Managing Aggressive Periodontitis - Decisions in Dentistry

Aggressive periodontitis is classified into localized and generalized forms. The localized form largely affects permanent incisors and first ... Apeer-reviewedjournalthatoffersevidence-basedclinicalinformationandcontinuingeducationfordentists. LikesFollowersSubscribe LoginStartearningCEUnitsinminutes! CourseLibrary NewUserExistingUserHelp HomeArticlesManagingAggressivePeriodontitis FIGURE1.Thispanoramicradiographofa33-year-oldmalepatientshowsthepresenceofmultipleperiodontalabscessesandgeneralized,moderatetosevereaggressiveperiodontaldisease.Itprovidesradiographicevidenceofsubgingivaletiologyandperiradicularandcrestalradiolucencies,indicatinggeneralizedverticalandhorizontalboneloss. LatestCECoursesPeriodontics ManagingAggressivePeriodontitis Cliniciansmustbevigilantinidentifyingthistypeofperiodontitissotreatmentcanbeginasearlyaspossibleinthediseaseprocess. ByDianaBronstein,DDS,MS,MS,DmitriyKravchenko,MPHandJonB.Suzuki,DDS,PhD,MBA,FACD,FICD OnSep1,2016 0 Share Cliniciansmustbevigilantinidentifyingthistypeofperiodontitissotreatmentcanbeginasearlyaspossibleinthediseaseprocess PURCHASECOURSEThiscoursewaspublishedintheSeptember2016issueandexpires09/30/19.Theauthorhasnocommercialconflictsofinteresttodisclose.This2credithourself-studyactivityiselectronicallymediated.OBJECTIVES Afterreadingthiscourse,theparticipantshouldbeableto: Definethethreebroadclassesofperiodontitis. Explaintheprimarycharacteristicsthathelpdefineaggressiveperiodontitis. Describethedistinctionsandcontroversyassociatedwithlocalizedandgeneralizedformsofaggressiveperiodontitis. Implementappropriatemanagementstrategies. Periodontaldiseaseisanumbrellatermforanumberofpathologiesthataffectthesupportingstructuresofteeth.Periodontitiscanbefurthersubcategorizedintothreebroadclassesbasedonradiographic,laboratoryandclinicalfeatures:chronicperiodontitis,aggressiveperiodontitis,andperiodontitisduetoasystemiccondition.1Ofthethree,aggressiveperiodontitisistheleastcommon;assuch,abetterunderstandingofthistypeofperiodontitisisneededinordertoimprovethediagnosisandmanagementofthedisease.2 Aggressiveperiodontitiswasdefinedbythe1999InternationalWorkshopfortheClassificationofPeriodontalDiseasesaccordingtothreeprimarycharacteristics:absenceofsystemicconditionsthatmightcontributetoperiodontaldisease,rapidlossofclinicalattachmentandalveolarbone,andfamilialaggregationofdiseasedindividuals.3Anumberofsystemicconditions,suchasdiabetesandcardiovasculardisease,havebeenimplicatedinthedevelopmentofperiodontitisinsusceptiblepatients.Becausethisconclusionhasbeendrawnmainlyfromcasereportsandnotcontrolledclinicalstudies,theexactnatureoftheassociationhasyettobedetermined.Itisthoughtthatthemostsignificanteffectofthesesystemicconditionsisalterationofthehostimmuneresponse.4 Inaggressiveperiodontitis,attachmentlossoccursatamuchfasterratethaninchronicperiodontitis,themorecommonvariant.Becausethecourseofdestructionoccursrapidly,evaluationofhistorical,radiographicandclinicaldataisnecessarytoestimatethestartofdisease.Somecliniciansinsistthatmassiveattachmentlossinarelativelyyoungpatientautomaticallyindicatesarapiddiseaseprogression.Yetsevereattachmentlosscanalsobeseeninaperiodontitis-susceptiblepatientwithalonghistoryofpoororalhygiene,evenwithaslowrateofprogression.Thus,itwasdeemedinappropriatetouseagealoneasaprimarycharacteristictodifferentiatebetweenthedifferentsubtypesofperiodontitis.5 