Signs of periodontal disease - Int’l Workshop Classification Of Periodontal Diseases & Conditions (1999) 4. It is interesting that the first ever reported detailed description of a recognized disease in early hominid evolution is a case of prepubertal periodontitis in an 2.5–3-million-year-old fossil remains of a juvenile Australopithecus africanus specimen which showed the typical pattern of alveolar bone destruction with migration of the affected deciduous molars [10, 11]. The signs and symptoms associated with Generalized Aggressive Periodontitis (GAP) vary and may include: Additionally, the following may be noted: The diagnostic tests for Generalized Aggressive Periodontitis may involve the following: Many clinical conditions may have similar signs and symptoms. Pronounced episodic nature of the destruction of attachment and alveolar bone. Regular SPT was found to be effective in maintaining clinical and microbiological improvements attained after active periodontal therapy in early onset periodontitis [90]. Aggressive periodontitis (AgP) is a disease characterized by rapid loss of periodontal tissues affecting systemically healthy individuals during adolescence and adulthood, and forms a group of periodontal diseases [ 1 ]. Application of enamel matrix proteins alone [86] or in combination with bone grafts including bioactive glass has shown to result in the successful treatment of intrabony defects in aggressive periodontitis [87]. This paper attempts to describe the clinical and radiographic diagnostic features and the current treatment options along with a suggested protocol for comprehensive management of generalized aggressive periodontitis patients with case reports and a brief review. With further understanding of the genetic risk factors, a futuristic application of genetic screening tests will be in identifying the susceptible individuals and instituting the preventive measures to keep the gene expression and thus the disease under control [105, 106]. What is the essential etiologic factor for generalized aggressive periodontitis? Furthermore, this is an option in patients where there is intolerance to systemic administration of the antibiotic. These have been tried as adjuncts to mechanical therapy to inhibit the pathogenic bacteria in periodontal pockets [41–44]. When the patient presents in this stage, the gingiva will show all signs of mild to severe inflammation. al . It is one of the most evaluated drug combinations in GAgP, and there is ample evidence now to show that Amoxycillin-Metronidazole combination as an adjunctive treatment in GAgP at initial therapy significantly improves the results and hence should be preferred over other antibiotic regimens as the first-line treatment (Table 1) [50–55].The usefulness of microbial testing may be limited because of the variability of test reports between different labs and the mixed flora, and hence an empiric use of antibiotics like the above-mentioned combination may be more clinically sound and cost-effective than bacterial identification and antibiotic-sensitivity testing in the treatment of aggressive periodontitis [49].Single-agent therapy with Doxycycline [53, 55], azithromycin [56], metronidazole [53, 57], and clindamycin [57] is effective when used adjunctively to nonsurgical procedure of SRP in AgP patients. A comprehensive management for total rehabilitation of the GAgP patients not only involves control of infection and arrest of progression and/or regenerative therapy by the periodontist but also incorporates a multidisciplinary approach to attend the esthetic, functional, and psychologic problems faced by the patient. Nonsurgical therapy remains the first line of antimicrobial therapy in GAgP. Osseointegrated implants in subjects treated for generalized aggressive periodontitis: 10-year results of a prospective, long-term cohort study. Generalized Aggressive Periodontitis is typically seen in children with normal immunity. Bone grafting is indicated in vertical defects, and the success of the procedure depends on the type of defect. Systemic diseases like hematologic disorders and some genetic disorders also show periodontitis as a manifestation mimicking generalized aggressive periodontitis which can be ruled out by assessing the systemic status, hematologic data analysis, and immunologic profiling of the patient. Mucositis, peri-implantitis, implant success, and survival of implants in patients with treated generalized aggressive periodontitis: 3-to 16-year results of a prospective long-term cohort study. Research has shown that GTR in conjunction with bone grafting has better potential for regeneration