Aggressive periodontitis

Question 1

Periodontitis

Answer 1

Inflammatory condition affecting supporting structure of the teeth
Multifactorial aetiology
Variety of presentations
Chronic. Aggressive, Localised and Generalised
forms
Different treatment strategies
Requires pt engagement

Question 2

What do we need for a perio party?

Answer 2

Over 800 bacterial species!

Host response

Question 3

Host response

Answer 3

Stress
-long term
-short term
-poor coping strategy
Diet
Exercise
Illness 
Sleep
Smoking

Question 4

Common features of poor host response

Answer 4

Pts otherwise clinically healthy
Rapid attachment loss and bone destruction
Familial aggregation

Question 5

Secondary features of host response

Answer 5

Microbial deposits not
consistent with
destruction.
A.a nos and for some P.g???
Phagocyte abnormalities
Hyper – responsive
inflam/immune response.
Attachment and bone loss may be self arresting

Question 6

Genetic polymorphisms as risk factors for AgP - background

Answer 6

Polymorphonuclear (PMN) defects result in severe perio disease
LAgP is associated with a PMN defect
• Chemotaxis
• Phagocytosis
• Bacterial Killing
AgP Patients have hyper-responsive PMN

Question 7

AAP classification of chronic perio

Answer 7

10-15% are susceptible to a more destructive process
Prevalent in adults but may occur in children.
Commensurate with oral hygiene and plaque levels, local
predisposing factors, smoking and stress.
Host factors determine the pathogenesis and progression
of disease
Rate of progression in most cases slow to moderate;
periods of rapid tissue destruction may occur.
Further periodontal tissue breakdown is likely to occur in
diseased sites that are left untreated

Question 8

AAP classification of aggressive perio

Answer 8

Localised and generalised
Primary features (major common features)
-non-contributory MH
-rapid attachment loss and bone destruction
-familial aggregation of cases

Question 9

Diagnosis of aggressive perio

Answer 9

History
-complaint
-HPC
-DH/ SH/ FH
-pt motivation for treatment
Clinical examination
-probing pocket depth
-PI & BI
-recession
-attachment loss (measured by taking PPD and REC)
-mobility
-furcation inolvement
Additional tests
-radiographs
-vitality tests

Question 10

Importance of diagnosis

Answer 10

Medico legal
Early management priority
Treatement modality
Early referral

Question 11

Antibiotics

Answer 11

Regimen
– Amoxicillin 500mg plus Metronidazole 400mg TDS 7 days
– Azithromycin 500mg once daily three days
Counterproductive unless includes thorough
debridement and homecare
Ideally during first cycle of Non surgical
MUST not be overprescribed

Question 12

Treatment strategy

Answer 12

Cause related therapy (initial therapy)

Corrective therapy

Question 13

Non-surgical therapy: hand instruments vs sonic and ultrasonic scalers

Answer 13

No differences in effectiveness
Several studies have reported the use of sonic and/or ultrasonic
instruments can result in a 20-50% savings in time

Question 14

Deep pockets

Answer 14

Why do we worry?
What does it mean for pt?
What does it mean for practitioner within
Band 2 treatment (3
UDAs)?
What does it mean for specialist?

Question 15

Non-surgical therapy: factors that influence complete calculus removal:

Answer 15

Extent of disease
Anatomical factors
Skills of operator
Instruments used

Question 16

Non-surgical therapy: approaches to subgingival infection control

Answer 16

Quadrant RSD (gold standard)
Single stage full mouth RSD
Same day full mouth RSD

Question 17

Why would non-surgical fail?

Answer 17

Pt failure
Operator failure
Anatomical failure

Question 18

Non-surgical failure: pt failure

Answer 18

• Poor motivation/cooperation
• Patient circumstances
• Patient medical history

Question 19

Non-surgical failure: operator failure

Answer 19

• Incorrect diagnosis

* Inadequate non surgical

Question 20

Non-surgical failure: anatomical failure

Answer 20

• Multiple intra-bony defects >3mm
• Furcation involvements
• Very deep sites
• Difficult anatomy of tooth bone or roots
• Difficult access
• Gingival Biotype

Question 21

Surgery

Answer 21

Aggressive cases higher likelihood of needing
surgery
Anatomical sites require surgical correction
Aims of surgery depend on clinical situation
• Pocket reduction
• Pocket elimination
• Regeneration
Often require more complex rehabilitation

Question 22

Maintenance

Answer 22

Key for all pts initially 3 monthly
hygienist visits
Supportive Periodontal therapy including OHI
Review annually including risk factors, hygiene
methods and motivation

Question 23

Referral acceptance into secondary care

Answer 23

Comprehensive diagnostic, treatment planning, and advice
service for patients with periodontal diseases
All referrals will be expected to contain the following
information:
• BPE scores;
• Summary of treatment already provided / the treatment
response;
• Details of known risk factors including smoking history
(pack years) and quit attempts;
• Evidence of longitudinal monitoring of patients for whom
there appears to be periodontal deterioration
In normal circumstances referrals will only be accepted
for treatment when the following treatment has been
undertaken:
•OHI with particular emphasis on
the appropriate form of interdental cleaning;
• Supragingival scaling and polishing;
• Subgingival scaling.
Patients should continue to see their own GDP for
routine dental examinations
GDP - responsible for routine elements of shared care
On completion of periodontal treatment, pre- and posttreatment
charts will be sent to the GDP for their information in
future monitoring and maintenance of the patient.
A recall interval programme of periodontal care in the primary
care practice will be suggested.

Question 24

Referral acceptance into secondary care - who gets considered for treatment?

Answer 24

• BPE scores of 3 or 4
• Advanced chronic periodontitis (post initial
treatment)
• Aggressive periodontitis
• Medical conditions, medication histories or syndromes that directly affect periodontal status
• Mucogingival problems, gingival recession or
other periodontal defects for which surgery may
be indicated, following initial therapy.
• Periodontal-endodontic lesions

Question 25

Referral acceptance into secondary care - pts who should not be referred for specialist advice and treatment planning are those

Answer 25

• With only gingivitis
• With poor oral hygiene or who are non responsive to, or non compliant with initial
hygiene phase therapy provided in primary care
• With BPE scores of 2 or less.
• Economic referrals