AGGRESSIVE PERIODONTITIS

Dr. LB KamaitDept of periodontlogy & Oral Implantology

Contents Introduction Classification and Clinical Characteristics Diagnostic Criteria for Chronic

periodontitis and Aggressive Periodontitis

Diagnostic Criteria for Localized and Generalized Aggressive Periodontitis

Therapeutic Modalities

05/01/2023

3

DEFINITION

“Aggressive periodontitis” defined as a group of rare, severe, rapidly progressing forms of periodontitis characterized by an early age of clinical manifestation and a distinctive tendency for cases to aggregate in families

-Jan Lindhe

Introduction Periodontitis is the pathological

manifestation of the host response against bacterial challenge that stems from a polymicrobial biofilm at the biofilm–gingival interface

Several subforms of the disease, and they are mainly characterized by their clinical phenotype rather than their etiology

Classification and Clinical Characteristics

The 1999 International Workshop for the Classification of Periodontal Diseases and Conditions defined the entity of aggressive periodontitis as being characterized by three primary features1. The rapid loss of attachment and tooth-

supporting bone2. The subject is otherwise healthy 3. The presence of familiar aggregation

Radiographs depicting progression of the osseous lesion in patient with localized aggressive periodontitis

A, January 29, 1979 B, August 16, 1979;

C, February 22, 1980; D, May 15, 1981

Classification and Clinical Characteristics

The Workshop defined several secondary features :1. Inconsistency of the low amounts of present etiological factors and the observed pronounced tissue destruction2. Strong colonization by A. actinomycetemcomitans and, in some populations, P. gingivalis3. Immunological differences that do not entail the diagnosis of periodontitis as a manifestation of systemic disease

a. Hyperresponsive macrophagesb. Abnormalities of neutrophil function

4. Self-limiting disease

Subgroups Localized Generalized

Generalized Aggressive periodontitis

Clinical views with minimal amounts of calculus and plaque

Generalized Aggressive periodontitis

Radiographically, bone loss of 50% or more was present at all teeth

Localized aggressive periodontitis

Clinical view showing minimal plaque and inflammation

Surgical appearance of the localized, vertical, angular bony defects affecting the mandibular incisors

Localized aggressive periodontitis

Radiographs showing localized, vertical, angular bone loss associated with the maxillary and mandibular first molars and the mandibular central incisors. The maxillary incisors show no apparent involvement

Diagnostic CriteriaCriterion Aggressive

PeriodontitisChronic Periodontitis

Rate of progression Rapid Slow, but rapid episodes are possible

Familiar aggregation Typical Can be present when families share imperfectoral hygiene habits

Presence of etiological factors (e.g., plaque, calculus, overhanging restorations)

Often minimal Often commensurate with observed periodontal destruction

Age Often in young patients (i.e., <35 years old) but can be found in all age groups

Often in older patients (i.e., >55 years old) but can be found in all age groups

Clinical inflammation signs

Sometimes lacking (especially in patientswith localized aggressive periodontitis)

Commensurate with amount of etiological factors present

Diagnostic Criteria for Localized and Generalized Aggressive Periodontitis

Criterion Localized Aggressive Periodontitis

Generalized Aggressive Periodontitis

Age of onset Circumpubertal Most often <30 years of age, but can also occur in older individuals

Serum antibody response against infecting agents

Robust Poor

Destruction pattern Localized attachment loss at incisors and first molars;interproximal attachment loss at two or more permanentteeth, one of which is a first molar, and involvement oftwo or fewer teeth other than the first molars and incisors

Generalized interproximal attachment lossat three or more permanent teeth otherthan the first molars and incisors

Additional Episodic nature of attachment loss

05/01/2023

15

Assessment of Radiographic Presentation

Radiographic evidence of periodontal bone loss is a very specific but not very sensitive diagnostic sign of periodontitis.

The vertical loss of alveolar bone around the first molars and incisors, which begins around puberty in otherwise healthy teenagers, is a classic diagnostic sign of LAP.

