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Dynamic therapeutic approach for individuals affected with

Article in Journal of the California Dental Association · June 2011 Source: PubMed

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Kian Kar Krikor Simonian University of Southern California University of Southern California

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Dynamic Therapeutic Approach for Individuals Affected With Aggressive Periodontitis

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'/01,'*1 Management of patients affected with aggressive periodontitis is complicated by several poorly understood etiological and modifying factors that create difficulty in establishing a universal treatment recommendation. The goal of this manuscript is to underscore the complexity of therapy and to provide some guidelines in the decision-making process and interdisciplinary therapy. A dynamic approach is presented to formulate strategies in diagnosis and treatment planning that is both patient- and site-specific.

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Kian Kar, $$0, (0, is an Hessam Nowzari, $$0, n assessing a patient with any disease, "e classification of “aggressive associate professor +.$, is a professor of it is important to identify causative periodontitis” was adopted by the  of Clinical , Clinical Dentistry, and and modifying factors that contribute workshop of American Academy of and clinical director of program director of to the disease initiation and progress to describe a specific Advanced Periodontology, Advanced Periodontology, Ostrow School of Dentistry, Ostrow School of in order to offer a treatment. How- pattern of diseases previously classi- University of Southern Dentistry, University Iever, because of a complex combination fied as periodontosis, localized juvenile California. He also is a of Southern California. of incompletely understood etiological periodontitis, generalized juvenile perio- diplomate, American Board He also is a diplomate, and risk factors in periodontitis, it is dontitis, early onset periodontitis, and of Periodontology, and in American Board of not possible to assign a simple cause- rapidly progressive periodontitis., "is private practice limited to Periodontology, and in periodontics and dental private practice limited to and-effect diagnosis (e.g., streptococcal classification was adopted to avoid using implant surgery in Mission periodontics and dental sore throat). "erefore, a classification a patient’s age as criteria for categorizing Viejo, Calif. implant surgery in Beverly system is utilized to study disease pat- . Instead, the classifi- Hills, Calif. terns and types in large populations cation is based on clinical, radiographic, Krikor Simonian, $$0, is a of patients to provide a framework for historical, and laboratory findings. clinical assistant professor, Advanced Periodontology, studying the epidemiology, etiology, Ostrow School of Dentistry, and treatment outcomes for a given Clinical Features of Aggressive University of Southern group of similar diseases.- As a start- Periodontitis California. He also is a ing point, such a system can serve to Aggressive periodontitis is a specific diplomate, American generate a clinical framework for peri- type of periodontitis with identifiable clin- Board of Periodontology, and in private practice odontal diagnosis. In clinical manage- ical and laboratory findings that are not limited to periodontics and ment of specific patients, a diagnosis characteristic for . surgery in should be made for the individual According to the consensus report Pasadena, Calif. within the classification framework. of American Academy of Periodontol-

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TABLE !

Characteristics of Localized and Generalized Aggressive Periodontitis According to American Academy of Periodontology Localized Aggressive Periodontitis