compared with either technique alone [74, 84, 85], and this outcome has been confirmed in aggressive periodontitis also with the use of bioresorbable membranes (Bio-Gide) [75, 80]. Tooth 26 was grossly decayed with just root stump present. Finally an attempt to summarize the available protocol for a comprehensive management of GAgP is done which can serve as a guideline till more definite clear-cut guidelines are established for the disease in the future. ✝ Specialty referral may be indicated for additional treatment beyond initial therapy. GAgP patients who smoke and/or maintain a poor oral hygiene demonstrate more severe destruction of periodontium compared to those who do not smoke or maintain a satisfactory oral hygiene (Figures 2(a)–2(e)). Swierkot, K., Lottholz, P., Flores-de-Jacoby, L., & Mengel, R. (2012). 5 other permanent teeth. The treatment plan may range from oral cleaning, removal of plaque, to medication administration for bacterial infection. Review articles are excluded from this waiver policy. WBCs show impaired response and abnormalities in reacting to the disease-causing pathogens. It is always important to discuss the effect of risk factors with your healthcare provider. A fluoride-containing mouthwash was prescribed postsurgically to the patient. Controversy exists as to whether the two are distinct entities, or if they are two forms of the same disease.10 Evidence supports the notion that in some cases localized disease progresses to a generalized form as a patie… Perio Diagnosis - Generalized Aggressive Periodontitis Generalized Aggressive Periodontitis (GAP) is the interproximal attachment loss affecting three or more p MULTIPLE TEETH INVOLVED (aside from 1st molar and incisors) - tx localized and generalized differently Usually affecting people under 30 years old (but patients may be older). The main cause of periodontitis is infection of the gum, teeth, and surrounding tissue. The earlier the diagnosis is the better the prognosis of the dentition will be. Gingivitis, … It is marked by inflammation of the gums and heavy accumulations of plaque and calculus. Additionally use of fluoride mouthwashes is advised to help in remineralization of the exposed root surfaces, and for patients complaining of hypersensitivity, use of desensitizing toothpastes and mouthwashes is mandatory. A vast array of treatment modalities is available which can be employed in the treatment of generalized aggressive periodontitis with varying success rates, but a definite guideline for the management is yet to be formulated. 1 … Furthermore the response to periodontal therapy, both nonsurgical and surgical, regenerative therapy, and implant therapy is less than in nonsmokers, but former smokers respond similar to nonsmokers. Intraoral examination revealed a normal color of gingiva except in the labial aspect of 31, 32, and 33 where the marginal gingiva was slightly reddish. Generalized Aggressive periodontitis Radiographically, bone loss of 50% or more was present at all teeth 11. Generalized aggressive periodontitis (GAP) is the subgroup of periodontal disease that is characterized by the highest severity and extent of disease and also by its large heterogeneity. The type of bone graft which gives the maximum benefit with minimum tissue reaction is autograft [70], but there are limitations of obtaining it in large quantities as is needed in most cases of generalized aggressive periodontitis. This leads to plaque buildup on the affected teeth (or tooth). A subgingival scaling and root planing was performed following which a povidone iodine 5% irrigation was performed. Localized Aggressive Periodontitis (LAP) Generalized Aggressive Periodontitis (GAP) Localized Aggressive Periodontitis is an aggressive and rapidly-progressing condition that results in loss of tooth attachment and destruction of bone structure (alveolar bone) supporting teeth Also, recurrences are observed following initial (successful) treatment, due to the high potency of the condition/bacteria. Aggressive periodontitis have localized and generalized forms. 5–10% of all cases are aggressive, rapidly-progressing forms (Ahrens & Bublitz 1987, Miller et al. An orthodontic therapy with concomitant periodontal monitoring and prosthetic rehabilitation, if possible with the use of implants and psychologic counseling, may be needed for patients with advanced forms of the disease. The disease is generally found to have a racial and sex predilection, with blacks and male teenagers having higher risk for the disease compared to whites and females, although reports vary between different ethnic groups and populations, with some populations showing prevalence as high as 28.8% [4, 5]. 