Generalized Aggressive Periodontitis

Generalized Aggressive Periodontitis

Classify periodontitis. Describe the etiology, clinical features, radiographic appearance and management of generalized aggressive periodontitis.
Answer.

Classification of Periodontitis

• Chronic Periodontitis
  • Localized: Less than 30% of sites involved.
  • Generalized: More than 30% of sites involved.
  • Slight: 1–2 mm clinical attchment loss.
  • Moderate: 3–4 mm clinical attchment loss.
  • Severe: More than 5 mm clinical attchment loss.

Read And Learn More: Periodontics Question And Answers

“Understanding the role of rapid bone loss in aggressive periodontitis”

• Aggressive Periodontitis
  • Localized: Slight, moderate or severe.
  • Generalized.
• Periodontitis as a Manifestation of Systemic Diseases
  • Associated with hematological disorders:
    • Acquired neutropenia.
    • Leukemias.
    • Others.

“Importance of studying generalized aggressive periodontitis for dental professionals”

• • Associated with genetic disorders:
    • Familial and cyclic neutropenia.
    • Down syndrome.
    • Leukocyte adhesion defiiency syndrome.
    • Papillon-Lefévre syndrome.
    • Chèdiak-Higashi syndrome.
    • Histiocytosis syndrome.
    • Glycogen storage disease.
    • Infantile genetic agranulocytosis.
    • Cohen syndrome.
    • Ehlers-Danlos syndrome (Types 4 and 8).
    • Hypophosphatasia.
    • Others.
• Necrotizing Periodontal Diseases
  • Necrotizing ulcerative gingivitis.
  • Necrotizing ulcerative periodontitis.
• Abscesses of the Periodontium
  • Gingival abscess.
  • Periodontal abscess.
  • Pericoronal abscess.
• Periodontitis Associated with Endodontic Lesions
  • Combined periodontic-endodontic lesions.
• Developmental or Acquired
  • Deformities and Conditions:
    • Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis:
      • Tooth anatomic factors.
      • Dental restorations/appliances.
      • Root fractures.
      • Cervical root resorption and cemental tear.

“Common challenges in diagnosing generalized aggressive periodontitis”

• • • Mucogingival deformities and conditions around teeth:
      • Gingival/soft tissue recession, facial or lingual surfaces, interproximal (papillary).
      • Lack of keratinized gingiva.
      • Decreased vestibular depth.
      • Aberrant frenum/muscle position.
      • Gingival excess:
        • Pseudopocket
        • Inconsistent gingival margin
        • Excessive gingival display
        • Gingival enlargement.
      • Abnormal color.

“Signs of generalized aggressive periodontitis in early stages”

• • • Mucogingival deformities and conditions on edentulous ridges:
      • Vertical and/or horizontal ridge deficiency.
      • Lack of gingival/keratinized tissue.
      • Gingival/soft tissue enlargement.
      • Aberrant frenum/muscle position.
      • Decreased vestibular depth.
      • Abnormal color.
    • Occlusal trauma:
      • Primary occlusal trauma.
      • Secondary occlusal trauma.

Generalized Aggressive Periodontitis

Generalized aggressive periodontitis is characterized by “generalized interproximal attachment loss affecting atleast three permanent teeth other than first molars and incisors”.

Generalized Aggressive Periodontitis Etiology

Patients with generalized aggressive form may exhibit minimum amount of microbial plaque associated with the affected teeth, i.e. quantitatively the amount of plaque seems to be inconsistent with amount of periodontal destruction; qualitatively most pathogenic organisms are associated, i.e. Porphyromonas gingivalis, A. actinomycetemcomitans and Bacteroides forsythus.

“Role of rapid attachment loss in diagnosing generalized aggressive periodontitis”

Generalized Aggressive Periodontitis Clinical Features

• It affects the individuals under the age of 30 years but older patients may also be affected.
• Two types of gingival responses are seen, i.e. one is severe, acutely inflamed tissue, oftn proliferating, ulcerated and firy red. Bleeding may occur spontaneously or with slight stimulation. The tissue response is believed to occur in destructive stage in which attchment and bone are actively lost. In other cases, gingival tissues may appear pink, free of inflammation and occasionally some degree of stippling along with deep pockets. Tissue response coincides with periods of quiescence in which bone level remain stationary.
• Presence of generalized interproximal attchment loss affecting at least three permanent teeth other than first molar and incisor.
• Some of the patients show systemic manifestations such as weight loss, mental depression and general malaise.

Generalized Aggressive Periodontitis Radiographic Appearance

Radiographic picture ranges from severe bone loss associated with minimum number of teeth to advance bone loss affecting majority of teeth in dentition.

Generalized Aggressive Periodontitis Management

Treatment for generalized aggressive periodontitis is divided into two categories i.e. non-surgical 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.

“Biomechanics of tissue destruction explained”

• 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 100mg twice daily for 14 days is given in conjunction with periodontal therapy.
  • Metronidazole 200mg thrice daily for 10 days is given in combination with scaling and root planning.
  • Combination of metronidazole 250mg and amoxicillin 250mg three times a day for 7 days along with surgical therapy show promising results.

“Comparison of localized vs generalized aggressive periodontitis”

• 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

“Asymptomatic vs symptomatic effects of prolonged treatment”

• Root resection or hemisection of the 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.