QAge of onset around puberty ogy on aggressive periodontitis the common features of the disease are: QRobust serum antibody response to infecting agents Q Patients are clinically healthy except QLocalized first molar/incisor presentation with interproximal attachment loss on at least two for the presence of periodontitis; permanent teeth, one of which is a first molar, and involving no more than two teeth other Q Rapid attachment loss and bone than first molars and incisors destruction; and Generalized Aggressive Periodontitis Q Familial aggregation. "e following secondary features may QUsually affecting individuals under the age of 30 but patients may be older also be present: QPoor serum antibody response to infecting agents Q Amounts of microbial deposits are inconsistent with the severity of peri- QPronounced episodic nature of the destruction of attachment and alveolar bone odontal tissue destruction; QGeneralized interproximal attachment loss affecting at least three permanent teeth other Q Elevated proportions of Aggrigati- than first molars and incisors bacter Actinomycetemcomitans and Porphy- romonas gingivalis in some populations; Q Phagocyte abnormalities; Q Hyper-responsive macrophage should be classified as “periodontitis as a strategy needs to address the strategic phenotype, including elevated levels of manifestation of systemic disease.” Nega- value (risk and cost benefit consider- PGE and IL-; tive effects of certain systemic conditions ations) of the remaining teeth in provid- Q Progression of attachment loss and will increase the patient’s susceptibility ing a functional and esthetic outcome, if bone loss may be self-arresting; and to microbial plaque and consequently to infection control and periodontal stability Q Lack of caries or low caries index. severe and extensive periodontal at- is to be achieved. In these circumstances, "e diagnosis and classification is tachment loss and early . "is a longer provisional phase period of nine based on clinical, radiographic, and group of diseases includes neutropenia, to  months is advisable to evaluate historical data and, some, or possibly all, hypophosphatasia, leukemias, Chediak– the outcome of periodontal therapy and of the above characteristics. Laboratory Higashi syndrome, leukocyte adhesion periodontal stability before committing testing may not be essential for assign- deficiency, Papillon–Lefèvre syndrome, to a definitive reconstructive phase. Oc- ing a diagnosis for aggressive periodon- trisomy , histiocytosis, and agranu- casionally, alternative restorative sugges- titis even though it could be helpful in locytosis. Proper management of these tions, such as shortened dental arch or clinical decision-making. "e influence patients requires management of systemic transitional fixed or removable prosthesis, of modifying risk factors (e.g., cigarette diseases that may be responsible for the may be considered. "is communication is smoking, emotional stress, drugs, sex patient’s severe periodontitis in conjunc- especially important when there are major hormones, etc.) should be considered tion with periodontal infection control., restorative treatment needs, particularly to manage individual patients who are when considering implant therapy. affected with aggressive periodontitis. Treatment Planning Patients with a history of severe "ere are enough specific features "e first factor in developing a treat- chronic periodontitis and aggressive to classify aggressive periodontitis into ment plan for patients who are affected by periodontitis may be at additional risk of localized and generalized forms. "ese aggressive periodontitis is to identify the adverse peri-implant soft-, and hard- features are presented in 1'/45 6. esthetic and functional needs amongst tissue outcomes. Peri-implant infec- A thorough review of medical and the patient, restorative dentist, and perio- tions share both bacteriological and family history will aid to identify indi- dontist. It is critical to identify patient histopathological similarities to both viduals whose periodontal disease may expectations, realistic attainability of the aggressive and chronic periodontitis.- be associated with specific syndromes treatment desires, treatment limitation, Patients with a history of periodontitis or systemic conditions. Individuals with risk of future breakdown, and dynamic pose a risk for peri-implant diseases, significant systemic modifiers of the nature of the therapy. When functional or thus, in younger patients with aggressive innate and adaptive immune responses esthetic concerns are present, treatment periodontitis, especially the general-

