Eliminating risk factors
Aggressive periodontitis is a rapidly destructive but less common form of periodontitis than chronic periodontitis (Fig 1). The aetiology is multifactorial including:
• The constituents and virulence of microbial plaque
• Host defence defects
• Genetic elements.
A new classification system for periodontal diseases was published in Annals of Periodontology in 1999 and designated a localised and a generalised form, which replace earlier classifications which placed too much emphasis on age presentation. Instead, the focus is on:
• Clinical findings
• Radiographic findings
• Historical findings
• Laboratory findings.
Clinical signs and symptoms
There is no direct correlation between the amount of bacterial deposit and severity of destruction. Likewise, disease progression is not linear and attachment or bone loss may spontaneously accelerate or slow down. The tissues may look relatively normal or only mildly inflamed until periodontal examination or radiographs reveal the severity and extent of the problem. (Fig 2) In other cases the appearance can show obvious clinical evidence of the disease.
Localised aggressive perio-dontitis (formerly known as juvenile periodontitis)
This periodontal disease is often associated with the presence of Actinobacill- usactinomycetemcomitans and with neutrophil dysfunction. Onset generally occurs around puberty and destruction is localised to permanent first molars and incisors. However, atypical forms of the disease do exist. Serum analysis shows evidence of an intense primary antibody response to bacterial infection.
Generalised aggressive periodontitis (formerly known as rapidly progressing periodontitis)
This form of periodontal disease usually occurs in subjects younger than 30 years of age. (Fig 3 and Fig 4) Proximal attachment losses occur during periods of disease activity and involve at least three permanent teeth, other than the first molars and incisors. A. actinomycetemcomitans and Porphyromonasging-ivalis are frequently involved. There is also evidence of abnormal neutrophil function. However, antibody response has been shown to be weak.
Treatment aims at attenuating or eliminating microbial aetiologic factors as well as modifying predisposing risk factors. This helps in arresting disease progression and contributes to prevention of disease recurrence.
Management of aggressive periodontitis may be difficult or even impossible. This may be due to:
• Systemic factors
• Immune dysfunction
• Specific pathogenic flora.
Treatment methods are the same as those used in chronic forms of periodontitis. In some cases, however, the main treatment goal is simply to limit the rate of disease progression.
Medical screening is sometimes advised to rule out systemic disease; this is especially the case in younger patients presenting with advanced forms of periodontitis who respond poorly to perio-dontal treatment. In these cases the dentist should collaborate closely with the doctor. This may modify some of the environmental risk factors.
Conventional mechanical treatment alone does not usually allow for satisfactory control of disease progression. Adjunct antimicrobial therapy eventually followed by surgery is therefore indicated. Long-term results depend on patient compliance and an appropriately scheduled supportive therapy regimen.
Various antibiotic regimes have been supported in the literature (tetracycline 250mg four times a day for 14 days; doxycycline 200mg loading dose, then 100mg daily for 13 days), but the following has particular efficacy against A. actinomycetemcomitans: Metronidazole 200mg or 400mg and amoxicillin 250mg or 500mg three times a day for seven to 10 days
When deciduous teeth are involved, eruption of permanent teeth should be monitored to detect attachment loss. When there is evidence of familial predisposition to aggressive periodontitis screening of other family members is advised.
Conditions for success
Treatment of patients suffering from aggressive periodontitis should aim to:
• Reduce clinical signs of gingival inflammation
• Reduce probing depth
• Stabilise or gain clinical attachment
• Establish evidence of bone repair through radiographic evaluation
• Improve occlusal stability
• Reduce clinically detectable plaque to a level compatible with periodontal health.
These conditions may not be attained if:
• Gingival inflammation persists
• Periodontal pockets persist or aggravate
• There is progressive loss of clinical attachment
• Tooth mobility increases
Severity and risk factors
Risk factors for aggressive periodontitis include excessive build-up of bacterial plaque, presence of specific bacterial strains or deleterious host response, tobacco use and systemic disease.
Severity is linked to these different parameters but as with chronic periodontitis, locally aggravating factors (dental, periodontal, functional or iatrogenic) are often involved.
Several factors may account for an altered host response:
• Neutrophil dysfunction
• Genetic predisposition
• Hormonal imbalance
• Nutritional deficiency.
The treatment goal is to reduce or eliminate risk factors.
About the author
Dr Alan Maxwell MSc BDS MGDS RCS (Edin)
Alan is a specialist in periodontics. He graduated from the University of Glasgow Dental School in 1982 and subsequently obtained his MGDS from the Royal College of Surgeons in Edinburgh in 1990. After obtaining his MSc in periodontology in 1997 at the University of Bristol he was accepted onto the specialist register in periodontics in 2000.
Dr Maxwell now works full-time as a periodontal specialist undertaking all aspects of treatment within his field, with a major focus on regenerative therapy and cosmetic periodontal surgery. Part of that time is spent working for Care Dental Focus in Crieff (01764 655 745).
He is a member of the British Society of Periodontology and has had his work published regularly in a number of leading dental journals. Alan also previously served as an examiner with the Royal College of Surgeons in Edinburgh and lectures to general dental practitioners on a regular basis. Alan would be glad to assess and treat any of your periodontal referrals.
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