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
2/1/2017
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
1. The rapid loss of attachment and tooth-
supporting bone
2. The subject is otherwise healthy
3. 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

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.
2/1/2017
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.
2/1/2017 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. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

30. 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.

31. 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

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

33. 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

34. 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

35. 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

36. 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)

37. 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

38. 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

39. 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

40. Antimicrobial Therapy.

41. 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.

42. 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%)

43. 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

44. 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

45. 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

46. 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