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Response of chronic andaggressive periodontitis totreatment
DA V I D E. DE A S & BR I A N L. ME A L E Y
In the late 1980s one of our residency mentors envi-
sioned a day when a combination of clinical indices,
microbiologic sampling and antibody profiles would
both indentify and direct the treatment of specific
periodontal diseases. Even though our knowledge
base has expanded significantly in the ensuing years,
this has clearly not yet happened.
The classification scheme introduced in 1999 listed
chronic periodontitis and aggressive periodontitis
as two of the major forms of periodontal disease
(1); but separating diseased patients into these two
groups based on this classification can be a sub-
jective task. On initial presentation the two diseases
share a number of clinical, microbiological and host
response features (37, 56). Even though genetic test-
ing and cytokine monitoring have opened new diag-
nostic vistas, it is still not always easy to identify one
disease from the other or to use these tests to predict
treatment outcome (28).
It can also be argued that because aggressive
periodontitis, although not rare, is a fairly uncommon
condition, little is known about its optimal manage-
ment. Protocols for treating chronic periodontitis are
fairly well established. Protocols for treating aggres-
sive periodontitis are largely empirical and have been
subjected to few well-controlled comparative studies
(72). In this section, we will focus on the response of
aggressive periodontitis to treatment, using as
comparison the response to treatment of chronic
periodontitis, about which much more is known. To
avoid confusion, the most current terminology for
both disease categories and pathogenic bacteria will
be used, even though different terms were often used
in the specific articles cited.
Diagnosis and prognosis
Establishing a diagnosis based on disease type,
extent, location and severity is an essential first step
in treatment, and the steps do not differ markedly
regardless of whether the patient has chronic perio-
dontitis or aggressive periodontitis. Although little
has been written about prognostic factors in aggres-
sive disease (28), persistent deep pockets, loss of
attachment, mobility, furcation invasion, suppura-
tion, plaque, calculus and other factors such as root
grooves, cervical enamel projections, root fractures
and poor restorations can help clinicians to predict
the outcome of both diseases. The extent of attach-
ment loss in a patient with aggressive periodontitis
may negatively influence the prognosis, but this may
be somewhat counterbalanced by a desire to go to
additional lengths not to extract teeth in younger
patients.
These tooth-level factors are used in the formula-
tion of prognosis in conjunction with a number of
subject-level factors, including smoking, genetic
predisposition, age, gender, race and contributing
medical conditions. This is appropriate regardless of
whether the potential outcome variable is tooth loss
or a surrogate variable such as probing depth or
attachment loss (64). The relative value of these
subject-level factors becomes more important if one
considers that tooth-level indicators, such as bleed-
ing on probing, have in some studies shown a greater
association with future attachment loss at a subject
level rather than at a site level (32).
Smoking, in particular, has been shown to be an
important subject-level prognostic factor in aggres-
sive periodontitis. In two separate studies of non-
surgical therapy, smokers with aggressive periodontal
disease responded significantly less well to treatment
than nonsmokers. Combining the results of these two
The opinions expressed in this article are those of the authors and
are not to be construed as official or as representing the views of the
United States Air Force or the Department of Defense.
154
Periodontology 2000, Vol. 53, 2010, 154–166
Printed in Singapore. All rights reserved
� 2010 John Wiley & Sons A/S
PERIODONTOLOGY 2000
studies, smokers with aggressive periodontitis were
3.8 times more likely to have ‡30% of sites not
responding to treatment, as well as higher levels of
Prevotella intermedia and Tannerella forsythia after
treatment (10, 28).
In general, it is likely that risk factors have similar
long-term influences on both chronic periodontitis
and aggressive periodontitis, although one could ar-
gue that with younger patient age and greater initial
attachment loss they may dictate a poorer long-term
prognosis in aggressive disease (64). Regardless,
modulating and correcting these risk factors are
critical in the treatment of both chronic periodontitis
and aggressive periodontitis.
This leads to a point that we feel must be stressed.
Every periodontist has had treatment success in pa-
tients with an initially poor overall prognosis. These
cases may involve strategic extractions, nonsurgical
and ⁄ or surgical therapy, oftentimes a complex
restorative phase and always a strict maintenance
regimen. We know through such cases that even the
most advanced or aggressive disease can be treated
successfully. Although it is impossible to determine a
common thread between these cases, it is likely that
most of them had at their core a highly motivated
patient. Therefore, the treatment plan presentation
should include a very frank discussion with the pa-
tient about the severity of the condition, the odds of
success and the requirement for near-perfect com-
pliance with plaque control, management of modi-
fiable risk factors and maintenance.
Just as essential for success is a clinician who is
comfortable in helping patients to control risk factors
(39). The therapist who is confident in ordering and
interpreting certain blood tests is likely to have more
influence with his patients than one who is not.
Similarly, the therapist who cannot only inform their
patients of the dangers of smoking, but can also assist
them with smoking cessation, may have better re-
sults. The patient with aggressive disease has given
the clinician a difficult task with an uncertain out-
come. Both must understand from the outset that
without good cooperation from the patient and
assertive management by the clinician the treatment
has little chance of long-term success.
Response to therapy – chronicperiodontitis
The clinical response and the microbiological re-
sponse to nonsurgical therapy in the treatment of
chronic periodontitis have been well documented. A
comprehensive meta-analysis of nonsurgical treat-
ment reported that following scaling and root planing
at sites with probing depths of 4–6 mm, clinicians
should expect a mean reduction in probing depth of
approximately 1 mm and a gain of clinical attach-
ment level of approximately 0.5 mm. In deeper sites
(probing depth ‡7 mm), the reduction in probing
depth averages approximately 2 mm and the gain in
clinical attachment level averages about 1 mm (29).
