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Aggressive Periodontitis
Aggressive Periodontitis as the name implies has one distinctive feature: rapid destruction of the
bone or more precisely rapid rate of bone loss. In the panorama, it will be evident that there is a
severe bone loss around the teeth.
The severity of the case can be seen through the probing depth. It is more severe when it is
deeper. This is just an example on aggressive periodontitis.
There are differences in the use between suffixes;itis means inflammation, -osis means
degenerative. That is why back in time people who called it Periodontosis thought it this a
degenerative disease and therefore causing loss of bone. They also called the types: localized
Juvenile, generalized Juvenile Periodontitis or rapidly progressive Periodontitis. These
classifications where made in 1999. However after 15 years, the common names are: Localized
aggressive and generalized aggressive periodontitis. Localized Juvenile is what we now call
Localized aggressive and generalized Juvenile is generalized aggressive. These two entities are
now called generalized aggressive.
Secondary Features:
Periodontics Sheet 13 Hala Kanan
Not all features will be there, which means that we dont need them all in order to formulate
the diagnosis. We do not need to do a microbiological sampling to check the presence of AA
and PG. But in general, this disease has: severe bone loss, healthy individual, the amount of
local factors does not explain the amount of bone loss and usually the patient is young
(secondary feature). A patient might be in his late thirties or early fourteens and might have
this disease. He is an older patient but might have the given features, for example if he was a
healthy individual with severe bone loss that is inconsistent with the amount of
microorganisms present and that has familial aggregation. Evidence might also be that
someone in the patients family has lost his/her teeth.
There cases which we call border line cases, in which periodontists would disagree on the
type of periodontitis. Some would say it is chronic and others will say it is aggressive. This is
because we still do not have a test that gives positive for the disease and negative for not. We
rely on features and multiple factors. There is a case, that will be shown if there is more time,
we have diagnosed and treated it as an aggressive case but when we sent it to the reviewer
there was a debate upon the type. Later it was accepted as an aggressive case. Border line
cases are mostly faced with older patients. There is no limit to distinguish between the two
types; long ago age was the distinguishing feature. Adult periodontitis (above 35 years) is the
name that used to be given to older people carrying the disease. For patients below 35 years,
it was called juvenile periodontitis. However, after the classification in 1999 it became no
longer the case because older people can have the disease from 8 years ago. It is not a proper
way to assign a disease category.
Why is it localized on first molars and incisors? This disease is one the most peculiar diseases;
why is that bone loss only occurs to first molars and incisors? Some said that because they are
the ones that stay for the longest period. But it does not vary with time. There are many
theories (no rigid explanation) for this particular subject:
1. The development of adequate defenses to bacteria such as AA after the initial colonization
of the teeth. After eruption of the teeth and the disease process takes place, defenses are
created to protect the remaining teeth. Therefore the ones that experienced bone loss are
the victims.
2. Another theory is: after the AA bacteria have established themselves and initiated the
disease, the patient starts having other types of bacteria that could neutralize the
pathogenic effect of the AA bacteria. This competition in the environment kind of limits
the ability of AA.
3. AA bacteria changes into becoming less pathogenic, losing some of its pathogenicity and
other types of bacteria starts to develop. And the defect in the cementum, i.e. the
defective cementum makes these teeth more susceptible to bone loss.
Features:
1. One of the vaulted features of the localized aggressive periodontitis is that there will be
minimal clinical information. When you actually look, you can notice that the patient has no
signs of inflammation such as swelling and redness. Minimal plaque, minimal mineralized
calculi and even we can barely notice any subgingival calculi. That is why in the localized
aggressive, the amount of local deposit does not coincide with the amount of disease.
General aggressive has much more deposits. The root could be clean, Something(couldnt
hear it) as well as rapid progression of the bone loss.
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Figure of a localized aggressive case: A severe bone loss, flat innovation, mostly clean roots no
calculi. Sometimes it is an incidental finding on an x-ray.
Prevalence
In a libelous population (diverse society with less than 1 percent of the total population) in an
ethnic background it is less than 0.2% of the whites and about 2% in blacks. Thus there is a
higher prevalence in the black society. In the US more African Americans have Periodontitis than
the white. They are 10 times more. Historically, it was thought the female was thought to have
more of this disease, and then it was found that it is because of ascertainment bias. It actually
higher in black male followed by black female, white females and least in white males.
