Periodontal Diseases In Children Health And Social Care Essay

periodontic Diseases In Children Health And Social C are EssayPeriodontics is a vast subject by itself and a pediatric dentist is call(a)ed upon to use the knowledge of the same while examining and planning the manipulation of children and young adults. Contrasting forms of periodontic un healthiness affect children and adolescents with varying prevalence, severity, and extent, leading to a diverse prognosis in these age themes. For an early diagnosis and interference of periodontic conditions in young patients, it is essential to be able to identify and sort the unhealthiness correctly at the earliest applying the basic principles along with understanding of etiology and risk factors. A pediatric dentist is in a unparalleled 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 un mutual i n children, however it is essential that children receive a periodontal screening as part of their regular dental consonant 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 harm.Key Words adolescents, fast-growing(a), chronic, gingivitis periodontal disease.clinical Relevance internalization of periodontal screening in regular dental examination by pediatric dentist can help in early diagnosis and handling of periodontal diseases. This would prevent further progression of disease and reduce the frequency of tooth overtaking.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 dis ease in children and adolescents.Different forms of periodontal disease affect children and adolescents. The diseases touching the periodontium can be limited to the gingival tissues or can be associated with destruction of the periodontal ligament and alveolar b whiz. there bring been various attempts to classify periodontal diseases. various classifications obtain been developed over a period of time.1-4Based on the World Workshop in Clinical Periodontics in 1989,3 the American Academy of Periodontology proposed a classification of periodontal disease as a) adult periodontitis b) early- intrusion periodontitis c) periodontal disease associated with general disease d) necrotizing ulcerative periodontitis and e) refractory periodontitis. Early- aggression periodontitis was further classified into a) pre-pubertal periodontitis ( localized and generalize) b) juvenile periodontitis c) rapidly progressive periodontitis.(mesa 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 some accepted classification system of periodontal diseases. The periodontal diseases are classified as 1) gingival diseases ( governing body induced and non plaque induced) 2) chronic periodontitis (localized and generalized) 3) belligerent 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 metamorphosed to chronic periodontitis and juvenile periodontitis to strong-growing periodontitis. These changes were made to press out the age-dependent criteria. chronic periodontitis was considered less age-dependent description than adult periodontitis. The de pot early- flak periodontitis was discarded as this form of disease can occur in children, adolescents and adults. localised 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)Table 11989 Classification Of Periodontal Diseases1999 Classification Of Periodontal DiseasesGingival diseases(Plaque induced and Non- Plaque Induced)Adult periodontitis chronic periodontitis(Localized and Generalized)Early-onset periodontitisAggressive periodontitis(Localized and Generalized).Periodontitis associated with systemic diseasePeriodontitis as a manifestation of systemic diseaseNecrotizing ulcerative periodontitisNecrotizing periodontal diseaseRefractory periodontitisAbscesses of periodontiumPeriodontitis associated with endodontic lesionsDevelopmental and acquired deformities and conditionsThe 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 adhesion bolshie and supporting off-white button 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 increase with age.14 Gingivitis starts in the broadleaf teething 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.16Table 2Changes introduced in 1999 classification in comparison to 1989 Classification Of Periodontal DiseasesA 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 rapidl y progressive periodontitis eliminated because of their heterogeneityPrepubertal 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 peripheral bone exit 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 solid difference was found in prevalence rates between males and females.20 Black males and white females were approximately collar times more likely to have localized early-onset periodontitis than black females and white males respectively.20Periodontitis in the deciduous dentition is generally clinically in significant, severe generalized periodontitis may be found in young children with grand systemic diseases, such as Papillon-Lefevre syndrome, cyclic neutropenia, agranulocytosis, Downs syndrome, hypophosphatasia and leukocyte adhesion deficiency.21Periodontal 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 some other diseases like primary herpetic gingivostomatitis may also affect children.(Table 3)Table 3Periodontal diseases affect children and adolescentsDental plaque-induced gingival diseasesChronic periodontitisAggressive periodontitisPeriodontitis as a manifestation of systemic diseasesNecrotizing periodontal diseasesDental plaque-induced gingival diseasesDefinition Plaque-induced gingivitis is defined as irritation of the gingiva in the absence of clinical concomi tant loss.23Gingivitis associated with dental plaque only Chronic marginal gingivitis is the most prevalent type of gingival change in childhood. Dental plaque causes inflammation at bottom 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).Table 4Universal features of gingival diseasesClinical signs of inflammationSigns 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 lossThe features of plaque-induced gingivitis24 are 1) plaque present at gingival margin 2) disease begins at the gingival margin 3) change in gingival color25,26 4) change in gingival contour25,26 5) sulcular temperature change27 6) increased gingival exudate28 7) bleeding upon searching25 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.29Gingival 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 h ormone levels during puberty in both(prenominal) 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 innocent 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.34Diabetes 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 prudence is an significant characteristic than plaque control in the severi ty of the gingival inflammation.35,36Gingivitis is oft associated with tooth eruption. Tooth eruption by itself does not cause gingivitis. The inflammation results from plaque accumulation nigh 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 list to accumulate plaque.37PeriodontitisPeriodontitis irrespective of the specific classification show irreversible loss of connective tissue attachment and apical migration of the junctional epithelium and true(p) 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 