The added effect of adjunctive antibiotic therapy has
been found to be modest, but statistically significant,
with an additional 0.2–0.6 mm decrease in probing
depth and 0.1–0.2 mm gain of clinical attachment
level over scaling and root planing alone (9, 24, 29).
The bacterial response following treatment is also
fairly consistent following scaling and root planing in
chronic periodontitis. Immediately after subgingival
scaling there is a significant decrease in the number
of gram-negative organisms that include numerous
periodontal pathogens, along with an increase in the
number of gram-positive cocci. This new microbiota
remains established for approximately 4–8 weeks
before returning to baseline by 12–24 weeks (5).
Depending on the regimen, adding antibiotics to the
treatment may further suppress the pathogenic
microbiota and delay the return to baseline (5).
Overall, although local and systemic antibiotics may
slightly improve clinical parameters over nonsurgical
therapy alone, there is general consensus that the use
of antibiotics in chronic periodontitis should be
reserved for those patients and sites that do not
respond to conventional treatment (5, 19, 20, 24, 26,
69).
The effects of surgical debridement as part of the
treatment of chronic periodontitis are also well doc-
umented (4, 18, 29, 33, 53). As outlined in a system-
atic review by Heitz-Mayfield et al. (25), in pockets
deeper than 6 mm surgical treatment resulted in an
additional 0.6 mm mean probing depth reduction and
0.2 mm additional attachment level gain over scaling
and root planing alone. In 4–6 mm pockets, surgical
treatment gained an additional 0.4 mm decrease in
probing depth, but a loss of 0.4 mm in attachment
level beyond scaling and root planing (25).
More difficult to assess independently are the ad-
ded effects of regenerative techniques in treating
chronic periodontitis. Depending on the depth and
morphology of osseous defects, the potential exists
for greater gains in probing depth, attachment levels
and bone fill. Bone grafting with a variety of materials
has been estimated to decrease probing depths and
lead to gains in clinical attachment of 0.5–1 mm
beyond that of surgical debridement alone (53). A
155
Response of chronic and aggressive periodontitis to treatment
comprehensive meta-analysis of regeneration studies
by Laurell et al. (40) found that guided tissue regen-
eration generally improved attachment levels and
bone fill by 2.7 and 2.1 mm respectively, beyond
surgical debridement alone. As most studies evalu-
ating surgical outcomes of regeneration techniques
selected groups on the basis of defects, rather on than
disease type, it is possible that the treatment groups
in these studies may also have included at least some
patients with aggressive periodontitis.
Response to therapy – aggressiveperiodontitis
The response to periodontal treatment in aggressive
periodontitis is much less well understood, in part
because the low prevalence of this disease makes it
difficult to recruit sufficient numbers of patients for
controlled clinical trials of different treatment
modalities (72). Also at this point we must distinguish
the treatment response between localized aggressive
periodontitis and generalized aggressive periodonti-
tis. This is partly because the two types of peri-
odontitis respond somewhat differently to treatment
and partly because the literature usually reports on
one group or the other.
It is also interesting to consider the way in which
the two types of aggressive disease respond to no
treatment. Gunsolley et al. (23) examined 327 pa-
tients with either localized aggressive periodontitis or
generalized aggressive periodontitis as part of a study
of families with early onset disease. Following base-
line examination of clinical indices, patients were
advised to have follow-up treatment. At a 15-year
follow-up, 88 of these patients were re-examined: 47
of them had received treatment and 41 had not. The
authors reported that while untreated sites in
patients with localized aggressive periodontitis
tended to stabilize over time, untreated sites in
patients with generalized aggressive periodontitis
showed increasing amounts of attachment loss and
tooth loss.
Localized aggressive periodontitis
Much of what we know about the response to
treatment of localized aggressive periodontitis was
discovered when this condition was known by other
terminology. One early study monitored five treat-
ment groups of �periodontosis� patients over a 3-year
treatment and follow-up period. Only the two
groups that received �local treatment� (consisting of
curettage, selective occlusal grinding, surgery and
oral hygiene instructions) as part of their therapy
showed improved clinical status (63). Another early
report described aggressive occlusal or incisal
grinding to allow the affected teeth to move occlu-
sally, in conjunction with open flap debridement of
the periodontal defects. Three cases were shown to
document the success of this approach, but it could
not be determined which portion of the treatment
regimen was responsible for the clinical improve-
ment (14).
There are few reports of nonsurgical therapy alone
as a treatment of localized aggressive periodontitis.
Slots & Rosling (61) evaluated nonsurgical treatment,
as one arm of a staged combination therapy, on the
clinical and microbiological parameters of 20 deep
pockets and 10 normal sites in six patients with
localized aggressive periodontitis. Upon re-evalua-
tion, the combination of oral hygiene instructions,
along with subgingival scaling and root planing, re-
duced, but did not eliminate, the number of spiro-
chetes, Aggregatibacter actinomycetemcomitans and
Capnocytophaga species and resulted in a small
improvement in post-treatment probing depths. A
similar treatment approach carried out by Kornman
& Robertson (38), in a group of eight patients with
localized aggressive periodontitis, evaluated scaling
and root planing alone as the first stage in a treat-
ment protocol where success was based on
improvement in clinical and microbiologic parame-
ters. They found that scaling and root planing alone
resulted in essentially no improvements in either
pocket depths or in the percentage of culturable
microbiota composed of black-pigmented Bactero-
ides species, surface translocating bacteria or A. ac-
tinomycetemcomitans.