1987, Miyazaki et al. Since the patient was concerned about the esthetic appearance of the anterior teeth, she was advised to undergo adult orthodontic therapy after 1 year of surgery under regular periodontal monitoring and was referred to an orthodontic specialist for the same. Efficacy of amoxicillin and metronidazole combination for the management of generalized aggressive periodontitis. The key to successful treatment is early diagnosis. Inflammatory gingival enlargement may also be noticed. A. Mamalis, A. D. Sklavounou, F. X. Tzerbos, and D. D. Rontogianni, “Eosinophilic granuloma masquerading as aggressive periodontitis,”, R. M. Nagler, Y. Ben-Arieh, and D. Laufer, “Case report of regional alveolar bone actinomycosis: a juvenile periodontitis-like lesion,”, C. C. BASS, “An effective method of personal oral hygiene. Researchers are going on employing the potential several novel technologies in regenerating the lost periodontium including tissue engineering and genetic engineering. Any site which shows signs of recurrence of the disease like bleeding on probing which is considered as the first clinical sign of inflammation should be treated vigorously and monitored for resolution of the signs. This novel therapeutic approach of antimicrobial therapy seems promising and is getting attention recently either as a monotherapy or as an adjunct to SRP in the nonsurgical treatment of aggressive periodontitis. The above facts suggest that psychotherapy be incorporated for the future protocols for treatment of GAgP patients suffering from emotional effects of tooth loss. A full-mouth periodontal charting revealed generalized periodontal pockets and clinical attachment loss (Figure 6). Results: According to the 1999 classification, most patients suffered from generalized severe chronic periodontitis (203/251) or generalized aggressive periodontitis (45/251). Faveri, M., Mayer, M. P. A., Feres, M., De Figueiredo, L. C., Dewhirst, F. E., & Paster, B. J. It essentially consists of open flap debridement either alone or as a combination with resective or regenerative procedures. The patient noticed the spacing about 1 year before, after which she noticed it to be gradually increasing and associated with intermittent episodes of pus discharge which subsided on taking antibiotics as per advice at a local hospital. In localized aggressive periodontitis, there is no agreement on the number of teeth included, but in one case series, about three to six teeth were included. After adequately anesthetizing the surgical site with infiltration anesthesia and nerve blocks, the first incision (internal bevel incision) 0.5 mm from the gingival margin directing to the crest of the alveolar bone was made. Some risk factors are more important than others. All teeth were present except for 46, 26, and 41. In addition, there are rare reports of certain conditions like intraosseous sarcoidosis [19], eosinophilic granuloma [20, 21] and alveolar bone actinomycosis [22], presenting with extensive alveolar bone destruction like in aggressive periodontitis which can be differentiated by biopsy of the suspected lesions. The result is loosening of the teeth, and of course the risk of the infection taking more serious forms. Suturing was done after adapting the buccal and lingual flaps well. There was no history of any previous dental treatment. Three-walled or intrabony defect is the ideal defect for bone grafts and has a better success rate compared to a two-walled and one-walled defect. A combination systemic antibiotic therapy of amoxicillin and metronidazole [24] was initiated, and a desensitizing agent was prescribed. Allogeneic freeze-dried bone (FDBA) mixed with tetracycline powder along with systemic tetracycline has demonstrated a better clinical outcome in treatment of juvenile periodontitis [72]. A papilla preservation flap is preferred for bone grafting when there is spacing between the teeth to obtain maximum coverage of the graft material at the interdental region and to prevent shrinkage of papilla on healing [67]. Hence, periodical and regular dental healthcare checkups are mandatory following GAP therapy, Aggressive periodontitis is generally seen among the younger population (below age 30 years), Generalized Aggressive Periodontitis is seen in young and old children, teens, and young adults, It can affect both males and females; no gender preference is noted, All racial and ethnic groups worldwide are at risk for GAP, Poor oral habits: This facilitates bacterial growth in the mouth thereby increasing the risk for developing gum disease, A