Generalized Aggressive Periodontitis and Its Treatment Options

Generalized aggressive periodontitis results in rapid destruction of the periodontium and can lead to early tooth loss in the affected individuals if not ... CaseReportsinMedicine+JournalMenuPDFJournaloverviewForauthorsForreviewersForeditorsTableofContentsSubmitCaseReportsinMedicine/2012/ArticleArticleSectionsOnthispageAbstractIntroductionDiscussionConclusionReferencesCopyrightRelatedarticlesCaseReport|OpenAccessVolume2012|ArticleID535321|https://doi.org/10.1155/2012/535321T.Roshna,K.Nandakumar,"GeneralizedAggressivePeriodontitisandItsTreatmentOptions:CaseReportsandReviewoftheLiterature",CaseReportsinMedicine,vol.2012,ArticleID535321,17pages,2012.https://doi.org/10.1155/2012/535321ShowcitationGeneralizedAggressivePeriodontitisandItsTreatmentOptions:CaseReportsandReviewoftheLiteratureT.Roshna1andK.Nandakumar21DepartmentofPeriodontics,People’sDentalAcademy,Bhopal462010,India2DepartmentofPeriodontics,AzeeziaDentalCollege,Kollam691537,IndiaShowmoreAcademicEditor:RemoPanaccioneReceived28Jul2011Revised04Oct2011Accepted07Oct2011Published12Jan2012Generalizedaggressiveperiodontitisresultsinrapiddestructionoftheperiodontiumandcanleadtoearlytoothlossintheaffectedindividualsifnotdiagnosedearlyandtreatedappropriately.Thediagnosticfeaturesofthediseasearecharacteristic,buttheclinicalpresentationandpatternsofdestructionsmayvarybetweenpatients.Successfulmanagementofthediseaseischallengingespeciallyifdiagnosedatadvancedstagesofthedisease,butnotimpossiblewiththecurrenttherapeuticchoicesforthedisease.Avastarrayoftreatmentmodalitiesisavailablewhichcanbeemployedinthetreatmentofgeneralizedaggressiveperiodontitiswithvaryingsuccessrates,butadefiniteguidelineforthemanagementisyettobeformulated.However,withtheexponentialrateofdevelopmentsinperiodontalresearch,regenerativetherapy,tissueengineering,andgenetictechnologies,thefutureseemspromisinginregardtooptionsatmanagingthedisease.Thispaperattemptstodescribetheclinicalandradiographicdiagnosticfeaturesandthecurrenttreatmentoptionsalongwithasuggestedprotocolforcomprehensivemanagementofgeneralizedaggressiveperiodontitispatientswithcasereportsandabriefreview.1.IntroductionAggressiveperiodontitis,asthenameimpliesisatypeofperiodontitiswherethereisrapiddestructionofperiodontalligamentandalveolarbonewhichoccursinotherwisesystemicallyhealthyindividualsgenerallyofayoungeragegroupbutpatientsmaybeolder[1,2].Althoughitsprevalencehasbeenreportedtobemuchlessthanthatofchronicperiodontitis,itcanresultinearlytoothlossintheaffectedindividualsifnotdiagnosedintheearlystagesandtreatedappropriately[3].Thediseaseisgenerallyfoundtohavearacialandsexpredilection,withblacksandmaleteenagershavinghigherriskforthediseasecomparedtowhitesandfemales,althoughreportsvarybetweendifferentethnicgroupsandpopulations,withsomepopulationsshowingprevalenceashighas28.8%[4,5].Aggressiveperiodontitis,firstdescribedin1923as“diffuseatrophyofthealveolarbone”[6],hasundergoneaseriesofterminologychangesovertheyearstobefinallynamedas“aggressiveperiodontitis”in1999[1,7].Thediseasewhichincludesbothlocalizedandgeneralizedformswaspreviouslyknownas“earlyonsetperiodontitis”whichincludedthethreecategoriesofperiodontitis—prepubertal,juvenile,andrapidlyprogressingperiodontitis[8,9].Itisinterestingthatthefirsteverreporteddetaileddescriptionofarecognizeddiseaseinearlyhominidevolutionisacaseofprepubertalperiodontitisinan2.5–3-million-year-oldfossilremainsofajuvenileAustralopithecusafricanusspecimenwhichshowedthetypicalpatternofalveolarbonedestructionwithmigrationoftheaffecteddeciduousmolars[10,11].Generalizedaggressiveperiodontitis(GAgP)ischaracterizedby“generalizedinterproximalattachmentlossaffectingatleast3permanentteethotherthanfirstmolarsandincisors”[12].Itisamultifactorialdiseasewhereinterplayofmicrobiologic,genetic,immunologic,andenvironmental/behavioralriskfactorsdecidestheonset,course,andseverity.PathogenicbacteriainthedentalplaqueespeciallyAggregatibacteractinomycetemcomitansandPorphyromonasgingivalis[13,14]haveanindispensablerolewhichelicitsanaggravatedhostresponsewhichinturnisdeterminedbythegeneticandimmunologicprofileofthepatientmodifiedbyenvironmentalriskfactorslikesmoking.Thispaperattemptstodescribethediagnosticfeaturesalongwiththeperiodontalmanagementoptionsofgeneralizedaggressiveperiodontitiswiththehelpofcasereportswithdifferentclinicalpresentationandpatternsofinvolvementandmanagedwithdifferenttreatmentmodalitiesavailable.FinallyanattempttosummarizetheavailableprotocolforacomprehensivemanagementofGAgPisdonewhichcanserveasaguidelinetillmoredefiniteclear-cutguidelinesareestablishedforthediseaseinthefuture.2.ClinicalFeaturesThemostcommonreportedcomplaintsarearecentlynoticedflaringandprogressingspacingofanteriorteethandbleedingfromgumscomparativelyinayoungpatientbutpatientscanbeolderaswell(Figures1(a)–1(c)).(a)(b)(c)(a)(b)(c)Figure1 (a)Patientpresentingwithflaringoftheanteriorteeth.(b)and(c)Deeppocketsrevealedbyprobinginaperiodontiumwithlackofclinicalinflammation.Patientsmaycomplainofhalitosisandpusdischargefromgums.Mobilityoftheaffectedteethwillbeseentowardsthelaterstagesoftheinfection.Patientswillbeotherwisesystemicallyhealthy.Severepainisrarelyexperiencedbythepatientsexceptinsituationswhereaperiodontalabscessdevelopsoraperiodontal-endodonticinfectionoccursviaaccessorycanalsortoothapex.Somepatientsmaycomplainofadullnaggingtypeofpainfromgums.Gingivalrecessionmaybeseenandpatientsmaycomplainoffoodimpactionduetolossofcontactpointsbetweenteeth.GAgPpatientswhosmokeand/ormaintainapoororalhygienedemonstratemoreseveredestructionofperiodontiumcomparedtothosewhodonotsmokeormaintainasatisfactoryoralhygiene(Figures2(a)–2(e)).(a)(b)(c)(d)(e)(a)(b)(c)(d)(e)Figure2 (a)–(d)ClinicalandradiographicappearanceofGAgPina25-year-oldsmokerwithpoororalhygiene.