Aggressive periodontitis

it is a lecture prepared by me for BDS students

1. Aggressive Periodontitis Dr. LB Kamait Dept of periodontlogy & Oral Implantology

2. Contents Introduction Classification and Clinical Characteristics Diagnostic Criteria for Chronic periodontitis and Aggressive Periodontitis Diagnostic Criteria for Localized and Generalized Aggressive Periodontitis Therapeutic Modalities

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 1/12/2016 3

4. 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

5. 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 features The rapid loss of attachment and tooth-supporting bone The subject is otherwise healthy The presence of familiar aggregation

6. 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

7. 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 destruction 2. Strong colonization by A. actinomycetemcomitans and , in some populations, P. gingivalis 3 . Immunological differences that do not entail the diagnosis of periodontitis as a manifestation of systemic disease a. Hyperresponsive macrophages b. Abnormalities of neutrophil function 4. Self-limiting disease

8. Subgroups Localized Generalized

9. Generalized Aggressive periodontitis Clinical views with minimal amounts of calculus and plaque

10. Generalized Aggressive periodontitis Radiographically , bone loss of 50% or more was present at all teeth

11. Localized aggressive periodontitis Clinical view showing minimal plaque and inflammation Surgical appearance of the localized, vertical, angular bony defects affecting the mandibular incisors

12. 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

13. Diagnostic Criteria Criterion Aggressive Periodontitis Chronic Periodontitis Rate of progression Rapid Slow, but rapid episodes are possible Familiar aggregation Typical Can be present when families share imperfect oral 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 patients with localized aggressive periodontitis) Commensurate with amount of etiological factors present

14. 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 permanent teeth , one of which is a first molar, and involvement of two or fewer teeth other than the first molars and incisors Generalized interproximal attachment loss at three or more permanent teeth other than the first molars and incisors Additional Episodic nature of attachment loss

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. 1/12/2016 15

16. 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. 1/12/2016 16

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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 .

29. 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

30. Regenerative Therapy Periapical radiograph of the right lateral incisor at the initial diagnosis Periapical radiograph taken 1 year after regenerative therapy.

31. 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

32. 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

33. 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

34. 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 )

35. 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

36. 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

37. 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

38. Antimicrobial Therapy.

39. 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.

40. 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 %)

41. Treatment Planning and Restorative Considerations 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

42. 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

43. 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

44. 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

45. Thank y ou