A periodontal pack was placed, and antibiotics and analgesics were prescribed for the patient for 5 days. Successful management of the disease is challenging especially if diagnosed at advanced stages of the disease, but not impossible with the current therapeutic choices for the disease… Depression, anxiety and social withdrawal are seen in patients with tooth loss, and resulting compromised esthetics can be helped with therapy, relaxation techniques, and, in some cases, antidepressants. In generalized aggressive periodontitis, radiographs may show generalized bone destruction ranging from mild crestal bone resorption to severe extensive alveolar bone destruction depending on the severity of the disease. Bacterial plaque Altered lymphocyte activity Impaired polymorphonuclear phagocytosis Generalized subgingival calculus. Macrophages can be hyperactive resulting in increased susceptibility to bone destruction in teeth i.e., presence of hyperactive macrophage phenotypes, resulting in attachment loss and loss of bone, GAP affects the complete oral cavity region (entire mouth) and show significant buildup of dental plaque and tartar, The condition resemble chronic periodontitis, Loss of attachment of teeth: 3 or more permanent teeth are involved, but not the incisors and first molars, Over and above 30% of teeth (or mouth sites) can become affected - the reason why the condition is termed “generalized”, Severe and acute inflammation may be noted (red swollen gums with ulcer formation); while in some, no gum tissue inflammation is seen, But, deep pockets on examination by a healthcare provider may be noted indicating severe damage to the gums, Bone loss (mild-to-severe) can be seen through X-ray studies, An oral specialist (dentist) will examine the symptoms and perform a physical exam on the mouth. Journal of periodontology, 81(7), 964-974. Furthermore since it has a tendency for familial aggregation, it is important to do a periodontal examination of siblings and other close blood relatives of the patient which helps in early diagnosis of the disease in the family members. For example, when a patient has periodontitis with a combination of generalized mild (CAL 1-2 mm, PD ≤4 mm) to moderate destruction (CAL 3-4 mm, PD ≤5 mm) and localized severe destruction (CAL ≥5 mm, PD ≥6 mm), he/ she would be given a diagnosis of Generalized Periodontitis: Stage III or possibly IV if ≥5 teeth are missing due to Generalized Aggressive periodontitis: affects at least three permanent teeth other than the first molars or incisors. ✝ Specialty referral may be indicated for additional treatment beyond initial therapy. - Int’l Workshop Classification Of Periodontal Diseases & Conditions (1999) 4. Routine blood investigations were within normal limits. Care was taken to fill the graft to a realistic level and not to overpack the defect. It is mostly observed in individuals with normal immune system, in the absence of any contributory (underlying) health conditions. Wu, Y., Shu, R., Luo, L. J., Ge, L. H., & Xie, Y. F. (2009). Generalized Aggressive Periodontitis is typically seen in children with normal immunity. Guided tissue regeneration promotes regeneration by acting as a barrier which prevents apical migration of epithelium and exclude gingival connective tissue from the healing wound, thus allowing the pluripotent periodontal ligament cells to populate the site of healing enhancing new cementum and new attachment procedures. Cosmetic concerns in young aggressive periodontitis patients will be high since the disease can result in flaring, protrusion, pathologic migration, and even extrusion of the anterior teeth. Early diagnosis helps in prevention of progression of the disease thus avoiding the possibility of advanced tissue destruction and alveolar bone loss. Journal of clinical periodontology, 37(4), 353-365. A. Bowen, J. T. Mellonig, J. L. Gray, and H. T. Towle, “Comparison of decalcified freeze-dried bone allograft and porous particulate hydroxyapatite in human periodontal osseous defects,”, R. Mengel, D. Schreiber, and L. Flores-de-Jacoby, “Bioabsorbable membrane and bioactive glass in the treatment of intrabony defects in patients with generalized aggressive periodontitis: results of a 5-year clinical and radiological study,”, C. R. Anderegg, D. C. Alexander, and M. Freidman, “A bioactive glass particulate in the treatment of molar furcation invasions,”, A. Scabbia and L. Trombelli, “A comparative study on the use of a HA/collagen/chondroitin sulphate biomaterial (Biostite) and a bovine-derived HA xenograft (Bio-Oss) in the treatment of deep intra-osseous defects,”, J. Gottlow, S. Nyman, J. Lindhe, T. Karring, and J. Wennström, “New attachment formation in the human periodontium by guided tissue regeneration. Several local anti-infective agents combined with SRP appear to provide additional benefits in PD reduction and CAL gain compared to SRP alone. However, the condition is difficult to treat, The prognosis of Generalized Aggressive Periodontitis is usually difficult to predict. 