Treatment of Generalised Aggressive Periodontitis: A 4-year Follow-up Case Report

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1 Tretment of Generlised Aggressive Periodontitis: A 4-yer Follow-up Cse Report Rui Fng LU 1, Li XU 1, Hun Xin MENG 1, Xing Hui FENG 1, Ki Ning LIU 1 Aggressive periodontitis comprises group of rre, often severe, rpidly progressive forms of periodontitis mostly chrcterised y n erly ge of clinicl mnifesttion nd distinctive tendency for cses to ggregte in fmilies. This cse report presents 16-yer-old femle ptient with clinicl nd rdiogrphic evidence of severe ttchment loss, whose mother ws lso ptient with severe periodontl destruction. The girl ws dignosed with generlised ggressive periodontitis nd received full-mouth scling nd root plning, one grft surgeries nd guided tissue regenertion on introny defects mesil of the mndiulr first molrs. Microiologicl nd immunologicl tests were performed on five selected sites efore nd t 2 months fter initil therpy. Clinicl nd rdiogrphic findings reported up to 4 yers postopertively indicted good effects nd stility of tretment outcome. Key words: ggressive periodontitis, periodontl initil therpy, one grft surgery, guided tissue regenertion A ggressive periodontitis (AgP) is group of infrequent types of periodontl diseses. It ffects systemiclly helthy individuls less thn 35 yers old, lthough ptients my e older 1. If the generlised interproximl ttchment loss ffects t lest three permnent teeth other thn first molrs nd incisors of ptients with AgP, it is usully dignosed s generlised ggressive periodontitis (GAgP). AgP my e universlly distinguished from chronic periodontitis y the ge of onset, the rpid rte of disese progression, the nture nd composition of the ssocited sugingivl microflor, ltertions in the host s immune response nd fmilil ggregtion of disesed individuls 2. Periodontl tretment of these ptients includes scling nd root plning, lone or in conjunction with systemtic ntiiotics, s well s surgicl nd interdisciplinry pproches. How- 1 Deprtment of Periodontology, Peking University School nd Hospitl of Stomtology, Beijng, P.R. Chin. Corresponding uthor: Dr Li Xu, Deprtment of Periodontology, Peking University School nd Hospitl of Stomtology, #22 Zhonggunsun Nndjie, Hidin District, Beijing 10081, P.R. Chin. Tel: ; Fx: ; E-mil: xulihome@263.net ever, there re only few reports of long-term follow-up of ptients with AgP in Chin. The im of this pper is to descrie the clinicl fetures of cse with AgP in Chin nd the long-term stility of the results otined with periodontl therpy. Cse report In 2006, 16-yer-old femle ptient ws referred to our deprtment for periodontl exmintion. Her chief complints were incresing moility of the right nterior mndiulr teeth for 3 months nd gum leeding on rushing for 5 yers (Fig 1). The ptient ws systemticlly helthy nd non-smoker. The periodontl sttus of her mother ws poor; she hd lost ll four centrl incisors, left mxillry lterl incisor nd oth mndiulr first molrs due to dvnced periodontl destruction, nd lveolr one loss of ll teeth ws more thn two-thirds of the root length, evluted y rdiogrphic exmintion (Fig 2). The periodontl sttus of the ptient s fther ws not severe, even though he hd smoked three to five cigrettes per dy for over 10 yers. Periodontl exmintion of the fther reveled no pocket depth more thn 5 mm nd for ll teeth lveolr one loss ws less 61

2 Fig 1 ) Clinicl front view of the ptient t initil exmintion, showing intense inflmmtion nd oedem of the gingiv nd extensive plque nd dentl clculus. ) Clinicl front view of the ptient t 4 yers fter periodontl tretment, showing tht the periodontl inflmmtion ws significntly reduced nd gingivl recession in the mndiulr incisors. Fig 2 Clinicl sttus of the ptient s mother on first visit. ) Teeth 11, 21, 22, 31, 36, 41 nd 46 hd een lost nd extensive dentl clculus nd gingivl recession were oserved. Clinicl exmintion reveled severe ttchment loss. ) Full-mouth peripicl rdiogrphs t initil exmintion reveled severe horizontl one loss to the picl third of the root length. The prognosis for most of the teeth ws hopeless. 62 Volume 15, Numer 1, 2012