(e)A19-year-oldsmokerwithGAgPdemonstratingsevereperiodontaldestruction.Thediseaseprogressesinalternatingperiodsofactivityandquiescence[15].Thisleadstotwotypesofpresentationatthetimeofexamination.Intheperiodsofquiescence,patientsarefreeofsymptomsandthegingivaappearspinkandhealthyeventhoughprobingrevealsdeepperiodontalpockets.Lackofvisiblesignsofclinicalinflammationdespitethepresenceofdeepperiodontalpocketsandsevereattachmentlossinanotherwisehealthyyoungindividualistheclassicsignofaggressiveperiodontitispresentingatthisstage(Figures1(a)–1(c)).Probingshouldbedonewithcalibratedperiodontalprobesatsixsitesaroundeachtooth.Theperiodsofinactivitymayremainforweekstomonthsorevenyearsandwillbefollowedbyperiodsofactivedisease.Duringthisperiod,therewillbeactivebonedestructionandattachmentloss.Whenthepatientpresentsinthisstage,thegingivawillshowallsignsofmildtosevereinflammation.Gingivamaybetender,fieryred,edematous,soft,andboggy.Bleedingonprobingorevenspontaneousbleedingandpurulentexudationmaybeevident.Inflammatorygingivalenlargementmayalsobenoticed.Themajorityofthepatientsrefertodentalconsultationatthisstageofthedisease(Figures3(a)–3(c)).(a)(b)(c)(a)(b)(c)Figure3 (a)–(c)Featuresofseveregingivalinflammationpresentedatthestageofactivedisease.Thisstagemayundergospontaneousremissionafteravaryingperiodofdestructionandtheinflammatorysymptomssubsidetoreappearafteraperiodofquiescence.Advancedstagesoftheuntreateddiseasewithsevereperiodontaldestructionmayshowextrusionofteeth,mobilityandpathologicmigration,furcationinvolvement,generalizedgingivalrecession,andlossofseveralteethduetospontaneousexfoliation.Somepatientsmayshowsystemicmanifestationssuchasweightloss,mentaldepressionandgeneralmalaise[16].3.RadiographicFeaturesLocalizedaggressiveperiodontitistypicallypresents“arc-shaped”mirrorimageradiolucencyinthefirstmolarsstartingfromthedistalaspectofsecondpremolarstothemesialaspectofthesecondmolar.Ingeneralizedaggressiveperiodontitis,radiographsmayshowgeneralizedbonedestructionrangingfrommildcrestalboneresorptiontosevereextensivealveolarbonedestructiondependingontheseverityofthedisease.Thedefectsmaybeacombinationofverticalandhorizontaldefects(Figures4(a)and4(b)).(a)(b)(a)(b)Figure4 (a)Arc-shapedradiolucencyatthe1stmolarregioninlocalizedaggressiveperiodontitis.(b)GeneralizeddistributionofbonelossseeninGAgPwithverticaldefects.4.DiagnosisEarlydiagnosisisofutmostimportanceforthepreventionofextensiveattachmentlossandbonelossexperiencedinaggressiveperiodontitis.DiagnosisismadeaccordingtothecriteriasetbytheAmericanAcademyofperiodontology,1999classificationofperiodontaldiseasesandconditions[1],usinghistory,clinicalfeatures,andradiographicfeaturesaidedbymicrobialexaminationifneeded.Familyhistorymayrevealahistoryofearlytoothlossintheparentsorimmediatebloodrelativesofthepatient[17].Theamountofmicrobialdepositswillbeinconsistentwiththeamountofdestructionwhencomparedtochronicperiodontitisandplaquewillbeminimal.Comparisonofserialradiographshelpsinassessingtherapidrateofbonedestructionandcanaidinthediagnosisofthedisease.5.DifferentialDiagnosisAggressiveperiodontitiscanbedifferentiatedfromchronicperiodontitisbytheageofonset,rapidrateofdiseaseprogression,thenatureandcompositionoftheassociatedsubgingivalmicroflora,alterationsinhostimmuneresponse,andafamilialaggregationofthediseasedindividuals[18].Systemicdiseaseslikehematologicdisordersandsomegeneticdisordersalsoshowperiodontitisasamanifestationmimickinggeneralizedaggressiveperiodontitiswhichcanberuledoutbyassessingthesystemicstatus,hematologicdataanalysis,andimmunologicprofilingofthepatient.Inaddition,therearerarereportsofcertainconditionslikeintraosseoussarcoidosis[19],eosinophilicgranuloma[20,21]andalveolarboneactinomycosis[22],presentingwithextensivealveolarbonedestructionlikeinaggressiveperiodontitiswhichcanbedifferentiatedbybiopsyofthesuspectedlesions.6.CaseReports6.1.CaseReport1A32-year-oldfemalepatientpresentedwiththecomplaintofarecentlynoticedspacingbetweentheupperfrontteeth.(Figures5(a)–5(d)).(a)(b)(c)(d)(a)(b)(c)(d)Figure5 (a)–(d)Deeppocketswerepresenteventhoughsignsofgingivalinflammationotherthanbleedingonprobingwereabsent.Thepatientnoticedthespacingabout1yearbefore,afterwhichshenoticedittobegraduallyincreasingandassociatedwithintermittentepisodesofpusdischargewhichsubsidedontakingantibioticsasperadviceatalocalhospital.Therewerenoassociatedcomplaintsotherthanacosmeticconcernfromthepatient.Therewasnohistoryofanypreviousdentaltreatment.Familyhistoryofsimilarcomplaintsorearlytoothlosscouldnotbeelicited.Thepatientwassystemicallyhealthywithnorelevantmedicalhistory.Therewerenoabnormalitiesdetectedinextraoralexaminationexceptforaslightlytenderandpalpableleftsubmandibularlymphnode.Fullcomplementofteethwaspresent.Theoralhygienestatusofthepatientwasgoodasrevealedbytheoralhygieneindex.Therewasminimalamountofcalculusandplaque.TherewasgradeImobilityof22,31,32,21and22.Proximalcontactswerelostbetweentheteeth14and13,13and12,21and22and22and23,22and24andbetweenloweranteriorteeth.Therewaslabialmigrationandflaringofupperandloweranteriorteethwithanevidentdistolabialmigrationof22.Gingivalexaminationrevealednormalcolorexceptforthelabialaspectof22whereitwasslightlyreddish.Themarginswereofknife-edgecontourexceptforthelabialaspectof22and42whereitwasbluntlyrounded.Thegingivawasfirmandresilientexceptintheregionon22whereitwassoftinconsistency.Therewasnolossofstipplingintheanteriorregions.ThepositionofthegingivalmarginwasapicaltotheCEJinthelabialaspectof22.Therewasgeneralizedbleedingonprobing,andexudationwaspresentonthelabialaspectof22.Alltogethertherewereminimalsignsofinflammationotherthanbleedingonprobing.Afull-mouthperiodontalchartingrevealedgeneralizedperiodontalpocketsandclinicalattachmentloss(Figure6).Figure6 Periodontalchartingshowinggeneralizeddeeppocketsandclinicalattachmentloss.Pocketswereespeciallydeeperinthemolarandincisorregionswithslightlylesserinvolvementinthepremolarregion.Theclinicalattachmentlossrangedfromamaximumof10 mminthemidpalatalaspectof16toaminimumof2 mminthepremolarregions.AnOPGandfull-mouthIOPAX-raywereperformedwhichrevealedthegeneralizeddistributionofalveolarbonelosswhichwasacombinationofbothhorizontalandverticalboneloss(Figure7).Routinebloodexaminationresultswerewithinnormallimits.Figure7 