In contrast to these findings are those reported by
Gunsolley et al. (23), mentioned above. These au-
thors reported that patients with localized aggressive
periodontitis who received treatment showed a gain
in periodontal attachment over the 15-year period
and that there was no difference in the response of
those who received scaling and root planing alone vs.
those treated surgically.
Two discoveries led to an emphasis on mechanical
debridement supplemented with chemotherapeutic
agents in the treatment of localized aggressive
periodontitis. The first was when the predominant
culturable microbiota of localized aggressive perio-
dontitis was identified and found to be susceptible to
tetracycline (49). The second was the finding that
A. actinomycetemcomitans, an important pathogen
associated with localized aggressive periodontitis,
156
Deas & Mealey
could penetrate the pocket epithelium, thus placing it
beyond the influence of subgingival scaling (7).
In response to these findings, the focus of treat-
ment studies shifted to combinations of conventional
therapy with systemic antibiotics. Slots & Rosling
(61), in the final step of their staged treatment study
mentioned above, administered 1 g of tetracycline-
HCl per day for 14 days following subgingival
debridement. The authors noted that after tetra-
cycline treatment the number of spirochetes, A. ac-
tinomycetemcomitans and Capnocytophaga species
were reduced to almost undetectable levels, and that
this corresponded to a 0.3 mm gain in attachment
level. They concluded that the combination of root
surface debridement and tetracycline was successful
in treating most localized aggressive periodontitis
sites. Similarly, Kornman & Robertson (38) reported
that the combination of scaling and root planing plus
tetracycline significantly improved the clinical indi-
ces in three of their eight patients, obviating the need
for surgical treatment in these patients; the other five
subjects required periodontal surgery.
These and other studies using the 1 g per day tet-
racycline regimen, both with (60) and without (51)
scaling and root planing, reported oftentimes dra-
matic improvements in both clinical and microbio-
logical assessments. It was noted, however, that up to
25% of patients treated in this manner experienced
continued disease progression (41). This failure to
respond to treatment was linked to a growing level of
bacterial resistance to tetracycline and other antibi-
otics such as amoxicillin, doxycycline and minocy-
cline (71). Of particular interest in treating localized
aggressive periodontitis was the discovery of resis-
tance of A. actinomycetemcomitans to tetracycline
(55, 70).
These problems with tetracycline treatment led to
the investigation of other systemic antibiotics com-
bined with scaling and root planing. Saxen & Asikai-
nen (55) divided 27 patients with localized aggressive
periodontitis into three groups receiving either sub-
gingival debridement alone or subgingival debride-
ment in combination with 1 g of tetracycline or
600 mg of metronidazole per day. A. actinomyce-
temcomitans was reduced below the detection
threshold in all test sites in metronidazole-treated
patients, but was found in 9 ⁄ 26 sites in the tetracy-
cline group. Tinoco et al. (65) compared the response
of an experimental group of 10 patients with localized
aggressive periodontitis treated with scaling and root
planing plus a metronidazole ⁄ amoxicillin regimen
vs. a similar sized control group receiving scaling and
root planing alone. One year following treatment, the
antibiotic group had better improvement than con-
trols in terms of probing depth, attachment level
measurements, radiographic analysis of crestal alve-
olar bone mass and elimination of A. actinomyce-
temcomitans from subgingival pockets.
Not much has been published about the treatment
of localized aggressive periodontitis with locally
delivered antibiotics in conjunction with scaling and
root planing. Mandell et al. (44) used tetracycline
fibers to treat 12 sites in four patients with localized
aggressive periodontitis. This treatment failed to
either stop the progression of attachment loss at
these sites or eliminate A. actinomycetemcomitans. It
is possible that this failure was caused by the inability
of tetracycline to adequately penetrate the pocket
epithelium, or possibly as a result of the repopulation
of A. actinomycetemcomitans from other potential
reservoirs in the mouth (70).
The rationale for surgery at localized aggressive
periodontitis sites is based both on the difficulty of
root instrumentation in deep pockets as well as a
perceived need to remove tissue invaded by
A. actinomycetemcomitans. A variety of surgical
techniques have been successfully utilized to treat
localized aggressive periodontitis, usually in combi-
nation with systemic antibiotics. Kornman &
Robertson (38) reported that modified Widman flap
surgery and a tetracycline regimen were effective at
treating sites with initially high levels of A. actino-
mycetemcomitans and black-pigmented Bacteroides
species. Lindhe & Liljenberg (42) treated 16 cases of
localized aggressive periodontitis with a combination
of tetracycline and modified Widman flap surgery.
After 5 years of maintenance, they found significant
improvements in probing depths and attachment
levels, and evidence of radiographic bone fill. Success
with other combinations of surgical debridement and
antibiotic therapy has also been reported (3, 27, 30).
Other authors have reported success of regenera-
tive techniques in the treatment of patients with
localized aggressive periodontitis. Autogenous grafts
of both osseous coagulum and frozen autogenous hip
marrow have been utilized, as well as osseous coag-
ulum grafts covered with soft tissue autografts (12,
15, 62). Yukna & Sepe (73) treated osseous defects in
12 patients with localized aggressive periodontitis
using freeze-dried bone allograft in a 4:1 mixture with
tetracycline powder. Following a strict 1-year main-
tenance regimen, 51 of the original 62 defects were
surgically re-entered. The authors found that the
average defect fill was 80%, and bone fill of greater
than 50% was achieved in 98% of the defects. Mabry
et al. (43) split 16 patients with localized aggressive
157
Response of chronic and aggressive periodontitis to treatment
periodontitis into two treatment groups depending
on whether or not they received systemic tetra-
cycline. Half of the defects in each group were treated
with surgical debridement alone, while the other half
received debridement and freeze-dried bone allo-
grafts mixed with tetracycline. The authors reported
that while grafted defects did better than debrided
defects in both groups, the combination of graft plus
systemic tetracycline was the superior treatment
overall.
