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Periodontology 2000, Vol.

53, 2010, 154166  2010 John Wiley & Sons A/S


Printed in Singapore. All rights reserved PERIODONTOLOGY 2000

Response of chronic and


aggressive periodontitis to
treatment
D A V I D E. D E A S & B R I A N L. M E A L E Y

In the late 1980s one of our residency mentors envi- Diagnosis and prognosis
sioned a day when a combination of clinical indices,
microbiologic sampling and antibody profiles would Establishing a diagnosis based on disease type,
both indentify and direct the treatment of specific extent, location and severity is an essential first step
periodontal diseases. Even though our knowledge in treatment, and the steps do not differ markedly
base has expanded significantly in the ensuing years, regardless of whether the patient has chronic perio-
this has clearly not yet happened. dontitis or aggressive periodontitis. Although little
The classification scheme introduced in 1999 listed has been written about prognostic factors in aggres-
chronic periodontitis and aggressive periodontitis sive disease (28), persistent deep pockets, loss of
as two of the major forms of periodontal disease attachment, mobility, furcation invasion, suppura-
(1); but separating diseased patients into these two tion, plaque, calculus and other factors such as root
groups based on this classification can be a sub- grooves, cervical enamel projections, root fractures
jective task. On initial presentation the two diseases and poor restorations can help clinicians to predict
share a number of clinical, microbiological and host the outcome of both diseases. The extent of attach-
response features (37, 56). Even though genetic test- ment loss in a patient with aggressive periodontitis
ing and cytokine monitoring have opened new diag- may negatively influence the prognosis, but this may
nostic vistas, it is still not always easy to identify one be somewhat counterbalanced by a desire to go to
disease from the other or to use these tests to predict additional lengths not to extract teeth in younger
treatment outcome (28). patients.
It can also be argued that because aggressive These tooth-level factors are used in the formula-
periodontitis, although not rare, is a fairly uncommon tion of prognosis in conjunction with a number of
condition, little is known about its optimal manage- subject-level factors, including smoking, genetic
ment. Protocols for treating chronic periodontitis are predisposition, age, gender, race and contributing
fairly well established. Protocols for treating aggres- medical conditions. This is appropriate regardless of
sive periodontitis are largely empirical and have been whether the potential outcome variable is tooth loss
subjected to few well-controlled comparative studies or a surrogate variable such as probing depth or
(72). In this section, we will focus on the response of attachment loss (64). The relative value of these
aggressive periodontitis to treatment, using as subject-level factors becomes more important if one
comparison the response to treatment of chronic considers that tooth-level indicators, such as bleed-
periodontitis, about which much more is known. To ing on probing, have in some studies shown a greater
avoid confusion, the most current terminology for association with future attachment loss at a subject
both disease categories and pathogenic bacteria will level rather than at a site level (32).
be used, even though different terms were often used Smoking, in particular, has been shown to be an
in the specific articles cited. important subject-level prognostic factor in aggres-
sive periodontitis. In two separate studies of non-
The opinions expressed in this article are those of the authors and
surgical therapy, smokers with aggressive periodontal
are not to be construed as official or as representing the views of the disease responded significantly less well to treatment
United States Air Force or the Department of Defense. than nonsmokers. Combining the results of these two

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Response of chronic and aggressive periodontitis to treatment