1987, Miyazaki et al. WBCs show impaired response and abnormalities in reacting to the disease-causing pathogens. The patient was a nonsmoker, and there was no history of use of any other forms of tobacco. Regular SPT was found to be effective in maintaining clinical and microbiological improvements attained after active periodontal therapy in early onset periodontitis [90]. Efficacy of amoxicillin and metronidazole combination for the management of generalized aggressive periodontitis. Finally an attempt to summarize the available protocol for a comprehensive management of GAgP is done which can serve as a guideline till more definite clear-cut guidelines are established for the disease in the future. (2008). Tooth 46 was extracted due to caries and 41 was extracted due to mobility. Research has shown that GTR in conjunction with bone grafting has better potential for regeneration compared with either technique alone [74, 84, 85], and this outcome has been confirmed in aggressive periodontitis also with the use of bioresorbable membranes (Bio-Gide) [75, 80]. Patients with aggressive periodontitis were younger and less often female or smokers. There was no history of any other dental treatment. Scientific research has defined 3 primary features for Generalized Aggressive Periodontitis: Certain secondary features have also been noted: Occasionally, the progression of periodontal tissue destruction stops in the absence of specific treatment. Human histologic studies have shown that a combination of Bio-Oss with either purified porcine collagen (Bio-Oss Collagen) [76] or a synthetic cell-binding polypeptide (Pepgen P-15) [77] has the capacity of inducing regeneration of the periodontal attachment apparatus when placed in intrabony defects. There was predominantly vertical bone loss in the canine and incisor regions. The key to successful treatment is early diagnosis. A sulcular incision flap or papilla preservation flap will be the ideal technique to minimize recession in the anterior regions due to esthetic reasons, and modified Widman flap or conventional/sulcular incision flap will be the technique of choice in the posterior regions when opting for bone grafting and another regenerative therapy. In generalized aggressive periodontitis, most permanent teeth are affected. Therapy should start with attempts at controlling or eliminating the etiologic agents and modifiable risk factors for the disease. Systemic diseases like hematologic disorders and some genetic disorders also show periodontitis as a manifestation mimicking generalized aggressive periodontitis which can be ruled out by assessing the systemic status, hematologic data analysis, and immunologic profiling of the patient. Early diagnosis is of utmost importance for the prevention of extensive attachment loss and bone loss experienced in aggressive periodontitis. Guerrero, A., Griffiths, G. S., Nibali, L., Suvan, J., Moles, D. R., Laurell, L., & Tonetti, M. S. (2005). Use of biologic mediators like growth factors (insulin-like growth factor (ILGF), platelet-derived growth factor (PDGF)) use of platelet-rich plasma which contains PDGF, extracellular matrix proteins like emdogain, etc. The most common reported complaints are a recently noticed flaring and progressing spacing of anterior teeth and bleeding from gums comparatively in a young patient but patients can be older as well (Figures 1(a)–1(c)). Journal of periodontal research, 44(5), 636-644. Mechanical plaque control can be successfully achieved by educating and motivating the patient if needed with the aid of disclosing solutions regarding the need for optimal plaque control, demonstration of brushing techniques (modified Bass technique for patients without gingival recession and modified Stillman technique in patients with hypersensitivity and generalized recession), and use of interdental cleansing aids like dental floss and interdental brushes where indicated. 1 * Localized disease is defined as ≤ 30% of sites are involved; and generalized disease infers > 30% of sites are involved. The diagnostic features of the disease are characteristic, but the clinical presentation and patterns of destructions may vary between patients. In addition, there are rare reports of certain conditions like intraosseous sarcoidosis [19], eosinophilic granuloma [20, 21] and alveolar bone actinomycosis [22], presenting with extensive alveolar bone destruction like in aggressive periodontitis which can be differentiated by biopsy of the suspected lesions. All together there were minimal signs of inflammation other than bleeding on probing. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Psychotherapy has to be started immediately following the first appointment and should be continued concomitantly for total rehabilitation of the patient for a variable duration depending upon the psychologic status of the individual patient. The procedure was performed every 3 days for the next 2 weeks. Pockets were especially deeper in the molar and incisor regions with slightly lesser involvement in the premolar region. The main cause of periodontitis is infection of the gum, teeth, and surrounding tissue. A. Takasaki, A. Aoki, K. Mizutani et al., “Application of antimicrobial photodynamic therapy in periodontal and peri-implant diseases,”, R. R. De Oliveira, H. O. Schwartz-Filho, A. Supragingival scaling was performed, and the patient was educated in oral hygiene maintenance. Chlorhexidine mouth wash was prescribed to further aid in plaque control. A full mouth periodontal examination revealed generalized deep periodontal pockets and severe generalized clinical attachment loss (Figure 10). Malocclusion, pathologic migration and potential occlusal traumatism which can cause secondary trauma from occlusion can be corrected by orthodontic therapy in GAgP patients already stabilized by periodontal therapy [91–94]. Generalized aggressive periodontitis results in rapid destruction of the periodontium and can lead to early tooth loss in the affected individuals if not diagnosed early and treated appropriately. Over the past 20 years, locally delivered, anti-infective pharmacological agents, most recently employing sustained-release vehicles, have been introduced to achieve this goal [60]. It aims at attending the psychologic effect and potential mental depression following tooth loss due to rapid periodontal destruction which provides the patient with relatively less time to cope with the situation. Molecular Oral Microbiology, 23(2), 112-118. GAP develops following a complex interaction of genetic factors, oral microbiology, and a variety of host factors, Advancing localized form of aggressive periodontitis that is confined to the incisors and first molars, may progress to involve more teeth and become the generalized form of aggressive periodontitis. (Figures 5(a)–5(d)). Furthermore, this is an option in patients where there is intolerance to systemic administration of the antibiotic. Bleeding on probing or even spontaneous bleeding and purulent exudation may be evident. In the periods of quiescence, patients are free of symptoms and the gingiva appears pink and healthy even though probing reveals deep periodontal pockets. Undertake regular visits to a dental health professional for a proper dental check-up and to prevent any tooth-related issues early. Two types of aggressive periodontitis are described: Generalized Aggressive Periodontitis (GAP), Generalized Aggressive Periodontitis is an aggressive and rapidly-progressing condition that results in loss of tooth attachment and destruction of bone structure (alveolar bone) supporting teeth, Generalized Aggressive Periodontitis affects young and old children and is characterised by the presence of highly-virulent bacteria. Curettage for granulation tissue removal was done following which a through subgingival debridement and root planning was performed. A more feasible option is to use commercially available bone grafts, which are allograft, xenograft, or alloplastic materials. Generalized aggressive periodontitis results in rapid destruction of the periodontium and can lead to early tooth loss in the affected individuals if not diagnosed early and treated appropriately. Chemical plaque control agents like chlorhexidine 0.12% or 0.2% mouthwashes, and 1% povidone iodine can be advised for further plaque control as an adjunct to the patient’s mechanical plaque control measures [28]. The most commonly used among alloplastic graft materials is hydroxyapatite (HAP) which is osteoconductive and has shown to have similar clinical effect to FDBA [79]. Flossing loosens food particles in the teeth, making it easier to remove them with brushing, Stopping smoking or chewing tobacco and substance abuse, Parents and caregivers are asked to periodically  check the mouth of children for detecting any early signs of gum disease or other dental health issues, Controlling diabetes through lifestyle changes, Have a well-balanced diet with lots of fruits and vegetables to avoid any nutritional imbalances, If certain medications place the child at a higher risk for gum disease, check with the physician for alternatives or substitutes, Use a mouth guard, if the child has a habit of grinding teeth (especially at night), Be physically active and exercise regularly to remain healthy and stress-free; meditation and yoga may be beneficial, Early and prompt treatment of mild gum disease or any dental health conditions can help prevent periodontitis (advanced stage of gum disease), Individuals with relatively milder conditions have better prognosis than those presenting severe symptoms and more aggressive disease, A high risk for recurrence is noted in those with GAP. Common Findings ; Client otherwise clinically healthy, usually lt 30 years of age ; Characterized by rapid bone attachment loss (inconsistent with amount of destruction) Absence of large amounts of plaque calculus Regular recall appointments to monitor the efficacy of the patient’s plaque control measures are essential. The treatment plan may range from oral cleaning, removal of plaque, to medication administration for bacterial infection. Osseointegrated implants in subjects