Radiographic findings may include an “arc-shaped loss of alveolar bone extending from the distal surface of the second premolar to the mesial surface of the second molar.”

Bone defects are usually wider than those that are usually seen with chronic periodontitis.

05/01/2023 16

Possible reasons for Localized distribution of AP After initial colonization of the first permanent teeth

to erupt, Aa evades the host defenses by different mech’ms, including production of PMNs chemotaxis inhibiting factor, endotoxin, collagenases, leukotoxin and other factors that allow bacteria to colonize the pocket and initiate the destruction of periodontal tissues. After the initial attack , adequate immune responses is stimulated to produce opsonic antibodies to enhance the clearance and phagocytosis of invading bacteria and neutralize the leukotoxic activities. Hence, colonization of other sites may be inhibited

initial colonization of the first permanent teeth

Aa evades the host defenses by production of PMNs chemotaxis inhibiting factor, endotoxin,

collagenases, leukotoxin

colonize the pocket and initiate the destruction of periodontal tissues

adequate immune responses is stimulated to produce opsonic antibodies

colonization of other sites may be inhibited

Possible reasons for Localized distribution of AP

Bacteria antagonistic to Aa colonize the periodontal tissues and inhibit Aa from further colonization

Aa may lose its leukotoxin producing ability for unknown reason

Defect in cementum formation may be responsible for the localization of these lesions

Therapeutic Modalities Early detection is critically important in

the treatment of aggressive periodontitis Because preventing further destruction is

often more predictable than attempting to regenerate lost supporting tissues.

At the initial diagnosis it is helpful to obtain any previously taken radiographs to assess the rate of progression of the disease

Therapeutic Modalities Educate the patient about the disease,

including the causes and the risk factors for disease

Stress the importance of the patient’s role in the success of treatment

Educating family members is another important factor because aggressive periodontitis is known to have familial aggregation

Therapeutic Modalities Family members, especially younger

siblings, of the patient diagnosed with aggressive periodontitis should be Examined for signs of disease Educated about preventive measures Monitored closely

Conventional Periodontal Therapy Conventional periodontal therapy for

aggressive periodontitis consists of Patient education Oral hygiene improvement Scaling and root planing Regular (frequent) recall maintenance

Response of aggressive periodontitis to conventional therapy alone has been limited and unpredictable

Conventional Periodontal Therapy Teeth with moderate to advanced

periodontal attachment loss and bone loss often have a poor prognosis

Some of these teeth should be extracted Some teeth may be pivotal to the

stability of that individual’s dentition It may be desirable to attempt treatment

to maintain them

Conventional Periodontal Therapy Treatment options for teeth with deep

periodontal pockets and bone loss may be nonsurgical or surgical

Surgery may be purely resective, regenerative, or a combination of these approaches

Surgical Resective Therapy. Can be effective to reduce or eliminate

pocket depth in patients with aggressive periodontitis

If a significant height discrepancy exists between the periodontal support of the affected tooth and the adjacent unaffected tooth gingival transition (following the bone) will often

result in deep probing pocket depth around the affected tooth despite surgical efforts

Surgical Resective Therapy. Important to realize the limitations of

surgical therapy and to appreciate the possible risk that surgical therapy may further compromise teeth that are mobile because of extensive loss of periodontal support

In a patient with severe horizontal bone loss, surgical resective therapy may result in increased tooth mobility and a nonsurgical approach may be indicated

Regenerative Therapy Intrabony defects, particularly vertical

defects with multiple osseous walls, are often amenable to regeneration with these techniques

Periodontal regenerative procedures have been successfully demonstrated in patients with localized aggressive periodontitis in some clinical case reports

Regenerative Therapy Although the potential for regeneration

in patients with aggressive periodontitis appears to be good, expectations are limited for patients with severe bone loss

This is especially true if the bone loss is horizontal and if it has progressed to involve furcations.