Guided-tissue regeneration has also been success-
ful in treating localized aggressive periodontitis. Sir-
irat et al. (59) compared guided-tissue regeneration
using expanded polytetrafluoroethylene membranes
with osseous resection in a group of six patients that
included two individuals with localized aggressive
periodontitis. While both techniques demonstrated
success at 1 year, the guided-tissue regeneration sites
demonstrated significantly better improvements in
probing depth and attachment gain. Fritz et al. (16)
showed that intrabony defects in patients with
localized aggressive periodontitis treated with ex-
panded polytetrafluoroethylene membranes had
slightly greater attachment gains than sites treated
with flap debridement, demineralized freeze-dried
bone, or alloplastic graft (Interpore�; Interpore
International, Irvine, CA); it was also noted that the
membrane sites had the greatest variability in results.
A separate study compared the success of guided-
tissue regeneration treatment with expanded poly-
tetrafluoroethylene membranes in two groups of 10
patients with either early onset periodontitis (mostly
localized aggressive periodontitis by description) or
chronic periodontitis. Both groups received Aug-
mentin� (SmithKline Beecham, King of Prussia, PA)
during the first week post-operatively. After a strict
maintenance regimen over a 12-month period,
putative periodontal pathogens were reduced to
undetectable levels from defects in both groups, and
all defects responded equally well from the stand-
point of probing depth reduction and attachment
level gains (74).
The results of the above studies suggest that where
allowed by defect morphology, regenerative tech-
niques work well for the treatment of localized
aggressive disease. It is important to note, however,
that each of the above studies contained few subjects
and defects, making between-group comparisons
difficult. This is illustrated in a study by DiBattista
et al. (13), who treated defects in seven patients with
localized aggressive periodontitis using four different
surgical treatment modalities (debridement; ex-
panded polytetrafluoroethylene membrane alone;
expanded polytetrafluoroethylene membrane + root
conditioning; expanded polytetrafluoroethylene
membrane + root conditioning + composite graft)
followed by post-operative systemic doxycycline. In
contrast to the above studies suggesting superior re-
sults with regenerative procedures, the authors of this
study reported that while all sites gained attachment
and defect fill, no significant differences were noted
between any of the surgical techniques.
Generalized aggressive periodontitis
Our knowledge of the response of generalized
aggressive periodontitis to treatment is hampered by
several factors. As mentioned earlier, because the
prevalence of aggressive periodontitis is low, treat-
ment studies have only been able to include small
numbers of subjects, which leads to an inability to
adequately compare multiple treatment groups. This
may be further complicated by the fact that it can be
extremely difficult to separate patients with general-
ized aggressive periodontitis from patients with se-
vere or refractory forms of chronic periodontitis.
Additionally, generalized aggressive periodontitis is
perhaps more likely to be confused with periodontitis
as a manifestation of systemic disease and does not
classically reach a �burned out� stage where it re-
sponds well to conventional periodontal therapy (23,
48). The bottom line is that the patient with gener-
alized aggressive periodontitis requires careful mon-
itoring, and close collaboration is necessary between
all members of a treatment team, including the
periodontist, the restorative dentist, the hygienist and
the patient�s physician (48).
Although antibiotic therapy is widely used in the
treatment of generalized aggressive periodontitis,
there are at least a few studies on this condition that
have investigated the effects of scaling and root
planing alone. Hughes et al. (28) conducted a
prospective intervention study of 79 patients with
generalized aggressive periodontitis. Following the
collection of baseline data, patients received non-
surgical root surface debridement in four visits
together with oral hygiene instructions. Upon
re-evaluation at 10 weeks, at initially deep sites, the
authors reported a mean reduction in probing depth
of 2.11 mm and a mean attachment level gain of
1.77 mm. They also reported that 32% of patients did
not respond to this treatment, and that smoking was
the biggest factor associated with nonresponse. A
more recent study evaluated ultrasonic debridement,
with or without chlorhexidine irrigation, in the
treatment of patients with generalized aggressive
158
Deas & Mealey
periodontitis. By 6 weeks, the probing depth at four
selected deep sites had been reduced by approxi-
mately 1 mm (according to median data), regardless
of the irrigant used in the treatment (21).
Additional information on scaling in patients with
generalized aggressive periodontitis can be gleaned
from studies where scaling and root planing without
antibiotics was used as either the first arm of a clin-
ical trial or as a control treatment. For example, Pu-
rucker et al. (52) provided scaling and root planing
for 30 patients with generalized aggressive perio-
dontitis as the first part of a study comparing anti-
biotic treatments. Two months after scaling they
found that the deepest sites in each quadrant expe-
rienced an approximate 1 mm reduction in probing
depth and a 0.5 mm gain in attachment levels. This is
consistent with the data obtained from the first arm
of a study comparing antibiotic regimens in the
treatment of generalized aggressive periodontitis
(72). In contrast are the findings of Sigusch et al. (57),
who saw no improvements in probing depths or
attachment levels following scaling and root planing
in their group of 48 patients with generalized
aggressive periodontitis. It is possible that the 3-week
re-evaluation used in this study was too soon to see a
clinical benefit.