Orthopantomogramofthepatientdemonstratinggeneralizeddistributionofboneloss.Basedonthehistory,examinationfindings,andtheradiographicfindings,adiagnosisofgeneralizedaggressiveperiodontitiswasmadeaccordingtothecriteriabyAAP1999classification.6.2.ManagementAthoroughsupragingivalscalingwasperformedfollowingwhichthepatientwasmotivatedforbetterplaquecontrol.Asulcusbrushingtechnique(modifiedBasstechnique)[23]wasdemonstrated,andthepatientwaseducatedontheuseofinterdentalcleansingaidsincludingdentalflossandinterdentalbrushes.Chlorhexidinemouthwashwasprescribedtofurtheraidinplaquecontrol.Systemicantibiotics(AmoxycillinandMetronidazole,250 mgofeachthricedaily)wereprescribedfor8days,andthepatientwasrecalledafter2weeksforevaluationoftheresponsetotreatment[24].Asubgingivalscalingwasperformedafterwhichthepatientwasadvisedtocontinuethechlorhexidinemouthwashes.Areevaluation2weeksaftersubgingivalscalingshowedareductioninprobingdepthsandabsenceofbleedingonprobing.Aquadrant-wisefull-mouthflapsurgerywasperformedincludingbonegraftinginrelationtothemolarregionswherepredominantlyverticalorintrabonydefectsweredetected.AmodifiedWidmanflapsurgery[25]inconjunctionwithbonereplacementgraftwasperformedinthemolarregions(Figures8(a)–8(e))whereasasulcularincisionflap(Kirklandflap)wasperformedinthemaxillaryandmandibularanteriorregiontominimizetherecessionafterhealingforestheticpurposes.(a)(b)(c)(d)(e)(f)(g)(a)(b)(c)(d)(e)(f)(g)Figure8 (a)–(e)ModifiedWidmanflapinconjunctionwithbonegraftingperformed.(f)Postoperativeevaluationshowingprobingdepthwithinnormallimits.(g)6-Monthpostoperativeintraoralperiapicalradiographs.Apreproceduralrinsewithantimicrobialagentwasdonetominimizethebacterialcountinthemouth.Afteradequatelyanesthetizingthesurgicalsitewithinfiltrationanesthesiaandnerveblocks,thefirstincision(internalbevelincision)0.5 mmfromthegingivalmargindirectingtothecrestofthealveolarbonewasmade.Theflapwasreflectedfollowingwhichsulcularincisionandinterdentalincisionweremadetoremovethewedgeoftissue.Curettageforgranulationtissueremovalwasdonefollowingwhichathroughsubgingivaldebridementandrootplanningwasperformed.Thedefectwasirrigatedwithnormalsaline,andarootconditioningwithtetracyclinewasperformed.Thegraftwasaxenograft(Bovinegraft—Ossopan),whichwasmixedwiththebloodfromthesurgicalsiteandplacedintothedefectafterpresuturingthesitewithsilksutures.Carewastakentofillthegrafttoarealisticlevelandnottooverpackthedefect.Suturingwasdoneafteradaptingthebuccalandlingualflapswell.Aperiodontalpackwasplaced,andantibioticsandanalgesicswereprescribedforthepatientfor5days.Afluoride-containingmouthwashwasprescribedpostsurgicallytothepatient.Healingwasuneventful,andapostoperativeevaluation3weeksaftersurgeryshowedabsenceofbleedingonprobingandprobingdepthswithinnormallimits(Figure8(f)).Thepatientwasputonregularrecallappointmentsforevaluationofthegingivalandperiodontalstatusandmaintenancetherapy.Apostoperativeradiograph6monthslatershowedasignificantbonefillinthemolarregionswheregraftingwasdonewithanincreaseinbonedensityofthealveolarcrestwithcorticatedboneformationsinthecrestattheotherareas(Figure8(g)).Theoralhygienemaintenanceandcomplianceofthepatientwasexcellent,andtherewerenosignsofrecurrenceofthediseasethroughoutthemaintenanceperiod.Sincethepatientwasconcernedabouttheestheticappearanceoftheanteriorteeth,shewasadvisedtoundergoadultorthodontictherapyafter1yearofsurgeryunderregularperiodontalmonitoringandwasreferredtoanorthodonticspecialistforthesame.6.3.CaseReport2A26-year-oldmalepatientpresentedwiththechiefcomplaintofgeneralizedpusdischargefromgumswhichhehadbeenexperiencingintermittentlyforthepast2years(Figures9(a)and9(b)).Pusdischargewasassociatedwithbadbreathandusuallysubsidedspontaneouslyafterafewweeks.Therewasnoassociatedcomplaintotherthanageneralizedmildhypersensitivitytocoldandsweetfood.Hehadahistoryofextractionoflowerleftposteriortoothduetocariesexposureandextractionoflowerfronttoothduetomobilityabout1yearbefore.Therewasnohistoryofanyotherdentaltreatment.(a)(b)(a)(b)Figure9 (a)and(b)Clinicalpresentationwithdeeppockets,recession,andpathologicmigrationofteeth.Thepatientwassystemicallyhealthy,andmedicalhistorydidnotrevealanyrelevantfindings.Familyhistoryrevealedthatthepatient’smotherhadsimilarcomplaintsofmobility,pusdischarge,andspontaneousexfoliationofsometeethfollowingwhichsheconsultedadentistandunderwenttotalextractionbytheageof40.Thepatientwasanonsmoker,andtherewasnohistoryofuseofanyotherformsoftobacco.Extraoralexaminationrevealedbilateralsubmandibularlymphnodeenlargement,whichwasfirm,mobile,andnontender.Allteethwerepresentexceptfor46,26,and41.Tooth46wasextractedduetocariesand41wasextractedduetomobility.Tooth26wasgrosslydecayedwithjustrootstumppresent.Theoralhygienestatusofthepatientwasfairwithmoderatedepositsofcalculusandplaque.Intraoralexaminationrevealedanormalcolorofgingivaexceptinthelabialaspectof31,32,and33wherethemarginalgingivawasslightlyreddish.Gingivalmarginswererounded,andexudationwaspresentinrelationtolabialaspectsofmandibularanteriorteethandmaxillarycentralincisors.Therewasgeneralizedbleedingonprobingandrecessioninrelationtomostoftheteeth,especiallymoreinmaxillarycentralincisorsandmandibularanteriorteeth.TherewasgradeImobilityof15and22andgradeIImobilityof11,12,21,31,32,33and42.Proximalcontactswerelostbetweenmaxillaryandmandibularanteriorteethwithpathologicmigrationof11,21,31,32,and42andextrusionof31.GradeIIfurcationinvolvementwaspresentwithmolarsandmaxillaryfirstpremolars.Afullmouthperiodontalexaminationrevealedgeneralizeddeepperiodontalpocketsandseveregeneralizedclinicalattachmentloss(Figure10).Figure10 Pretreatmentperiodontalchartingshowsdeeppocketswithgeneralizedclinicalattachmentloss.Severeperiodontaldestructionwasevidentwithmorethan10 mmofclinicalattachmentlossatmultiplesitesespeciallyintheincisorandcanineregions.OPGandIOPAX-raysrevealedageneralizeddistributionofperiodontalbonelossespeciallysevereintheincisorandcanineregionswiththemolarsandpremolarsaffectedtoalesserdegree(Figure11).Therewaspredominantlyverticalbonelossinthecanineandincisorregions.Routinebloodinvestigationswerewithinnormallimits.Figure11 