Age is not necessarily an indicator of aggressive perio as you may have a periodontitis-sensitive patient may have neglected their OH over a decade. Conversely severe attachment loss in an elderly patient may not be the result of year long-lasting neglect.
The patient is healthy and is not suffering from any systemic disease that could lead to periodontitis.
Systemic diseases can lead to altered host response to periodontal pathogens – “Periodontitis as a manifestation of systemic disease”
Familial aggressive periodontitis
Secondary features but not universally necessary to diagnose:
Low amounts of etiological factors (plaque) combined with pronounced tissue destruction
Strong colonisation of A.actinomycetemcomitans and P.gingivalis
Destruction pattern: Local attachment loss – Incisors and 1st molars. Interproximal attachment loss at 2 or more permanent teeth – one of which 1st molar and 2 or less other teeth (excluding 1st molar/incisors).
Vertical loss of alveolar bone around 1st molars and incisors – begins at puberty in healthy teenagers – Classic diagnostic signs of LAP.
Serum Ab response against pathogens – More pronounced systemic Ab titres against periodontal pathogens than in GAP. Stronger humoral response (natural killer T cells).
↑Perio susceptibility + ↑Host Response = Disease limited in extent ∴ LAP
Given that the patient has aggressive periodontitis – response to conventional periodontal therapy will be unpredictable and the overall prognosis will be poorer in comparison to chronic perio cases. Overriding success of treatment will be down educating the patient about the disease and stressing the importance of the patient’s role in success of treatment.
Preliminary phase - Emergency treatment
Patient not in pain and no sign of acute infection
Extraction of hopeless teeth and provisional replacement? – Poor prognosis of UL4 due to grade II mobility. Check for fremitus on all mobile teeth. Options: Delay xla until after tx is completed, XLA and leave gap, essix retainer with tooth, single tooth denture, bridge, implant once periodontially stable? (Saving questionable teeth may jeopardise adjacent teeth and lead to loss of bone needed for implants)
Supportive periodontal therapy – every 3 months to maintain good OH. Modified bass technique and use of interproximal cleaning aids. Patient may be cleaning prior to appointments as 40% bleeding may indicate neglect on other occasions
RSD on sites >4mm pocketing – Patient has already undergone full mouth RSD, has it been successful? If not, why not? Vertical bone defects difficult to clean.
Full yearly 6PPC – Establish baseline *Check furcation involvement with Nabers Probe)
Deep periodontal pockets will be difficult to instrument. High prevalence of vertical defects that need to be resolved.
Regenerative therapy – BioOss/Emdogain to repair bony defects.
Open-flap surgical debridement, RSD, application of tetracycline solution), allo/xenogenic bone graft (human/porcine). Modified Widman Flap used – Expose interproximal bone – Replace flap margins at new level of bony crest to reduce pocket.