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ized type, it is prudent to defer major "is approach is dynamic, both in plan- Mechanical implant therapy to later stages when ning and therapeutic recommendations. , as initial the patient is older.- "is strategy may Unlike chronic periodontitis where phase nonsurgical therapy, is traditionally reduce the chance of early peri-implant there are more established protocols performed by quadrants at different ap- complications and provide a better long- for therapy, the authors are suggest- pointments. "e efficacy of this approach term prognosis of implant prosthesis. ing that within the overall classification has been demonstrated by a classical When no major functional or esthetic of localized or generalized aggressive series of studies by Badersten et al.- concerns are present, the aims of the periodontitis, existing therapeutic ap- Furthermore, a number of systematic therapeutic approaches are primarily on proaches need to be tailored individually reviews on the efficacy of different mo- maintaining the periodontium. Localized based on clinical features and perceived dalities of mechanical nonsurgical peri- aggressive periodontitis has been report- patient- and site-specific diagnoses. odontal therapy have been published.- ed to be self-limiting, whereas individuals "is decision-making process is adap- However, the effectiveness and the with the generalized form continue to tive to following clinical parameters: efficiency of the traditional mechanical lose periodontal attachment and teeth Q Systemic association; therapy have mostly been analyzed in a over time; however, the residual peri- Q Chief complaint and patient patient population affected by chronic odontal lesion and bony defects are major expectations (functional and esthetic periodontitis. Aggressive periodontitis contributing factor for future periodontal demands including restorative/recon- is considered a more site-specific and disease as the patient ages.,, Also, some struction needs); bacterial-specific periodontal infection cases of localized aggressive periodontitis Q Onset of the disease and patient’s age; that is strongly correlated to the host or progress to generalized aggressive perio- Q Pattern (distribution) of the disease; early-in-life periodontal infection.,, dontitis, that may resemble or transform Q Severity of attachment loss (pocket While mechanical debridement is effec- to chronic periodontitis at a later stage.- depths and clinical attachment loss, tive in the reduction of bacterial plaque, Additionally, risk factors have similar radiographic bone loss and bony defects); specific bacteria repopulate periodontal long-term influences on both chronic Q Quantity of etiological factors pocket within three to seven days after periodontitis and aggressive periodonti- (plaque and index/code); treatment, restoring bacterial counts tis, although one could argue that with Q Severity of gingival inflammation to almost pretreatment levels. younger patient age and greater initial (gingival index and bleeding on probing); Periodontal pathogens commonly attachment loss may dictate a poorer Q Bacteriological association and con- associated with aggressive periodonti- long-term prognosis in aggressive disease. sideration of systemic antibiotic therapy tis, such as A. actinomycetemcomitans, Since patients are mostly evaluated at and adjunctive local anti-infective therapy; Bacteroides species, and P. gingivalis, a cross-section of a time, it requires a Q Initial mechanical debridement colonize different intraoral habitats in careful assessment of history and the (scaling and root planing) protocol; addition to periodontal pockets, includ- clinical presentation of periodontitis Q Periodontal re-evaluation and ing the tongue, buccal mucosa, saliva, to identify a past history of aggressive supportive (maintenance) therapy; and tonsils.- Saliva probably acts as disease to identify a “burn out” stage that Q Surgical therapy for infection control the major vector of bacterial transmis- may be masked or confused with chronic and repair of periodontal defects; and sion in most inter-individual cases. periodontitis among the middle-aged or Q Implant therapy. When there is an increase in periodontal older population or with periodontitis "is dynamic approach should be pathogens around teeth, similar microbial as a manifestation of systemic disease. applied to both diagnostic (such as flora are observed around neighboring Since the aggressive forms of perio- radiographic and laboratory tests) and implants as well, indicating an intraoral dontitis have distinctive features from therapeutic procedures. Following is transmission of those presumptive chronic periodontitis and potentially a review and implementation recom- periodontal pathogens., "erefore, if respond differently to therapy, the au- mendations considering above clinical periodontal treatment does not result thors are suggesting a tailored treat- parameters to provide guidelines for in elimination of pathogens from the ment planning approach in treatment of infection control and periodontal repair of mucous membranes as well as periodontal patients with aggressive periodontitis., individuals with aggressive periodontitis. pockets, these surfaces may function as:

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TABLE "

Original Protocol of Full-Mouth Disinfection Introduced by Quirynen et al.49

QFull-mouth scaling and root planing (the entire dentition in two visits within 24 hours, i.e., two consecutive days) under local anesthesia

