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
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
29.
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
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
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
Editor's Notes
“Aggressive periodontitis” defined as comprises 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
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 (i.e., the rate of disease progression and other features) rather than their (still partially unknown) etiology
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 (i.e., not suffering from any systemic disease or condition that could be responsible for the present periodontitis)
The presence of familiar aggregation
Workshop defined several secondary features that are generally found in aggressive periodontitis cases but that are not universally necessary to diagnose the disease entity:
1. Inconsistency of the low amounts of present etiological factors (i.e., plaque) and the observed pronounced tissue destruction
2. Strong colonization by Aggregatibacter actinomycetemcomitans and, in some populations, Porphyromonas 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
Early detection is critically important in the treatment of aggressive periodontitis (generalized or localized)
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
One of the most important aspects of treatment success is to educate the patient about the disease, including the causes and the risk factors for disease, and to 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
Conventional periodontal therapy for aggressive periodontitis consists of patient education, oral hygiene improvement, scaling and root planing, and regular (frequent) recall maintenance. It may or may not include periodontal flap surgery
Unfortunately, the response of aggressive periodontitis to conventional therapy alone has been limited and unpredictable
Teeth with moderate to advanced periodontal attachment loss and bone loss often have a poor prognosis and pose the most difficult challenge
some of these teeth should be extracted; however, other teeth may be pivotal to the stability of that individual’s dentition, and thus it may be desirable to attempt treatment to maintain them
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 that is difficult to manage, and a nonsurgical approach may be indicated
Numerous studies support the use of adjunctive tetracycline along with mechanical debridement for the treatment of A. actinomycetemcomitans–associated aggressive periodontitis
Given the 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
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
The primary advantage of local therapy is that 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, and therefore more therapeutic levels, of the medication.
Successful management of patients with aggressive periodontitis must include tooth replacement as part of the treatment plan
In some advanced cases of aggressive periodontitis, the 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 and teeth that are further compromised
Initially, the use of dental implants was suggested and implemented with much caution in patients with aggressive periodontitis because of an unfounded fear of bone and implant loss
However, evidence to the contrary appears to support the use of dental implants in patients treated for aggressive periodontal disease
Thus it is possible to consider the use of dental implants in the overall treatment plan for patients with aggressive periodontitis.
When patients with aggressive periodontitis are transferred to maintenance care, their periodontal condition must be stable (i.e., no clinical signs of disease and no periodontal pathogens)
Each maintenance visit should consist of a medical history review, an inquiry about any recent periodontal problems, assessment risk of factors, a comprehensive periodontal and oral examination, thorough root debridement, and prophylaxis, followed by a review of oral hygiene instructions.