JCDA Express Issue 8 2012

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Management of Aggressive Periodontitis

In this edition of JCDA Express, Drs. Robert Durand, assistant professor at the University of Montreal, Andrea R. Hsu, recent graduate in periodontology at the University of Minnesota, and Popi Stylianou, periodontology resident at the University of Minnesota, bring forward 3 articles that examine aggressive periodontitis: a review of current treatment approaches and expected responses; evidence of a treatment plan that appears to provide significant clinical benefits; and a long-term study on the possible risks for patients with implants.

What are the etiology, risk factors, and treatment options for aggressive periodontitis?

Deas DE, Mealey BL. Response of chronic and aggressive periodontitis to treatment. Periodontology 2000. 2010;53:154-66.

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JCDA Clinical Pearl: Although patients with aggressive periodontitis have a poor initial prognosis, a patient's favourable response to initial therapy and excellent compliance to a strict maintenance schedule will allow the long-term retention of teeth.

Key Points:

• Distinguishing between chronic and aggressive periodontitis and predicting treatment outcomes is not always easy; the authors examine the response to therapy for aggressive periodontitis—both localized and generalized—in comparison to the well-documented treatment responses for chronic periodontitis.
• Prognosis of teeth affected by either chronic or aggressive periodontal diseases is influenced by tooth-level factors (e.g., persistent deep pockets, loss of attachment, mobility) and subject-level factors (e.g., smoking, genetic predisposition, age).
• For both localized and generalized aggressive periodontitis (GAP), the low number of treatment subjects makes it difficult to compare current treatments. GAP is more difficult to distinguish from chronic periodontitis and is less likely to reach a stage where it responds well to conventional periodontal therapy.
• Aggressive periodontitis can be differentially diagnosed as a manifestation of systemic diseases. Therefore, a thorough social, family, and medical history should be gathered.
• Initial therapy of aggressive periodontitis should include case presentation, oral hygiene instructions, and scaling and root planing in combination with systemic antibiotics followed by a re-evaluation 4 to 6 weeks later.
• The most commonly used systemic antibiotics are amoxicillin 500 mg in combination with metronidazole 500 mg three times daily for 7 to 10 days.
• Positive results have been shown in aggressive periodontitis patients after open flap debridement or regenerative therapy in combination with systemic antibiotics. However, the authors underline the importance of always starting with nonsurgical therapy before initiating the surgical phase.
• Patients with aggressive periodontitis are at high risk for recurrent disease, possibly due to residual deep pockets and an increased inflammatory response; the authors recommend monthly maintenance for the first 6 months after completing active treatment, then bimonthly for 6 more months. Thereafter, they are seen every 3 months for periodontal recalls.

Reasons for recommending this article: This article provides the dental practitioner with a good overview of the etiology and risk factors related to aggressive periodontitis as well as treatment options. The documented results after nonsurgical and surgical therapy to manage aggressive periodontitis are discussed and recommendations are presented.

What are the clinical benefits of systemic antibiotics as an adjunct to full-mouth scaling and root planing?

Sgolastra F, Petrucci A, Gatto R, Monaco A. Effectiveness of systemic amoxicillin/metronidazole as an adjunctive therapy to full-mouth scaling and root planing in the treatment of aggressive periodontitis: a systematic review and meta-analysis. J Peridodontol. 2012;83(6):731-43. Epub 2011 Nov 3.

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JCDA Clinical Pearl: Generalized aggressive periodontitis (GAP) is strongly and specifically associated with the prevalence of the periodontal pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Tannerella forsythia. Initial nonsurgical treatment should focus on the elimination of these pathogens. The combination of full-mouth scaling and root planing (FMSRP) in conjunction with systemic amoxicillin/metronidazole (AMX/MET) has been found to be the treatment of choice.

Key Points:

• The findings of this study support the effectiveness of AMX/MET as an adjunctive treatment to FMSRP. The meta-analysis included 181 patients from 6 randomized controlled trials.
• Three studies evaluated the microbiological effects of FMSRP with or without the adjunctive use of AMX/MET and found significant reduction of the red complex species and A. actinomycetemcomitans for both treatment modalities. One study demonstrated more favourable results for the combined treatment.
• The combination of FMSRP and AMX/MET demonstrated significant clinical attachment level (CAL) gain and probing depth (PD) reduction with a mean difference of 0.58 mm and 0.42 mm, respectively.
• No significant risk difference was found between the two treatment modalities in terms of occurrence of adverse events.
• Most patients showed full compliance and in the few cases of noncompliance, the main reason was due to occurrence of diarrhea and vomiting.

Reasons for recommending this article: This article provides evidence to the dental practitioner of the additional benefits of using AMX/MET in conjunction with FMSRP in the treatment of GAP. Clinical and microbiological outcomes from the combined treatment benefit these patients more than FMSRP alone and should be taken into consideration.

How does generalized aggressive periodontitis affect implant survival and success rates?

Swierkot K, Lottholz P, Flores-de-Jacoby L, Mengel R. Mucositis, peri-implantitis, implant success and survival of implants in subjects with treated generalized aggressive periodontitis: 3- to 16-year results of a prospective long-term cohort study. J Periodontol. 2012;83(10):1213-25. Epub 2012 Jan 20.

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JCDA Clinical Pearl: Patients with GAP have lower implant survival and success rates: they have a greater risk of implant failure (5 times), of peri-implant mucositis (3 times) and peri-implantitis (14 times).

Key Points:

• Due to the lower prevalence of GAP, very few articles have addressed the long-term response of implants in this population. Although this long-term prospective cohort study initially had 53 patients (179 implants), 19 patients (91 implants) remained after 10 years and only 4 patients (20 implants) remained after 16 years.

• Implant success is often defined differently from one study to another, and more commonly evaluated in patients with chronic periodontitis, making it difficult to compare results between studies. Based on the criteria of implant success defined in this article, only 33% of GAP patients and 50% of periodontally healthy individuals had successful implants. Implant survival rate was 96% in GAP patients and 100% in healthy patients
• Over 56% of GAP patients presented with peri-implant mucositis and 26% with peri-implantitis. In comparison, 40% of healthy individuals presented with peri-implant mucositis and 10% with peri-implantitis.
• Implant placement in regenerated or nonregenerated bone, implant types (machined surface or partially machined surface), and implant dimensions did not significantly affect rates of implant survival, implant success, complications, peri-implant mucositis, and peri-implantitis.
• Long-term studies have reported an increased prevalence of peri-implant mucositis and peri-implantitis in periodontally diseased patients with poor oral hygiene. While specific factors contributing to the development and/or progression from peri-implant mucositis to peri-implantitis have yet to be identified, adherence to a strict recall schedule may be beneficial.
• The implementation of a regular recall program (3-month interval) appears to be effective in negating the effects of smoking; in this study, tobacco consumption did not seriously influence peri-implant health of periodontally treated patients.

Reasons for recommending this article: The findings of this study add to our current understanding of the long-term response of implants placed in patients with GAP. It also further highlights the importance of compliance and adherence to a regular recall program to control the overall disease progression and monitor peri-implant breakdown in this higher risk population.