Aggressive Periodontitis: Need to Assess the Prevalence and to plan the Management Strategies in Indian Scenario
Aggressive periodontitis is considered as a multifactorial disease, comprising of a heterogeneous group of infectious diseases characterized by the complex host-microbial interaction in the periodontium. Aggressive nature and early onset of the disease have been found to depend with respect to bacterial etiology, host susceptibility, hereditary and environmental factors and often modified by behavioral factors.
The loss of attachment, or destruction of the periodontal ligament and loss of adjacent supporting bone, is seen in adult cases, as well as in early-onset disease, which affects young persons who otherwise appear healthy. The disease is often associated with severe congenital defects of hematological origin, alterations in neutrophil chemotaxis function, systemic conditions such as metabolic disorders (diabetes mellitus, female hormonal alterations), drug-induced disorders, hematologic disorders/leukemia, and immune system disorders.
As per the classification given by American Academy of Periodontology, periodontitis may be of three types i.e., aggressive periodontitis (AP), chronic periodontitis and periodontitis associated with systemic disease. This classification is based on difference in respect to bacterial etiology, host response and clinical disease progression. However the evidences suggest that underlying host susceptibility factors play a significant role in disease manifestation. Hereditary factors are also suggested to play an important role in comparison to environmental factors in manifesting the early onset of periodontitis. High prevalence of infection in siblings of affected individuals has also reported by many workers.
It is documented well now that smoking has a profound effect on the predisposition to periodontal diseases, independent of oral hygiene, age, or any other risk factor. However, it has also been documented that there is no difference between smokers and nonsmokers when compared in terms of amounts of plaque accumulation, in the prevalence of the principal bacteria, which are considered pathogenic for periodontitis.
But at the same time we also must note that reports suggests that smoking causes suppression in vascular reaction, which subsequently leads gingivitis, masking effect on the signs of inflammation, association between refractory periodontitis and a polymorphonuclear leukocyte defect in the peripheral blood.
Recently, an association of smoking with osteoporosis has shown, so dental surgeons have also tried to link it with dental alveolar bone loss. More than 500 bacteria have been identified within periodontal pockets, so it is next to impossible to say accurately that which particular species may have contributed in development of periodontal lesion.
However, a finite set of pathogenic bacteria, sometimes working alone, or in combinations, cause periodontal diseases in humans. Simple antimicrobial treatment is not enough to treat the aggressive periodontitis, since the presence of both gram-negative and positive anaerobic and facultative rods, gram positive anaerobic cocci, have been reported in the periodontal lesions. Most of them have shown a variety and variability in sensitivity to antibiotics.
Three pathogens have an especially strong association with the presence of progressive periodontal disease: Actinobacillus actinomycetemcomitans, spirochetes of acute narcotizing gingivitis, and Porphyromonas gingivalis . One potential virulence factor recently ascribed to P. gingivalis and A. actinomycetemcomitans, which is shared by a number of respiratory and enteric pathogens, is the ability to enter mammalian cells. These pathogens are very often the cause of continued loss of periodontal attachment despite diligent conventional mechanical periodontal therapy, as well as causing refractory periodontitis, localized juvenile periodontitis, and other types of early-onset periodontitis.
Evaluation of the patient’s periodontal status requires obtaining a relevant medical and dental history and conducting a thorough clinical and radiographic examination, with evaluation of extraoral and intraoral structures. A medical history should be taken and evaluated to identify predisposing conditions that may affect treatment, patient management and outcomes. Such conditions include, but are not limited to, diabetes, hypertension, and pregnancy. Factors, which may also play a role in treatment outcome, are smoking, substance abuse and medications.
Adult periodontitis is defined as inflammation of the gingiva and the adjacent dental attachment apparatus. The disease is characterized by loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone. As discussed earlier, dental plaque bacteria play a key role in what is now understood to be the complex process by which the common types of oral diseases occur C’ dental caries and periodontal diseases. As with other infectious diseases, there is a balance between the host immune responses on one hand, and the microbial pathogenesis on the other hand. In health, host immune responses are sufficient to hold in check the pathogenic potential of both the normal resident microbial flora and exogenous microbial pathogens. Infectious diseases such as periodontal disease occur when this equilibrium is disturbed. Clinical features may include combinations of the following signs and symptoms: edema, erythema, gingival bleeding upon probing, and/or suppuration.