Overwhelmingevidencesuggeststhatgeneticfactorsplayaroleinhostsusceptibilitytoperiodontaldiseases.Vieiraetal6analyzedtheclinicalparametersofperiodontaldiseasestoassessfamilialaggregationofsuchtraits.Thestudyfoundtherewasfamilialaggregationofdentalplaquemeasurements,evenafteradjustingforconfoundingfactors,suchasage,sex,raceandoralhygienehabits.Althoughotherindicatorsofperiodontaldiseasewerealsocompared,theplaqueindexshowedthegreatestfamilialcongruity.6 Inpatientswithaggressiveperiodontitis,thequantityofplaquedepositionisofteninconsistentwiththeseverityoftissuedestruction.Inmostcases,thegingivaappearsclinicallyhealthywithnosignsofinflammation,andcalculusdepositsareminimal.However,plaqueandcalculusdepositsarevisibleinsomepatients,andclinicalinflammationispresentincasesofadvanceddisease.7 Properlyfunctioningneutrophilsarenecessarytomaintainperiodontalhealth.Thisisevidencedbythelargenumberofgeneticneutrophildefectsassociatedwithsevereperiodontaldisease.Theseinclude,butarenotlimitedto,Kostmannsyndrome,Chediak-Higashisyndrome,Papillon-Lefevresyndrome,alpha-1antitrypsindeficiency,leukocyteadhesiondeficiencyandgranulomatousdisease.Theproposedmechanismforperiodontaldiseasedevelopmentamongindividualswithabnormalneutrophilfunctionseemstobeineffectivechemotaxisandphagocytosis.Theconsensusisthatchronicactivationofcertainenzymes,suchasproteinkinaseC,anddown-regulationofothers,suchasdiacylglycerolkinase,decreaseschemotaxisandphagocytosis,and,ultimately,antimicrobialactivity.8 Immunologicalmediatorsplayaroleinthepathogenesisofseveraloraldiseases,periodontaldiseaseamongthem.Theinitiationofperiodontaldiseaserequiresthepresenceofpathogens,aswellasasusceptiblehost.Tohandlethecontinuousmicrobialchallengepresentinsubgingivalbiofilm,theimmunesystemactivatesspecializedcells—knownasmacrophages—asadefensemechanism.Whenthemicrobialchallengeoverwhelmstheimmunesystem,exacerbatedtissuedestructionresults.9 LOCALIZEDVERSUSGENERALIZED FIGURE1.Thispanoramicradiographofa33-year-oldmalepatientshowsthepresenceofmultipleperiodontalabscessesandgeneralized,moderatetosevereaggressiveperiodontaldisease.Itprovidesradiographicevidenceofsubgingivaletiologyandperiradicularandcrestalradiolucencies,indicatinggeneralizedverticalandhorizontalboneloss. Aggressiveperiodontitisisclassifiedintolocalizedandgeneralizedforms.Thelocalizedformlargelyaffectspermanentincisorsandfirstmolars.Thegeneralizedformmostlyaffectsthepermanentdentition(Figure1).Controversyexistsastowhetherthetwoaredistinctentities,oriftheyaretwoformsofthesamedisease.10Evidencesupportsthenotionthatinsomecaseslocalizeddiseaseprogressestoageneralizedformasapatientages,whileinothercasescharacteristicsofbothdiseasesareprevalentinthesameindividual. Conversely,onestudysuggestedthatthetwomightbeuniqueentitiesbecauseindividualswithlocalizedaggressiveperiodontitis(LAP)respondedwelltotreatment,whereaspatientswithgeneralizedaggressiveperiodontitis(GAP)continuedtodemonstratetissuedestruction,despitetreatment.11Manyauthorswhohavestudiedperiodontaldiseaseinayoungpopulation(ages15to30)havenotedtheclinicalperiodontalcharacteristicsandotherdemographicdataofthisgroupdifferstrikinglyfromthefeaturesofperiodontaldestructioninolderindividuals.Infact,the1989classificationsystemadoptedbytheAmericanAcademyofPeriodontologywasbasedlargelyonageofonsetandrateofprogression.Youngindividualswithsignsofperiodontitisweredeemedtohavejuvenileperiodontitis,andpatientswitharapidrateoftissuedestructionwerediagnosedwithrapidlyprogressiveperiodontitis. Thissystemgeneratedmuchcriticism,soanewclassificationsystememerged.Highfield12notesthatthedifficultyinestablishingauniformsetofcriteriafortheclassificationofperiodontaldiseaseliesintheheterogenicityoftheclinicalpresentationandlackofunderstandingofthetruenatureofthedifferencesinclinicalpresentation.Anumberofstudies,forinstance,supportthenotionthatLAPtendstooccurbetweentheagesof11and13.Basedontheamountofperiodontaldestructionseenatthetimeofdetection,however,itisassumedthatthediseaseprocessbeganearlier.13Furthermore,LAPdiffersfromGAPinthattheformerhasadistinctmicrobialetiology—Aggregatibacteractinomycetemcomitans(Aa).Thismicroorganismwasfirstidentifiedasaperiodontalpathogenin1975.Sincethen,mostcross-sectionalstudieshaveshownittobeassociatedwithperiodontaldiseaseinadolescents. Fineetal14followed96studentsforayeartodeterminewhetherharboringAawouldleadtoboneloss—amajorindicatorofaggressivedisease.Theauthorsnotedthatsixof36Aa-positive,initiallyhealthychildrenwerefoundtohavebonelossatthe1-yearfollow-up,comparedwithnoneofthe58Aa-negativesubjects.TheyconcludedthatAaisassociatedwithboneloss,butnotallsubjectswhocarryAawilldevelopperiodontaldisease.14AmorerecentstudylookedattheassociationamongserumIgGresponsestoanumberofperiodontalpathogens,includingAa,Porphyromonasgingivalis(Pg),andTannerellaforsythia(Tf).Althoughonlythedeepestpocketsineachquadrantwereexamined,theauthorsfoundnodifferencesinmicrobiallevelsbetweenGAPandLAP.TheauthorsshowedthatinGAPsubjects,levelsofPg,TfandAacorrelatedwithclinicalparameters,butnotwithserumIgG.NeithervariablecorrelatedwithdiseaseseverityinLAP,however.Furthermore,therewasnodifferenceinserumresponsetoPgandAaamongpatientswithGAPandLAP.HighantibodytiterstoTFwerefoundinmorethanone-thirdofGAPpatients,buttheywereundetectableinthosewithLAP.15 MANAGINGAGGRESSIVEPERIODONTITIS Historically,patientswithag­gressiveperiodontitishaveexperiencedpooroutcomes,andradicaltreatmentswereoftenimplemented.Morerecently,how­ever,theeffectivenessofsurgicalandnon­surgicalperiodontalthera­pyhasbeendemonstrated.PhaseIisthefirststepinperiodontaltherapy,anditsgoalistosignificantlydecreaseoreliminatethemicrobialload,aswellasfactorsthatcontributetoperiodontaldisease.Theseinclude,butarenotlimitedto,supra-andsubgingivalinstrumentationtoremovecalculus,treatmentoffoodimpactionareas,andrestorationofcarieslesions.Someauthorsarguethatnonsurgicaltherapyalonemaybesufficientifthediseaseisinitsearlystages.Bouzianeetal16lookedatclinicalandradiographicoutcomesofpatientswithGAPwhoweretreatedwithnonsurgicaltherapyatintervalsofthreemonths,sixmonthsandfiveyearspost-treatment.Theauthorsconcludedthistherapyresultedinterminationofdiseaseprogression,resolutionofinflammation,decreasedpocketdepthsandotherfavorableclinicaloutcomes.16 