studies, smokers with aggressive periodontitis were comprehensive meta-analysis of nonsurgical treat-
3.8 times more likely to have 30% of sites not ment reported that following scaling and root planing
responding to treatment, as well as higher levels of at sites with probing depths of 46 mm, clinicians
Prevotella intermedia and Tannerella forsythia after should expect a mean reduction in probing depth of
treatment (10, 28). approximately 1 mm and a gain of clinical attach-
In general, it is likely that risk factors have similar ment level of approximately 0.5 mm. In deeper sites
long-term influences on both chronic periodontitis (probing depth 7 mm), the reduction in probing
and aggressive periodontitis, although one could ar- depth averages approximately 2 mm and the gain in
gue that with younger patient age and greater initial clinical attachment level averages about 1 mm (29).
attachment loss they may dictate a poorer long-term The added effect of adjunctive antibiotic therapy has
prognosis in aggressive disease (64). Regardless, been found to be modest, but statistically significant,
modulating and correcting these risk factors are with an additional 0.20.6 mm decrease in probing
critical in the treatment of both chronic periodontitis depth and 0.10.2 mm gain of clinical attachment
and aggressive periodontitis. level over scaling and root planing alone (9, 24, 29).
This leads to a point that we feel must be stressed. The bacterial response following treatment is also
Every periodontist has had treatment success in pa- fairly consistent following scaling and root planing in
tients with an initially poor overall prognosis. These chronic periodontitis. Immediately after subgingival
cases may involve strategic extractions, nonsurgical scaling there is a significant decrease in the number
and or surgical therapy, oftentimes a complex of gram-negative organisms that include numerous
restorative phase and always a strict maintenance periodontal pathogens, along with an increase in the
regimen. We know through such cases that even the number of gram-positive cocci. This new microbiota
most advanced or aggressive disease can be treated remains established for approximately 48 weeks
successfully. Although it is impossible to determine a before returning to baseline by 1224 weeks (5).
common thread between these cases, it is likely that Depending on the regimen, adding antibiotics to the
most of them had at their core a highly motivated treatment may further suppress the pathogenic
patient. Therefore, the treatment plan presentation microbiota and delay the return to baseline (5).
should include a very frank discussion with the pa- Overall, although local and systemic antibiotics may
tient about the severity of the condition, the odds of slightly improve clinical parameters over nonsurgical
success and the requirement for near-perfect com- therapy alone, there is general consensus that the use
pliance with plaque control, management of modi- of antibiotics in chronic periodontitis should be
fiable risk factors and maintenance. reserved for those patients and sites that do not
Just as essential for success is a clinician who is respond to conventional treatment (5, 19, 20, 24, 26,
comfortable in helping patients to control risk factors 69).
(39). The therapist who is confident in ordering and The effects of surgical debridement as part of the
interpreting certain blood tests is likely to have more treatment of chronic periodontitis are also well doc-
influence with his patients than one who is not. umented (4, 18, 29, 33, 53). As outlined in a system-
Similarly, the therapist who cannot only inform their atic review by Heitz-Mayfield et al. (25), in pockets
patients of the dangers of smoking, but can also assist deeper than 6 mm surgical treatment resulted in an
them with smoking cessation, may have better re- additional 0.6 mm mean probing depth reduction and
sults. The patient with aggressive disease has given 0.2 mm additional attachment level gain over scaling
the clinician a difficult task with an uncertain out- and root planing alone. In 46 mm pockets, surgical
come. Both must understand from the outset that treatment gained an additional 0.4 mm decrease in
without good cooperation from the patient and probing depth, but a loss of 0.4 mm in attachment
assertive management by the clinician the treatment level beyond scaling and root planing (25).
has little chance of long-term success. More difficult to assess independently are the ad-
ded effects of regenerative techniques in treating
chronic periodontitis. Depending on the depth and
Response to therapy chronic morphology of osseous defects, the potential exists
periodontitis for greater gains in probing depth, attachment levels
and bone fill. Bone grafting with a variety of materials
The clinical response and the microbiological re- has been estimated to decrease probing depths and
sponse to nonsurgical therapy in the treatment of lead to gains in clinical attachment of 0.51 mm
chronic periodontitis have been well documented. A beyond that of surgical debridement alone (53). A

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comprehensive meta-analysis of regeneration studies curettage, selective occlusal grinding, surgery and
by Laurell et al. (40) found that guided tissue regen- oral hygiene instructions) as part of their therapy
eration generally improved attachment levels and showed improved clinical status (63). Another early
bone fill by 2.7 and 2.1 mm respectively, beyond report described aggressive occlusal or incisal
surgical debridement alone. As most studies evalu- grinding to allow the affected teeth to move occlu-
ating surgical outcomes of regeneration techniques sally, in conjunction with open flap debridement of
selected groups on the basis of defects, rather on than the periodontal defects. Three cases were shown to
disease type, it is possible that the treatment groups document the success of this approach, but it could
in these studies may also have included at least some not be determined which portion of the treatment
patients with aggressive periodontitis. regimen was responsible for the clinical improve-
ment (14).
There are few reports of nonsurgical therapy alone
Response to therapy aggressive as a treatment of localized aggressive periodontitis.
periodontitis Slots & Rosling (61) evaluated nonsurgical treatment,
as one arm of a staged combination therapy, on the
The response to periodontal treatment in aggressive clinical and microbiological parameters of 20 deep
periodontitis is much less well understood, in part pockets and 10 normal sites in six patients with
because the low prevalence of this disease makes it localized aggressive periodontitis. Upon re-evalua-
difficult to recruit sufficient numbers of patients for tion, the combination of oral hygiene instructions,
controlled clinical trials of different treatment along with subgingival scaling and root planing, re-
modalities (72). Also at this point we must distinguish duced, but did not eliminate, the number of spiro-
the treatment response between localized aggressive chetes, Aggregatibacter actinomycetemcomitans and
periodontitis and generalized aggressive periodonti- Capnocytophaga species and resulted in a small
tis. This is partly because the two types of peri- improvement in post-treatment probing depths. A
odontitis respond somewhat differently to treatment similar treatment approach carried out by Kornman
and partly because the literature usually reports on & Robertson (38), in a group of eight patients with
one group or the other. localized aggressive periodontitis, evaluated scaling
It is also interesting to consider the way in which and root planing alone as the first stage in a treat-
the two types of aggressive disease respond to no ment protocol where success was based on
treatment. Gunsolley et al. (23) examined 327 pa- improvement in clinical and microbiologic parame-
tients with either localized aggressive periodontitis or ters. They found that scaling and root planing alone
generalized aggressive periodontitis as part of a study resulted in essentially no improvements in either
of families with early onset disease. Following base- pocket depths or in the percentage of culturable
line examination of clinical indices, patients were microbiota composed of black-pigmented Bactero-
advised to have follow-up treatment. At a 15-year ides species, surface translocating bacteria or A. ac-
follow-up, 88 of these patients were re-examined: 47 tinomycetemcomitans.
of them had received treatment and 41 had not. The In contrast to these findings are those reported by
authors reported that while untreated sites in Gunsolley et al. (23), mentioned above. These au-
patients with localized aggressive periodontitis thors reported that patients with localized aggressive
tended to stabilize over time, untreated sites in periodontitis who received treatment showed a gain
patients with generalized aggressive periodontitis in periodontal attachment over the 15-year period
showed increasing amounts of attachment loss and and that there was no difference in the response of
tooth loss. those who received scaling and root planing alone vs.
those treated surgically.
Two discoveries led to an emphasis on mechanical
Localized aggressive periodontitis
debridement supplemented with chemotherapeutic
Much of what we know about the response to agents in the treatment of localized aggressive
treatment of localized aggressive periodontitis was periodontitis. The first was when the predominant
discovered when this condition was known by other culturable microbiota of localized aggressive perio-
terminology. One early study monitored five treat- dontitis was identified and found to be susceptible to
ment groups of periodontosis patients over a 3-year tetracycline (49). The second was the finding that
treatment and follow-up period. Only the two A. actinomycetemcomitans, an important pathogen
groups that received local treatment (consisting of associated with localized aggressive periodontitis,