3 Fig 3 ) Full-mouth peripicl rdiogrphs t initil exmintion reveled horizontl one loss up to hlf of the root length in incisors, ngulr ony defects mesil of the left nd right mndiulr first molrs extending to out two-thirds of the root length, nd fuzziness nd rek in the continuity of the one crest in the remining teeth. ) Full-mouth peripicl rdiogrphs t 4 yers fter initil periodontl therpy. Note tht the crests of interdentl sept re cler nd there is ovious one fill mesil of the left mxillry first molr nd oth mndiulr first molrs. 63

4 thn one-third of the root length. Informed consents for periodontl therpy nd clinicl smple collection were otined from the ptient nd her prents. Exmintions of the ptient included n introrl exmintion, full-mouth proing depth (PD) nd ttchment loss (AL) t six sites round ech tooth, tooth moility, furction involvements, full-mouth peripicl rdiogrphs nd complete lood count nd iochemicl nlysis. The dt collected reveled tht the verge PD of the full mouth ws 4.8 ± 1.5 mm nd verge AL ws 3.0 ± 0.9 mm. There ws deep PD of 9 to 10 mm mesil of the left nd right mndiulr first molrs, with grde I furction involvement on the uccl side. Mndiulr incisors demonstrted grde I to II moility with PD of 5 to 9 mm. Rdiogrphic exmintion reveled tht the verge reltive one height for ll teeth ws 76.6% [(ottom of defect mesil nd distl to root pex / cementoenmel junction (CEJ) to root pex) 100%]. The rdiogrphs lso reveled introny defects mesil of the left nd right mndiulr first molrs, nd tht horizontl one loss in the mxillry nd mndiulr incisors ws out hlf the root length. Fuzziness nd rek in the continuity of the lmin dur t the one crest of the rest of the teeth were oserved (Fig 3). The lood test reveled low lumin/gloulin rtio, while lood glucose, lkline phosphtse nd other liver function tests produced norml results. Bsed on the medicl history nd exmintions, the ptient ws dignosed s GAgP. The ptient received periodontl initil therpy, including instruction in tooth rushing using the Bss method nd the use of interdentl rushes, nd scling nd root plning of ll teeth under locl nesthesi. The ptient ws reclled for mintennce cre every 2 months nd received prophylxis scling. If necessry, the ptient ws remotivted nd reinstructed in orl hygiene procedures. Six months fter the initil phse of periodontl therpy, re-evlution of the periodontl sttus reveled tht orl hygiene ws good, PD of most sites ws 1 to 3 mm nd the verge PD of the mouth ws 3.0 ± 0.6 mm. Deep pockets of 7 to 9 mm persisted mesil of oth mndiulr first molrs (see Fig 5). Flp surgeries in conjunction with one grfts were deemed necessry for oth mndiulr first molrs. The left nd right mndiulr first molrs were treted seprtely, ccording to the principles of one grft surgery. Under locl nesthesi, full-thickness mucoperiostel flps were rised fcilly nd lingully from the mndiulr second premolrs to the second molrs nd ll grnultion tissue ws removed from the defects. A two to three-wll comintion introny defect ws found mesil of oth first molrs. In the right first molr, the distnce etween the CEJ nd the ottom of the defect ws 8 mm nd the distnce etween the CEJ nd the pproximl one defect ws 2 mm (Fig 4). The root surfces were conditioned with tetrcycline for 3 minutes nd susequently rinsed thoroughly with sterile sline. The one defects were filled with Bio-Oss Collgen (Geistlish, Switzerlnd) to the lveolr crest (Fig 4). Flps were repositioned nd closed with verticl internl mttress sutures nd covered y periodontl dressings. The ptient ws dvised to rinse with 0.12% chlorhexidine solution twice dy for 4 weeks nd to tke moxicillin 0.5 g three times dy for 7 dys. The sutures were removed fter 14 dys. Recll ppointments were once week during the first month, nd once every month during the following 5 months. Re-evlution t 6 months fter surgery showed tht PD t the mesil sites of oth mndiulr first molrs ws 5 mm with leeding on proing, nd rdiogrphic exmintion reveled only prtilly filled introny defects (Figs 5 nd 5). A second round of surgicl therpy ws plnned, comprising one grft surgery nd guided tissue regenertion (GTR) for the left nd right mndiulr first molrs, respectively. After full-thickness mucoperiostel flp elevtion nd deridement, n introny defect ws oserved mesil of oth teeth. In the right first molr, the distnce etween the CEJ nd the ottom of the defect ws 5 mm (Fig 4c), which ws then completely filled with lood moistened Bio-Oss nd covered y Bio-Gide memrne (Geistlish, Switzerlnd) (Fig 4d), the wound nd memrne were securely covered with the mucoperiostel flp. Rdiogrphic exmintion t 6 months post second surgicl therpy showed lmost completely one fill, nd the originl PD of 8 to 9 mm ws reduced to 4 mm (Fig 5c). The ptient ws then put into regulr periodontl mintennce of every 2 to 3 months. Four yers fter initil therpy, periodontl exmintion reveled tht the verge PD ws 2.9 ± 0.6 mm, the verge AL ws 3.4 ± 0.8 mm, with no PD greter thn 4 mm (Fig 1). A full-mouth series of rdiogrphs showed tht one level ws stle nd ovious one fill mesil of the left mxillry first molr nd oth mndiulr first molrs. The verge reltive one height for ll teeth ws 88.2% (Fig 3), with n increse in one height of 8.4% (88.2% vs. 76.6%) compred with the rdiogrph tken efore tretment (Fig 3). Gingivl creviculr fluid (GCF) ws otined from the mesiouccl sites of the right mxillry centrl incisor nd first premolr, the left mxillry first molr nd the left nd right mndiulr first molrs efore nd t 64 Volume 15, Numer 1, 2012