QBrushing of dorsum of tongue for one minute with 1 percent gel Q Source of reinfection for the healing Q and healthy periodontium after Mouthrinsing twice with 0.2 percent chlorhexidine mouth rinse for one minute (during the last 10 seconds, the patient had to gargle in an attempt to reach the tonsils) treatment;, Q Source of transmission to family QSubgingival irrigation of all pockets three times within 10 minutes with chlorhexidine 1 percent members; and gel after both sessions of scaling and root planing and repeated on Day 8, using a syringe with marks at 6 and 8 mm Q Reservoir for infection of tissues , around implants. QMouthrinsing at home with 10 ml of 0.2 percent chlorhexidine mouthrinse twice daily for one Quirynen described that periodontal minute for the following two weeks pathogens are present in various ecologic Q instructions including toothbrushing, interdental cleaning with interdental niches and that the transmission of these brushes or other aids, and tongue brushing may occur from individual to individual as well as within the oral cavity among sites. "is evidence reinforces the need for a full-mouth approach to periodon- periodontitis, full-mouth scaling and root subgingival periodontal pathogens, tal infection control especially in cases planing utilizing a full-mouth disinfection including A. actinomycetemcomitans of aggressive periodontitis rather than approach is performed preferably within black-pigmented Bacteroides species, treating individual sites. Full-mouth  hours. In cases of localized aggres- and Capnocytophaga species.- disinfection control as described by sive periodontitis generalized scaling Similarly, local antibiotic therapy does Quirynen (1'/45 8) consists of mechani- (debridement) and localized root plan- not seem to eliminate A. actinomycetem- cal debridement within a short span of ing will be performed in one session. comitans when used in treatment of local- time (- hours) with adjunctive use of When initial heavy inflammation with ized aggressive periodontitis.,, To tar- local anti-infective agents for additional tenacious and heavy calculus and deep get these specific presumptive periodontal disinfection (i.e., chlorhexidine) during pockets are present, the patient will be pathogens that are highly associated the initial healing period (two weeks). scheduled for an early re-evaluation within with aggressive periodontitis, mechanical "is protocol may be supplemented two weeks of initial scaling and root planing debridement needs to be supplemented with systemic antibiotic therapy when to retreat areas with residual detectable with systemic antibiotics. Using this indicated. "is approach considerably calculus, with the aim of mechanical disrup- strategy, the number of spirochetes, A. reduces the chance of re-infection of tion of biofilm (if indicated, systemic antibi- actinomycetemcomitans and Capnocytopha- treated pockets by bacterial transloca- otic will be administered after initial scaling ga were reduced to undetectable levels tion from other untreated pockets or the and root planing regardless of the need and significant improvement in clinical intraoral sites. Furthermore, Guerrero for early re-evaluation). Patients without outcomes were observed.,,, "e use also reported greater clinical improve- adequate home care (more than  percent of systemic antibiotics may enhance ment using an enhanced mechani- O’Leary plaque index) will be scheduled gains in attachment level and alter the cal debridement within  hours and for biweekly plaque control appointments. subgingival bacterial profiles. Addition- full-mouth disinfection through use of Remaining patients will be re-evaluated ally, full-mouth scaling and root planing, systemic antibiotic therapy and chlor- monthly for the first three months. along with systemic combination metron- hexidine rinses for two weeks, compared idazole and amoxicillin or metronidazole to traditional quadrant scaling and root Antibiotic Therapy alone, and antimicrobial rinses have planing for treatment of patients with A number of studies have demon- been advocated for patients with gener- generalized aggressive periodontitis. strated minimal improvement and high alized aggressive periodontitis.-,- Considering a dynamic approach, percentage of nonresponders when Some authors propose systemic an- the decision to perform nonsurgical using mechanical debridement alone tibiotic therapy for all cases of moderate mechanical debridement is dependent in treatment of patients with aggres- to severe periodontitis without microbial on presentation of etiological and local sive periodontitis.- "is is due to testing. "is recommendation is made factors (plaque, calculus, and pocket the fact that nonsurgical therapy alone regardless of a diagnosis of chronic or depths). In cases of generalized aggressive does not completely eradicate certain aggressive periodontitis.,, However,