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Response of chronic and aggressive periodontitis to treatment

could penetrate the pocket epithelium, thus placing it antibiotic group had better improvement than con-
beyond the influence of subgingival scaling (7). trols in terms of probing depth, attachment level
In response to these findings, the focus of treat- measurements, radiographic analysis of crestal alve-
ment studies shifted to combinations of conventional olar bone mass and elimination of A. actinomyce-
therapy with systemic antibiotics. Slots & Rosling temcomitans from subgingival pockets.
(61), in the final step of their staged treatment study Not much has been published about the treatment
mentioned above, administered 1 g of tetracycline- of localized aggressive periodontitis with locally
HCl per day for 14 days following subgingival delivered antibiotics in conjunction with scaling and
debridement. The authors noted that after tetra- root planing. Mandell et al. (44) used tetracycline
cycline treatment the number of spirochetes, A. ac- fibers to treat 12 sites in four patients with localized
tinomycetemcomitans and Capnocytophaga species aggressive periodontitis. This treatment failed to
were reduced to almost undetectable levels, and that either stop the progression of attachment loss at
this corresponded to a 0.3 mm gain in attachment these sites or eliminate A. actinomycetemcomitans. It
level. They concluded that the combination of root is possible that this failure was caused by the inability
surface debridement and tetracycline was successful of tetracycline to adequately penetrate the pocket
in treating most localized aggressive periodontitis epithelium, or possibly as a result of the repopulation
sites. Similarly, Kornman & Robertson (38) reported of A. actinomycetemcomitans from other potential
that the combination of scaling and root planing plus reservoirs in the mouth (70).
tetracycline significantly improved the clinical indi- The rationale for surgery at localized aggressive
ces in three of their eight patients, obviating the need periodontitis sites is based both on the difficulty of
for surgical treatment in these patients; the other five root instrumentation in deep pockets as well as a
subjects required periodontal surgery. perceived need to remove tissue invaded by
These and other studies using the 1 g per day tet- A. actinomycetemcomitans. A variety of surgical
racycline regimen, both with (60) and without (51) techniques have been successfully utilized to treat
scaling and root planing, reported oftentimes dra- localized aggressive periodontitis, usually in combi-
matic improvements in both clinical and microbio- nation with systemic antibiotics. Kornman &
logical assessments. It was noted, however, that up to Robertson (38) reported that modified Widman flap
25% of patients treated in this manner experienced surgery and a tetracycline regimen were effective at
continued disease progression (41). This failure to treating sites with initially high levels of A. actino-
respond to treatment was linked to a growing level of mycetemcomitans and black-pigmented Bacteroides
bacterial resistance to tetracycline and other antibi- species. Lindhe & Liljenberg (42) treated 16 cases of
otics such as amoxicillin, doxycycline and minocy- localized aggressive periodontitis with a combination
cline (71). Of particular interest in treating localized of tetracycline and modified Widman flap surgery.
aggressive periodontitis was the discovery of resis- After 5 years of maintenance, they found significant
tance of A. actinomycetemcomitans to tetracycline improvements in probing depths and attachment
(55, 70). levels, and evidence of radiographic bone fill. Success
These problems with tetracycline treatment led to with other combinations of surgical debridement and
the investigation of other systemic antibiotics com- antibiotic therapy has also been reported (3, 27, 30).
bined with scaling and root planing. Saxen & Asikai- Other authors have reported success of regenera-
nen (55) divided 27 patients with localized aggressive tive techniques in the treatment of patients with
periodontitis into three groups receiving either sub- localized aggressive periodontitis. Autogenous grafts
gingival debridement alone or subgingival debride- of both osseous coagulum and frozen autogenous hip
ment in combination with 1 g of tetracycline or marrow have been utilized, as well as osseous coag-
600 mg of metronidazole per day. A. actinomyce- ulum grafts covered with soft tissue autografts (12,
temcomitans was reduced below the detection 15, 62). Yukna & Sepe (73) treated osseous defects in
threshold in all test sites in metronidazole-treated 12 patients with localized aggressive periodontitis
patients, but was found in 9 26 sites in the tetracy- using freeze-dried bone allograft in a 4:1 mixture with
cline group. Tinoco et al. (65) compared the response tetracycline powder. Following a strict 1-year main-
of an experimental group of 10 patients with localized tenance regimen, 51 of the original 62 defects were
aggressive periodontitis treated with scaling and root surgically re-entered. The authors found that the
planing plus a metronidazole amoxicillin regimen average defect fill was 80%, and bone fill of greater
vs. a similar sized control group receiving scaling and than 50% was achieved in 98% of the defects. Mabry
root planing alone. One year following treatment, the et al. (43) split 16 patients with localized aggressive

