease: Localized : < 30% of sites involved; Generalized: >30% of sites involved.
Severity of disease: Mild: 1-2mm of clinical attachment loss; Moderate: 3-4 mm of clinical attachment loss; Severe: â‰¥5mm of clinical attachment loss.
Definition: Aggressive periodontitis encompasses distinct types of periodontitis that affect people who, in most cases, otherwise appear healthy. It tends to have a familial aggregation and there is a rapid rate of disease progression. Aggressive periodontitis occurs in localized and generalized forms.45
Aggressive periodontitis can be classified as localized aggressive periodontitis and generalized aggressive periodontitis.
Clinical Features:46 (Table 6)
Non-contributory medical history
Rapid attachment loss and bone destruction
Familial aggregation of disease
Secondary features that are generally present but may not be present in all cases:
1) Amount of microbial deposits inconsistent with the severity of periodontal destruction.
2) Elevated proportions of Actinobacillus actinomycetemcomitans.
3) Phagocytic abnormalities
4) Hyper-responsive macrophage phenotype, including elevated production of PGE2 and interleukin-1Î² in response to bacterial endotoxins.
5) Progression of attachment loss and bone loss may be self-arresting.
The diagnosis may be made on historical, radiographic and clinical data. In addition to primary and secondary features common to all aggressive periodontitis patients, following features can be identified:
Localized aggressive periodontitis:
1) Circumpubertal onset; 2) Localized first molar/incisor show interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors; 3) Robust serum antibody response.
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Generalized aggressive periodontitis:
1) Usually affecting persons under 30 years of age but patients may be older; 2) Generalized interproximal attachment loss affecting at least three permanent teeth, other than first molars and incisors; 3) Pronounced episodic nature of destruction of attachment and alveolar bone. 4) Poor serum antibody response.
Chronic and aggressive periodontitis have numerous common clinical features, but the common features are not necessarily alike in both forms of the disease. It is well recognized that both chronic and aggressive periodontitis are complex infections that occur in susceptible hosts and are caused by biofilms.47-49 In addition, host immune response to the biofilms is largely responsible for periodontal destruction.50,51 Successful management of both forms of periodontitis includes reduction of bacterial load.52 The untreated disease invariably leads to loss of tooth.
Clinical Features of Aggressive periodontitis
Non-contributory medical history.
Rapid attachment loss and bone destruction
Familial aggregation of disease.
Secondary features: generally present but not universal:
Amount of microbial deposits inconsistent with the severity of periodontal destruction.
Elevated proportions of Actinobacillus actinomycetemcomitans.
Hyper-responsive macrophage phenotype, including elevated production of PGE2 and interleukin-1Î².
Progression of attachment loss and bone loss may be self-arresting.
Localized aggressive periodontitis:
Localized first molar/incisor involvement with interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors.
Robust serum antibody response.
Generalized aggressive periodontitis:
Usually affecting persons under 30 years of age but patients may be older;
Generalized interproximal attachment loss affecting at least three permanent teeth, other than first molars and incisors;
Pronounced episodic nature of destruction of attachment and alveolar bone.
Poor serum antibody response.
Similarities and differences in clinical features of chronic and aggressive periodontitis:
One of the shared clinical characteristics of chronic and aggressive periodontitis is that affected individuals have no known medical or general health conditions that might contribute to development of their periodontitis. If an individual has a systemic disease that modifies the initiation and clinical course of periodontal infections, the resulting periodontitis should be classified as periodontitis as a manifestation of systemic disease.4
Chronic and aggressive forms of periodontitis have a number of significant clinical differences including: (i) age of onset; (ii) rates of progression; (iii) patterns of destruction; (iv) clinical signs of inflammation and (v) amount of plaque and calculus. The clinical differences are the primary basis for classifying individuals into one of the categories of periodontitis.