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TABLE #

Recommendation for Use of Oral Systemic Antimicrobial Therapy Based on Detection of Putative Periodontal Pathogens (adopted from Slots) otics are used, making it a more viable the red complex pathogens (P. gingivalis, Detection any of the following: treatment option. "e effectiveness of T. Forsythia, T. denticola), A. actinomyce- QA. actinomycetemcomitans systemic antibiotic treatment increases temcomitans, and enteric gram-negative Q Red complex71 when it is administered immediately rods, a retest may be indicated if clinical  QTannerella forsythia after scaling and root planing. Both the presentation of a given case would consti- QP. gingivalis American Academy of Periodontology and tute suspicion of specific infection (i.e., in QTreponema denticola the European Federation of Periodontolo- cases of severe periodontal disease specially gy indicate that the adjunctive use of sys- among young individuals). However, Antibiotic recommendation: temic antibiotic therapy benefits patients once a negative detection is confirmed, no Q250 mg amoxicilllin-375 mg metronidazole /TID/eight days with aggressive periodontitis. However, systemic antibiotic therapy is advised. "is QIn cases of penicillin allergy: both also emphasize that the optimal strategy is employed to avoid unnecessary QMetronidazole alone drug, dosage, and duration to provide exposure of patients to a course of sys- (500 mg/TID/8 days) the greatest effect is not completely temic antibiotic therapy. Yet, a subsequent , QIn case of metronidazole and penicillin understood. Nevertheless, the choice bacterial retesting is recommended if no allergy: of antibiotic treatment is best deferred to significant clinical improvement is observed QClincamycin 300 mg/TID/8 days or the result of bacteriological sampling. after initial mechanical debridement and/ QAzithromycin (250-500 mg/QD/ It should be mentioned here that or subsequent surgical therapy. Use of local 4-7 days) there is growing evidence supporting the antimicrobial therapy may be considered Detection of: potential role of viruses in pathogenesis for specific sites with supra bony pockets QEnteric gram-negative rods of aggressive periodontitis. It appears that to reduce gingival inflammation only when a high periodontal load of active viruses no systemic antibiotic therapy is indicated. Antibiotic recommendation: such as the Epstein–Barr virus or cyto- Moreover, several local anti-infective QCiprofloxacin (500 mg/BID/8 days) megalovirus is associated with aggressive agents are reported to provide favorable No detection of any of the following: periodontitis. "ere are hypotheses of syn- clinical outcome in control of inflammation QA. actinomycetemcomitans, ergistic viral and bacterial co infections in and antibacterial property that might be of QRed complex: 71 the pathogenesis of aggressive periodon- significance in management of periodontal QTannerella forsythia titis; but their role, if any, in the initiation infection among patients with aggres- QP. gingivalis of the disease is not defined.- "erefore, sive periodontitis including . percent QTreponema denticola the potential benefit of an antiviral treat- chlorhexidine,  percent povidone-iodine QEnteric gram-negative rods ment strategy is not currently established. for professional use and .-. percent so- No systemic antibiotic therapy When utilizing the concept of dy- dium hypochlorite for patient self-care.,,

QD=once daily, BID=twice daily, TID=thrice daily namic therapeutic approach for the use Recommendation is for or systemically healthy adults of antibiotic therapy, one has to make Surgical Therapy with normal body weight. a clinical judgment as to when and how "ere is a general agreement that (local or systemic) to administer antibiotic favorable therapeutic outcome can be therapy. As mentioned earlier, the deci- achieved treating patients with local- widespread use of systemic antibiotic sion for the type of antibiotic is best to be ized aggressive periodontitis even with therapy in a large population of people deferred to bacterial sampling since the cases of severe periodontal attachment affected by periodontitis has a potential presence or absence of certain pathogens loss. "e rationale for surgery among of selecting antibiotic resistance species. may change the decision to administer dif- patients with aggressive periodontitis is Moreover, patients with aggressive perio- ferent choices or combination of antibiotic in part related to the perceived need to dontitis benefit more than the patients regiments. 1'/45 : summarizes treatment remove tissue invaded by A. actinomy- with chronic periodontitis from adjunc- recommendations based on the detection cetemcomitans as well as P. g i n g i va l i s . - tive use of systemic antibiotic therapy., of putative periodontal pathogens. When Because the presence of these species Clinically, the magnitude of change in a patient with classification of aggressive within epithelial cells may not be elimi- some sites may be greater when antibi- periodontitis is not positive for any of nated after nonsurgical and systemic