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periodontitis into two treatment groups depending expanded polytetrafluoroethylene membrane + root
on whether or not they received systemic tetra- conditioning; expanded polytetrafluoroethylene
cycline. Half of the defects in each group were treated membrane + root conditioning + composite graft)
with surgical debridement alone, while the other half followed by post-operative systemic doxycycline. In
received debridement and freeze-dried bone allo- contrast to the above studies suggesting superior re-
grafts mixed with tetracycline. The authors reported sults with regenerative procedures, the authors of this
that while grafted defects did better than debrided study reported that while all sites gained attachment
defects in both groups, the combination of graft plus and defect fill, no significant differences were noted
systemic tetracycline was the superior treatment between any of the surgical techniques.
overall.
Guided-tissue regeneration has also been success-
Generalized aggressive periodontitis
ful in treating localized aggressive periodontitis. Sir-
irat et al. (59) compared guided-tissue regeneration Our knowledge of the response of generalized
using expanded polytetrafluoroethylene membranes aggressive periodontitis to treatment is hampered by
with osseous resection in a group of six patients that several factors. As mentioned earlier, because the
included two individuals with localized aggressive prevalence of aggressive periodontitis is low, treat-
periodontitis. While both techniques demonstrated ment studies have only been able to include small
success at 1 year, the guided-tissue regeneration sites numbers of subjects, which leads to an inability to
demonstrated significantly better improvements in adequately compare multiple treatment groups. This
probing depth and attachment gain. Fritz et al. (16) may be further complicated by the fact that it can be
showed that intrabony defects in patients with extremely difficult to separate patients with general-
localized aggressive periodontitis treated with ex- ized aggressive periodontitis from patients with se-
panded polytetrafluoroethylene membranes had vere or refractory forms of chronic periodontitis.
slightly greater attachment gains than sites treated Additionally, generalized aggressive periodontitis is
with flap debridement, demineralized freeze-dried perhaps more likely to be confused with periodontitis
bone, or alloplastic graft (Interpore; Interpore as a manifestation of systemic disease and does not
International, Irvine, CA); it was also noted that the classically reach a burned out stage where it re-
membrane sites had the greatest variability in results. sponds well to conventional periodontal therapy (23,
A separate study compared the success of guided- 48). The bottom line is that the patient with gener-
tissue regeneration treatment with expanded poly- alized aggressive periodontitis requires careful mon-
tetrafluoroethylene membranes in two groups of 10 itoring, and close collaboration is necessary between
patients with either early onset periodontitis (mostly all members of a treatment team, including the
localized aggressive periodontitis by description) or periodontist, the restorative dentist, the hygienist and
chronic periodontitis. Both groups received Aug- the patients physician (48).
mentin (SmithKline Beecham, King of Prussia, PA) Although antibiotic therapy is widely used in the
during the first week post-operatively. After a strict treatment of generalized aggressive periodontitis,
maintenance regimen over a 12-month period, there are at least a few studies on this condition that
putative periodontal pathogens were reduced to have investigated the effects of scaling and root
undetectable levels from defects in both groups, and planing alone. Hughes et al. (28) conducted a
all defects responded equally well from the stand- prospective intervention study of 79 patients with
point of probing depth reduction and attachment generalized aggressive periodontitis. Following the
level gains (74). collection of baseline data, patients received non-
The results of the above studies suggest that where surgical root surface debridement in four visits
allowed by defect morphology, regenerative tech- together with oral hygiene instructions. Upon
niques work well for the treatment of localized re-evaluation at 10 weeks, at initially deep sites, the
aggressive disease. It is important to note, however, authors reported a mean reduction in probing depth
that each of the above studies contained few subjects of 2.11 mm and a mean attachment level gain of
and defects, making between-group comparisons 1.77 mm. They also reported that 32% of patients did
difficult. This is illustrated in a study by DiBattista not respond to this treatment, and that smoking was
et al. (13), who treated defects in seven patients with the biggest factor associated with nonresponse. A
localized aggressive periodontitis using four different more recent study evaluated ultrasonic debridement,
surgical treatment modalities (debridement; ex- with or without chlorhexidine irrigation, in the
panded polytetrafluoroethylene membrane alone; treatment of patients with generalized aggressive