Management is the same, it goes in non-surgical therapy, surgical therapy (1)access surgery,
2)resective surgery, or regenerative surgery (graft)), oral hygiene instructions, and unique to
aggressive periodontitis is that we only use systemic antibiotics. Chronic periodontitis we can
also use systemic antibiotics. What do we use? For the longest time the antibiotic used was a
doxycycline 10 gram twice a day for 14 or 21 days. They used to think that the concentration of
the doxycycline in the GCF is high; it becomes more concentrated in the fluid rather than in the
plasma. Now, we know that it is not the case. Doxycycline is not the first line of choice for
antibiotics, but it could be given 100 milligrams twice a day for 14 days. What we do now is a
combination of amoxicillin500 three times a day for 10 days and metronidazole 250 3 times a
day for 10 days. This is the best option used to suppress the bacterial growth. Another option is
azithromycin 500mg once a day for three days or ciprofloxacin500mg twice a day for 10 days. Or
cephalosporin can be used but some studies showed its not preferable to use it.
We try to regenerate some of the lost bone. The treatment is to graft, if its an isolated tooth.
Generalized aggressive
Usually affects individuals under the age of 30. Poor antibody response is found as opposed to
high antibody response. Minimum plaque is found but not as characteristic as for the localized.
What we see in the generalized aggressive is generalized interproximal attachment loss with at
least 3 permanent teeth other than the first molar and incisors.
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1. Severe inflamed tissue. (in comparison with the minimal inflammation seen in the localized
aggressive)
2. Tissues that appear pink and healthy.
Figure: it could deceive you without an X-ray or a perio probe. The bone loss is everywhere.
One of the features of chronic periodontitis is usually horizontal bone loss. However this is not
exclusive. In the aggressive case it is usually a vertical bone loss. But then again that does not
mean that is the only way to bone loss.
Figure: a combination of horizontal and vertical bone loss. They are not mutually exclusive. They
could happen at the same time. Horizontal bone loss and the other tooth has a vertical defect
could occur at the same time.
Radiographic Presentations
Bone loss of various stabilities is present.If you have the access to previous X-rays, you can see
extreme rate (rapid) of bone loss. The problem is that when we see the patient for the first time,
we are seeing him/her for one point of time therefore we have no reference or base line to
compare. The annual rate of attachment of bone is about 0.5 mm in chronic periodontitis. In the
aggressive case it is from 0.1 to 1 mm. there is a big difference; twice the rate of attachment loss
we see in the chronic case.
There has been a study conducted in the 1960s and ended in the 1970s and occurred in Sri
Lanka. They studied and examined the cases for about 10 years in a tea planation without
treating them. They went and examined people and came back after ten years to the same
people and compared their results to people in Norway. Norwegians have high dental
awareness, constantly receive dental prophylaxis and have excellent oral hygiene. While the Sri
Lanken Tea laborers have no dental hygiene and are the exact opposite of the Norwegians. To
monitor the differences, they compared the two extremes. So many studies came out of this,
one of which is the rate of bone detachment. Only 8% of these patients showed severe
progression attachment loss (0.1-1mm). 11% had absolutely no disease and no attachment loss.
81% had chronic periodontitis. These people (11%) did not practice any form of oral hygiene,
they still had no periodontitis. The patient has to be susceptible to the disease; it is not only
about the oral hygiene. Less than 1% of this age group had generalized aggressive periodontitis.
This is because they usually have localized.??
The prevalence is higher in black than white and in males than females.
The aggressive periodontitis has the same management; surgical and non-surgical. Non-surgical:
plaque control and systemic antibiotics.
Some secondary risk factors like neutrophils defects and genetic factors. In some reports AA
was not detected, in other reports AA was detected in healthy sites. That is why it is not
absolutely specific. Some patients might not have AA but still have Aggressive Periodontitis. This
means it is not a cause effect.
1. Serotypes.
AA might have different types that have different machinery of producing different
proteins.Proteins, toxins or the way they stimulate the immune response could be different
between two different serotypes of the same species. They have found that serotype B is the
prevalent type of AA in the cases that have aggressive periodontitis in the US. And type A has
been shown to invade periodontal tissues. That is why we prescribe systemic antibiotics. There
is evidence that AA can be found within the periapical tissue that is why we prescribe
antibiotics, if it invaded the pocket or root tissues. After applying instrumentation on the root
surface or the pocket, the antibiotics will deal with the remaining bacteria (those which
remained in the tissues).
Periodontics Sheet 13 Hala Kanan
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