Orthopantomogramshowinggeneralizedbonelosswithadvancedverticaldefectin13and33regions.Adiagnosisofgeneralizedaggressiveperiodontitiswasmadeaccordingtotheestablishedcriteria(AmericanAcademyofPeriodontology,1999).6.4.ManagementSupragingivalscalingwasperformed,andthepatientwaseducatedinoralhygienemaintenance.ThepatientwasadvisedtofollowamodifiedStillmantechniqueofbrushingsincethepatienthadrootexposureandhypersensitivityandalsoadvisedtouseinterdentalbrushesanddentalflossforoptimalplaquecontrol.Thepatientwasprescribedtopicalantimicrobialagents(metronidazolegel)alongwithchlorhexidinemouthwashfor2weeks.Acombinationsystemicantibiotictherapyofamoxicillinandmetronidazole[24]wasinitiated,andadesensitizingagentwasprescribed.Arecallvisitafter2weeksshowedreductionininflammationandpercentageofsitesshowingbleedingonprobing.Exudationwaspersistentinrelationto11and33regions.Asubgingivalscalingandrootplaningwasperformedfollowingwhichapovidoneiodine5%irrigationwasperformed.Anonsustainedprofessionallydeliveredlocaldrugdeliverywithmetronidazolegelwasinjectedsubgingivallyatsites33and11,followingwhichaperiodontaldressingwasgivenatthesite.Theprocedurewasperformedevery3daysforthenext2weeks.Evaluationafter3weeksshowedcompleteabsenceofbleedingonprobing,exudation,andsignificantreductioninprobingpocketdepth.Thepatientwasputonmaintenancetherapyduringwhichhecontinuedwiththetopicalantimicrobialagentsanddesensitizingagentsandwasevaluatedforsurgicaltherapy.Afull-mouthflapsurgerywithbonegrafts(synthetichydroxyapatite(HAP)),whereindicated,wasperformedsextantwiseatintervalsoftwoweeks.Inaddition,thedefectatsite33wastreatedwithguidedtissueregeneration(GTR)withbioresorbablecollagenmembraneinconjunctionwithsyntheticbonegraft(HAP)(Figures12(a)–12(f)).(a)(b)(c)(d)(e)(f)(a)(b)(c)(d)(e)(f)Figure12 (a)–(c)Flapsurgeryinconjunctionwithbonegrafting(HAP)andpapillapreservationflapbetween11and21.(d)–(f)Deepcircumferentialdefecttreatedwithbonegraftinginconjunctionwithguidedtissueregeneration.Postoperativeclinicalevaluationshowedexcellentgingivalconditionwithreductioninprobingdepthstonormallevels(Figures13(a)and13(b)).RadiographsshowedbonefillintheregionwherebonegraftsaloneorinconjunctionwithGTRwereused(Figures13(c)and13(d)).Regularrecallappointmentsweregivenformaintenancetherapyduringwhichthetreatmentresultswerewellmaintained.However,therewasaslightincreaseinrecessionduetoshrinkageofgingivaonhealingandhypersensitivityafterthesurgerywhichgraduallysubsidedonregularuseofdesensitizingagentsandfluoridemouthwashes.(a)(b)(c)(d)(a)(b)(c)(d)Figure13 (a)and(b)Postoperativephotographsshowingprobingdepthswithinnormallimitswithexcellentgingivalcondition;however,therewasslightincreaseinrecessionafterhealing.(c)and(d)Comparisonofpreoperativeand1yearpostoperativeradiographsshowsgoodbonefillatthedefectinrelationto33.7.DiscussionThekeytosuccessfultreatmentisearlydiagnosis.Earlydiagnosishelpsinpreventionofprogressionofthediseasethusavoidingthepossibilityofadvancedtissuedestructionandalveolarboneloss.Theearlierthediagnosisisthebettertheprognosisofthedentitionwillbe.Furthermoresinceithasatendencyforfamilialaggregation,itisimportanttodoaperiodontalexaminationofsiblingsandotherclosebloodrelativesofthepatientwhichhelpsinearlydiagnosisofthediseaseinthefamilymembers.ManagementofGAgPpatientsessentiallyconsistsofanonsurgicalphase,surgicaltherapyaninterdisciplinarytherapyandalifelongsupportiveperiodontaltherapy.7.1.Nonsurgical/EtiotropicPhaseofTherapyNonsurgicaltherapyremainsthefirstlineofantimicrobialtherapyinGAgP.Earlystagesofthediseasewithmildtomoderateperiodontalandbonedestructionmaybemanagedentirelybynonsurgicaltherapywithsystemicantibioticsasanadjuvanttomechanicaltherapy.Therapyshouldstartwithattemptsatcontrollingoreliminatingtheetiologicagentsandmodifiableriskfactorsforthedisease.Thediseasehasastronggeneticpredisposition.Thehostresponseofthepatientorthesusceptibleindividualtopathogenicbacteriainthedentalplaqueplaysavitalroleinthepathogenesisandexpressionofthedisease,andthishostresponseisgeneticallydeterminedandisanunmodifiableriskfactorisatpresentbythecurrenttreatmentmeasures[26].However,sincetheexpressionofthediseaseinsusceptibleindividualsisalsoinfluencedbymicrobialandenvironmentalriskfactors,thediseasecanbesuccessfullykeptundercontrolbycontrollingthemicrobialandenvironmentalfactors.Thisunderliestheimportanceofoptimalplaquecontrolbothbypersonallyemployedmethodsusedbythepatienthimselfandprofessionallyemployedplaquecontrolmeasuresbythedentalteamtothepatient.Evenaminimalamountofplaqueisenoughtoelicituntowardhostresponseinthosepatientssusceptibletothedisease,andareducedresistancetotheinvasionofsubgingivalplaquecanbecompensatedforbyacorrespondinglystrongemphasisontotalplaquecontrol[27].Mechanicalplaquecontrolcanbesuccessfullyachievedbyeducatingandmotivatingthepatientifneededwiththeaidofdisclosingsolutionsregardingtheneedforoptimalplaquecontrol,demonstrationofbrushingtechniques(modifiedBasstechniqueforpatientswithoutgingivalrecessionandmodifiedStillmantechniqueinpatientswithhypersensitivityandgeneralizedrecession),anduseofinterdentalcleansingaidslikedentalflossandinterdentalbrusheswhereindicated.Thisbehavioralmodificationfromthepatientneedsapositivereinforcementandencouragementfromthedentalteam.Regularrecallappointmentstomonitortheefficacyofthepatient’splaquecontrolmeasuresareessential.Chemicalplaquecontrolagentslikechlorhexidine0.12%or0.2%mouthwashes,and1%povidoneiodinecanbeadvisedforfurtherplaquecontrolasanadjuncttothepatient’smechanicalplaquecontrolmeasures[28].AminefluorideandstannousfluoridemouthrinsesandtoothpastesasanadjuncttomechanicaloralhygieneproceduresinGAgPpatientswerefoundtobeeffectiveincontrollingsupragingivalplaqueaccumulationsinaggressiveperiodontitis[29,30].Additionallyuseoffluoridemouthwashesisadvisedtohelpinremineralizationoftheexposedrootsurfaces,andforpatientscomplainingofhypersensitivity,useofdesensitizingtoothpastesandmouthwashesismandatory.SmokinghasbeenwelldocumentedasasignificantriskfactorforaggressiveperiodontitiswithGAgPpatientswhosmokehavingmoreaffectedteethandmorelossofclinicalattachmentthannonsmokingpatientswithGAgP[31].Furthermoretheresponsetoperiodontaltherapy,bothnonsurgicalandsurgical,regenerativetherapy,andimplanttherapyislessthaninnonsmokers,butformersmokersrespondsimilartononsmokers.Thisunderliesthetherapeuticeffectofsmokingcessationandcessationofotherformsoftobacco,andpatientsshouldbeadvisedofthebenefitsofsmokingcessationandthepotentialrisksofsmokinginworseningtheirperiodontalcondition,andifneededexpertcounselingforcessationofthehabitshouldbesought[32–36