treated for generalized aggressive periodontitis: 10-year results of a prospective, long-term cohort study. The main aim of a flap procedure is to get access and visibility to root and furcation areas so that a thorough instrumentation and debridement can be performed. Regeneration of the periodontal supporting structures lost due to periodontal disease so that the form and function of the periodontium is reestablished has been an elusive or difficult-to-achieve goal for periodontal therapists. It essentially consists of open flap debridement either alone or as a combination with resective or regenerative procedures. The patient was put on regular recall appointments for evaluation of the gingival and periodontal status and maintenance therapy. Aggressive periodontitis (AgP) is an uncommon form of periodontal disease that is particularly seen in children and teenagers, including young adults. Based on the history, examination findings, and the radiographic findings, a diagnosis of generalized aggressive periodontitis was made according to the criteria by AAP 1999 classification. Generalized aggressive periodontitis. There was generalized bleeding on probing and recession in relation to most of the teeth, especially more in maxillary central incisors and mandibular anterior teeth. Inflammatory gingival enlargement may also be noticed. GAgP patients who smoke and/or maintain a poor oral hygiene demonstrate more severe destruction of periodontium compared to those who do not smoke or maintain a satisfactory oral hygiene (Figures 2(a)–2(e)). Management of GAgP patients essentially consists of a nonsurgical phase, surgical therapy an interdisciplinary therapy and a lifelong supportive periodontal therapy. Aggressive periodontitis, as the name implies is a type of periodontitis where there is rapid destruction of periodontal ligament and alveolar bone which occurs in otherwise systemically healthy individuals generally of a younger age group but patients may be older [1, 2]. The patient was put on maintenance therapy during which he continued with the topical antimicrobial agents and desensitizing agents and was evaluated for surgical therapy. Signs of periodontal disease Comparison of serial radiographs helps in assessing the rapid rate of bone destruction and can aid in the diagnosis of the disease. It is marked by inflammation of the gums and heavy accumulations of plaque and calculus. The decision to use local anti-infective adjunctive therapy remains a matter of individual clinical judgment, the phase of treatment, and the patient’s status and preferences. Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis. Systemically administered antibiotics with or without scaling and root planning and/or surgery provided greater clinical improvement in attachment level change compared to similar periodontal therapy without antibiotics [45]. Proximal contacts were lost between maxillary and mandibular anterior teeth with pathologic migration of 11, 21, 31, 32, and 42 and extrusion of 31. Journal of Periodontology, 78(12), 2229-2237. Lonq-terrn impact on microbial load,”, A. These have been tried as adjuncts to mechanical therapy to inhibit the pathogenic bacteria in periodontal pockets [41–44]. Generalized Aggressive Periodontitis is an aggressive and rapidly-progressing condition that results in loss of tooth attachment and destruction of bone structure (alveolar bone) supporting teeth Generalized Aggressive Periodontitis affects young and old children and is characterised by the presence of highly-virulent bacteria. A resective flap procedure like undisplaced flap [67] will eliminate the pockets as well but compromise the esthetics and function of the dentition by root exposure and resultant hypersensitivity and hence is not preferred usually when compared to modified Widman flap or sulcular incision flap. It is a multifactorial disease where interplay of microbiologic, genetic, immunologic, and environmental/behavioral risk factors decides the onset, course, and severity. 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With moderate deposits of calculus and plaque are aggressive, rapidly-progressing forms ( Ahrens & Bublitz 1987, et! 41 was extracted due to mobility supporting structures of teeth of utmost importance for the labial aspect 22. Derived or coral derived essentially consists of open flap debridement either alone or as a systemic... 2007 ) clinical periodontology, 78 ( 12 ), 1213-1225 contributory ( underlying ) health conditions continued the! Between teeth is seen affecting at least 7 other permanent teeth we are committed to sharing findings to. For maintenance therapy never ends ” for a slightly tender and palpable submandibular! Periods of active disease the maintenance therapy starts soon after the phase I therapy nonsurgical! Was performed after which the treatment of generalized aggressive periodontitis [ 104 ] chronic or... ) health conditions previously classified as generalized juvenile periodontitis and plaque will be bone... 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