158
Response of chronic and aggressive periodontitis to treatment

periodontitis. By 6 weeks, the probing depth at four receiving no antibiotic treatment. When combined
selected deep sites had been reduced by approxi- with an enhanced scaling and root planing protocol,
mately 1 mm (according to median data), regardless the authors found that both metronidazole and
of the irrigant used in the treatment (21). clindamycin significantly improved the clinical re-
Additional information on scaling in patients with sponse beyond that of the doxycycline or control
generalized aggressive periodontitis can be gleaned groups. A similar controlled study, evaluating the
from studies where scaling and root planing without relative effectiveness of antibiotic regimens, was
antibiotics was used as either the first arm of a clin- conducted by Xajigeorgiou et al. (72). Six weeks after
ical trial or as a control treatment. For example, Pu- scaling and root planing, 43 patients with generalized
rucker et al. (52) provided scaling and root planing aggressive periodontitis were divided into four
for 30 patients with generalized aggressive perio- groups to receive metronidazole amoxicillin, doxy-
dontitis as the first part of a study comparing anti- cycline, metronidazole, or placebo for 714 days,
biotic treatments. Two months after scaling they depending on the drug. At 6 months from baseline,
found that the deepest sites in each quadrant expe- the clinical differences between the four groups were
rienced an approximate 1 mm reduction in probing minor, although the proportions of sites with probing
depth and a 0.5 mm gain in attachment levels. This is depths >6 mm were significantly reduced in the two
consistent with the data obtained from the first arm groups treated with metronidazole. The timing of the
of a study comparing antibiotic regimens in the antibiotic treatment in this study may be questioned in
treatment of generalized aggressive periodontitis light of a more recent report by Kaner et al. (36), who
(72). In contrast are the findings of Sigusch et al. (57), found that administering metronidazole amoxicillin
who saw no improvements in probing depths or immediately after scaling and root planing was more
attachment levels following scaling and root planing effective in resolving deep sites in patients with
in their group of 48 patients with generalized generalized aggressive periodontitis than the same
aggressive periodontitis. It is possible that the 3-week drug regimen given 3 months later.
re-evaluation used in this study was too soon to see a An overall examination of these three controlled
clinical benefit. studies of adjunctive antibiotic treatment suggests a
The adjunctive use of systemic antibiotics to treat minimal additional benefit of antibiotic use. It is
generalized aggressive periodontitis is logical in the- important to remember, however, that these reports
ory but has been the subject of few controlled clinical contain averaged data, and clinical experience sug-
trials. A study by Guerrero et al. (22) compared the gests that the magnitude of change in some sites may
results of scaling and root planing alone to the results be greater when antibiotics are used, making it a more
found following scaling and root planing plus treat- viable treatment option. It is also impossible to know
ment with systemic metronidazole and amoxicillin in the level of patient compliance in taking the antibi-
a group of 41 patients with generalized aggressive otics in these studies. In a recent study, Guerrero et al.
periodontitis. All treatment was provided within 24 h (22) examined 18 patients with generalized aggressive
and patients in both groups used chlorhexidine rinses periodontitis taking metronidazole amoxicillin in
for 2 weeks following treatment. The results demon- conjunction with nonsurgical therapy. They found
strated that clinical parameters improved at 2 and that subjects who were fully compliant in taking their
6 months for both groups. In sites originally 7 mm, medications had probing depth reductions of 0.9 mm
the antibiotic group experienced an additional and attachment level gains of 0.8 mm beyond those
1.4 mm reduction in probing depth and a 1 mm gain who were noncompliant or only partially compliant.
in attachment level when compared with the control Local-delivery antibiotic treatment has also been
group. In sites initially 46 mm deep, the difference evaluated in the treatment of generalized aggressive
was more modest, with a reduction of 0.4 mm in periodontitis. In one study of 30 patients with gen-
probing depth and 0.5 mm in attachment gain eralized aggressive periodontitis, half of the subjects
compared with controls. By 6 months, disease pro- received monolithic tetracycline fibers at affected
gression was noted at 1.5% of sites in patients of the sites while the other half received systemic Aug-
antibiotic group compared with 3.3% of sites in mentin. The results suggested that both groups
controls. improved compared to treatment with scaling alone,
Sigusch et al. (57) divided 48 patients with gener- with no statistically significant differences observed
alized aggressive periodontitis into four groups to between groups (52). A more recent study reported
compare systemically administered doxycycline, that tetracycline fibers, in conjunction with scaling
metronidazole or clindamycin with a control group and root planing, in patients with generalized