The adjunctive use of systemic antibiotics to treat
generalized aggressive periodontitis is logical in the-
ory but has been the subject of few controlled clinical
trials. A study by Guerrero et al. (22) compared the
results of scaling and root planing alone to the results
found following scaling and root planing plus treat-
ment with systemic metronidazole and amoxicillin in
a group of 41 patients with generalized aggressive
periodontitis. All treatment was provided within 24 h
and patients in both groups used chlorhexidine rinses
for 2 weeks following treatment. The results demon-
strated that clinical parameters improved at 2 and
6 months for both groups. In sites originally ‡7 mm,
the antibiotic group experienced an additional
1.4 mm reduction in probing depth and a 1 mm gain
in attachment level when compared with the control
group. In sites initially 4–6 mm deep, the difference
was more modest, with a reduction of 0.4 mm in
probing depth and 0.5 mm in attachment gain
compared with controls. By 6 months, disease pro-
gression was noted at 1.5% of sites in patients of the
antibiotic group compared with 3.3% of sites in
controls.
Sigusch et al. (57) divided 48 patients with gener-
alized aggressive periodontitis into four groups to
compare systemically administered doxycycline,
metronidazole or clindamycin with a control group
receiving no antibiotic treatment. When combined
with an enhanced scaling and root planing protocol,
the authors found that both metronidazole and
clindamycin significantly improved the clinical re-
sponse beyond that of the doxycycline or control
groups. A similar controlled study, evaluating the
relative effectiveness of antibiotic regimens, was
conducted by Xajigeorgiou et al. (72). Six weeks after
scaling and root planing, 43 patients with generalized
aggressive periodontitis were divided into four
groups to receive metronidazole ⁄ amoxicillin, doxy-
cycline, metronidazole, or placebo for 7–14 days,
depending on the drug. At 6 months from baseline,
the clinical differences between the four groups were
minor, although the proportions of sites with probing
depths >6 mm were significantly reduced in the two
groups treated with metronidazole. The timing of the
antibiotic treatment in this study may be questioned in
light of a more recent report by Kaner et al. (36), who
found that administering metronidazole ⁄ amoxicillin
immediately after scaling and root planing was more
effective in resolving deep sites in patients with
generalized aggressive periodontitis than the same
drug regimen given 3 months later.
An overall examination of these three controlled
studies of adjunctive antibiotic treatment suggests a
minimal additional benefit of antibiotic use. It is
important to remember, however, that these reports
contain averaged data, and clinical experience sug-
gests that the magnitude of change in some sites may
be greater when antibiotics are used, making it a more
viable treatment option. It is also impossible to know
the level of patient compliance in taking the antibi-
otics in these studies. In a recent study, Guerrero et al.
(22) examined 18 patients with generalized aggressive
periodontitis taking metronidazole ⁄ amoxicillin in
conjunction with nonsurgical therapy. They found
that subjects who were fully compliant in taking their
medications had probing depth reductions of 0.9 mm
and attachment level gains of 0.8 mm beyond those
who were noncompliant or only partially compliant.
Local-delivery antibiotic treatment has also been
evaluated in the treatment of generalized aggressive
periodontitis. In one study of 30 patients with gen-
eralized aggressive periodontitis, half of the subjects
received monolithic tetracycline fibers at affected
sites while the other half received systemic Aug-
mentin�. The results suggested that both groups
improved compared to treatment with scaling alone,
with no statistically significant differences observed
between groups (52). A more recent study reported
that tetracycline fibers, in conjunction with scaling
and root planing, in patients with generalized
159
Response of chronic and aggressive periodontitis to treatment
aggressive periodontitis was more effective than
scaling and root planing alone (54). These studies
suggest that local-delivery antibiotic treatment may
be of benefit in situations where systemic antibiotics
are contraindicated.
While the use of antibiotics in periodontal treat-
ment will probably always be controversial, reports
from both the American Academy of Periodontology
and the European Federation of Periodontology
contain valuable guidelines for their use. Both of
these reports, following exhaustive literature sear-
ches, determined that patients with aggressive
periodontitis appear to benefit from the adjunctive
use of systemic antibiotics during treatment; how-
ever, both also emphasized that knowledge of the
optimal drug, dosage and duration providing the
greatest effect was unknown at this time (24, 26).
One final element of nonsurgical therapy in the
treatment of aggressive periodontitis is the use of
enhanced root planing techniques. Moreira et al. (47)
divided 30 patients with generalized aggressive peri-
odontitis into two groups to evaluate traditional
quadrant-wise scaling using a full-mouth debride-
ment approach where all scaling was completed
within 24 h. Both groups received systemic metro-
nidazole and amoxicillin as well as chlorhexidine
rinses. While clinical parameters improved in both
groups, there were no significant differences between
groups at either 2 or 6 months. Sigusch et al. (58)
compared traditional scaling and root planing with
an enhanced root planing technique in a group of 42
patients with generalized aggressive periodontitis
who were also treated with systemic metronidazole.
The test group subjects received an additional round
of root planing where the instrumentation frequency
of curet strokes per root surface was based on the
probing depth. At 6 and 24 months, the authors re-
ported significantly improved probing depth reduc-
tion and attachment level gain using the enhanced
technique.
Beyond isolated case reports, very little has been
published about the surgical treatment of generalized
aggressive periodontitis; it is possible that this may be
because of an overall reluctance of clinicians to per-
form surgery on patients with generalized aggressive
periodontitis. There are several perfectly logical rea-
sons for this: severe attachment loss on presentation;
possible links with covert or undetected systemic
disease; the inability to control risk factors; a history
of poor surgical outcomes with previous patients with
generalized aggressive periodontitis; or a reluctance
to perform surgery in patients with poor prognoses.
Of the 48 patients with generalized early onset peri-
odontitis, re-examined after 15 years by Gunsolley
et al. (23), 28 had received treatment, and in some
cases that treatment included surgery. While many of
the details of these patients, regarding risk factors
and follow-up care, are unknown, it was clear to the
authors that they had received little benefit from
therapy. While a cautious approach to surgery in
patients with generalized aggressive periodontitis is
prudent, there is at least some evidence that it can be
successful under certain circumstances.
Buchmann et al. (6) followed 13 patients with
generalized aggressive periodontitis for 5 years
through active and maintenance therapy. For each
patient, they monitored attachment level measure-
ments on two teeth with >50% bone loss per
quadrant at baseline, as well as at 3, 6, 12, 24, 36, 48
and 60 months after treatment. Patients received
systemic metronidazole ⁄ amoxicillin during both
scaling and root planing and surgical phases of
treatment. Of the 100 sites followed to 60 months, 86
with initial probing depths of ‡6 mm were subjected
to modified Widman flap procedures with no osseous
surgery. Three months following treatment, there was
a mean 2.23 mm gain of clinical attachment at all
sites that remained stable over the maintenance
period. Individual sites had attachment level gains of
as much as 7 mm, and only 7.1% of sites did not
respond to initial treatment. It is important to note
that smoking and systemic disease were exclusion
criteria in this study.
A more recent study by Mengel et al. (46) used
radiographs and clinical indices to follow a group of
16 healthy, nonsmoking patients with generalized
aggressive periodontitis through active therapy and
maintenance for 5 years. The sites monitored in-
cluded only those with one to three wall intrabony
defects of ‡4 mm, and furcation defects were ex-
cluded. Twenty-two of the defects were treated with
bioabsorbable membrane alone, and 20 were treated
with bioactive glass. After 5 years, the authors re-
ported mean probing depth reductions and attach-
ment level gains of 3.6 mm and 3.0 mm at the
membrane-treated sites, and mean probing depth
reductions and attachment level gains of 3.5 and
3.3 mm at the sites receiving bioactive glass. The
authors further reported a radiographic defect fill of
47.5% in membrane-treated defects and 65% fill in
bioactive glass-treated sites, although the variation at
individual sites was large. Approximately 25% of the
sites in both groups had probing depths of ‡5 mm
after 5 years.
Very little has been written about the use of enamel
matrix derivative in aggressive periodontitis (35, 69).
160
Deas & Mealey
In the larger of two case reports, Vandana et al. (68)
used enamel matrix derivative to treat selected
defects in four patients with aggressive periodontitis
and compared the results at 9 months with similar
defects in a control group of four patients with
chronic periodontitis. The authors reported signifi-
cant improvements in both probing depths and
attachment levels, and no differences were found
between the two groups.
A possible conclusion of the above studies is that if
risk factors, especially smoking, can be eliminated,
and if compliance with maintenance care is high,
then surgical therapy can be as beneficial to the pa-
tient with generalized aggressive periodontitis as it is
to any other patient. The relatively high rate of sites
breaking down over time, however, suggests a likely
need for retreatment during the maintenance phase.
Periodontal maintenance
Regardless of whether the original diagnosis is
chronic periodontitis or aggressive periodontitis, the
goal of maintenance care following active periodontal
treatment is to maintain the level of periodontal
health achieved during active therapy. Given their
initial susceptibility to disease, patients with aggres-
sive periodontitis before therapy have to be consid-
ered at high risk for recurrent disease after therapy.
There are several potential reasons for this. Given the
amount of pocket formation and attachment loss
possible in aggressive disease, it is likely that after
therapy, the patient with aggressive periodontitis
may have residual deep pockets. Although this is
somewhat controversial, there is some evidence to
support the concept that additional attachment loss
is more likely to occur at sites with deeper residual
pocket depths (2, 8). A recent retrospective study by
Matuliene et al. (45) re-examined 172 patients at time
points from 3 to 27 years after active periodontal
therapy. They found that compared with probing
depths of £3 mm, residual probing depths of 5–7 mm
represented significant risk factors for both attach-
ment loss and tooth loss.
Residual deep sites may explain why the long-term
treatment effect on bacterial pathogens may be lim-
ited in patients with aggressive periodontitis. Two
recent reports demonstrated that despite a favorable
initial clinical outcome, the site effect of mechanical
therapy plus systemic metronidazole and amoxicillin
on potential pathogens was transient, and the extent
of tissue invasion by these bacteria did not decrease
following treatment (31, 67).
Another reason to fear additional attachment loss
in aggressive disease is an increased inflammatory
response. An experimental gingivitis study by Trom-
belli et al. (66) demonstrated that patients with
aggressive periodontitis had a significantly higher
inflammatory response, as measured by gingival
crevicular fluid flow, than periodontally healthy pa-
tients. If, as some have suggested, persistent gingival
inflammation results in a greater risk for tooth loss
and attachment loss over time, then the patient with
aggressive periodontitis may be at increased risk. For
example, the previously mentioned study by Gun-
solley et al. (23) showed that patients with general-
ized early onset periodontitis, even when treated,
tended to experience continued tooth loss and
attachment loss over time. Kamma et al. (34) fol-
lowed a group of 25 patients with aggressive perio-
dontitis through active therapy and maintenance
care at 3–6-month intervals over a 5-year period.
Twenty of the 25 patients experienced additional
attachment loss, of ‡2 mm, following treatment at a
total of 134 sites.
Despite this increased risk for recurrence, there is
evidence that attachment loss can be stabilized, after
therapy, in patients with aggressive periodontitis.
Lindhe & Liljenberg (42) used a combination of sur-
gical debridement and systemic tetracycline to treat
16 patients with localized aggressive periodontitis
and 12 older patients with chronic periodontitis.