Adult periodontitis with slight to moderate destruction is characterized by a loss of up to 1/3 of the supporting periodontal tissues; a loss of over 1/3 of the periodontal supporting tissues is seen in advanced adult periodontitis. Radiographic evidence of bone loss is apparent in advanced adult periodontitis, and may be evident in adult periodontitis with slight to moderate destruction. Adult periodontitis with slight to moderate or advanced loss of periodontal supporting tissues may be localized, involving one area of a tooth’s attachment, or more generalized, involving several teeth or the entire dentition. A patient may simultaneously have areas of health and adult periodontitis with slight, moderate, and advanced destruction.
The therapeutic goals of periodontal therapy are to alter or eliminate the microbial etiology and contributing risk factors for periodontitis, thereby arresting the progression of disease and preserving the dentition in a state of health, comfort, and function with appropriate esthetics; and to prevent the recurrence of periodontitis. In addition, regeneration of the periodontal attachment apparatus, where indicated, may be attempted. Clinical judgment is an integral part of the decision-making process.
Many factors affect the decisions for appropriate therapies and the expected therapeutic results. Patient-related factors include systemic health, age, compliance, therapeutic preferences, and patient’s ability to control plaque. Other factors include the clinician’s ability to remove sub-gingival deposits, prosthetic demands, and the presence and treatment of teeth with more advanced adult periodontitis.
In general the treatment should include oral hygiene instruction, and reinforcement and evaluation of the patient’s plaque control; mechanical therapy, i.e., supra- and sub-gingival scaling and root planing to remove microbial plaque and calculus; and control of other local factors. If this initial therapy resolves the periodontal condition, supportive periodontal therapy should be scheduled at appropriate intervals; but if the periodontal condition is not resolved, periodontal surgery should be considered to correct anatomic defects, and/or to regenerate hard and soft tissues.
Early-onset periodontitis encompasses distinct types of periodontitis that affect young persons who, in most cases, otherwise appear healthy. The age of the disease onset, the rapid rate of the disease progression, manifestations of defects in host response, and composition of the associated subgingival microbial flora may distinguish early-onset periodontitis from adult periodontitis.
Early-onset periodontitis includes three forms: prepubertal periodontitis localized and generalized juvenile periodontitis, and rapidly progressive periodontitis. There is evidence that genetic factors influence susceptibility to the different forms of early onset periodontitis. However, it is unlikely that a specific gene will be identified as causing enhanced disease susceptibility. It is more likely that the genetic influences are as multifactorial as the diseases themselves, and a complex interplay between genetically determined host responses and environmental challenges may determine whether disease is present.
Pre-pubertal periodontitis is associated with attachment loss (gingival pocket formation and radiographic evidence of bone loss) around teeth of the deciduous and/or permanent dentition. It can occur between the time of tooth eruption and the beginning of puberty. As a consequence of this destruction, exfoliation of the deciduous teeth starts prior to the eruption of the permanent dentition. Pre-pubertal periodontitis may occur in either generalized or localized forms. The generalized form is most frequently associated with severe congenital defects of hematological origin and is usually accompanied by alterations in neutrophil chemotaxis function.
Some forms of pre-pubertal periodontitis can be considered to be complications of a severe systemic disorder, such as acrodynia, cementopathia, Ch’diak-Higashi syndrome, chronic neutropenia, histiocytosis X, HIV infection, hypophosphatasia, leukemia, Papillon-Lef’vre syndrome, and fibrous dysplasia. The localized form is usually not associated with a systemic disorder, and presently there is no evidence that localized prepubertal periodontitis will carry over to the permanent dentition. In most reported cases of generalized prepubertal periodontitis with congenital defects of hematologic origin, the disease could not be arrested unless all the teeth were extracted. There are very few reports concerning the treatment of localized prepubertal periodontitis in which aggressive treatment consisted of extraction of hopeless teeth, scaling and root planing, daily subgingival irrigation, and antibiotic coverage.
In general, the data support conservative supportive treatment of localized prepubertal periodontitis, which includes mechanical therapy, antibiotic coverage, and maintenance. Juvenile periodontitis also presents in either localized or generalized forms. Generalized juvenile periodontitis (GJP) usually occurs in the late teenage years and affects most teeth.