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antibiotic therapy, it is plausible that site-specific healing potential, the timing ous clinical inflammation and deep pock- recolonization may occur, which might of the surgical intervention, and defect ets of > mm with bleeding on probing, a contribute to recurrent or refractory morphology rather than the choice of surgical treatment for root debridement disease. Furthermore, since periodon- materials and surgical techniques. In such as Modified Widman flap with no tal lesions associated with deep pockets, choosing inductive techniques, it is osseous resection is indicated. However, molars, furcation sites, and angular important to consider the potential any resective surgery should be avoided bone defects respond less favorably to for post surgical complication of using at this stage to allow a potential for repair repeated nonsurgical instrumentation, a barrier membranes. Sites with mem- of osseous defects. Many authors have surgical approach may be considered for brane show a significant variability in reported good success of osseous induc- debridement versus repeated nonsurgi- result due to potential of exposure and tive surgery to repair intraosseous defects cal instrumentation on the sites with bacterial contamination. Furthermore, in patients with generalized aggressive evidence of inflammation after nonsur- membrane contamination is highly as- periodontitis.,- Once the infection is gical therapy.- Surgical techniques for sociated with less favorable results.- under control, osseous corrective sur- root debridement have been successfully gery may be indicated to correct residual utilized to treat localized aggressive peri- osseous defects during the long-term odontitis in combination with systemic )& *.--0)&< maintenance phase of the treatment. antibiotics with significant improve- An apically positioned flap with osseous ments in probing depths and attachment inductive techniques, recontouring (osseous surgery) is a very levels, and evidence of radiographic bone it is important to effective approach in correcting remaining fill after five years of maintenance.,- shallow to medium intraosseous defects,  Also to repair bony defects, osseo- consider the reducing pockets and subgingival detec- inductive surgical procedures with the potential for post tion of A. actinomycetemcomitans., use of autografts, allografts, alloplast, Resective types of periodontal surgery are with or without barrier membranes, surgical complication of more effective than access flap surgery in have been reported with successful and using barrier membranes. combating subgingival A. actinomycetem- favorable outcomes in treating local- comitans apparently due to the excision of ized aggressive periodontitis lesions.- A. actinomycetemcomitans-infected gingival Each of the above studies contained few tissue and pocket reduction to levels per- subjects and defects, making com- "e result from Nowzari et al. under- mitting adequate oral hygiene measures in parisons between the groups difficult. scores the importance of full-mouth the long-term maintenance of patients. In contrast. Gunsolley reported that infection control prior to considering In choosing corrective/recec- among patients with localized aggressive surgical repair of periodontal lesions. tive surgical approaches, it is critical periodontitis who received treatment, In cases of generalized aggressive to observe bony defect anatomy and there was no difference in periodon- periodontitis, there is an overall reluc- morphology as well as esthetic implica- tal attachment gain over the -year tance among clinicians to perform surgi- tions of such treatment modalities with period for those who received scaling cal therapy. Some of the reasons for this an understanding of the risk-benefit and root planing alone compared to reluctance are severe attachment loss on outcome, the ultimate goals of periodon- those who were treated surgically. presentation, possible risk of unknown tal therapy and reconstructive treat- "e fact that different authors report or undetected systemic disease, a history ment needs for a particular patient. favorable results using different non- of unfavorable surgical outcomes with surgical as well as surgical modalities previous experiences, or a reluctance to Maintenance and Reconstructive (including different bone graft materi- perform surgery in patients with un- Restorative Therapy als and membranes and in different known prognosis and risk factors. While When clinical improvement is combinations) may suggest that the a cautious approach to surgery in patients achieved with initial infection control, healing of aggressive periodontitis le- with generalized aggressive periodontitis a two-month maintenance schedule is sions may be related to the diagnosis, is prudent, in sites where there is continu- planned for the first six to nine months.