Regenerative Therapy

Facial view of the circumferential osseous defect around the lower right lateral incisor during open flap surgery

Facial view of reentered surgical site 1 year after treatment.Bone fill around all surfaces

Regenerative Therapy

Periapical radiograph of the right lateral incisor at the initial diagnosis

Periapical radiograph taken 1 year after regenerative therapy.

Antimicrobial Therapy. The presence of periodontal pathogens,

specifically Aggregatibacter actinomycetemcomitans, has been implicated as the reason that aggressive periodontitis does not respond to conventional therapy alone

Use of systemic antibiotics was thought to be necessary to eliminate pathogenic bacteria (especially A. actinomycetemcomitans) from the tissues

Antimicrobial Therapy. Systemic antimicrobials in conjunction

with scaling and root planing offer benefits over scaling and planing alone in terms of clinical attachment level, probing pocket depth, and reduced risk of additional attachment loss

Herrera et al

Antimicrobial Therapy. Systemic use of combined amoxicillin and

metronidazole as an adjunct to scaling and root planing for the treatment of generalized aggressive periodontitis showed significant clinical attachment gain (p < 0.05) and pocket reduction (p < 0.05) as compared to scaling and root planing alone

Sgolastra et al

Antimicrobial Therapy. Genco et al treated localized aggressive

periodontitis patients with scaling and root planing plus systemic administration of tetracycline (250 mg, four times daily for 14 days every 8 weeks)

Postoperative radiographs ofthe patient A, November 6,1981; B, March 3, 1982

Treatment consisted of oral hygiene instruction, scaling and root planing concurrently with 1 g oftetracycline per day for 2 weeks, and modifiedWidman flaps

Antimicrobial Therapy. Numerous studies support the use of

adjunctive tetracycline along with mechanical debridement for the treatment of A. actinomycetemcomitans–associated aggressive periodontitis

Possible emergence of tetracycline-resistant A. actinomycetemcomitans, there is concern that tetracycline may not be effective

In these cases the combination of metronidazole and amoxicillin may be advantageous

Antimicrobial Therapy. Criteria for selection of antibiotics are not

clear

Good clinical and microbiologic responses have been reported with several individual antibiotics and antibiotic combinations

In practice, antibiotics are often used empirically without microbial testing

Antimicrobial Therapy.

Local Delivery Primary advantage

Smaller total dosages of topical agents can be delivered inside the pocket

Avoiding the side effects of systemic antibacterial agents while increasing the exposure of the target microorganisms to higher concentrations

More therapeutic levels, of the medication.

Full-Mouth Disinfection The concept was described by Quirynen et al Consists of full-mouth debridement completed

in two appointments within a 24-hour period Tongue is brushed with a chlorhexidine gel

(1%) for 1 minute Mouth is rinsed with a chlorhexidine solution

(0.2%) for 2 minutes Periodontal pockets are irrigated with a

chlorhexidine solution (1%)

Treatment Planning and RestorativeConsiderations

Successful management of patients with aggressive periodontitis must include tooth replacement as part of the treatment plan

Overall treatment success for the patient may be enhanced if severely compromised teeth are extracted

Retention of severely diseased teeth over time may result in additional bone loss

Use of Dental Implants use of dental implants was suggested

and implemented with much caution because of an unfounded fear of bone and implant loss

evidence appears to support the use of dental implants in patients treated for aggressive periodontal disease

it is possible to consider the use of dental implants in the overall treatment

Periodontal Maintenance When patients with aggressive

periodontitis are transferred to maintenance care, their periodontal condition must be stable

Frequent maintenance visits appear to be one of the most important factors in the control of disease and the success of treatment

Periodontal Maintenance The duration between these recall visits

is usually short during the first period after the patient’s completion of therapy, generally no longer than 3-month intervals

Monitoring as frequently as every 3 to 4 weeks may be necessary when the disease is thought to be active

Thank you