See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/51553924 Dynamic therapeutic approach for individuals affected with aggressive periodontitis Article in Journal of the California Dental Association · June 2011 Source: PubMed CITATION READS 1 164 3 authors: Kian Kar Krikor Simonian University of Southern California University of Southern California 14 PUBLICATIONS 86 CITATIONS 16 PUBLICATIONS 210 CITATIONS SEE PROFILE SEE PROFILE Hessam Nowzari University of Southern California 100 PUBLICATIONS 3,280 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Impacted Teeth View project All content following this page was uploaded by Kian Kar on 31 May 2014. The user has requested enhancement of the downloaded file. $%&'()* '++,-'*. !"# $%&'(#), *%) +,, ( - . Dynamic Therapeutic Approach for Individuals Affected With Aggressive Periodontitis 45#( 4#', ""6, 76; 4'54%' 657%(5#(, ""6; #(" 8/66#7 (%9:#'5, ""6, ;8" '/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. #&>8%'6 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 Dentistry, 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 Periodontology 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- periodontal disease. 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 chronic periodontitis. dental implant surgery in should be made for the individual According to the consensus report Pasadena, Calif. within the classification framework. of American Academy of Periodontol- $&(/ 0122 !"# $%&'()* '++,-'*. !"# $%&'(#), *%) +,, ( - . 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 tooth loss. "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- !"2 $&(/ 0122 !"# $%&'(#), *%) +,, ( - . ized type, it is prudent to defer major "is approach is dynamic, both in plan- Mechanical Debridement implant therapy to later stages when ning and therapeutic recommendations. Scaling and root planing, 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