A diagnosis is a summary statement of the clinician’s best estimate regarding the disease or condition detected in a given patient. It is derived from a thorough analysis of all information collected during a review of relevant data from medical â„ dental histories, the results of diagnostic tests, and findings from a careful clinical examination.53,54 A diagnosis should be a short and concise statement that gives an idea of disease present in a specific patient. It provides a foundation about appropriate treatment approaches. The diagnosis may not precisely be according to the classification system. The exact definition of case is not a main issue in the management of specific patients in clinical practice, as the diagnosis is tailor-made for the individual.55 The clinical distinction between chronic and aggressive periodontitis may be difficult sometimes. This distinction becomes insignificant from a treatment viewpoint as anti-infective therapies are successful for both forms of the disease.55
Periodontitis as a manifestation of systemic diseases:
Systemic diseases that predispose patients to highly destructive disease of the primary teeth, the diagnosis is periodontitis as a manifestation of systemic disease. This group is classified as:56(Table 7)
Associated with hematological disorders: 1) Acquired neutropenia; 2) Leukemias; 3) Others.
Associated with genetic disorders: 1) Familial and cyclic neutropenia; 2) Down’s syndrome; 3) Leukocyte adherence deficiency syndrome; 4) Papillon-Lefèvre syndrome; 5) Chediak-Higashi syndrome; 6) Histocytosis syndromes; 7) Glycogen storage disease; 8) Infantile genetic agranulocytosis; 9) Cohen syndrome; 10) Ehlers-Danlos syndrome (Types IV and VIII); 11) hypophosphatasia.
Not Otherwise specified.
Not otherwise specified includes diseases like osteoporosis and estrogen deficiency which have shown to affect periodontium but data regarding their effect requires confirmation. It was emphasized in the consensus report that other systemic conditions may be added after the evidence is available.
Defects in neutrophil and immune cell function associated with these diseases may play an important role in increased susceptibility to periodontitis and other infections. Periodontitis as a manifestation of systemic disease in children is a rare disease that frequently begins between the time of eruption of the primary teeth up to the age of 5.57,58 In the localized form, affected sites exhibit rapid bone loss and minimal gingival inflammation.57
Quantitative (agranulocytosis or neutropenia) or qualitative (chemotactic or phagocytic) leukocytic deficiencies show evidence of severe annihilation of the periodontal tissues. Quantitative deficiencies are generally accompanied by destruction of the periodontium of all teeth, whereas qualitative defects are often associated with localized destruction affecting only the periodontium of certain teeth.59
Neutropenia. Patients present with a diverse periodontal manifestations. In the malignant form there is ulceration and necrosis of the marginal gingiva. Bleeding from gums is generally present and attached gingiva may get involved.60 In cyclic, chronic, and familial benign neutropenia the lesions show deep periodontal pockets and extensive, generalized bone loss involving the permanent dentition.61-63 Bone resorption may be seen in the deciduous dentition.64,65
Leukemia. Periodontal lesions have been frequently observed in patients with leukemia, particularly those with an acute form. Generalized gingival enlargement was apparent in 36% of the individuals with acute and in 10% of those with chronic forms.66 Gingival swelling due to infiltration by leukemic cells is a feature of acute monocytic leukemic.67 Gingival bleeding is also a common sign of the disease in both acute and chronic leukemia and may relate to the associated thrombocytopenia.68
Down’s Syndrome. Patients with Down syndrome show a generalized early periodontitis, which commences in the deciduous dentition69,70 and continues into the adult dentition. The prevalence and severity of periodontal disease in individuals with Down syndrome is exceedingly high in comparison to their siblings71 or other mentally subnormal persons.70 Several studies have reported increased prevalence and severity of periodontal disease in children of older age groups.69,70 The periodontal destruction is most commonly seen around the incisor and molar teeth.69 The short roots of the mandibular incisors72 and the bone loss in the mandibular anterior region, can lead to the premature loss of these teeth.70