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After nine months, radiographic evalu- the lack of professional dental visit there advanced loss of attachment; progno- ation of residual bony defects may be are no existing caries and no restorative sis of the maxillary dentition is poor. indicated to correct remaining osseous therapy for any previously existed caries. However, the mandibular arch does defects and deep pockets (> mm specially He was also positive for red complex not require a functional or esthetic on posterior teeth). Based on the clini- bacteria (P. gingivalis, T. Forsythia, T. rehabilitation. "erefore, a reasonable cal outcome of therapy patient should be denticola) and A. Actinomycetemcomitans. treatment approach will be a transi- scheduled on a long-term maintenance Clinically, generalized gingival inflam- tional maxillary removable prosthesis interval of two to three months for a close mation, generalized deep pockets of and maintenance of mandibular teeth monitoring of periodontal condition, - mm with generalized bleeding on from Nos.  to  (>)5*1)-& rant scaling and root planing in a single therapeutic approach. Use of such ap- session, one week after extraction of proach is exemplified in periodontal is under control, osseous nonmaintainable/poor prognosis teeth; treatment planning of the following cases corrective surgery may be Q Systemic antibiotic therapy with of individuals affected with generalized amoxicillin and metronidazole ( mg or localized aggressive periodontitis. "e indicated to correct residual each one every eight hours for eight days); quotation marks are used to reference osseous defects during the Q Oral hygiene instructions and . patients own words of their history and percent chlorhexidine for two weeks; and chief complaints for case description. long-term maintenance phase Q Periodontal re-evaluation six weeks of the treatment. post scaling and root planing followed by Case 1 three-month periodontal maintenance. "is case presents a -year-old Afri- Surgical therapy was not indicated can-American male from a North African since neither deep pocket depths (> origin with no systemic condition (non- Although there are detectable etiological mm), nor clinically detectable inflamma- smoker ASA I). He reported to Depart- factors (plaque and calculus) they are not tion was detected after initial therapy. ment of Advanced Periodontology with a abundant and not consistent with the ex- >))

$&(/ 0122 !"= !"# $%&'(#), *%) +,, ( - . Full-mouth periodontal probing (charting and aAachment loss) Radiographic examination Oral hygiene instructions Bacterial sampling Caries control Extraction of hopeless teeth Interim RPD if indicated

Detection of No detection of putitative A. actinomycetemcomitans, periodontal pathogens Tannerella forsythia P. gingivalis Treponema denticola, Enteric rods

Full-mouth sealing and root planing Full-mouth scaling and root planing utilizing a full-mouth disinfection utilizing a full-mouth disinfection approach (preferably one approach (preferably one appointment or within one week) appointment or within one week) Systemic antibiotic therapy Local anti-infective therapy Local anti-infective therapy in in conjunction to mechanical conjunction to mechanical debridement debridement and self-care and self-care for two weeks for two weeks.

Two- week interval plaque control and OHI appointments Eight week periodontal re-evaluation Full-mouth periodontal probing and aAachment gain (charting)

Bleeding on probing and/or NO bleeding on probing or clinical inflammation clinical inflammation Pocket depth >5 mm Pocket depth <5 mm

Flap debridement

Two-month periodontal maintenance for 6 months

Radiographic evaluation of osseous defects

Osseous corrective surgery to correct osseous defects on sites with residual of >5 mm probing with BOP (inductive or respective) Implant and restorative reconstruction 2-3 month periodontal maintenance therapy

$)'<,'( 6. Dynamic therapeutic approach in treatment planning for individuals affected by aggressive periodontitis.

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>))). teeth: Nos. , , and . A fixed partial den- patient, control and stability of peri- Q Systemic antibiotic therapy (cip- ture was previously fabricated to replace odontal disease condition is essential. A rofloxacin  plus metronidazole  No.  that was previously removed two to transitional removable prosthesis would mg two times a day for eight days) since three years prior to periodontal consul- be considered during periodontal therapy T. forsythia and enteric gram-negative tation because of “looseness” and “gum as a provisional replacement of the miss- rods were detected by microbial testing; infection.” Initially generalized bleed- ing teeth. His treatment plan includes: Q Two weeks re-evaluation for plaque ing on probing with generalized pocket Q Oral hygiene instruction (ini- control and OHI for two months; depths of - mm and areas of moder- tial plaque index of  percent); Q Periodontal re-evaluation in six ate to advanced horizontal and vertical Q Bacterial sampling; weeks post scaling and root planing for osseous defects were detected (>)

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>))) mandibular le? lingual preinitial therapy; (<, ., '&$ )) postinitial therapy indicating overall resolution yet localized residual inflammation. (Courtesy of Yvonne Tam DDS, USC Periodontology resident.) >)

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