].7.1.1.MechanicalAntimicrobialTherapyScalingandrootplaning(SRP)whicheliminatesthemicrobialbacterialloadfromtheperiodontalpocketsandremovesthelocaletiologicfactorsisperformedeitherasaquadrant-wiseSRPat2-weekintervalorasafullmouthscalingandrootplanningcompletedonthesameday.However,bothmodalitieshavebeenfoundtobeefficaciouswithsignificantimprovementinclinicalparameters,andtheclinicianshouldselectthetreatmentmodalitybasedonthepracticalconsiderationsrelatedtothepatientpreferenceandclinicalworkload[37].Anotherapproachtomechanicalantimicrobialtherapyisaone-stagefullmouthdisinfectiontherapydevisedbyQuirynenetal.,whichwasfoundtoresultinanimprovedclinicaloutcomeandmicrobialimprovementinearlyonsetperiodontitiscomparedtoquadrant-wiseSRP[38,39].Full-mouthdisinfectiontherapyincludesfull-mouthdebridement(scalingandrootplanning,brushingofthetonguewith1%chlorhexidinefor1minute,rinsingofthemouthwitha0.2%chlorhexidinesolutionfor2minutes,andirrigationofperiodontalpocketswith1%chlorhexidinesolution),completedin2appointmentswithina24-hourperiod[40].7.1.2.PhotodynamicTherapyandLaserIrradiationThesehavebeentriedasadjunctstomechanicaltherapytoinhibitthepathogenicbacteriainperiodontalpockets[41–44].Photodynamictherapy(PDT)isanoninvasivephotochemicalapproachforinfectioncontrolwhichcombinestheapplicationofanontoxicchemicalagentorphotosensitizerwithlow-levellightenergyandhasshownclinicalevidenceofefficienteradicationofperiodontalbacteriafromsubgingivalsites[41].ThisnoveltherapeuticapproachofantimicrobialtherapyseemspromisingandisgettingattentionrecentlyeitherasamonotherapyorasanadjuncttoSRPinthenonsurgicaltreatmentofaggressiveperiodontitis.BothPDTandSRPhavebeenshowntohavesimilarclinicalresultsinthenonsurgicaltreatmentofaggressiveperiodontitis[42,43].Laserirradiationofsubgingivalsitestoeradicateperiodontopathicmicroorganismsisalsobeingconsideredinthenonsurgicaltherapyofperiodontitispatients.DiodelasertreatmenthasshownasuperiorclinicalandmicrobiologicaleffectwhenusedalongwithSRP,comparedtoSRPaloneorlasertherapyaloneinaggressiveperiodontitispatients[44].Aregularrecallvisitpreferablyatone-weekintervalsshouldbeperformedespeciallyattheinitialstagesofthetreatmenttomonitortheefficiencyofthepatient’splaquecontrolmeasuresandtoassesstheresponseofthepatienttowardsnonsurgicaltherapy.7.1.3.ChemicalAntimicrobialTherapyintheManagementofGAgPRoleofSystemicAntibioticTherapyinGAgPSystemicantibioticsareindicatedinaggressiveperiodontitissincethepathogenicbacterialikeAggregatibacteractinomycetem-comitansandPorphyromonasgingivalishavebeenfoundtobetissueinvasiveandmechanicaltherapyisinsufficienttoeliminatethebacteriafromthesesites[58,59].Systemicallyadministeredantibioticswithorwithoutscalingandrootplanningand/orsurgeryprovidedgreaterclinicalimprovementinattachmentlevelchangecomparedtosimilarperiodontaltherapywithoutantibiotics[45].Earliertetracyclineswereusedextensivelyforthispurposesincesystemictetracyclinewasfoundtobeausefuladjuncttomechanicalperiodontaltherapyinpatientswithaggressiveperiodontitis[46–48],buttheconcernfortetracyclineresistancehasshiftedthefocustotheuseofotherantibioticsbothascombinationtherapyorserialantibiotictherapy[49].ThepreferredcombinationantibiotictherapyatpresentfortreatmentofGAgPis250 mgofamoxicillinthricedailyalongwithmetronidazole250 mgtwicedailyfor8days[24,49].ItisoneofthemostevaluateddrugcombinationsinGAgP,andthereisampleevidencenowtoshowthatAmoxycillin-MetronidazolecombinationasanadjunctivetreatmentinGAgPatinitialtherapysignificantlyimprovestheresultsandhenceshouldbepreferredoverotherantibioticregimensasthefirst-linetreatment(Table1)[50–55].Theusefulnessofmicrobialtestingmaybelimitedbecauseofthevariabilityoftestreportsbetweendifferentlabsandthemixedflora,andhenceanempiricuseofantibioticsliketheabove-mentionedcombinationmaybemoreclinicallysoundandcost-effectivethanbacterialidentificationandantibiotic-sensitivitytestinginthetreatmentofaggressiveperiodontitis[49].Single-agenttherapywithDoxycycline[53,55],azithromycin[56],metronidazole[53,57],andclindamycin[57]iseffectivewhenusedadjunctivelytononsurgicalprocedureofSRPinAgPpatients.ThecriteriaforselectionofantibioticsarenotclearinAgP;thechoicedependsonthecase,disease-relatedfactorsandpatient-relatedfactorslikecompliance,allergies,andpotentialsideeffects.ModeoftherapyAntibioticsusedUsualrecommendeddosageCombinationtherapyMetronidazole+Amoxicillin250 mgofeachthricedailyfor8daysMetronidazole+Ciprofloxacin500 mgofeachtwicedailyfor8daysSingle-AgenttherapyDoxycyclineorMinocycline100–200 mgoncedailyfor21daysMetronidazole500 mgthricedailyfor8daysTetracycline250 mg4timesdailyfor1weekAzithromycin500 mgoncedailyfor3daysClindamycin300 mgthricedailyfor10daysTable1 ThelistofantibioticregimenswithevidenceofsuperiorclinicaloutcomewhenusedasanadjuvanttoSRPinGAgP[24,45–57].7.1.4.LocalDrugDeliveryofAntimicrobialAgentsTopicalapplicationofantimicrobialagentsandlocaldrugdeliveryisalsoatreatmentoptionespeciallyiftherearelocalizedareasofexudationanddeeppocketsnotrespondingadequatelytomechanicalandsystemicantibiotictherapy.Localdrugdeliverydeliversthedrugsathighconcentrationsatthesiteofinfectionwhencomparedtosystemicantibiotictherapy.Furthermore,thisisanoptioninpatientswherethereisintolerancetosystemicadministrationoftheantibiotic.Severallocalanti-infectiveagentscombinedwithSRPappeartoprovideadditionalbenefitsinPDreductionandCALgaincomparedtoSRPalone.Overthepast20years,locallydelivered,anti-infectivepharmacologicalagents,mostrecentlyemployingsustained-releasevehicles,havebeenintroducedtoachievethisgoal[60].Thoughthereismoreevidenceonitsapplicationinchronicperiodontitis,tillfutureresearchesareavailable;thesameagentscanbeemployedinaggressiveperiodontitispatientsaswellempirically.AdjunctiveuseofLDDagentslikecontrolledreleasebiodegradablechlorhexidinegluconatechip[61,62],tetracyclinefibers[63,64],andminocycline-Hclgel[65]hasbeentriedinaggressiveperiodontitiswithsuperiorclinicaloutcomes.Thedecisiontouselocalanti-infectiveadjunctivetherapyremainsamatterofindividualclinicaljudgment,thephaseoftreatment,andthepatient’sstatusandpreferences.Anevaluationoftheresponsetononsurgicaltreatmentisdone2-3weeksaftertreatmentduringwhichthegingivalandperiodontalstatusofthepatientwillbereevaluatedandcomparedwiththepretreatmentvaluestoassesstheresponsetotherapyandtoassesstheareaswhichneedsurgicaltherapy.Siteswithpersistingpockets>5 