Leukocyte Adhesion Deficiency Syndrome. Defects in numbers of cell-cell adhesion receptors on the neutrophil surface may lead to increased inclination to periodontitis and other infectious diseases in conditions such as leukocyte adhesion deficiency syndrome.73 Young patients with leukocyte adhesion deficiency syndrome present with severe inflammatory periodontal disease.74-76 Leukocyte adhesion deficiency syndrome is a rare autosomal recessive disease. The disease is generally fatal and children with deficiencies in expression of the leukocyte function associated family of adhesins suffer from severe periodontal infections.73
Papillon-Lefèvre Syndrome. Papillon-Lefèvre syndrome is a disease with autosomal recessive inheritance.77 The disease shows signs of diffuse palmar-plantar keratosis with a severe generalized periodontitis, usually seen before puberty with early loss of deciduous and permanent teeth.78-80 A frequency of 1 in 4 million in the general population has been reported.80 25% have been reported to have an increased susceptibility to infection, and 33% have a history of consanguinity.79 Teeth are normally lost in the order of eruption.79 Haim Munk syndrome is also characterized by presence of palmoplantar hyperkeratosis and severe early-onset periodontitis. Genetic studies of the diseases exhibiting palmoplantar keratosis and early-onset periodontitis suggested that the gene defect in Haim Munk syndrome is not genetically linked to the more common forms of palmoplantar keratosis.81 It has been reported that there is a high degree of consanguinity in these families and that they are most likely part of the similar syndrome.82
Chediak-Higashi Syndrome. Chediak-Higashi syndrome is as an autosomal recessive disease associated with severe periodontitis.83,84 The people suffering from this disease are extremely susceptible to bacterial infections Neutrophil chemotaxis and bactericidal functions are abnormal in these patients. Generalized, severe gingivitis, extensive loss of alveolar bone, and premature loss of teeth are features commonly seen.85
Histiocytosis Syndromes. This group of diseases includes may affect infants, children, and adults. The periodontal lesions may clinically resemble necrotizing ulcerative periodontitis lesions. The lesions are punched-out necrotic ulcers with considerable granulation tissue, tissue necrosis, and marked bone loss. Biopsy of the granulation tissue can help in diagnosing the condition.86 Skeletal surveys and chest radiographs will assist in determining the extent of the disease.
Glycogen storage disease. This is an autosomal recessive condition associated with defective carbohydrate metabolism. Clinical features include reduced neutrophil numbers, impaired neutrophil function and periodontal disease.87,88
Infantile genetic agranulocytosis. This disease presents with severe neutropenia and has been linked with periodontitis similar to the early-onset form. This is a rare autosomal recessive disorder.89,90
Cohen’s syndrome. This is also an autosomal recessive condition is characterized frequent and extensive alveolar bone loss.88 The patients also suffer from non-progressive mental and motor retardation, obesity, dysmorphia, and neutropenia.91
Ehlers-Danlos Syndrome. The Ehlers-Danlos syndrome is autosomal dominant disorder. Ehlers-Danlos syndrome is classified into 10 types and is characterized by defective collagen synthesis. Types IV and VIII have an increased susceptibility to periodontitis.92 Type VIII is linked with fragile oral mucosa and blood vessels. It is also associated with severe generalized periodontitis with manifestation of generalized early-onset periodontitis.93 Ehlers-Danlos syndrome type VIII has clinical similarity to the early-onset form, causing premature loss of permanent teeth.94
Hypophosphatasia. Patients present with decreased serum alkaline phosphatase levels. There is severe loss of alveolar bone and premature loss of the deciduous teeth.95-97 Premature loss of deciduous dentition primarily involves anterior region.97
Periodontitis as a manifestation of systemic diseases
Associated with hematological disorders:
Associated with genetic disorders:
Familial and cyclic neutropenia;
Leukocyte adherence deficiency syndrome;
Glycogen storage disease;
Infantile genetic agranulocytosis;
Ehlers-Danlos syndrome (Types IV and VIII);
Not Otherwise specified
Necrotizing periodontal diseases:
Necrotizing periodontal disease
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