Patients were seen monthly for maintenance care
during the first 6 months, then every 3 months until
the end of the study. The authors reported that in
general, diseased sites in the patients with localized
aggressive periodontitis responded as well to treat-
ment as sites in the patients with chronic periodon-
titis, although 4 of the 12 patients in the localized
aggressive periodontitis group (a total of six sites)
needed to be retreated for disease recurrence over the
5-year study period.
The previously mentioned study by Buchmann et
al. (6) followed the treatment of 13 patients with
aggressive periodontitis (by description, generalized
aggressive periodontitis) through modified Widman
flap surgery and systemically administered metro-
nidazole and amoxicillin. Following treatment, the
patients were recalled at 3–6-month intervals for
maintenance, which included subgingival instru-
mentation, under local anesthesia, at all sites deeper
than 4 mm showing bleeding on probing. After 5 years
of maintenance care, the authors found that only
1.4–5.3% of sites underwent disease progression dur-
ing the recorded intervals, with an additional 2–4% of
sites experiencing additional attachment level gain.
161
Response of chronic and aggressive periodontitis to treatment
Finally, Zucchelli et al. (74) used guided-tissue
regeneration to treat single intrabony defects in 10
patients with localized early onset periodontitis and
compared their results with the same treatment in
patients with chronic periodontitis. At 1 year, defects
in the early onset group experienced a mean probing
depth reduction of 7.1 mm and an attachment level
gain of 6.1 mm. The authors attributed the success of
treatment in part to an aggressive maintenance
schedule of monthly professional cleanings and oral
hygiene reinforcement.
Treatment planning
The process of treatment planning for periodontitis
patients is well established and an attempt will not be
made to review each step. While the generally
accepted phases of treatment – systemic, initial, re-
evaluation, surgical, maintenance, and restorative –
seem well suited for patients with both diseases, the
amount of specific planning required at each step
may be greater for the patient with aggressive disease
(Table 1). In general, we would expect the patient
with aggressive periodontitis to have experienced
attachment loss at a younger age, at a faster rate and
to a greater extent than the patient with chronic
periodontitis. If the expectation of the patient and the
provider is to retain teeth, this cannot help but
complicate the treatment-planning process.
In the systemic phase, for example, the patient
with chronic periodontitis may require little beyond
an awareness of existing medical conditions and
medications. The systemic phase for the patient with
aggressive periodontitis is likely to be much more
complex. Because periodontitis as a manifestation of
systemic diseases can present as aggressive perio-
dontitis, it is critical that the practitioner performs a
thorough medical history. In addition, it is our
opinion that the patient with generalized aggressive
periodontitis, especially, should be referred for a
complete blood count and either a casual or a fasting
blood glucose test. Although the cause-and-effect
relationship is uncertain, monitoring other systemic
factors, such as weight loss, depression and malaise
has also been recommended (48). Beyond that, a
heightened requirement for identification and mod-
ulation of risk factors is essential. It may also be a
good idea to review the patient�s social history to
identify stress-related factors (17, 34).
In the initial phase, a thorough explanation of the
disease process and its contributing factors is given to
patients with both chronic and aggressive disease, but
Table 1. Treatment planning sequence for patients withperiodontitis
Systemic phase
– review of medical history, medications, family history,
social history*
– laboratory screening tests (complete blood count,
fasting blood glucose)*
– medical consultation if indicated
– identification ⁄ modulation of risk factors (e.g.
smoking, stress, diet)*
– assess the need for a stress-reduction protocol during
therapy
Initial phase
– emergency treatment if needed
– explanation of the disease process and contributing
factors*
– review of oral hygiene instructions
– occlusal analysis and treatment of localized trauma
from occlusion
– bacterial sampling of selected pockets*
– dental consultations (e.g. caries control, root canal
therapy, strategic value of teeth for eventual
restoration, orthodontic assessment)
– extraction of hopeless teeth
– scaling and root planing
– local or systemic antibiotic treatment*
Re-evaluation
– re-assess prognosis of individual teeth and overall
dentition
• probing depths
• attachment level measurements
• bleeding on probing
• furcation invasion
• mobility
• root sensitivity
– oral hygiene
– bacterial sampling of selected pockets* (if not
completed during the initial phase)
– additional laboratory tests (e.g. 2-h postprandial
glucose)*
– medical consultation if indicated*
– assessment of modulation of risk factors*
– patient motivation
162
Deas & Mealey
in our view should be given special emphasis in the
patient with aggressive periodontitis. Likewise, both
types of patients should be given a comprehensive
review of oral hygiene techniques; however, standard
brushing ⁄ flossing instructions are less likely to be
sufficient for patients with aggressive disease, espe-
cially those who have experienced attachment loss
that has exposed furcations and root concavities.
Monitoring compliance with oral hygiene procedures
is critical in both groups, but may be more difficult in
the aggressive patient if chlorhexidine rinses are
prescribed frequently during treatment. Given the
likelihood of greater attachment loss at an earlier age,
another element of the initial phase that may have
added emphasis in patients with aggressive peri-
odontitis is consultation with other dental specialists
to assess the strategic long-term restorative value of
certain teeth before starting periodontal therapy. This
may guide the periodontist in recommending
extractions of questionable teeth. Finally, because
aggressive periodontitis often demonstrates a familial
pattern, the practitioner should assess the family
history of periodontal problems and consider evalu-
ation of siblings and parents (11, 50).
In our view, the treatment of aggressive periodon-
titis should start with scaling and root planing in
combination with systemic antibiotics. The exception
to this may be in certain cases of localized aggressive
periodontitis, where surgical debridement is an
acceptable first step if dictated by time or third-party
payment constraints. If surgical treatment (including
initial extraction of hopeless teeth) is undertaken in
the patient with aggressive disease, we recommend a
biopsy of associated granulation tissues to rule out
certain pathological entities such as Langerhans� cell
histiocytosis.