mmdepth,verticalbonedefectswhichneedregenerativetherapy,difficulttoinstrumentareaslikefurcationinvolvement,andareaswhichneedrecontouringorresectiveosteoplastyareindicationsforsurgery.7.2.SurgicalTherapyItessentiallyconsistsofopenflapdebridementeitheraloneorasacombinationwithresectiveorregenerativeprocedures.Themainaimofaflapprocedureistogetaccessandvisibilitytorootandfurcationareassothatathoroughinstrumentationanddebridementcanbeperformed.FlaptechniqueslikemodifiedWidmanflap[25],modifiedflapoperation/Kirklandflap(sulcularincisionflap)[66]achievethisaimwithouteliminatingthepockets.Aresectiveflapprocedurelikeundisplacedflap[67]willeliminatethepocketsaswellbutcompromisetheestheticsandfunctionofthedentitionbyrootexposureandresultanthypersensitivityandhenceisnotpreferredusuallywhencomparedtomodifiedWidmanflaporsulcularincisionflap.Laser-assistedsurgery(Nd:YAGlaser)issuggestedasavalidalternativetoconventionalscalpelsurgicaltherapy,inindividualsatincreasedsurgicalrisklikeincoagulationandplateletfunctiondisorders[68].7.2.1.RegenerativeSurgicalTherapyRegenerationoftheperiodontalsupportingstructureslostduetoperiodontaldiseasesothattheformandfunctionoftheperiodontiumisreestablishedhasbeenanelusiveordifficult-to-achievegoalforperiodontaltherapists.Variousmodalitiesarebeingemployedforperiodontalregenerationwhichincludesuseofbonereplacementgrafts,barriermembranesorguidedtissueregeneration(GTR),biologicmodifierslikegrowthanddifferentiationfactors(GDF),andextracellularmatrixproteinslikeenamelmatrixproteins(EMD)oruseofacombinationoftheabovetechniquesandmaterialswhichhasbeenextensivelyreviewedelsewhere[69].Asulcularincisionflaporpapillapreservationflapwillbetheidealtechniquetominimizerecessionintheanteriorregionsduetoestheticreasons,andmodifiedWidmanflaporconventional/sulcularincisionflapwillbethetechniqueofchoiceintheposteriorregionswhenoptingforbonegraftingandanotherregenerativetherapy.Apapillapreservationflapispreferredforbonegraftingwhenthereisspacingbetweentheteethtoobtainmaximumcoverageofthegraftmaterialattheinterdentalregionandtopreventshrinkageofpapillaonhealing[67].Biomodificationoftherootsurface(Rootconditioning)withcitricacid,tetracycline,orfibronectinispreferablewhenperformingbonegraftingorGTRforbetterclinicalresults[69].7.2.2.BoneReplacementGraftsBonegraftingisindicatedinverticaldefects,andthesuccessoftheproceduredependsonthetypeofdefect.Three-walledorintrabonydefectistheidealdefectforbonegraftsandhasabettersuccessratecomparedtoatwo-walledandone-walleddefect.Thetypeofbonegraftwhichgivesthemaximumbenefitwithminimumtissuereactionisautograft[70],buttherearelimitationsofobtainingitinlargequantitiesasisneededinmostcasesofgeneralizedaggressiveperiodontitis.Amorefeasibleoptionistousecommerciallyavailablebonegrafts,whichareallograft,xenograft,oralloplasticmaterials.Allograftsusedforperiodontalgraftsincludemineralizedfreeze-driedboneallografts(FDBAs)whichareosteoconductive,anddecalcifiedfreeze-driedboneallografts(DFDBAs)whichareosteoinductive.Decalcificationofthegraftexposesthecomplexbonemorphogenicproteins(BMPs)fromitsmatrixwhichcaninduceosteoblasticproliferationintherecipientsite.DFDBA,becauseofitsosteoinductiveproperty,hasshowntohavebetterresultsthanthealloplasticmaterialswhichareosteoconductive[71].Allogeneicfreeze-driedbone(FDBA)mixedwithtetracyclinepowderalongwithsystemictetracyclinehasdemonstratedabetterclinicaloutcomeintreatmentofjuvenileperiodontitis[72].Xenograftsusedareeitherbovinederivedorcoralderived.Anosteoconductivebovine-derivedanorganicbone,Bio-Oss,hasbeensuccessfullyusedinperiodontaldefectswithresultingboneregenerationandnewattachmentinthesedefects[73–75].HumanhistologicstudieshaveshownthatacombinationofBio-Osswitheitherpurifiedporcinecollagen(Bio-OssCollagen)[76]orasyntheticcell-bindingpolypeptide(PepgenP-15)[77]hasthecapacityofinducingregenerationoftheperiodontalattachmentapparatuswhenplacedinintrabonydefects.Corallinegraftsimplantedintohumanperiodontaldefectshaveproducedbetterclinicalresultswhencomparedtonongraftedsites[78].Syntheticgrafts/alloplasticgraftshavebeenconsideredprimarilyasdefectfillers.Themostcommonlyusedamongalloplasticgraftmaterialsishydroxyapatite(HAP)whichisosteoconductiveandhasshowntohavesimilarclinicaleffecttoFDBA[79].Otheralloplasticgraftswhichcanbeusedarebetatricalciumphosphateandbioactiveglass[80,81].Asynthetichydroxyapatite/equinetypeIcollagen/chondroitinsulphatebiomaterial(Biostite)hasbeenfoundtoshowcomparableimprovementstoBio-Ossintermsofclinicalattachmentgain,pocketdepthreduction,andradiographicbonefillinthetreatmentofdeepintraosseousdefects[82].7.2.3.GuidedTissueRegenerationGuidedtissueregenerationpromotesregenerationbyactingasabarrierwhichpreventsapicalmigrationofepitheliumandexcludegingivalconnectivetissuefromthehealingwound,thusallowingthepluripotentperiodontalligamentcellstopopulatethesiteofhealingenhancingnewcementumandnewattachmentprocedures.GTRhasshowntohaveagreatereffectonprobingmeasuresofperiodontaltreatmentthanopenflapdebridementalone,includingimprovedattachmentgain,reducedpocketdepth,lessincreaseingingivalrecession,andmoregaininhardtissueprobingatreentrysurgery[83].ResearchhasshownthatGTRinconjunctionwithbonegraftinghasbetterpotentialforregenerationcomparedwitheithertechniquealone[74,84,85],andthisoutcomehasbeenconfirmedinaggressiveperiodontitisalsowiththeuseofbioresorbablemembranes(Bio-Gide)[75,80].7.2.4.BiologicMediatorsandExtracellularProteinsAwidearrayofregenerativematerialsisbeingconsideredforuseinperiodontitis.Useofbiologicmediatorslikegrowthfactors(insulin-likegrowthfactor(ILGF),platelet-derivedgrowthfactor(PDGF))useofplatelet-richplasmawhichcontainsPDGF,extracellularmatrixproteinslikeemdogain,etc.areofpromisingresults.Applicationofenamelmatrixproteinsalone[86]orincombinationwithbonegraftsincludingbioactiveglasshasshowntoresultinthesuccessfultreatmentofintrabonydefectsinaggressiveperiodontitis[87].Beneficialeffectsofplatelet-richplasma(PRP)inthetreatmentofperiodontaldefectshavebeendemonstratedbyclinicalandradiographicmeasurementstogetherwithreentryresultsshowingmarkedimprovementsfrombaselinewithincreasedstabilizationofwholedentitionincludingthehopelessteeth[88,89].Variouscommerciallyavailableregenerativematerialsincludingbonereplacementgrafts,GTRmembranes,enamelmatrixderivatives,areinthemarketforuseinperiodontaltherapywithvaryingresults,andthechoiceofthematerialdependsonthedentist’spreferenceandexperiencewiththeproductshelpinginclinicaljudgmentofthetherapeuticresultsofindividualproductsandproceduresandtheircost-benefitratio.7.3.RoleofMaintenanceTherapyinManagementofAggressivePeriodontitisTheimportanceofsupportiveperiodontaltherapyhastobestressedinmanagementofaggressiveperiodontitis.RegularSPTwasfoundtobeeffectiveinmaintainingclinicalandmicrobiologicalimprovementsattainedafteractiveperiodontaltherapyinearlyonsetperiodontitis[90].ThemaintenancetherapystartssoonafterthephaseItherapyornonsurgicaltherapyandshouldbecontinuedthroughoutthelifetimeofthepatient.Orinotherwords,“maintenancetherapyneverends”foraGAgPpatient.Inordertomaintaintheoptimalresultsgotbysurgeryandtopreventtherecurrenceofthedisease,alifelongmaintenancetherapyismandatorybecauseofthestronggeneticsusceptibilityoftheindividualtothedisease.Thefrequencyoftherecallvisitsdependsontheresponseoftheindividualtotreatmentandpresenceofotherriskfactorslikeenvironmentalfactorsbutgenerallywillbemorefrequentthanthatinchronicperiodontitisorinlocalizedaggressiveperiodontitis.Anysitewhichshowssignsofrecurrenceofthediseaselikebleedingonprobingwhichisconsideredasthefirstclinicalsignofinflammationshouldbetreatedvigorouslyandmonitoredforresolutionofthesigns.7.4.InterdisciplinaryApproachforManagementofResultantEsthetic,Functional,andPsychologicProblemsinGAgPAcomprehensivemanagementfortotalrehabilitationoftheGAgPpatientsnotonlyinvolvescontrolofinfectionandarrestofprogressionand/orregenerativetherapybytheperiodontistbutalsoincorporatesamultidisciplinaryapproachtoattendtheesthetic,functional,andpsychologicproblemsfacedbythepatient.Anorthodontictherapywithconcomitantperiodontalmonitoringandprostheticrehabilitation,ifpossiblewiththeuseofimplantsandpsychologiccounseling,maybeneededforpatientswithadvancedformsofthedisease.7.4.1.CombinedPeriodontal-OrthodonticTherapyCosmeticconcernsinyoungaggressiveperiodontitispatientswillbehighsincethediseasecanresultinflaring,protrusion,pathologicmigration,andevenextrusionoftheanteriorteeth.Malocclusion,pathologicmigrationandpotentialocclusaltraumatismwhichcancausesecondarytraumafromocclusioncanbecorrectedbyorthodontictherapyinGAgPpatientsalreadystabilizedbyperiodontaltherapy[91–94].Orthodontictreatmentcanbecommencedonceattachmentgainandbonestabilityisachievedafterperiodontaltherapybutisgenerallyadvisedtopostponetill3monthsto1yearafteractiveperiodontaltherapy.Acombinedperiodontalandorthodontictreatmentdemandsadetailedevaluationinbothspecialties,particularlywhentheperiodontiumisreduced.Periodontalevaluationsarescheduledconcomitantlywithorthodonticappointmentstomonitortheperiodontalstabilityasthetoothmovementoccurs.7.4.2.ProsthodonticRehabilitation,ImplantTherapy,andImplantSupportedProsthesisGingivalrecessionwithlossofinterdentalpapillaespeciallyintheanteriorteethisunaestheticespeciallywhenthepatientsmilesandthefeasibilityofrootcoverageperiodontalplasticsurgerywillbelimitedingeneralizedaggressiveperiodontitisbecauseofthelargenumberofteethinvolvedandtheadvancedinterdentalboneloss.Aporcelain,resin,silicone,orcopolyamideremovablegingivalprosthesis(gumveneer/gingivalmask)canbefabricatedtomasktherecessionandimprovetheappearanceoftheanteriorteeth[95].Therestorationoftheteethlostduetoperiodontitisshouldbedonewithfixedorremovableprosthesisdependingonthebonesupportoftheremainingteeth.ContradictorytotheearlierconceptthatimplantsarenotafeasibleoptioninGAgPpatients,theuseofimplantsandimplant-supportedprosthesistorestorethelostteethisincreasinglyconsideredasatreatmentoptioninwell-maintainedGAgPpatientseventhoughtheriskofbonelossandattachmentlossaroundimplantsishigherthanthatinchronicperiodontitispatientsorperiodontallyhealthyindividuals,withresearchesshowinggoodsurvivalofimplantsovera10-yearperiod[96].SeveralreportsaretherewhichhavesuccessfullyusedosseointegratedimplantsinoralrehabilitationofpartiallyedentulouspatientstreatedforGAgP[97–99].7.4.3.PsychotherapyPerhapstheleastrecognizedandthemostunderestimatedaspectinthetotalrehabilitationofapatientwithGAgPpresentingwithmultipletoothlossand/oradvancedperiodontaldestructionnecessitatingextractionofmultipleteethistheneedforpsychologicalcounselingandpsychotherapy.Itaimsatattendingthepsychologiceffectandpotentialmentaldepressionfollowingtoothlossduetorapidperiodontaldestructionwhichprovidesthepatientwithrelativelylesstimetocopewiththesituation.Theemotionaleffectsoftoothlossaredevastatingforsomepatientsandhaveadramaticimpactontheirlife,andtheytakelongertimetocometotermswiththetoothloss[100].Preparingthepatientswithadvanceddiseasehavingmultipleteethwithhopelessprognosisemotionallyforextractionalsohastobedealtwithcarefullybythedentist,ifneededusingmultipleappointments,andtheextentoftheimpactthatbadnews,suchashavingtoloseteeth,hasonanindividualismostoftendependentonthewayinwhichtheinformationiscommunicated[101].Depression,anxietyandsocialwithdrawalareseeninpatientswithtoothloss,andresultingcompromisedestheticscanbehelpedwiththerapy,relaxationtechniques,and,insomecases,antidepressants.Anyoftheabovesymptomsshouldbeaddressedwithaqualifiedpsychotherapisttoimprovethequalityoflife.Psychotherapyhastobestartedimmediatelyfollowingthefirstappointmentandshouldbecontinuedconcomitantlyfortotalrehabilitationofthepatientforavariabledurationdependinguponthepsychologicstatusoftheindividualpatient.Inaddition,stressreductionprotocolsmayhelpinmanagementofthediseaseassuchintheviewoftherecentsuggestionsoftheproposedmechanismsbywhichstresscancontributetotheonset,exacerbationandmaintenanceoftheperiodontaldisease[102].Arecentstudyreportedthatpsychotherapyofferedat3levels(individual,group,andconjointfamilypsychotherapy)toGAgPpatientsgavepositivepsychologiceffectsthatrestoredtheirabilitytosocializeintheirenvironmentcontributingtotheirpositiveexperienceinlife[103].TheabovefactssuggestthatpsychotherapybeincorporatedforthefutureprotocolsfortreatmentofGAgPpatientssufferingfromemotionaleffectsoftoothloss.7.4.4.OtherTreatmentModalitiesandFutureTrendsinManagementofAggressivePeriodontitisHostmodulationtherapywithsystemicallyandlocallyadministeredagentsisunderresearchfortherapyinaggressiveperiodontitis.SubantibacterialdoseofDoxycyclinehasbeenapprovedforuseinchronicperiodontitis,butitsuseinaggressiveperiodontitishastobeconfirmedbyresearch.AdjunctiveuseoflocallyadministeredalendronategelwithSRPforhostmodulationhasshownpromisingresultsinaggressiveperiodontitis[104].Newergenerationsofregenerativematerialsandadvancesintissueengineeringforregenerationandgeneticengineeringtomodifythegeneticriskfactorsseemtobereallypromisinginthefuture.Withfurtherunderstandingofthegeneticriskfactors,afuturisticapplicationofgeneticscreeningtestswillbeinidentifyingthesusceptibleindividualsandinstitutingthepreventivemeasurestokeepthegeneexpressionandthusthediseaseundercontrol[105,106].7.4.5.ASuggestedProtocolfortheComprehensiveandTotalRehabilitationofGAgPPatientswiththeCurrentTreatmentModalities FormoredetailsseeFigure14.Figure14 Thetreatmentcommenceswithanonsurgicalphasefollowingwhichpsychotherapysessionsarestartedfortheneedypatients,andpatientsareputonmaintenancetherapy/supportiveperiodontaltherapythereafter.Whilethepatientisonmaintenancetherapy,oneormoreofthe3modalitiesofsurgicalperiodontaltherapycanbeperformeddependingupontheindicationandonceperiodontiumhasbeenstabilized,aninterdisciplinarytreatmentfortherestorationoflostteethandcorrectionofcosmeticproblemsiscompletedfollowingwhichthepatientcontinuesfora“lifelong”maintenancetherapy.8.ConclusionEventhoughtheprevalenceofaggressiveperiodontitisismuchlowerthanchronicperiodontitis,themanagementofaggressiveperiodontitisismorechallengingcomparedtothatofchronicperiodontitisbecauseofitsstronggeneticpredispositionasanunmodifiableriskfactor.Researchersaregoingonemployingthepotentialseveralnoveltechnologiesinregeneratingthelostperiodontiumincludingtissueengineeringandgeneticengineering.Thekeytosuccessfulmanagementatpresentliesinearlydiagnosisofthediseaseandrigoroustreatmentemployingthedifferenttreatmentmodalitiesmentionedinthepaperalongwithsystemicantibiotictherapyfollowedbymeticulouslifelongmaintenancetherapy.Withthecurrenttreatmentmodalities,successfullong-termmaintenanceofthedentitioninahealthyandfunctionalstatecanbeachieved.Acomprehensiveperiodontaltreatmentconsistingofmechanical/surgicalandsystemicantimicrobialtherapyisfoundtobeanappropriatetreatmentregimenforlong-termstabilizationofperiodontalhealthwitharrestofperiodontaldiseaseprogressionin95%oftheinitiallycompromisedlesions[107].Furtherunderstandingoftheetiology,riskfactors,pathogenesis,andhostimmuneresponseinaggressiveperiodontitisalongwithadvancesinregenerativeconcepts,tissueengineering,andgenetherapyisneededforformulatingbettermanagementprotocolsinthetreatmentofgeneralizedaggressiveperiodontitis.ReferencesG.C.Armitage,“Developmentofaclassificationsystemforperiodontaldiseasesandconditions,”AnnalsofPeriodontology,vol.4,no.1,pp.1–6,1999.Viewat:GoogleScholarAmericanAcademyofPeriodontology,“Parameteronaggressiveperiodontitis,”JournalofPeriodontology,vol.71,no.5,pp.867–869,2000.Viewat:GoogleScholarR.T.DemmerandP.N.Papapanou,“Epidemiologicpatternsofchronicandaggressiveperiodontitis,”Periodontology2000,vol.53,no.1,pp.28–44,2010.Viewat:PublisherSite|GoogleScholarJ.M.Albandar,M.B.Muranga,andT.E.Rams,“PrevalenceofaggressiveperiodontitisinschoolattendeesinUganda,”JournalofClinicalPeriodontology,vol.29,no.9,pp.823–831,2002.Viewat:PublisherSite|GoogleScholarC.SusinandJ.M.Albandar,“AggressiveperiodontitisinanurbanpopulationinsouthernBrazil,”JournalofPeriodontology,vol.76,no.3,pp.468–475,2005.Viewat:PublisherSite|GoogleScholarB.Gottlieb,“Diediffuseatrophydesalveolarknochens,”ZeitschriftFurStomatologie,vol.21,p.195,1923.Viewat:GoogleScholarE.GuzeldemirandH.U.Toygar,“Fromalveolardiffuseatrophytoaggressiveperiodontitis:abriefhistory,”JournaloftheHistoryofDentistry,vol.54,no.3,pp.96–99,2006.Viewat:GoogleScholarR.R.Ranney,“Classificationofperiodontaldiseases,”Periodontology2000,vol.2,pp.13–25,1993.Viewat:GoogleScholarJ.Caton,“Periodontaldiagnosisanddiagnosticaids:consensusreport,”inProceedingsoftheWorldWorkshopinClinicalPeriodontics,AmericanAcademyofPeriodontology,1989.Viewat:GoogleScholarU.Ripamonti,“PaleopathologyinAustralopithecusafricanus:asuggestedcaseofa3-million-year-oldprepubertalperiodontitis,”AmericanJournalofPhysicalAnthropology,vol.76,no.2,pp.197–210,1988.Viewat:GoogleScholarU.Ripamonti,“ThehardevidenceofalveolarbonelossinearlyhominidsofsouthernAfrica.Ashortcommunication,”JournalofPeriodontology,vol.60,no.2,pp.118–120,1989.Viewat:GoogleScholarN.Lang,P.M.Bartold,M.Cullinanetal.,“Consensusreport:aggressiveperiodontitis,”AnnalsofPeridontology,vol.4,p.53,1999.Viewat:GoogleScholarB.Schacher,F.Baron,M.Roßberg,M.Wohlfeil,R.Arndt,andP.Eickholz,“Aggregatibacteractinomycetemcomitansasindicatorforaggressiveperiodontitisbytwoanalysingstrategies,”JournalofClinicalPeriodontology,vol.34,no.7,pp.566–573,2007.Viewat:PublisherSite|GoogleScholarG.C.Armitage,“Comparisonofthemicrobiologicalfeaturesofchronicandaggressiveperiodontitis,”Periodontology2000,vol.53,no.1,pp.70–88,2010.Viewat:PublisherSite|GoogleScholarJ.M.Goodson,A.C.Tanner,A.D.Haffajee,G.C.Sornberger,andS.S.Socransky,“Patternsofprogressionandregressionofadvanceddestructiveperiodontaldisease,”JournalofClinicalPeriodontology,vol.9,no.6,pp.472–481,1982.Viewat:GoogleScholarR.C.Page,L.C.Altman,J.L.Ebersoleetal.,“Rapidlyprogressiveperiodontitis.Adistinctclinicalcondition,”JournalofPeriodontology,vol.54,no.4,pp.197–209,1983.Viewat:GoogleScholarA.Stabholz,W.A.Soskolne,andL.Shapira,“Geneticandenvironmentalriskfactorsforchronicperiodontitisandaggressiveperiodontitis,”Periodontology2000,vol.53,no.1,pp.138–153,2010.Viewat:PublisherSite|GoogleScholarG.C.ArmitageandM.P.Cullinan,“Comparisonoftheclinicalfeaturesofchronicandaggressiveperiodontitis,”Periodontology2000,vol.53,no.1,pp.12–27,2010.Viewat:PublisherSite|GoogleScholarL.Suresh,A.Aguirre,R.J.Buhite,andL.Radfar,“Intraosseous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