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Deas & Mealey

aggressive periodontitis was more effective than odontitis, re-examined after 15 years by Gunsolley
scaling and root planing alone (54). These studies et al. (23), 28 had received treatment, and in some
suggest that local-delivery antibiotic treatment may cases that treatment included surgery. While many of
be of benefit in situations where systemic antibiotics the details of these patients, regarding risk factors
are contraindicated. and follow-up care, are unknown, it was clear to the
While the use of antibiotics in periodontal treat- authors that they had received little benefit from
ment will probably always be controversial, reports therapy. While a cautious approach to surgery in
from both the American Academy of Periodontology patients with generalized aggressive periodontitis is
and the European Federation of Periodontology prudent, there is at least some evidence that it can be
contain valuable guidelines for their use. Both of successful under certain circumstances.
these reports, following exhaustive literature sear- Buchmann et al. (6) followed 13 patients with
ches, determined that patients with aggressive generalized aggressive periodontitis for 5 years
periodontitis appear to benefit from the adjunctive through active and maintenance therapy. For each
use of systemic antibiotics during treatment; how- patient, they monitored attachment level measure-
ever, both also emphasized that knowledge of the ments on two teeth with >50% bone loss per
optimal drug, dosage and duration providing the quadrant at baseline, as well as at 3, 6, 12, 24, 36, 48
greatest effect was unknown at this time (24, 26). and 60 months after treatment. Patients received
One final element of nonsurgical therapy in the systemic metronidazole amoxicillin during both
treatment of aggressive periodontitis is the use of scaling and root planing and surgical phases of
enhanced root planing techniques. Moreira et al. (47) treatment. Of the 100 sites followed to 60 months, 86
divided 30 patients with generalized aggressive peri- with initial probing depths of 6 mm were subjected
odontitis into two groups to evaluate traditional to modified Widman flap procedures with no osseous
quadrant-wise scaling using a full-mouth debride- surgery. Three months following treatment, there was
ment approach where all scaling was completed a mean 2.23 mm gain of clinical attachment at all
within 24 h. Both groups received systemic metro- sites that remained stable over the maintenance
nidazole and amoxicillin as well as chlorhexidine period. Individual sites had attachment level gains of
rinses. While clinical parameters improved in both as much as 7 mm, and only 7.1% of sites did not
groups, there were no significant differences between respond to initial treatment. It is important to note
groups at either 2 or 6 months. Sigusch et al. (58) that smoking and systemic disease were exclusion
compared traditional scaling and root planing with criteria in this study.
an enhanced root planing technique in a group of 42 A more recent study by Mengel et al. (46) used
patients with generalized aggressive periodontitis radiographs and clinical indices to follow a group of
who were also treated with systemic metronidazole. 16 healthy, nonsmoking patients with generalized
The test group subjects received an additional round aggressive periodontitis through active therapy and
of root planing where the instrumentation frequency maintenance for 5 years. The sites monitored in-
of curet strokes per root surface was based on the cluded only those with one to three wall intrabony
probing depth. At 6 and 24 months, the authors re- defects of 4 mm, and furcation defects were ex-
ported significantly improved probing depth reduc- cluded. Twenty-two of the defects were treated with
tion and attachment level gain using the enhanced bioabsorbable membrane alone, and 20 were treated
technique. with bioactive glass. After 5 years, the authors re-
Beyond isolated case reports, very little has been ported mean probing depth reductions and attach-
published about the surgical treatment of generalized ment level gains of 3.6 mm and 3.0 mm at the
aggressive periodontitis; it is possible that this may be membrane-treated sites, and mean probing depth
because of an overall reluctance of clinicians to per- reductions and attachment level gains of 3.5 and
form surgery on patients with generalized aggressive 3.3 mm at the sites receiving bioactive glass. The
periodontitis. There are several perfectly logical rea- authors further reported a radiographic defect fill of
sons for this: severe attachment loss on presentation; 47.5% in membrane-treated defects and 65% fill in
possible links with covert or undetected systemic bioactive glass-treated sites, although the variation at
disease; the inability to control risk factors; a history individual sites was large. Approximately 25% of the
of poor surgical outcomes with previous patients with sites in both groups had probing depths of 5 mm
generalized aggressive periodontitis; or a reluctance after 5 years.
to perform surgery in patients with poor prognoses. Very little has been written about the use of enamel
Of the 48 patients with generalized early onset peri- matrix derivative in aggressive periodontitis (35, 69).

160
Response of chronic and aggressive periodontitis to treatment

In the larger of two case reports, Vandana et al. (68) Another reason to fear additional attachment loss
used enamel matrix derivative to treat selected in aggressive disease is an increased inflammatory
defects in four patients with aggressive periodontitis response. An experimental gingivitis study by Trom-
and compared the results at 9 months with similar belli et al. (66) demonstrated that patients with
defects in a control group of four patients with aggressive periodontitis had a significantly higher
chronic periodontitis. The authors reported signifi- inflammatory response, as measured by gingival
cant improvements in both probing depths and crevicular fluid flow, than periodontally healthy pa-
attachment levels, and no differences were found tients. If, as some have suggested, persistent gingival
between the two groups. inflammation results in a greater risk for tooth loss
A possible conclusion of the above studies is that if and attachment loss over time, then the patient with
risk factors, especially smoking, can be eliminated, aggressive periodontitis may be at increased risk. For
and if compliance with maintenance care is high, example, the previously mentioned study by Gun-
then surgical therapy can be as beneficial to the pa- solley et al. (23) showed that patients with general-
tient with generalized aggressive periodontitis as it is ized early onset periodontitis, even when treated,
to any other patient. The relatively high rate of sites tended to experience continued tooth loss and
breaking down over time, however, suggests a likely attachment loss over time. Kamma et al. (34) fol-
need for retreatment during the maintenance phase. lowed a group of 25 patients with aggressive perio-
dontitis through active therapy and maintenance
care at 36-month intervals over a 5-year period.
Periodontal maintenance Twenty of the 25 patients experienced additional
attachment loss, of 2 mm, following treatment at a
Regardless of whether the original diagnosis is total of 134 sites.
chronic periodontitis or aggressive periodontitis, the Despite this increased risk for recurrence, there is
goal of maintenance care following active periodontal evidence that attachment loss can be stabilized, after
treatment is to maintain the level of periodontal therapy, in patients with aggressive periodontitis.
health achieved during active therapy. Given their Lindhe & Liljenberg (42) used a combination of sur-
initial susceptibility to disease, patients with aggres- gical debridement and systemic tetracycline to treat
sive periodontitis before therapy have to be consid- 16 patients with localized aggressive periodontitis
ered at high risk for recurrent disease after therapy. and 12 older patients with chronic periodontitis.
There are several potential reasons for this. Given the Patients were seen monthly for maintenance care
amount of pocket formation and attachment loss during the first 6 months, then every 3 months until
possible in aggressive disease, it is likely that after the end of the study. The authors reported that in
therapy, the patient with aggressive periodontitis general, diseased sites in the patients with localized
may have residual deep pockets. Although this is aggressive periodontitis responded as well to treat-
somewhat controversial, there is some evidence to ment as sites in the patients with chronic periodon-
support the concept that additional attachment loss titis, although 4 of the 12 patients in the localized
is more likely to occur at sites with deeper residual aggressive periodontitis group (a total of six sites)
pocket depths (2, 8). A recent retrospective study by needed to be retreated for disease recurrence over the
Matuliene et al. (45) re-examined 172 patients at time 5-year study period.
points from 3 to 27 years after active periodontal The previously mentioned study by Buchmann et
therapy. They found that compared with probing al. (6) followed the treatment of 13 patients with
depths of 3 mm, residual probing depths of 57 mm aggressive periodontitis (by description, generalized
represented significant risk factors for both attach- aggressive periodontitis) through modified Widman
ment loss and tooth loss. flap surgery and systemically administered metro-
Residual deep sites may explain why the long-term nidazole and amoxicillin. Following treatment, the
treatment effect on bacterial pathogens may be lim- patients were recalled at 36-month intervals for
ited in patients with aggressive periodontitis. Two maintenance, which included subgingival instru-
recent reports demonstrated that despite a favorable mentation, under local anesthesia, at all sites deeper
initial clinical outcome, the site effect of mechanical than 4 mm showing bleeding on probing. After 5 years
therapy plus systemic metronidazole and amoxicillin of maintenance care, the authors found that only
on potential pathogens was transient, and the extent 1.45.3% of sites underwent disease progression dur-
of tissue invasion by these bacteria did not decrease ing the recorded intervals, with an additional 24% of
following treatment (31, 67). sites experiencing additional attachment level gain.

161
Deas & Mealey

Finally, Zucchelli et al. (74) used guided-tissue Table 1. Treatment planning sequence for patients with
regeneration to treat single intrabony defects in 10 periodontitis
patients with localized early onset periodontitis and
Systemic phase
compared their results with the same treatment in review of medical history, medications, family history,
patients with chronic periodontitis. At 1 year, defects social history*
in the early onset group experienced a mean probing
laboratory screening tests (complete blood count,
depth reduction of 7.1 mm and an attachment level fasting blood glucose)*
gain of 6.1 mm. The authors attributed the success of
medical consultation if indicated
treatment in part to an aggressive maintenance
schedule of monthly professional cleanings and oral identification modulation of risk factors (e.g.
hygiene reinforcement. smoking, stress, diet)*
assess the need for a stress-reduction protocol during
therapy
Treatment planning Initial phase

The process of treatment planning for periodontitis emergency treatment if needed


patients is well established and an attempt will not be explanation of the disease process and contributing
made to review each step. While the generally factors*
accepted phases of treatment systemic, initial, re- review of oral hygiene instructions
evaluation, surgical, maintenance, and restorative
occlusal analysis and treatment of localized trauma
seem well suited for patients with both diseases, the from occlusion
amount of specific planning required at each step
bacterial sampling of selected pockets*
may be greater for the patient with aggressive disease
(Table 1). In general, we would expect the patient dental consultations (e.g. caries control, root canal
with aggressive periodontitis to have experienced therapy, strategic value of teeth for eventual
restoration, orthodontic assessment)
attachment loss at a younger age, at a faster rate and
to a greater extent than the patient with chronic extraction of hopeless teeth
periodontitis. If the expectation of the patient and the scaling and root planing
provider is to retain teeth, this cannot help but
local or systemic antibiotic treatment*
complicate the treatment-planning process.
In the systemic phase, for example, the patient Re-evaluation
with chronic periodontitis may require little beyond
re-assess prognosis of individual teeth and overall
an awareness of existing medical conditions and dentition
medications. The systemic phase for the patient with
probing depths
aggressive periodontitis is likely to be much more
complex. Because periodontitis as a manifestation of attachment level measurements
systemic diseases can present as aggressive perio- bleeding on probing
dontitis, it is critical that the practitioner performs a
furcation invasion
thorough medical history. In addition, it is our
opinion that the patient with generalized aggressive mobility
periodontitis, especially, should be referred for a root sensitivity
complete blood count and either a casual or a fasting
oral hygiene
blood glucose test. Although the cause-and-effect
relationship is uncertain, monitoring other systemic bacterial sampling of selected pockets* (if not
completed during the initial phase)
factors, such as weight loss, depression and malaise
has also been recommended (48). Beyond that, a additional laboratory tests (e.g. 2-h postprandial
heightened requirement for identification and mod- glucose)*
ulation of risk factors is essential. It may also be a medical consultation if indicated*
good idea to review the patients social history to
assessment of modulation of risk factors*
identify stress-related factors (17, 34).
In the initial phase, a thorough explanation of the patient motivation
disease process and its contributing factors is given to
patients with both chronic and aggressive disease, but