5 c d Fig 4 ) Clinicl intrsurgicl view of the right mndiulr first molr. ) The mesil introny defect ws filled with Bio-Oss Collgen. c) Clinicl intrsurgicl view t second surgicl therpy (6 months fter the first one grft surgery). The mesil introny defect, which ws nrrower nd shllower thn t the first surgery (), ws filled with Bio-Oss nd covered y Bio-Gide memrne (d). c Fig 5 Long-cone prlleling technique. ) Rdiogrph of the right mndiulr first molr efore first surgery. ) Rdiogrph t 6 months fter the first surgicl one grft procedure. c) Rdiogrph t 6 months fter the second surgicl one grft nd GTR procedure. Compred with the originl sitution (), pronounced new one formtion mesil of the tooth cn e oserved. 2 months fter periodontl initil therpy. Polymerse chin rection mplifiction of Porphyromons gingivli (Pg), Tnnerell forsythi (Tf), Treponem denticol (Td) nd Aggregticter ctinomycetemcomitns (A) ws performed in the smples of GCF from the right mxillry first premolr, the left mxillry first molr nd the right mndiulr first molr. Butyric cid, propionic cid, 25-hydroxyvitmin D3 (25(OH)D 3 ) nd interleukin-6 (IL-6) concentrtions were nlysed from the GCF superntnt (Tles 1 nd 2). 65

6 Tle 1 The clinicl nd microiologicl results for mesiouccl sites of mxillry right first premolr, mxillry left first molr nd mndiulr right first molr t seline nd 2 months fter periodontl initil therpy Mxillry right first premolr Mxillry left first molr Mndiulr right first molr Bseline 2 months Bseline 2 months Bseline 2 months PLI BI AL (mm) Pg Tf Td A Butyric cid (mmol/l) Propionic cid (mmol/l) PLI, plque index; PD, proing depth; BI, leeding index; AL, ttchment loss; Pg, Porphyromons gingivli; Tf, Tnnerell forsythi; Td, Treponem denticol; A, Aggregticter ctinomycetemcomitns. Tle 2 The clinicl nd immunologicl results for mesiouccl sites of mndiulr left first molr nd mxillry right centrl incisor t seline nd 2 months fter periodontl initil therpy Mndiulr left first molr Mxillry right centrl incisor Bseline 2 months Bseline 2 months PLI PD (mm) BI AL (mm) (OH)D 3 (mmol/l) IL-6 (mmol/l) PLI, plque index; PD, proing depth; BI, leeding index; AL, ttchment loss; 25(OH)D 3, 25-hydroxyvitminD3; IL-6, interleukin 6. Deep pockets in the mesiouccl sites of the right mxillry centrl incisor nd first premolr nd left mxillry first molr reduced to no more thn 4 mm t 2 months fter initil therpy, menwhile the microiologicl testing showed tht A, Tf nd Td were negtive in these sites (these periodontl pthogens hd een positive efore tretment). The concentrtion of utyric cid, propionic cid, 25(OH)D 3 nd IL-6 lso showed significnt decrese in these sites (Tles 1 nd 2). Deep pockets in the mesiouccl sites of the left nd right mndiulr first molrs, which hd introny defects, did not reduce oviously fter initil therpy. In the right first molr, Pg, Td nd Tf were ll detected efore nd t 2 months fter initil therpy; A ws negtive efore tretment, ut ws positive t 2 months fter initil therpy. There ws lso no ovious reduction of utyric cid, 25(OH)D 3 nd IL-6 concentrtions in the GCF superntnt, ut the propionic cid level incresed for the left mndiulr first molr t 2 months fter tretment (Tles 1 nd 2). 66 Volume 15, Numer 1, 2012