periodontitisThe 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.39The term incidental attachment loss was used by Le 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.38,42The 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 sho w 4 mm of attachment loss on one or more teeth.39 An epidemiological survey of early-onset periodontitis in 14 to 17 age old adolescents used attachment loss of 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.Chronic periodontitisDefinition 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.43Clinical Features44(Table 5)1. Chronic periodontitis is the most common form of periodontal disease in adults but can be found in children and adolesce nts affecting both the primary and secondary dentitions.2. The amount of periodontal destruction is proportionate to local factors.3. The composition of microbic 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), master (3 to 4 mm clinical attachment loss), or severe (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. advance can only be confirmed by repeated clinical examinati ons and is considered likely to occur in diseased sites that are left untreated. It usually has softened to moderate rates of progression, but may have periods of rapid progression.Table 5Clinical Features of Chronic periodontitisMost 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.Severity of disease Mild 1-2mm of clinical attachment loss Moderate 3-4 mm of clinical attachment loss Severe 5mm of clinical attachment loss.Aggressive periodontitisDefinition 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.45Aggressive periodontitis can be classified as localized aggressive periodontitis and generalized aggressive periodontitis.Clinical Features46 (Table 6)Primary featuresNon-contributory checkup history rapid attachment loss and bone destructionFamilial aggregation of diseaseSecondary features that are generally present but may not be present in all cases1) Amount of microbial deposits inconsistent with the severity of periodontal destruction.2) Elevated proportions of Actinobacillus actinomycetemcomitans.3) Phagocytic abnormalities4) Hyper-responsive macrophage phenotype, including elevated production of PGE2 and interleukin-1 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 identifiedLocalized aggressive periodontitis1) Circumpubertal onset 2) Localized firstly 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.Generalized aggressive periodontitis1) 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 inf ections 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.Table 6Clinical Features of Aggressive periodontitisPrimary featuresNon-contributory medical history.Rapid attachment loss and bone destructionFamilial aggregation of disease.Secondary features generally present but not universalAmount of microbial deposits inconsistent with the severity of periodontal destruction.Elevated proportions of Actinobacillus actinomycetemcomitans.Phagocytic abnormalitiesHyper-responsive macrophage phenotype, including elevated production of PGE2 and interleukin-1.Progression of attachment loss and bone loss may be self-arresting.Localized aggressive periodontitisCircumpubertal onsetLocalized first molar/incisor involvement with inte rproximal 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 periodontitisUsually affecting persons under 30 years of age but patients may be olderGeneralized interproximal attachment loss affecting at least three permanent teeth, other than first molars and incisorsPronounced episodic nature of destruction of attachment and alveolar bone.Poor serum antibody response.Similarities and differences in clinical features of chronic and aggressive periodontitisOne 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 cla ssified as periodontitis as a manifestation of systemic disease.4Chronic 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 clinicians 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 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 precise ly 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.55Periodontitis as a manifestation of systemic diseasesSystemic 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 as56(Table 7)Associated with hematological disorders 1) Acquired neutropenia 2) Leukemias 3) Others.Associated with contractable disorders 1) Familial and cyclic neutropenia 2) Downs syndrome 3) Leukocyte adherence deficiency syndrome 4) Papillon-Lefvre syndrome 5) Chediak-Higashi syndrome 6) Histocyto sis syndromes 7) Glycogen stock disease 8) Infantile genetic agranulocytosis 9) Cohen syndrome 10) Ehlers-Danlos syndrome (Types IV and VIII) 11) hypophosphatasia.Not other than 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 borderline gingival inflammation.57Quantitative (agranulocytosis or neutropenia) or qualita tive (chemotactic or phagocytic) leukocytic deficiencies show evidence of severe annihilation of the periodontal tissues. Quantitative deficiencies are generally go with by destruction of the periodontium of all teeth, whereas qualitative disfigurements are often associated with localized destruction affecting only the periodontium of certain teeth.59Neutropenia. 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 enormous, generalized bone loss involving the permanent dentition.61-63 Bone resorption may be seen in the deciduous dentition.64,65Leukemia. 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.68Downs 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 unremarkably 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.70Leukocyte shackle 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 allele 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.73Papillon-Lefvre Syndrome. Papillon-Lefvre 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 th e 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.82Chediak-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.85Histiocytosis 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.87,88Infantile genetic agranulocytosis. This disease presents with severe neutropenia and has been linked with periodontitis similar to the early-onset form. Thi s is a rare autosomal recessive disorder.89,90Cohens 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.91Ehlers-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.94Hypophosphatasia. Patients present with decreased serum alkaline phosphatase levels. There is severe loss of alveolar bone and premature lo ss of the deciduous teeth.95-97 Premature loss of deciduous dentition primarily involves anterior region.97Table 7Periodontitis as a manifestation of systemic diseasesAssociated with hematological disordersAcquired neutropeniaLeukemiasOthers.Associated with genetic disordersFamilial and cyclic neutropeniaDowns syndromeLeukocyte adherence deficiency syndromePapillon-Lefvre syndromeChediak-Higashi syndromeHistocytosis syndromesGlycogen storage diseaseInfantile genetic agranulocytosisCohen syndromeEhlers-Danlos syndrome (Types IV and VIII)Hypophosphatasia.Not Otherwise specifiedNecrotizing periodontal diseasesNecrotizing periodontal disease