AGGRESSIVE PERIODONTITIS

DR.AHMEDTH4YEAR

Important features of Aggressive periodontitis It was know as juvenile periodontitis

It generally affects systemically healthy individuals less than 30 years old

Although patients may be older.Aggressive periodontitis may be distinguished from chronic

periodontitis by: 1.The age of onset ,

2.the rapid rate of disease progression ,3.The nature and composition of the subgingival microflora ,

4.Alterations in the hosts immune response 5.A familial aggregation of diseased individuals.

LOCALIZED AGGRESSIVE PERIODONTITI S Clinical Characteristics Localized aggressive periodontitis (LAP) has an age of onset around puberty .

Clinically it is characterized as having "localized first molar/incisor presentation.

The attachment loss on is involving NO more than two teeth other than first molars and

incisors."

LAP : ACCENTUATED BONE DESTRUCTION

IN THE INCISOR AND 1ST MOLAR AREAS

LAP : ACCENTUATED BONE DESTRUCTIONIN THE INCISOR AND 1ST MOLAR AREAS

Important features:

A striking feature of LAP is the lack of clinical inflammation despite the presence of deep periodontal pockets. Furthermore, the amount of plaque on the affected teeth is minimal and inconsistent with the amount of periodontal destruction present.

The plaque that is present forms a thin biofilm on the teeth and rarely mineralizes to form calculus.

Although the quantity of plaque may be limited, it often contains elevated levels of Actinobacillus actinomycetemcomitans (A.a) and in some patients, Porphvromonas gingivalis(P.g).

Localized aggressive periodontitis progresses rapidly. The rate of bone loss is about three to four times faster than in chronic periodontitis.

Other clinical features of LAP may include: Distolabial migration of maxillary incisors with diastema formation .

Distolabial MIGRATION

Increasing mobility of first molars .Sensitivity of denuded root surfaces to thermal and

tactile stimuli . Deep dull radiating pain during mastication because

of irritation of the supporting structures by mobile teeth and impacted food. Periodontal abscesses .

Regional lymph node enlargement.

Radiographic Findings: Vertical loss of alveolar bone around the first molars and incisors, beginning around puberty in healthy teenagers, is a classic diagnostic sign of LAP. Radiographic findings may include an "arc-shaped loss of alveolar bone extending from distal surface of second premolar to mesial

surface of second molar.“

arc-shaped loss of alveolar bone

GENERALIZED AGGRESSIVE PERIODONTITIS

Clinical Characteristics of Generalized aggressive periodontitis (GAP) usually affects individuals under the age of 30 but older patients also may be affected.

Clinically, GAP is characterized by "generalized interproxirnal attachment loss affecting at least

three permanent teeth other than first molars

and incisors".-.

As seen in LAP, patients with GAP have small amounts of bacterial plaque associated with the affected teeth .

Qualitatively, Porphvromonas giriaivalis. A. actinomycetem comitans and Tannerella forsythia/ (Red Complx bacteria )frequently are detected in the plaque that is present.

In contrast to LAP, individuals affected with GAP produce a poor antibody response to the pathogens present

EXUDATE EXPRESED FROM A PERIODONTAL POCKET BY DIGITAL PRESSUR

 The destruction occurs episodically with periods of advanced destruction followed by stages of quiescence of variable length (weeks to months or years) .

Radiographs show bone loss that has progressed since the previous evaluation..

In cases of GAP, the gingival tissue response is a severe acutely inflamed tissue, often proliferating ulcerated and fiery red.

Bleeding may occur spontaneously or with slight stimulation. Suppuration may be an important feature

.This tissue response occurs in the destructive stage in which attachment and bone are actively lost.

 In other cases, the gingival tissues may appear pink, free of inflammation. However, deep pockets can be demonstrated by probing. This tissue response coincide with periods of quiescence in which the bone level remains stationary. In other cases, the gingival tissues may appear pink, free of inflammation. However, deep pockets can be demonstrated by probing.