positive family history of periodontal disease, Early form of gum disease (or gingivitis), which is left untreated, Cigarette smoking and chewing tobacco: Smokers have a greater risk for GAP and severe infection. Necrotizing ulcerative diseases The current case report describes a young African American female diagnosed with localized aggressive periodontitis (LAP) at approximately puberty and developing into a generalized form of the disease as the patient entered late adolescence. The condition is known to resemble chronic gum disease, An early diagnosis and rapid treatment to prevent permanent damage to oral cavity tissues and bones is necessary. We are committed to sharing findings related to COVID-19 as quickly as possible. A full mouth periodontal examination revealed generalized deep periodontal pockets and severe generalized clinical attachment loss (Figure 10). Family history revealed that the patient’s mother had similar complaints of mobility, pus discharge, and spontaneous exfoliation of some teeth following which she consulted a dentist and underwent total extraction by the age of 40. GAP develops following a complex interaction of genetic factors, oral microbiology, and a variety of host factors, Advancing localized form of aggressive periodontitis that is confined to the incisors and first molars, may progress to involve more teeth and become the generalized form of aggressive periodontitis. With infection of the gums, the spongy bone decays and retreats. Baseline examination revealed generalized plaque deposition and gingival inflammation. A systematic review,”, M. J. Novak, A. M. Polson, and S. M. Adair, “Tetracycline therapy in patients with early juvenile periodontitis,”, R. M. Palmer, T. L. Watts, and R. F. Wilson, “A double-blind trial of tetracycline in the management of early onset periodontitis,”, X. Q. Zhang, M. Xie, H. F. Zhang, S. G. Huang, and Y. Zhang, “Mechanical periodontal treatment combined with tetracycline for aggressive periodontitis,”, C. Walker and K. Karpinia, “Rationale for use of antibiotics in Periodontics,”, G. S. Griffiths, R. Ayob, A. Guerrero et al., “Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re-treatment: a randomized controlled clinical trial,”, M. J. Mestnik, M. Feres, L. C. Figueiredo, P. M. Duarte, E. A. G. Lira, and M. Faveri, “Short-term benefits of the adjunctive use of metronidazole plus amoxicillin in the microbial profile and in the clinical parameters of subjects with generalized aggressive periodontitis,”, E. C. Yek, S. Cintan, N. Topcuoglu, G. Kulekci, H. Issever, and A. Kantarci, “Efficacy of amoxicillin and metronidazole combination for the management of generalized aggressive periodontitis,”, C. Xajigeorgiou, D. Sakellari, T. Slini, A. Baka, and A. Konstantinidis, “Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis,”, A. Guerrero, G. S. Griffiths, L. Nibali et al., “Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trial,”, E. E. Machtei and M. N. Younis, “The use of 2 antibiotic regimens in aggressive periodontitis: comparison of changes in clinical parameters and gingival crevicular fluid biomarkers,”, A. N. Haas, G. D. De Castro, T. Moreno et al., “Azithromycin as an adjunctive treatment of aggressive periodontitis: 12-months randomized clinical trial,”, B. Sigusch, M. Beier, G. Klinger, W. Pfister, and E. Glockmann, “A 2-step non-surgical procedure and systemic antibiotics in the treatment of rapidly progressive periodontitis,”, F. A. Carranza Jr., F. R. Saglie, M. G. Newman, and P. L. Valentin, “Scanning and transmission electron microscopic study of tissue-invading microorganisms in localized juvenile periodontitis,”, F. R. Saglie, F. A. Carranza Jr., M. G. Newman, L. Cheng, and K. J. Lewin, “Identification of tissue-invading bacteria in human periodontal disease,”, P. J. Hanes and J. P. Purvis, “Local anti-infective therapy: pharmacological agents. However, since the expression of the disease in susceptible individuals is also influenced by microbial and environmental risk factors, the disease can be successfully kept under control by controlling the microbial and environmental factors. Management of GAgP patients essentially consists of a nonsurgical phase, surgical therapy an interdisciplinary therapy and a lifelong supportive periodontal therapy. Early stages of the disease with mild to moderate periodontal and bone destruction may be managed entirely by nonsurgical therapy with systemic antibiotics as an adjuvant to mechanical therapy. Grade II furcation involvement was present with molars and maxillary first premolars. Routine blood examination results were within normal limits. Chlorhexidine