162
Response of chronic and aggressive periodontitis to treatment

Table 1. Continued may guide the periodontist in recommending


Surgical phase (if indicated; may proceed to maintenance extractions of questionable teeth. Finally, because
or return to initial phase) aggressive periodontitis often demonstrates a familial
pattern, the practitioner should assess the family
antibiotic treatment*
history of periodontal problems and consider evalu-
monitor healing of previously treated sites ation of siblings and parents (11, 50).
Maintenance phase In our view, the treatment of aggressive periodon-
monthly for the first 6 months following treatment,
titis should start with scaling and root planing in
then combination with systemic antibiotics. The exception
bimonthly until 12 months, then extending to to this may be in certain cases of localized aggressive
3 months* periodontitis, where surgical debridement is an
probing, attachment level measurements 6 months acceptable first step if dictated by time or third-party
after completion of treatment, then at each payment constraints. If surgical treatment (including
maintenance visit initial extraction of hopeless teeth) is undertaken in
yearly radiographs of at-risk teeth* the patient with aggressive disease, we recommend a
biopsy of associated granulation tissues to rule out
assessment of oral hygiene, risk factor modulation
certain pathological entities such as Langerhans cell
prophylaxis, topical fluoride treatment if indicated, histiocytosis.
treatment of hypersensitivity
While the literature may be somewhat equivocal on
subgingival scaling of deep pockets the added value of antibiotics as an adjunct to initial
host modulation therapy if indicated* therapy, especially in patients with generalized
aggressive periodontitis, it is our view that this is a
local delivery antibiotic treatment of at-risk sites
worthwhile step. Even if the main benefit of antibiotic
full-mouth scaling and root planing (with or without therapy is to reduce the number of sites with probing
adjunctive antibiotics if indicated by general depths >6 mm (72), many clinicians have noted that
breakdown)*
the magnitude of improvement at individual sites
definitive occlusal adjustment if indicated may be improved with antibiotic therapy (22). The
consider extraction of teeth with progressive disease combination of metronidazole 500 mg three times
to preserve alveolar bone* daily plus amoxicillin 500 mg three times daily is
Restorative phase
probably the most popular antibiotic regimen in the
current literature; however, its superiority over other
assessment of prosthesis cleansability and function
antibiotics, either singly or in combination, is spec-
*Areas of special emphasis for patients with aggressive periodontitis. ulative at best. Furthermore, we recommend (i) the
initiation of antibiotic therapy 24 h before starting
scaling and root planing, and (ii) that root planing is
in our view should be given special emphasis in the performed over the short time period during which
patient with aggressive periodontitis. Likewise, both the antibiotic is prescribed.
types of patients should be given a comprehensive Although there is limited evidence to suggest that
review of oral hygiene techniques; however, standard enhanced root planing techniques may offer an ad-
brushing flossing instructions are less likely to be ded treatment response to nonsurgical therapy (58),
sufficient for patients with aggressive disease, espe- in our view there is value in any reasonable protocol
cially those who have experienced attachment loss that enhances patient and provider confidence. If a
that has exposed furcations and root concavities. full-mouth debridement approach demonstrates an
Monitoring compliance with oral hygiene procedures added commitment or sense of importance to the
is critical in both groups, but may be more difficult in treatment, then it may be worthwhile. The outcome
the aggressive patient if chlorhexidine rinses are of treatment in aggressive periodontitis is uncertain.
prescribed frequently during treatment. Given the Improvements in either compliance or clinical indi-
likelihood of greater attachment loss at an earlier age, ces, even if somewhat placebo based, are always
another element of the initial phase that may have welcomed.
added emphasis in patients with aggressive peri- A 46-week re-evaluation interval seems as valid
odontitis is consultation with other dental specialists for a patient with aggressive periodontitis as for one
to assess the strategic long-term restorative value of with chronic periodontitis. The re-evaluation should
certain teeth before starting periodontal therapy. This closely resemble the initial evaluation, with review of

163
Deas & Mealey

medical history, risk factors, oral hygiene techniques scaling and systemic antibiotics, or host-modulation
and clinical indices. At this point, regardless of therapy, can be used to treat a generalized
whether the initial diagnosis is chronic periodontitis recurrence.
or aggressive periodontitis, the clinician would expect
at least some resolution of disease indicators. If this is
the case, then proceeding to either a maintenance Summary and future directions
phase or a surgical phase, depending on the re-
sponse, seems justified. Patients with aggressive periodontitis can be both
If, however, there is no significant positive re- rewarding and frustrating to treat in clinical practice.
sponse to initial therapy, we recommend a return to Interindividual variation in response to therapy can
the initial phase for additional data collection and be widespread, and we do not clearly understand the
treatment. At this point, bacterial culture and sensi- reasons for this variable response. It is possible that
tivity testing of the deepest pockets may be war- new research into the resolution of inflammation
ranted, along with a 2-h postprandial glucose test, may reveal basic differences between patients with
which is a more sensitive test for diabetes mellitus chronic periodontitis and those with aggressive dis-
than either fasting or casual glucose tests. Depending ease. In addition, future research involving modula-
on the outcome, the clinician may choose to repeat tion of host inflammatory responses may clarify the
subgingival scaling with a different antibiotic regi- reasons for the differences in clinical outcomes be-
men, possibly using the enhanced scaling and root tween patients. We think it likely that this research
planing techniques referred to previously. Depending could result in further alterations to the classification
on the results of the 2-h postprandial test, the patient of periodontal diseases, as with more knowledge of
may be referred to his physician for evaluation of his the mechanisms of disease it is possible that patients
metabolic status. In our opinion, there is little to be currently classified as having aggressive periodontitis
gained, and potentially much to be lost, by pro- may be found not to represent a single diagnostic
ceeding to a surgical phase in patients who have entity. Better understanding of the true nature of
demonstrated little or no improvement in clinical patients currently identified as having aggressive
indices following well-delivered initial therapy. If the periodontitis may therefore lead to more effective
response to initial therapy is equivocal, then it may treatment approaches.
be prudent to perform surgery in a limited, isolated
area and to monitor healing during a period of trial
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