The disease has been associated with a variable microbial etiology that may include Actinobacillus actinomycetemcomitans and Porphyromonas gingivalis. Contributing risk factors such as smoking should be considered. Localized juvenile periodontitis (LJP) has an age of onset at or around puberty and is associated with molar and incisor bone and attachment loss. However, atypical patterns of disease have been observed. Association with the periodontal pathogen Actinobacillus actinomycetemcomitans and neutrophil function abnormalities frequently characterizes the localized form. Both GJP and LJP may exhibit abnormalities in host immune cell functions that appear to follow a familial pattern.
The goal of treatment in early-onset periodontitis is to alter or eliminate the microbial etiology and the contributing risk factors, and faster regeneration of the periodontal apparatus. Due to the complexity of this type of periodontal disease with respect to systemic factors, immune defects, and the microbial flora, control of the disease may not be possible in all instances. In such cases, a reasonable treatment objective is to slow the progression of the disease by administering the appropriate antibiotic regimen, and providing repeated microbiological testing and an intensified, supportive periodontal therapy program.
Rapidly progressive periodontitis (RPP) is typically found in patients 20-35 years old. With the exception of the age of onset, the clinical, microbiological, and immunologic diagnostic findings in RPP are similar to those in GJP. In general, treatment methods for early-onset periodontal diseases may be similar to those used for adult periodontitis. These methods should include oral hygiene instruction, and reinforcement and evaluation of the patient’s plaque control; supra- and sub-gingival scaling and root planing to remove microbial plaque and calculus; control of other local factors; occlusal therapy as necessary; periodontal surgery as necessary; and supportive periodontal therapy. In addition, a general medical evaluation may determine if systemic disease is present in children and young adults who exhibit severe periodontitis, particularly if early-onset periodontitis appears to be resistant to therapy. Consultation with the patient’s physician may be indicated to coordinate medical care in conjunction with periodontal therapy.
In the early stages of disease, lesions may be treated with adjunctive antimicrobial therapy combined with scaling and root planing with or without surgical therapy. Microbiological identification and antibiotic sensitivity testing may be considered. The long-term outcome may depend upon the patient’s compliance, and delivery of supportive periodontal therapy at appropriate intervals, as determined by the clinician. If primary teeth are affected, eruption of permanent teeth should be monitored to detect possible attachment loss. A number of systemic factors have been documented as capable of affecting the periodontium and/or treatment of periodontal disease.
Systemic etiologic components may be suspected in patients who exhibit periodontal inflammation or destruction, which appears disproportionate to the local irritants. Periodontal therapy may be modified based on the current medical status of the patients. Periodontal organisms may be the source of infections elsewhere in the body. Therefore, those infections may also affect systemic health. The therapeutic goal is to achieve a degree of periodontal health consistent with the patient’s overall health status. Achieving this goal, however, may be directly affected by the degree of control of the systemic condition. The systemic and psychological status of the patient should be identified, therefore, to reduce medical risks that may compromise or alter the periodontal treatment. Patients with systemic conditions that contribute to progression of periodontal diseases may be successfully treated using established periodontal treatment techniques. However, the systemic/psychologic status of the periodontal patient may alter the nature of therapy rendered and may adversely affect treatment outcomes.
In past few years, we observed that the increasing numbers of cases of aggressive periodontitis are being encountered in our OPD and most of them belong to the same vicinity, almost similar habits, similar socio-economic status, etc. Then, we went for a thorough literature search that, if there is availability of any kind of data on the prevalence, early detection, treatment rational and management strategies for the disease for Indian population. But, to the best of our knowledge, no such kind of database is available for the Indian population on aggressive periodontitis, a severe disease of periodontium with genetic predisposition and coupling association with several systemic disorders.
Therefore, in order to formulate the treatment strategies and management of disease, and further to get the complete interactive static figures of different identified factors associated with the disease, a questionnaire and clinical observation based comprehensive database and data base management system (DBMS) should be developed. DBMS will provide lots of information associated with the treatment rational for individual patient, management strategies for preventive measures, public awareness, association of aggressive periodontitis with factors identified and other systemic diseases, etc. Further, the DBMS developed with the database for aggressive periodontitis will be of immense use for dental practitioners, physicians, local, state and National level health regulating agencies in the country.
Vandana A. Pant and R. M. Mathur
Saraswati Dental College, Lucknow – (U.P) India
[email protected],
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