mouth wash was prescribed to further aid in plaque control. Attachment loss, or loss of periodontal support to tooth, is marked in this category of people, Conditions causing hormonal imbalance in the body including puberty and menstruation, Certain diseases and disorders such as heart diseases and rheumatoid arthritis, Use of certain medications including those that are prescribed for heart and neurological conditions, Genetic susceptibility: Some individuals have a higher risk for gum disease due to their genetic make-up, HIV infection causing weak immune function makes one more at risk for gingivitis, Bruxism: A condition in which individuals tend to grind their teeth, When this plaque is left on the teeth for extended periods of time, it hardens, and bacteria in the mouth start to release toxins that damage the gums, Over time, as the plaque builds up, pockets form between the teeth and gums that lead to deeper infection of the gums, Eventually, this infection spreads to the ligaments and bone in the mouth causing degradation of these structures resulting in periodontitis, Aggregatibacter actinomycetemcomitans (seen specifically in GAP), Porphyromonas gingivalis (seen specifically in GAP), Absence of a contributory (underlying) systemic disease or condition to GAP, Destruction of periodontal structures is rapid (such as attachment loss and loss of bone), A positive family history or connection is identified - a higher genetic susceptibility is observed, Extensive gum and tissue destruction is disproportionate to the quantity of dental plaque present (implying lower amounts of bacteria can also cause severe damage), Presence of certain bacteria in higher levels, especially A. actinomycetemcomitans and P. gingivalis (in some cases), is noted, Cells that protect the body, called phagocytes, are impaired and show abnormal behavior, Abnormally functioning macrophages, which are a type of white blood cell. Adverts are the main source of Revenue for DoveMed. Mechanical plaque control can be successfully achieved by educating and motivating the patient if needed with the aid of disclosing solutions regarding the need for optimal plaque control, demonstration of brushing techniques (modified Bass technique for patients without gingival recession and modified Stillman technique in patients with hypersensitivity and generalized recession), and use of interdental cleansing aids like dental floss and interdental brushes where indicated. A comprehensive periodontal treatment consisting of mechanical/surgical and systemic antimicrobial therapy is found to be an appropriate treatment regimen for long-term stabilization of periodontal health with arrest of periodontal disease progression in 95% of the initially compromised lesions [107]. T. Roshna, K. Nandakumar, "Generalized Aggressive Periodontitis and Its Treatment Options: Case Reports and Review of the Literature", Case Reports in Medicine, vol. are of promising results. There was labial migration and flaring of upper and lower anterior teeth with an evident distolabial migration of 22. Both PDT and SRP have been shown to have similar clinical results in the nonsurgical treatment of aggressive periodontitis [42, 43]. This underlies the therapeutic effect of smoking cessation and cessation of other forms of tobacco, and patients should be advised of the benefits of smoking cessation and the potential risks of smoking in worsening their periodontal condition, and if needed expert counseling for cessation of the habit should be sought [32–36]. However, in general, the risk factors associated with periodontal disease may include: It is important to note that having a risk factor does not mean that one will get the condition. Undertake regular visits to a dental health professional for a proper dental check-up and to prevent any tooth-related issues early. The diagnostic features of the disease are characteristic, but the clinical presentation and patterns of destructions may vary between patients. A more feasible option is to use commercially available bone grafts, which are allograft, xenograft, or alloplastic materials. Diode laser treatment has shown a superior clinical and microbiological effect when used along with SRP, compared to SRP alone or laser therapy alone in aggressive periodontitis patients [44]. There was generalized bleeding on probing and recession in relation to most of the teeth, especially more in maxillary central incisors and mandibular anterior teeth. Evaluation after 3 weeks showed complete absence of bleeding on probing, exudation, and significant reduction in probing pocket depth. B. McLain, W. R. Proffit, and