Aggressive Periodontitis

Question 8. Define aggressive periodontitis. Discuss in detail about microbiology, clinical features, radiographic features and management of aggressive periodontitis.
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Write short note on aggressive periodontitis.
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Write short note on clinical and radiographic features of aggressive periodontitis.
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Discuss the etiology, clinical features and treatment of aggressive periodontitis.

Answer. Aggressive periodontitis is defined as a disease of periodontium occurring in an otherwise healthy adolescent which is characterized by rapid loss of alveolar bone but more than one tooth of permanent dentition. The amount of destruction present does not commensurate with the amount of local irritants.

Microbiology/Etiology

Localized Aggressive Periodontitis

• A. actinomycetemcomitans is a Gram-negative, facultative, non-motile, capnophilic, short coccobacilli which strongly caused strongly causing localized aggressive periodontitis. It is the key microorganism. There are fie sterotype antigen may be related to specificc sites of infection. Five sterotypes i.e. a, b, c, d, e of A. actinomycetemcomitans are identifid in localized aggressive periodontitis.
• Gram-positive organisms such as streptococci, actinomyces and peptostreptococci.
• Capnocytophaga species are seen.
• Campylobacter rectus
• Fusobacterium nucleatum
• Eikenella corrodens are also seen.
• P. gingivalis: It is the main organism associated with
• localized aggressive periodontitis
• Spirochetes
• Viruses: Cytomegalovirus, Epstein-Barr Virus

Generalized Aggressive Periodontitis

• P. gingivalis
• Aggregatibacter actinomycetemcomitans
• Tannerella forsythia

Aggressive Periodontitis Clinical Features

Read And Learn More: Periodontics Question And Answers

• Age and sex distribution: Both the sexes with female predilection from puberty to 20 years of age.
• Distribution of lesion: Three areas of localization of bone loss has been described.
  • 1st molar or incisor.
  • 1st molar or Incisor + Additional teeth not exceeding 14 teeth.
  • Generalized involvement.
• For localized Juvenile periodontitis classical distribution in the first molar and the incisors, with least destruction in cuspid and premolar area.
• Most striking feature is lack of clinical inflammation with presence of deep periodontal pocket.
• Formation of plaque which really mineralize to become calculus.
• Most common initial symptoms are movability and migration of 1st molar and incisors.
• As disease progress other symptom like root surface sensitivity, dull radiating pain, periodontal abscess formation and lymph node enlargement may occur.
• Presence of distolabial migration of maxillary incisors resulting in diastema formation.
• There is increase in the mobility of maxillary and mandibular incisors as well as first molars.
• There is presence of deep, dull radiating pain at the time of mastication due to irritation of supporting structures by mobile teeth and impacted food. Now the periodontal abscess may form and regional lymph node enlargement can occur.
• Patient may complaint of sensitivity of denuded root surfaces to thermal as well as tactile stimuli.
• In various cases of localized aggressive periodontitis, disease appears to be self limiting. Attachment loss and bone destruction do not spread to other teeth. This phenomenon of self limiting activity along with advanced age is known as Burn out phenomenon.
• Isolated areas of attachment loss in otherwise healthy dentitions including recession associated with traumatic injuries, tooth position, impacted third molars, endodontic infection, root fractures, subgingival caries and subgingival restorations.

Generalized Aggressive Periodontitis

• Age and sex distribution: It affects person between puberty and 30 years, no sex discrimination.
• No specific pattern, all or most of the teeth are affected.
• Two types of gingival responses are seen, i.e. one is severe; acutely inflamed tissue which is often proliferating, ulcerated and fiery red, spontaneous bleeding and suppuration are commonly seen. In other cases, gingival tissue may appear pink and free of inflammation but deep pockets are seen by probing.
• Some of the persons may have systemic manifestations such as weight loss, mental depression and general malaise.
• Presence of poor serum antibody response.

Aggressive Periodontitis Radiographic Features

Localized Aggressive Periodontitis

• Vertical or angular bone loss around the 1st molar and incisors.
• Presence of ‘arc-shaped’ alveolar bone loss around first molars which extend from distal surface of second premolar to mesial surface of second molar. So, the bilateral “arc shaped’ bone loss is the mirror image and is characteristic of localized aggressive periodontitis.
• Presence of widening of periodontal ligament.

Generalized Aggressive Periodontitis

Radiographic picture can range from severe bone loss associated with the minimal number of teeth, to advanced bone loss affecting the majority of teeth in the dentition.

Management/Treatment of Aggressive Periodontitis

Treatment for aggressive periodontitis is divided into two categories, i.e. nonsurgical and surgical.

Nonsurgical Treatment

• Phase 1 therapy
  • Educate and motivate the patient.
  • Oral hygiene instructions are given to the patient and counseling of the family members should be done.
  • Scaling and root planning should be done.
  • Anatomical factors should be corrected and occlusal adjustment should be done if needed.
  • Recall appointments should be kept for maintenance.
• Full mouth disinfection
  • Full mouth scaling and root planning (two visits under 24 hours)
  • Dorsum of tongue should be brushed by the patient for 60 seconds with 1% chlorhexidine gel.
  • Peritonsillar region should be sprayed by chlorhexidine for two times a day.
  • 1% of chlorhexidine should be applied subgingivally in full depth of periodontal pockets till 10 minutes.
  • Mouth should be rinsed by 0.2% chlorhexidine mouthwash for 2 minutes.
• Antibiotic therapy
  • Doxycycline 100 mg twice daily for 14 days is given in conjunction with periodontal therapy.
  • Metronidazole 200 mg thrice daily for 10 days is given in combination with scaling and root planning.
  • Combination of metronidazole 250 mg and amoxicillin 250mg three times a day for 7 days along with surgical therapy show promising results.
• Local drug delivery system: In this small total doses of topical agents are delivered inside the pocket, thereby avoiding the side effects of systemic anti – bacterial agents. Additional direct delivery enhances the exposure of target microorganism to higher concentration and subsequently gives more therapeutic outcomes. Various local drug delivery agents are formulated in form of solutions, gels, chips and fibers.
• Host Modulation: Agents are administered which modulate the host response towards the disease. Administration of subantimicrobial – dose doxycycline may help to prevent periodontal tissue destruction by controlling action of matrix metalloproteinases.
• Photodynamic therapy: It eradicates the target cells i.e. periodontal pathogens by reactive oxygen particles produced by photosensitizing compounds.

Surgical Therapy

• Modified Widman flap surgery can be done along with systemic tetracycline therapy.
• Regenerative procedures i.e.
  • Flap surgery + bone graft +antibiotic therapy + maintenance therapy
  • Flap surgery + bone graft + GTR membrane + antibiotics + maintenance therapy
• Root resection or hemisection of affected first molar tooth, depending on the indication.
• Autotransplantation i.e. extraction of involved mandibular first molar and autotransplantation of incompletely erupted third molar in socket.
• Extraction of hopeless teeth.
• Implant therapy is a good option in such cases.

Periodontal Maintenance Care

• Recall visits should be kept frequently.
• In every 3 to 4 months, a medical history review, periodontal and oral examination, scaling and root planning and last but not the least reinforcement of oral hygiene instructions.