While the literature may be somewhat equivocal on
the added value of antibiotics as an adjunct to initial
therapy, especially in patients with generalized
aggressive periodontitis, it is our view that this is a
worthwhile step. Even if the main benefit of antibiotic
therapy is to reduce the number of sites with probing
depths >6 mm (72), many clinicians have noted that
the magnitude of improvement at individual sites
may be improved with antibiotic therapy (22). The
combination of metronidazole 500 mg three times
daily plus amoxicillin 500 mg three times daily is
probably the most popular antibiotic regimen in the
current literature; however, its superiority over other
antibiotics, either singly or in combination, is spec-
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
performed over the short time period during which
the antibiotic is prescribed.
Although there is limited evidence to suggest that
enhanced root planing techniques may offer an ad-
ded treatment response to nonsurgical therapy (58),
in our view there is value in any reasonable protocol
that enhances patient and provider confidence. If a
full-mouth debridement approach demonstrates an
added commitment or sense of importance to the
treatment, then it may be worthwhile. The outcome
of treatment in aggressive periodontitis is uncertain.
Improvements in either compliance or clinical indi-
ces, even if somewhat placebo based, are always
welcomed.
A 4–6-week re-evaluation interval seems as valid
for a patient with aggressive periodontitis as for one
with chronic periodontitis. The re-evaluation should
closely resemble the initial evaluation, with review of
Table 1. Continued
Surgical phase (if indicated; may proceed to maintenance
or return to initial phase)
– antibiotic treatment*
– monitor healing of previously treated sites
Maintenance phase
– monthly for the first 6 months following treatment,
then
bimonthly until 12 months, then extending to
3 months*
– probing, attachment level measurements 6 months
after completion of treatment, then at each
maintenance visit
– yearly radiographs of at-risk teeth*
– assessment of oral hygiene, risk factor modulation
– prophylaxis, topical fluoride treatment if indicated,
treatment of hypersensitivity
– subgingival scaling of deep pockets
– host modulation therapy if indicated*
– local delivery antibiotic treatment of at-risk sites
– full-mouth scaling and root planing (with or without
adjunctive antibiotics if indicated by general
breakdown)*
– definitive occlusal adjustment if indicated
– consider extraction of teeth with progressive disease
to preserve alveolar bone*
Restorative phase
– assessment of prosthesis cleansability and function
*Areas of special emphasis for patients with aggressive periodontitis.
163
Response of chronic and aggressive periodontitis to treatment
medical history, risk factors, oral hygiene techniques
and clinical indices. At this point, regardless of
whether the initial diagnosis is chronic periodontitis
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
phase or a surgical phase, depending on the re-
sponse, seems justified.
If, however, there is no significant positive re-
sponse to initial therapy, we recommend a return to
the initial phase for additional data collection and
treatment. At this point, bacterial culture and sensi-
tivity testing of the deepest pockets may be war-
ranted, along with a 2-h postprandial glucose test,
which is a more sensitive test for diabetes mellitus
than either fasting or casual glucose tests. Depending
on the outcome, the clinician may choose to repeat
subgingival scaling with a different antibiotic regi-
men, possibly using the enhanced scaling and root
planing techniques referred to previously. Depending
on the results of the 2-h postprandial test, the patient
may be referred to his physician for evaluation of his
metabolic status. In our opinion, there is little to be
gained, and potentially much to be lost, by pro-
ceeding to a surgical phase in patients who have
demonstrated little or no improvement in clinical
indices following well-delivered initial therapy. If the
response to initial therapy is equivocal, then it may
be prudent to perform surgery in a limited, isolated
area and to monitor healing during a period of trial
maintenance before proceeding to other sites.
If the response to initial therapy supports pro-
ceeding to a surgical phase, the goals of surgical
treatment are similar to those in a patient with
chronic periodontitis. Surgical modalities are selected
according to these goals and include all forms of
treatment such as flap debridement, regenerative
therapy, respective therapy and even tooth extrac-
tion, as indicated in each individual case.
Ultimately, a clinician�s success in treating
patients with aggressive periodontitis may be most
dependent on the maintenance program. It seems
critical to very slowly extend the maintenance
interval in these patients, with very careful moni-
toring of probing depths, risk factors and signs of
inflammation. In general, we recommend monthly
maintenance for the first 6 months after completing
active treatment, then bimonthly for 6 more
months. If the patient is stable during this first year,
maintenance intervals can be extended to 3 months.
Subgingival scaling in combination with local
delivery of antibiotics is a good way to manage
isolated sites of recurring disease, while full-mouth
scaling and systemic antibiotics, or host-modulation
therapy, can be used to treat a generalized
recurrence.
Summary and future directions
Patients with aggressive periodontitis can be both
rewarding and frustrating to treat in clinical practice.
Interindividual variation in response to therapy can
be widespread, and we do not clearly understand the
reasons for this variable response. It is possible that
new research into the resolution of inflammation
may reveal basic differences between patients with
chronic periodontitis and those with aggressive dis-
ease. In addition, future research involving modula-
tion of host inflammatory responses may clarify the
reasons for the differences in clinical outcomes be-
tween patients. We think it likely that this research
could result in further alterations to the classification
of periodontal diseases, as with more knowledge of
the mechanisms of disease it is possible that patients
currently classified as having aggressive periodontitis
may be found not to represent a single diagnostic
entity. Better understanding of the true nature of
patients currently identified as having aggressive
periodontitis may therefore lead to more effective
treatment approaches.
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