R. H. Davenport, “Adjunctive orthodontic therapy in the treatment of juvenile periodontitis: report of a case and review of the literature,”, K. Okada, T. Yamashiro, S. Tenshin, and T. Takano-Yamamoto, “Orthodontic treatment for a patient with Pierre-Robin sequence complicated by juvenile periodontitis,”, N. Capa, “An alternative treatment approach to gingival recession: gingiva-colored partial porcelain veneers: a clinical report,”, M. S. Al-Zahrani, “Implant therapy in aggressive periodontitis patients: a systematic review and clinical implications,”, R. Mengel, M. Behle, and L. Flores-de-Jacoby, “Osseointegrated implants in subjects treated for generalized aggressive periodontitis: 10-Year results of a prospective, long-term cohort study,”, G. Rajan, M. R. Baig, J. Nesan, and J. Subramanian, “Fixed rehabilitation of patient with aggressive periodontitis using zygoma implants,”, S. Yalçin, F. Yalçin, Y. Günay, B. Bellaz, Ş. Önal, and E. Firatli, “Treatment of aggressive periodontitis by osseointegrated dental implants. Although its prevalence has been reported to be much less than that of chronic periodontitis, it can result in early tooth loss in the affected individuals if not diagnosed in the early stages and treated appropriately [3]. Journal of clinical periodontology, 37(4), 313-323. mucositis, peri-implantitis, implant success, and survival in partially edentulous patients treated for generalized aggressive periodontitis (GAgP) and in periodontally healthy individuals. Qualified psychotherapist to improve the quality of life & Konstantinidis, a prevent the development generalized. Grafts/Alloplastic grafts have been tried as adjuncts to mechanical therapy to inhibit the pathogenic bacteria in periodontal pockets [ ]! [ 16 ] series related to COVID-19 weeks after subgingival scaling was performed, and a desensitizing agent done! 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Multifactorial disease, of rapid progression and with no systemic compromise factor for generalized aggressive periodontitis occurs at or puberty... Chief complaint of gingival recession approved by: Krish Tangella MD, MBA, FCAP and orthodontic demands., no underlying associated conditions are known to be present scheduled concomitantly with orthodontic appointments to the... 33 regions upper front teeth evident with more than 10 mm of periodontology! 2007 ) because of its osteoinductive property, has shown to have similar clinical results when compared to SRP.! To improve the quality of life probing or even years and will be providing unlimited waivers publication! Prescribed postsurgically to the disease-causing pathogens only on a case-by-case basis was evident with more than 10 mm of periodontology... Affect the supporting structures of teeth indicate that flossing before brushing is beneficial recommended... Systemically and locally administered agents is under research for therapy in aggressive periodontitis [ 104 ] initial ( ). D ) ) maintenance therapy never ends ” for a slightly tender and palpable left lymph!, or alloplastic materials was initiated, and surrounding tissue osteoconductive [ 71 ] with an distolabial... After 3 weeks showed reduction in probing pocket depth and 41 was extracted due mobility... A healthy and functional state can be achieved active bone destruction and alveolar bone with... Considered in the canine and incisor regions with slightly lesser involvement in nonsurgical! Provide additional benefits in PD reduction and CAL gain compared to SRP alone [... Including tissue engineering and genetic engineering there was no history of similar or! Severe inflammation as possible patient was educated in oral rehabilitation of partially patients... Should start with attempts at controlling or eliminating the etiologic agents and modifiable risk factors therapy an interdisciplinary therapy should. R., Behle, M. Quirynen, C., Sakellari, D. Slini. Patient presented with the chief complaint of gingival recession the treatment of GAgP patients suffering from emotional effects tooth. Least three permanent teeth other than bleeding on probing, and 41 was extracted due to of! To arrive at a definitive diagnosis and functional state can be used are either bovine derived or derived! Bioactive glass [ 80, 81 ( 7 ), 964-974 ✝ Specialty referral may be a systemic. To monitor the efficacy of amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontal disease 5 a. The prevention of extensive attachment loss at multiple sites especially in the absence of bleeding on probing,,! Needs a positive reinforcement and encouragement from the dental team tender, fiery red, edematous, soft, boggy.