Impact of periodontal treatment in combination with tonsillectomy plus methylprednisolone pulse therapy and angiotensin blockade for pediatric IgA nephropathy.

BACKGROUND: We previously reported the efficacy of extensive eradication of infectious foci in oral and ENT lesions, combined with tonsillectomy plus methylprednisolone (MP) pulse therapy, for curing pediatric Henoch-Schönlein purpura (HSP) and HSP nephritis. In the present study, we used this therapy in patients with pediatric IgA nephropathy (IgAN) to assess whether similar results could be obtained. PATIENTS AND METHODS: In 11 pediatric patients newly diagnosed with IgAN, exploration for infectious foci showed severe oral infection, including dental caries and apical periodontitis, in many. The overall decayed, missing and filled teeth score was elevated to 5.91. Two patients had rhinosinusitis. After extensive treatment of infectious foci, patients underwent tonsillectomy plus MP pulse therapy with angiotensin II receptor blockade. RESULTS: Clinical remission was achieved in all patients with pediatric IgAN (various histologic grades). Remission was achieved by 7.2 ± 5.7 months after initiation of steroid therapy, and disappearance of proteinuria by 3.3 ± 3.0 months. The mean duration of oral steroid administration was 9.5 ± 3.6 months. No relapse has occurred during follow-up of 4.3 ± 2.4 y. CONCLUSIONS: Careful examination and thorough elimination of infectious foci in oral and ENT lesions can optimize the effect of tonsillectomy plus MP pulse therapy, promoting recovery from IgAN.

Periodontal and ENT therapy in the treatment of pediatric Henoch-Schönlein purpura and IgA nephropathy.

Henoch-Schönlein purpura (HSP) and IgA nephropathy (IgAN) are both IgA1-related vasculitis caused by vascular deposition of IgA1-containing immune complexes. A pathological role of the tonsils in the development of HSP and IgAN has been suggested. Tonsils are a mucosaassociated lymphoid organ. Since oral and sinonasal cavities are anatomically directly connected to the tonsils, delivering exogenous antigens into the tonsils to induce local and systemic antibody responses, we examined the infectious status of these cavities when we treated HSP and IgAN. In 40 HSP children (6.7±2.5 years), apical periodontitis, rhinosinusitis, and otitis media were identified in 21 (53%, 4.9±2.8 affected teeth), 19 (48%), and 4 (10%) of them, whereas in 11 IgAN children (10.4±2.5 years), these diseases were observed in 6 (55%, 5.8±4.6 affected teeth), 2 (18%), and 0 (0%) of them, respectively. We first treated the patients with extensive eradiation of infectious foci, including antimicrobial treatment and root canal therapy. In 31 HSP patients, such dental and/or ENT therapy resulted in a complete cure without development of nephritis or recurrent attacks. For the remaining 9 HSP and 11 IgAN patients, we further performed tonsillectomy plus methylprednisolone (MP) pulse therapy to control their intractable symptoms, including aggravated purpura, recurrent HSP attacks or nephritis. Using this therapeutic strategy, all of the HSP patients attained clinical remission. All of the IgAN patients with various histological grades also achieved normalization of urinalysis by 7.2±5.7 months after the start of steroid therapy. No relapses were observed in both diseases during followup for 2-10 years. In pediatric HSP and IgAN, apical periodontitis and rhinosinusitis may be involved in abnormal immune responses in both the tonsils and whole body. We conclude that extensive elimination of these infectious foci is beneficial to optimize the effect of tonsillectomy plus MP pulse therapy.

Efficacy of early dental and ENT therapy in preventing nephropathy in pediatric Henoch-Schönlein purpura.

In a previous study, we demonstrated the benefit of tonsillectomy for early recovery from Henoch-Schönlein purpura (HSP) nephritis (HSPN), suggesting the pathological role of tonsils in HSP (Inoue et al., Clin Nephrol 67:298-305, 2007). In this study, we evaluated the efficacy of extensive eradication of infectious foci directly connected to the tonsils, including those involved in oral as well as ear, nose, and throat (ENT) diseases, in reducing the nephropathy in HSP. For this purpose, we examined the focal points of infection in 40 newly diagnosed HSP patients. After these focal points of infection had been identified, they were extensively eradicated; when the clinical course was intractable, we also considered tonsillectomy. After administering such therapy to HSP patients, we prospectively followed them up for 0.6 to 8 years. The identified focal infections included dental caries in 28 (70%), apical periodontitis in 21 (53%), rhinosinusitis in 19 (48%), tonsillitis in five (13%), and otitis media in four (10%) of the 40 patients. Seventeen patients (43%) had more than two simultaneous infectious foci, whereas, in five (13%), no infectious focus was found. In 32 patients, antimicrobial treatment with concurrent dental and/or ENT therapy resulted in a complete cure without development of HSPN or recurrent attacks. In eight patients, we performed tonsillectomy-adenotonsillectomy to treat their clinical symptoms, including aggravated purpura and recurrent attacks of HSP or HSPN. All patients were completely cured. The overall incidence of HSPN was only three out of the 40 patients (8%). Oral and ENT diseases were found with high percentages in HSP patients. Early and extensive treatment for these lesions and tonsillectomy-adenotonsillectomy for intractable cases may prevent the complication of HSPN, contributing to the early curing of HSP.