Some patients with GAP may have systemic manifestations such as weight loss, mental depression and general malaise .

They should receive medical levaluations to rule out possible systemic involvement.

AGGRESSIVE PERIODONTITIS IN A 30 YEAR OLD PATIENT

AGGRESSIVE PERIODONTITIS IN A 32 YEAR OLD PATIENT

The radiographic picture in GAP range from severe bone loss associated with minimal number of teeth to advanced bone loss affecting the majority of teeth in the dentition. Sites in GAP patients demonstrated osseous destruction of 25 to 60 % during a 9-week period. Despite this extreme loss, other sites in the same patient showed no bone loss.

RISK FACTORS FOR AGGRESSIVE PERIODONTITIS Microbiologic Factors- Although

several specific microorganisms are detected in patients with LAP (A actinomycetemcomitans (A.

a.), Capnocytophaga sp. Eikenella corrodens, Prevotella intermedia and Campyiobacter rectus) ,

A. a. is implicated as the primary pathogen associated with this disease is based on the

following evidence:

1 -High frequency of A. a. (approximately 90%) in lesions characteristic of LAP.

2 -Elevated levels of A. a. were showed in sites with evidence of disease progression.

3 -Elevated serum antibody titers to A. actinomvcetemcomitans is showed in many patients with LAP.

4 -A correlation between reduction in the subgingival load of A. a. during treatment and a» successful clinical response.

5 -A. a. produces a number of virulence factors that may contribute to the disease process.

 Immunoloqic Factors: Some immune defects are implicated in the pathogenesis of aggressive periodontitis. The human leukocyte antigens (HLA), which regulate immune responses, were evaluated as markers for aggressive periodontitis. HLA-A9 and B15 antigens are consistently associated with aggressive periodontitis. Patients with aggressive periodontitis display functional defects of PMNs which can impair either the chemotacticattraction of PMN to the site of infection or their ability to phagocytose and kill microorganisms.

 Genetic Factors- All individuals are not equally susceptible to aggressive periodontitis. A familial pattern of alveolar bone loss have implicated genetic factors in aggressive periodontitis.- Genetic predisposition for LAP suggest that a major gene plays a role in this disease, which is transmitted through an autosomal dominant mode of inheritance .

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Environmental Factors- The amount and duration of smoking can influence the extent of destruction seen in young adults

 TREATMENT OF AGGRESSIVE PERIODONTITIS

Standard periodontal therapy: Such therapy has included

Oral hygiene instruction and patient’ motivation

scaling and root planing.

flap surgery with and without bone grafts, root amputations, hemisections, occlusal

adjustment and strict plaque control

Maybe extraction and implant placements .

However, response was unpredictable. Frequent maintenance visits appear to be most important.

Lack of response of aggressive periodontitis to local therapy alone is the result of the presence of A. actinomycetemcomitans in the tissues where it remains after therapy to reinfect the pocket. Systemic use ofantibiotics eliminates bacteria from the tissues ( Combination of Amoxicillin and Metranidazole).

Old Approach to Therapy. Patients who are diagnosed as having an early form of aggressive periodontitis may respond to standard periodontal therapy. In almost all cases, systemic tetracycline (250mg of tetracycline 4 times daily for at least 1 week)should be given in conjunction with local mechanical therapy. If surgery is indicated, systemic tetracycline should be taken approximately 1 hour before surgery.

Doxycycline 100 mg/day may also be used.Chlorhexidine rinses should also be prescribed and continued for several weeks to aid healing and augment plaque control.

In refractory localized aggressive periodontitis cases,tetracycline- resistant Actinobacilfus species have been suspected. After performing antibiotic susceptibilityt ests, the clinician may consider a combination of amoxicillin and metronidazole.

Answer the following Questions and bring the answers by the next lecture .

How to differentiate between chronic and aggressive periodontitis? Make a table to answer the question

How to differentiate between localized and generalized aggressive periodontitis? Make a table to answer the question

What is the old names of chronic and aggressive periodontitis?

Thank You