Themanagementofaggressiveperiodontitisremainsachallengeforcliniciansbecauseofalackofstandardizedprotocolsforeffectivediseasecontrol.Forinstance,asubsetofaggressiveperiodontitispatientsmaycontinuetoexhibitperiodontaldestructionduetopersistentperiodontalpathogens.Thesepatientsoftenrequireadjunctivelocalandsystemicchemotherapeutictherapy.Typicalsystemicantibioticregimenshaveincludedamoxicillinandmetronidazole,althoughotherclassesofantibioticsarealsoprovingtobeeffective.OnegroupofresearchersevaluatedtheefficacyofadjunctivemoxifloxacininthetreatmentofGAP.Theyconcludedthatwhencomparedwithscalingandrootplaningwithplacebo,adjunctivemoxifloxacintherapyachievedsignificantlygreaterimprovementinbleedingonprobing,pocketdepthandclinicalattachmentgain.17 Antibioticspresentsomedisadvantages,however,suchasadversesystemiceffectsandallergicreactions.Alternately,Moreiraetal18describeantimicrobialphotodynamictherapy,anoveladjuncttotraditionalinstrumentationandantimicrobialtherapy.Theprinciplesofthistreatmentrelyontheeliminationofmicrobialcellsthroughtheuseofaphotosensitizingagentandalow-intensitylaserlightsource.Afteracontrolled,randomized,double-blindstudy,theauthorsconcludedthatscalingandrootplaning,combinedwithantimicrobialphotodynamictherapy,wasmoreeffectiveinreducingpocketdepththanscalingandrootplaningaloneatthe90-dayfollow-up.18 PhaseIIofperiodontaltherapyinvolvessurgicalprocedureswiththeintentionofimprovingtheprognosisofteeth(ortheirreplacements)andenhancingesthetics.Thisisaccomplishedviaanumberofsurgicaloptions,including,butnotlimitedto,resectiveprocedures—suchasgingivectomiesandosseousresections—andregenerativeflapswithgrafts.Theseproceduresarenotmeanttotreatdisease,but,rather,toprovideanenvironmentthatisconducivetohealingofmucosalandgingivaltissues.Assuch,periodontalsurgeryisoftenperformedonnoninflamedtissueandintheabsenceofperiodontalpockets.Recently,manynewtechnologies,suchaslasers,havebeenproposedforperiodontalsurgery.Mostaimtoreplacetheuseofscalpels,curets,electrocauterydevicesandotherestablishedsurgicalinstruments—althoughmoreresearchisneededtodemonstratetheefficacyofthesenewtechnologies.19 CASEREPORTS ThefollowingcasereportsprovideexamplesofpatientswithLAPandGAPbeforeandafterperiodontaltreatment. LocalizedAggressivePeriodontitis A14-year-oldgirlpresentedwithlocalizedaggressivemoderateperiodontitis(Figure2andFigure3).Thepatientunderwentmicrobialtestingtoobtainasulcularsamplecollectionofanaerobicsubgingivalperiodontalpathogens.Afteranalysisoftheresults,shewasprescribedanantibioticregimenofamoxicillinandmetronidazole,andfourquadrantsofscalingandrootplaning.Datacollectedtwoyearslatershowthatthepatientremainsperiodontallystable(Figure4andFigure5).Increasedlevelsofbleedingonprobing,probingdepthandclinicalattachmentlevels,however,indicatedthepresenceofresidual,mildlocalizedperiodontaldisease. Infollow-upmicrobialtestingtwoyearsposttreatment,thebacteriologicalanalysisrevealedincreasedriskofdisease,yetthespectrumhadchangedandthesusceptibilityofthemicrobialsubgingivalflorahadshifted.Thepatientismaintainedincloseintervals(twotothreemonths),asriskofdiseaseandpredilectiontoperiodontitisremainhighinthiscase.Recommendedoralhygieneisaggressiveandvigorous,andmayincludeanantimicrobialdailymouthrinse,interproximalcleaning,anduseofanoralirrigatorandpoweredtoothbrush. FIGURE2.Theupperrightquadrantofa14-year-oldwithlocalizedaggressiveperiodontitispresentswithalargediastemabetween#9and#10.Thepapillaeappearslightlybulbous,andprobingdepthis5mmto6mm. FIGURE3.TherightquadrantsofthepatientfromFigure2beforeundergoingperiodontaltreatment. FIGURE4.Theupperrightquadrantofthesamepatienttwoyearsafteractivetreatment.Thediastemabetween#9and#10isstillpresent,butappearsreducedinwidth. FIGURE5.Theupperrightquadranttwoyearsafterperiodontaltreatment. GeneralizedAggressivePeriodontitis A32-year-oldmalepresentedwithgeneralizedsevereaggressiveperiodontitis.Hehadmultipleabscesses,deepprobingdepths,bleedingonprobingwithvisibleinflammation,bulbouspapillaeandpathologicmigrationofteeth.Thesesymptomsindicatedacutedisease,withurgenttreatmentneeded(Figure6throughFigure9).Diabeteswasruledout.Afterdiagnosis,thepatientwastreatedconservativelywithfourquadrantsofscalingandrootplaningandadjunctivechemotherapeutics.Whilethelong-termprognosisispoorduetothesevereandgeneralizedattachmentloss,theshort-termgoalistomaintaindentitionforaslongaspossible.Thepatientremainsatthree-monthperiodontalmaintenanceintervalsoneyearafterinitialtreatment,andwasprescribedanaggressiveantimicrobialoralhygieneregimen(Figure10). FIGURE6.This32-year-oldmalepatientpresentedwithmultipleabscesses,deepprobingdepths,andbleedingonprobing,withvisibleinflammation,bulbouspapillaeandpathologicmigrationofteeth. FIGURE7.Apanoramicradiographshowsfulldentitionwithgeneralizedseverebonelossandsomesubgingivaletiology. FIGURE8.Thepatienthadinflammationandrecession,withsuppurationandbleedingonpalatalview.Multipleanteriordiastemaspresentduetopathologicmigrationstemmingfromattachmentloss. FIGURE9.Tooth#30mesial-buccalwitha12mmprobingdepthpretreatment. FIGURE10.Posttreatment,thepatienthasreducedinflammationandetiology,withreduceddiastemasbetween#8and#9. CONCLUSION Astheleastcommonformofperiodontaldisease,aggressiveperiodontitisisalsotheleastunderstood.Untiladditionalhigh-qualityresearchprovidesevidenceonthemosteffectivetreatmentapproach,cliniciansmustbevigilantinidentifyingtheclinicalsignsofaggressiveperiodontitissoavarietyofstrategiescanbeimplementedasearlyinthediseaseprocessaspossible. References HolmstrupP.Non-plaque-inducedgingivallesions.AnnPeriodontol.1999;4:20–29. SusinC,HaasAN,AlbandarJM.Epidemiologyanddemographicsofaggressiveperiodontitis.Periodontol2000.2014;65:27–45. LangNP,BartoldPM,CullinanM,etal.InternationalClassificationWorkshop.Consensusreport:aggressiveperiodontitis.AnnPeriodontol.1999:4:53. BearPN.Thecaseforperiodontosisasaclinicalentity.JPeriodontol.1971:42:516–520. ArmitageGC,CullinanMP.Comparisonoftheclinicalfeaturesofchronicandaggressiveperiodontitis.Periodontol2000.2010;53:12–27. VieiraAR,AlbandarJM.Roleofgeneticfactorsinthepathogenesisofaggressiveperiodontitis.Periodontol2000.2014;65:92–106. LiljenbergB,LindheJ.Juvenileperiodontitis.Somemicrobiological,histopathologicalandclinicalcharacteristics.JClinPeriodontol.1980;7:48–61. ScottDA,KraussJL.Neutrophilsinperiodontalinflammation.FrontOralBiol.2012;15:56–83. ShaddoxLJ,WiedeyE,BimsteinI,etal.Hyper-responsivephenotypeinlocalizedaggressiveperiodontitis.JDentRes.2010;89:143–148. AlbandarJM.Aggressiveperiodontitis:casedefinitionanddiagnosticcriteria.Periodontol2000.2014;65:13–26. BrownLJ,AlbandarJM,BrunelleJA,LöeH.Early-onsetperiodontitis:progressionofattachmentlossduring6years.JPeriodontol.1996;67:968–975. HighfieldJ.Diagnosisandclassificationofperiodontaldisease.AustDentJ.2009:54:S11–S26. EresG,SaribayA,AkkayaM.PeriodontaltreatmentneedsandprevalenceoflocalizedaggressiveperiodontitisinayoungTurkishpopulation.JPeriodontol.2009;80:940–944. FineDH,MarkowitzK,FurgangD,etal.Aggregatibacteractinomycetemcomitansanditsrelationshiptoinitiationoflocalizedaggressiveperiodontitis:longitudinalcohortstudyofinitiallyhealthyadolescents.JClinMicrobiol.2007;45(12):3859–3869. SaraivaL,RebeisES,MartinsEdeS,etal.IgGseralevelsagainstasubsetofperiodontopathogensandseverityofdiseaseinaggressiveperiodontitispatients:across-sectionalstudyofselectedpocketsites.JClinPeriodontol.2014;41:943–951. BouzianeA,BenrachadiL,AbouqalR,EnnibiO.Outcomesofnonsurgicalperiodontaltherapyinseveregeneralizedaggressiveperiodontitis.JPeriodontalImplantSci.2014;44:201–206. ArdilaCM,Martelo-CadavidJF,Boderth-AcostaG,Ariza-GarcésAA,GuzmánIC.Adjunctivemoxifloxacininthetreatmentofgeneralizedaggressiveperiodontitispatients:clinicalandmicrobiologicalresultsofarandomized,triple-blindandplacebo-controlledclinicaltrial.JClinPeriodontol.2015;42:160–168. MoreiraAL,NovaesABJr,GrisiMF,TabaMJr,SouzaSL,etal.Antimicrobialphotodynamictherapyasanadjuncttononsurgicaltreatmentofaggressiveperiodontitis:asplit-mouthrandomizedcontrolledtrial.JPeriodontol.2015;86:376–386. CarranzaFANewmanMG,TakeiHH,KlokkevoldPR.Chapter53:PhaseIIPeriodontalTherapy.Carranza’sClinicalPeriodontology.St.Louis,MO:SaundersElsevier.2015;552–556. FromDecisionsinDentistry.September2016;2(09):46–49. 0 Share PrintEmailFacebookTwitterLinkedin DianaBronstein,DDS,MS,MS DianaBronstein,DDS,MS,MS,isanassociateprofessorintheDepartmentofPeriodontologyatNovaSoutheasternUniversityCollegeofDentalMedicineinFortLauderdale,Florida.SheisadiplomateoftheAmericanAcademyofPeriodontologyandadiplomateandfellowoftheInternational CongressofOralImplantology.Shecanbereachedat[email protected]. DmitriyKravchenko,MPH DmitriyKravchenko,MPH,isastudentinNova SoutheasternUniversity’sdualmedicalanddentaldegreeprogram. Heisscheduledtograduatein2017withdoctorofdentalsurgery andmedicaldoctordegrees JonB.Suzuki,DDS,PhD,MBA,FACD,FICD JonB.Suzuki,DDS,PhD,MBA,FACD,FICD,isaprofessorofmicrobiology andimmunologyintheSchoolofMedicineandofperiodontologyand oralimplantologyintheSchoolofDentistryatTempleUniversityin Philadelphia.HeisalsochairmanoftheU.S.FoodandDrug AdministrationDentalProductsPanel.SuzukiservesasfacultyattheU.S.WalterReed NationalMedicalCenterinBethesda,Maryland,andholdsprofessorshipsattheUniversityof Maryland,UniversityofWashingtonandNovaSoutheasternUniversity. 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