7 Discussion This young femle presented with the mjor common fetures of AgP, including non-contriutory medicl history, rpid ttchment loss, one destruction nd fmilil ggregtion 3. Due to the lck of knowledge in orl helthcre, there ws extensive plque nd dentl clculus, much of which ws very severe, which is quite chrcteristic of ptients with AgP in Chin. There my e some genetic or immunologicl fctors tht hve not een found nd so we cn not chnge in ptients with AgP 4. Active periodontl therpy nd periodontl mintennce t 3-month or shorter intervls re therefore essentil for preventing further progression of the tissue destructive process 5. GTR nd one grft procedures in periodontitis lesions represent exciting therpeutic modlities nd hve een shown to mintin stility for long time, which ws in ccordnce with other reports 6. It hs een reported tht mny indictors, including puttive periodontl pthogens 7, cytokines 8 nd cteri metolic cids 9, re ssocited with periodontl destruction. In this cse, we chose some of these indictors nd tested for them oth efore nd fter initil therpy. The results showed tht the chnges in the potentil indictors were in correspondence with the clinicl chnges. In sites tht responded well to the initil therpy, the indictors tested showed ovious reduction, while in sites tht did not responded well to the initil therpy, the indictors tested showed no ovious reduction or even incresed in concentrtion. Wht ws interesting ws tht in the introny defect mesil of the right mndiulr first molr, A recolonised fter the initil periodontl tretment. This might indicte recolonistion of A from other pocket sites or from the sliv fter tretment 10. Within the limittion of this cse report, no ovious reduction in the indictors ws found to men reltively poor prognosis nd tht more ctive tretment my e needed, including flp surgery, djunctive ntiiotics nd more frequent reclls. Active periodontl therpy nd mintennce cn led to long-term success in ptients with AgP. References 1. Armitge GC. Development of clssifiction system for periodontl diseses nd conditions. Ann Periodontol 1999;4: Armitge GC, Cullinn MP. Comprison of the clinicl fetures of chronic nd ggressive periodontitis. Periodontol ;53: Novok KF, Novok MJ. Aggressive periodontitis. In: Crzz s Clinicl Periodontology, ed 10. Missouri: Elsevier, 2006: Meng H, Xu L, Li Q et l. Determinnts of host susceptiility in ggressive periodontitis. Periodontol ;43: Roslem W, Rescl B, Teles RP et l. Effect of non-surgicl tretment on chronic nd ggressive periodontitis: Clinicl, immunologic, nd microiologic findings. J Periodontol 2011;82: Snt An AC, Pssnezi E, Todescn SM et l. A comined regenertive pproch for the tretment of ggressive periodontitis: Longterm follow-up of fmilil cse. Int J Periodontics Restortive Dent 2009;29: Teles RP, Gursky LC, Fveri M et l. Reltionships etween sugingivl microiot nd GCF iomrkers in generlized ggressive periodontitis. J Clin Periodontol 2010;37: Liu K, Meng H, Lu R et l. Initil periodontl therpy reduced systemic nd locl 25-hydroxy vitmin D(3) nd interleukin-1et in ptients with ggressive periodontitis. J Periodontol 2010;81: Tsud H, Ochii K, Suzuki N et l. Butyrte, cteril metolite, induces poptosis nd utophgic cell deth in gingivl epithelil cells. J Periodontl Res 2010;45: Johnson JD, Chen R, Lenton PA et l. Persistence of extrcreviculr cteril reservoirs fter tretment of ggressive periodontitis. J Periodontol 2008;79: