Diagnosis of aggressive periodontitis: A dilemma?

Periodontitis is one of the leading causes of tooth loss in the adult population. This disease can be classified into various categories, and one of the most destructive amongst them is aggressive periodontitis (AgP). The incidence of AgP is lower than other types of periodontitis. However, it affects young individuals and can cause severe destruction of tooth-supporting structures including tooth loss if left untreated. The current classification for diagnosing periodontal disease was established by the American Academy of Periodontology (AAP) in 1999. This classification provided strict guidelines to aid in AgP diagnosis. These include three main factors: systemically healthy individual, rapid loss of clinical attachment, and familial aggregation. In spite of these specific guidelines, AgP diagnosis is often missed clinically due to various reasons. There is still a vast variation in the diagnostic criteria for identifying AgP and not all practitioners utilize the AAP guidelines for their diagnosis. Furthermore, the definition of the disease might be changing in the future to better represent the current understanding of the disease. Since early diagnosis and prompt treatment is key in treating these patients, it is important to have calibration in the diagnosis process. This review aims to identify sources of variation and ambiguity in diagnosing AgP among dental practitioners. For this purpose, we have conducted an extensive literature search and outlined the various diagnostic aids for AgP patients reported in the literature. Understanding and correcting these variations can simplify the diagnostic process leading to faster treatment of patients affected with AgP. This review also emphasizes the importance of minimizing the bias in identifying patients with AgP and highlights the best tools for this purpose.

Disease Staging Index for Aggressive Periodontitis

Major advances in the knowledge about the aetiopathogenesis of aggressive periodontitis (AgP) have been achieved. An ever increasing number of scientific articles related to AgP are published every year contributing significantly to the knowledge of this unique and complex disease. AgP has been classified into localised and generalised forms based on their extent and disease progression with distinct clinical and radiological features. A classification of AgP based on severity (mild, moderate and severe) exists; however, it is not easily applicable. Therefore, studies on AgP do not categorise the disease based on severity. A disease staging index for AgP is proposed based on clinical and radiological features, as well as risk factors. Based on the presence or absence of risk factors confirmed by longitudinal studies, cases of AgP can be divided into low risk, medium risk and high risk profiles for disease progression. Clinicians can devise a broad treatment plan for their AgP cases based on this staging. More frequent recall intervals are proposed for patients at medium and high risk for disease progression. Ten cases of AgP with 10-year follow-up were used to validate the staging index by retrospectively assigning prognosis and associating it with tooth loss. The use of this staging by researchers would increase external validity of research on AgP. Long-term analysis of AgP cases are needed to validate this staging index longitudinally.

An investigation of blood hemogram and estimation of serum iron and protein levels in aggressive periodontitis patients: a clinic biochemical study

AIM

The aim of this study is to investigate the blood hemogram and estimation of serum iron and proteins level in aggressive periodontitis patients.

MATERIALS AND METHODS

A total of 85 patients were selected and divided into two groups, 45 patients are with aggressive periodontitis and 40 patients are healthy. Periodontal parameters such as gingival infammation oral hygiene index, Russell's periodontal index and radiograph were taken. Total 10 ml blood was collected and sent for estimation of blood hemogram protein estimation and serum electrophoresis.

RESULTS

There was statistical signifcant difference observed in relation to gingival infammation oral hygiene hemoglobin and total iron binding capacity level between both the groups.

CONCLUSION

It has been concluded that periodontitis does not induce anemia like state, as the hematological and biochemical parameters were almost equally affected in periodontally healthy and periodontally diseased individuals, but some parameters showed statistical significant difference between the both groups.

CLINICAL SIGNIFICANCE

In the present study, the clinical periodontal parameters, red blood cell parameters and serum iron and ferritin levels were compared among control and test groups. It was found that the values of gingival infammation, oral hygiene and periodontal index, hemoglobulin level and total iron binding protein were statistically signifcant between the groups. However, the values of erythrocyte count, white blood cell count, serum iron and serum proteins, serum electrophoresis did not show any signifcant correlation.

Microbial profile of patients with periodontitis compared with healthy subjects

OBJECTIVE

To define and compare the microbiologic profile of subgingival plaque in German patients with periodontitis (including aggressive and advanced chronic periodontitis) and healthy subjects and to determine significant association between isolates and clinical status. Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, and Tannerella forsythia are major periodontal pathogens, though it is recognized that other species may also contribute to the pathogenesis of periodontal disease.

METHOD AND MATERIALS

Thirty-three patients with clinical and radiologic proof of aggressive and advanced chronic periodontitis and 20 healthy subjects were enrolled in this study. Clinical indices were recorded as six-point measurements on each tooth. Samples of the subgingival plaque were taken with paper points from four teeth of each individual. The samples were divided into two parts. One part was immediately cultivated, while the other one was stored at -20°C until analyzed by real-time polymerase chain reaction.

RESULTS

A total of 284 anaerobic isolates (224 isolates from patients and 60 isolates from healthy controls) were identified. Forty different anaerobic species were isolated, with a mean of 6.78 species per patient and 3 species per healthy control subject. Significant differences in prevalence (after adjusting for multiple comparisons, P < .001) were found for Prevotella intermedia and nigrescens, Fusobacterium nucleatum, T forsythia, Treponema denticola, and Veillonella parvula. The first four species were associated with the aggressive periodontitis group and V parvula with healthy subjects.

CONCLUSION

When compared with healthy controls, the microbial profile of subgingival plaque from periodontitis was found to contain known periodontal pathogens with a different prevalence to that described in earlier studies. P intermedia/nigrescens, F nucleatum, T forsythia, and T denticola have been found in lower proportions and small quantities in healthy subjects.

C-reactive protein as a marker of periodontal disease

Periodontal subgingival pathogens affect local and systemic immune and inflammatory response and cause the release of cytokines; this results in periodontal destruction and initiation of an acute phase systemic inflammatory response characterized by the release of C-reactive proteins (CRP). This study set out to evaluate the serum concentration of CRP that can be used as a marker of periodontal disease as well as a risk indicator for cardiovascular disease. Based on their periodontal status, 45 patients were divided into three groups. The following clinical parameters were recorded: plaque index, gingival index, bleeding index, probing pocket depth, and clinical attachment levels. Scoring was done on six tooth surfaces for all teeth. For the CRP assessment, blood samples were collected from subjects at the time of clinical examination. The results indicated an increase in serum CRP levels in patients with generalized aggressive periodontitis and chronic periodontitis as compared to controls.

IL-1-polymorphism and severity of periodontal disease

OBJECTIVE

To determine the association between the interleukin (IL)-1-polymorphism and the severity of periodontal disease prior to active periodontal therapy.

MATERIALS AND METHODS

Two hundred and six patients with obtained baseline x-rays were tested for IL-1-polymorphism. Relative bone loss before active periodontal treatment was measured with a Schei ruler and classified in five groups. Descriptive statistics and backward stepwise linear regression analyses were performed.

RESULTS

Forty-nine patients with moderate (mChP), 79 with severe chronic (sChP) and 78 with aggressive periodontitis (AgP) were included. Age correlated significantly with bone loss and number of teeth at baseline. Gender, smoking and IL-1-polymorphism were neither associated with bone loss nor with number of teeth prior to treatment. After adjusting for age as well as gender, AgP was significantly associated with more severe bone loss in untreated periodontal disease (p = 0.036). In non-smokers, mean number of teeth prior to active periodontal therapy correlated significantly with presence of IL-1 polymorphism.

CONCLUSION

The IL-1-polymorphism is associated with lower number of teeth in non-smokers with untreated periodontal disease. Untreated AgP is associated with more severe bone loss than untreated ChP.

Localized aggressive multiparous periodontitis: a newly documented entity

This article describes a form of localized aggressive periodontitis (LAP) in young multiparous women and denotes this form of periodontitis as localized aggressive multiparous periodontitis (LAMP). The authors retrospectively reviewed six cases of LAP in healthy multiparous women who were followed clinically for more than five years, examining clinical histories, clinical findings, and radiographic features. Age, race, gender, parity, location of attachment loss, rate of attachment loss, and symptoms were recorded. LAMP is characterized by asymmetrical attachment loss along the distal proximal area of the maxillary and/or mandibular first permanent molars in multiparous females with a median age of 27. The mean annual rate of attachment loss in the maxillary first molars was calculated at 0.5 mm. LAMP progresses to involve the mandibular incisors but, unlike LAP, appears to spare the maxillary incisors. The authors suggest that LAMP is a recognizable periodontal disease that can be diagnosed in young, multiparous females via clinical history, periodontal examination, and radiographs. This study presents potential pathogenic pathways and suggests a possible answer to the paradox of why aging women become more edentulous than men despite better overall dental care.

Salivary calcium concentration in relation to periodontal health of female tobacco smokers: a pilot study

OBJECTIVE

The aim of this pilot study was to assess the possibility of differences in the calcium concentration of the saliva between smoker and nonsmoker patients with or without periodontitis.

METHOD AND MATERIALS

A total of 44 women were enrolled in this study. Exclusion criteria were severe general health problems, the prescription of medication, and fewer than 16 remaining teeth. The study population comprised 24 smokers (4 periodontitis free, 16 with chronic and 4 with aggressive periodontitis; mean age 50.2 years +/- 6.9) and 20 nonsmokers (10 periodontitis free, 9 with chronic and 1 with aggressive periodontitis; mean age 54.7 years +/- 15.6). Clinical parameters (bone loss; plaque, gingival and calculus indices; and pocket depth) were recorded, and stimulated saliva samples were collected. The calcium concentration of each saliva sample was measured by atomic absorption spectrophotometry. Statistical analysis was performed with the MANOVA test.

RESULTS

The mean salivary calcium level in the smokers (57.76 μg/mL +/- 18.8) was significantly (P < .05) higher than in the nonsmokers (44.6 μg/mL +/- 7.8). Periodontal examination revealed significantly greater bone loss, a deeper mean probing depth, and a higher amount of calculus (P < .05) among the smokers. However, there were no statistically significant differences between the smokers and the nonsmokers as concerns the plaque and bleeding indices.

CONCLUSIONS

Within their limits, the present findings seem to indicate that patients with periodontitis who smoke exhibit higher salivary calcium levels than those in nonsmokers. However, the clinical significance of these findings remains to be determined in large-scale controlled studies.

Periodontitis as a manifestation of chronic benign neutropenia

BACKGROUND

A subcategory of chronic neutropenia is chronic benign neutropenia, which is characterized by a prolonged non-cyclic neutropenia as the sole abnormality, with no underlying disease to which the neutropenia can be attributed. Chronic neutropenia is defined as a low absolute neutrophil count for >6 months. In this presentation, periodontitis seems to be the sole manifestation of a juvenile patient with chronic benign neutropenia. A 7-year-old white male presented with periodontitis of the primary dentition and early tooth loss. His medical and dental history was otherwise unremarkable. Suspecting some systemic illness as the underlying cause, the patient was referred for a medical consultation and a series of blood tests.

METHODS

Blood analyses included a complete blood count (CBC), sequential multiple analyzer 24 (SMA 24), glycated hemoglobin levels, and screening for anti-white blood cell antibodies. Blood levels of calcium, vitamin D, dihydroxyvitamin-D, phosphorus, and alkaline phosphatase were also measured. Liver function tests were performed.

RESULTS

Following analysis of recent and previous blood test results, a diagnosis of chronic benign neutropenia was assigned. The patient's periodontal condition was treated with scaling and root planing, oral hygiene instruction, and antimicrobial mouthrinses. Three-month recall visits were recommended as a follow-up protocol.

CONCLUSIONS

This case represents the importance of diagnosing periodontal disease as a possible indicator of underlying systemic disease. When a patient presents with an unusual, generalized form of periodontal disease, screening for systemic disorders is required, as the oral condition may be the first or only manifestation of a systemic abnormality. This case also illustrates the reason for the change in classification of such a condition to periodontitis as a manifestation of systemic disease. This condition was previously classified as prepubertal periodontitis, a disease diagnosis that focused on the patient's age at the onset of the disease rather than the etiology.

Relationship ofActinobacillus actinomycetemcomitansSerotype b to Aggressive Periodontitis: Frequency in Pure Cultured Isolates

BACKGROUND

To our knowledge, the association of the five serotypes of Actinobacillus actinomycetemcomitans (A. actinomycetemcomitans) to the new diagnostic classification scheme defined by the American Academy of Periodontology in 1999 has not yet been described. The goal of this study was to characterize the frequencies of the five serotypes of A. actinomycetemcomitans in A. actinomycetemcomitans isolates from various forms of periodontitis using both old and new diagnostic classifications and to determine the relationships between serotype and age and clinical diagnosis.

METHODS

A total of 345 A. actinomycetemcomitans isolates from 115 A. actinomycetemcomitans culture-positive subjects (mean age 38.0 +/- 18.3 years, 59% female) were collected. Based on the new classifications, 33 subjects had aggressive periodontitis and 82 chronic periodontitis. According to old classifications, there were six prepubertal periodontitis (PPP), 12 localized juvenile periodontitis (LJP), 15 post-localized juvenile periodontitis (PLJP), 28 refractory periodontitis (Ref-P), and 54 adult periodontitis (AP) cases. Serotypes of A. actinomycetemcomitans were determined by an indirect immunofluorescence assay using serotype-specific polyclonal antisera to A. actinomycetemcomitans strains ATCC 29523, ATCC 43728, ATCC 33384, IDH 781 and IDH 1705 (serotype a, b, c, d, and e, respectively). Proportions of serotype b were examined between different diagnostic and age groups with a Z-test for proportions.

RESULTS

Most subjects (n = 100, 86.96%) were infected with a single serotype (22 serotype a, 44 serotype b, 30 serotype c, 1 serotype d, and 3 serotype e). There were 11 subjects (9.57%) with two serotypes and two subjects (1.74%) with 3 serotypes. Two individuals had isolates lacking any detectable serotype antigen. Serotype b was the predominant serotype in children under 18 years of age and young adults between 19 to 35 years, although serotype b status was not significantly associated with age. Serotypes d and e were not found in patients under 35 years old. In 62 adult patients, one subject had serotype d and three had serotype e. Serotype b was the most common serotype in aggressive periodontitis (60.61%). The proportion of cases with serotype b was significantly higher in aggressive periodontitis compared to chronic periodontitis (P = 0.031). Other serotypes were not significantly associated with new diagnostic categories. Serotypes d and e were not detected in aggressive periodontitis.

CONCLUSION

The results of this study show that proportions of serotype b of A. actinomycetemcomitans are significantly greater in culture-positive patients with aggressive periodontitis than those with chronic periodontitis.

Position paper: periodontal diseases of children and adolescents

Children and adolescents are subject to several periodontal diseases. Although there is a much lower prevalence of destructive periodontal diseases in children than in adults, children can develop severe forms of periodontitis. In some cases, this destructive disease is a manifestation of a known underlying systemic disease. In other young patients, the underlying cause for increased susceptibility and early onset of disease is unknown. These diseases are often familial, suggesting a genetic predisposition for aggressive disease. Current modalities for managing periodontal diseases of children and adolescents may include antibiotic therapy in combination with non-surgical and/or surgical therapy. Since early diagnosis ensures the greatest chance for successful treatment, it is important that children receive a periodontal examination as part of their routine dental visits.

Periodontal conditions in patients with juvenile idiopathic arthritis

OBJECTIVE

Our aim was to compare the periodontal conditions in a group of juvenile idiopathic arthritis (JIA) patients with those in a control group of healthy subjects (CTR).

MATERIAL AND METHODS

Thirty-two patients with JIA and 24 controls were selected. The measurements used to diagnose periodontal disease included plaque and bleeding scores, probing depths (PDs) and clinical attachment loss (CAL). Laboratory indicators of JIA activity included the erythrocyte sedimentation rate (ESR) and capsule-reactive protein (CRP). The Mann-Whitney test was used to evaluate the data (alpha = 0.05).

RESULTS

The mean ages were 15.9 (+/- 2.7) years and 14.7 (+/- 2.3) years for groups JIA and CTR, respectively. The median ESR was 42 mm/h 13 mm/h in the CTR group (p = 0.032) and the median CRP was 1.9 and 0.4 mg/l, respectively (p = 0.001). The prevalence of patients with a proximal attachment loss of 2mm or more in the JIA group was 25% and in controls it was 4.2%. The mean percentages of visible plaque and marginal bleeding were similar in the JIA (54 +/- 22 and 30 +/- 16, respectively) and CTR groups (44 +/- 18 and 29 +/- 11, respectively). The mean percentages of sites with PD > or = 4 mm were significantly higher in the JIA group (3 +/- 4.7) than in the CTR group (0.4 +/- 1.7) (p = 0.012). The mean percentages of sites with proximal CAL > or = 2 mm were 0.7 (+/- 1.4) in the JIA group and 0.001 (+/- 0.2) in the CTR group (p = 0.022).

CONCLUSION

Adolescents with JIA present more periodontal attachment loss than healthy controls, in spite of similar plaque and marginal bleeding levels.

Classifying periodontitis among adolescents: implications for epidemiological research

OBJECTIVES

To evaluate the performance of four clinical classification systems proposed for periodontitis in young subjects when applied to epidemiological data on clinical attachment loss. We assess the extent to which the use of different case definition systems may influence the outcome of descriptive and analytical epidemiological studies.

METHODS

The data originate in a screening examination for periodontitis carried out among 9162 high school students. Each of four previously published classification systems was applied to the data. The prevalence of cases according to each system was estimated and the association between case status, as defined by each system, and a set of candidate determinant variables was assessed using multivariable logistic regression analyses.

RESULTS

The four classification systems yielded rather different prevalence estimates. For localized periodontitis the estimates varied by a factor of 10, and for generalized periodontitis, these varied by a factor of 30. The results of the logistic regression analyses using the different case-definitions essentially confirmed the results of a population-based analysis. However, the precision of the estimates decreased with decreasing numbers of cases identified by the classification systems.

CONCLUSIONS

From an epidemiological point of view there is little justification for the use of the complicated classification systems. An approach based on the simple definition of a case as a person with clinical attachment loss, e.g. >/=3 mm, is preferable.

Associations of serum concentrations of IgG, IgA, IgM and interleukin-1beta with early-onset periodontitis classification and race

BACKGROUND

The significance of serum concentrations of various antibodies and cytokines in the pathogenesis of early-onset periodontitis (EOP) is not well understood. Recent reports suggest differences between young blacks and whites in certain humoral responses, regardless of periodontal status. This study was undertaken to compare the serum concentrations of IgG, IgA, IgM, and IL-1beta in EOP subjects with that of healthy controls, and to study the effect of race on these levels.

MATERIAL AND METHODS

This case-control study included 228 individuals, 19-25 years old who were selected from a larger population examined in the National Survey of Oral Health of United States Children in 1986/1987. The subjects were classified by their EOP status and they included 166 subjects with EOP and 62 healthy controls. Blood samples were used to assess the serum concentrations of IgG, IgM, IgA, IgG subclass, and IL-1beta.

RESULTS

The serum concentrations of IgG, IgG subclasses, IgA, and IgM in blacks were not significantly different in the generalized, localized and incidental EOP groups as compared to the healthy controls. The serum IL-1beta concentration was slightly and uniformly lower in the EOP groups than in the control group, although not statistically significant. Blacks had significantly higher serum concentrations of total IgG, and of IgG1, IgG2 and IgG3 than whites and Hispanics. Hispanics had significantly higher serum concentrations of IgM and IgG4 than whites and blacks. Hispanics also had a significantly higher serum concentration of IL-1beta than blacks.

CONCLUSIONS

Total antibody response in blacks is not associated with EOP classification. Race has a significant effect on serum antibody concentrations irrespective of disease classification, with blacks having significantly higher serum concentrations of IgG1, IgG2 and IgG3 than whites and Hispanics.

Application of Lamendin's adult dental aging technique to a diverse skeletal sample

Lamendin et al. (1) proposed a technique to estimate age at death for adults by analyzing single-rooted teeth. They expressed age as a function of two factors: translucency of the tooth root and periodontosis (gingival regression). In their study, they analyzed 306 singled rooted teeth that were extracted at autopsy from 208 individuals of known age at death, all of whom were considered as having a French ancestry. Their sample consisted of 135 males, 73 females, 198 whites, and 10 blacks. The sample ranged in age from 22 to 90 years of age. By using a simple formulae (A = 0.18 x P + 0.42 x T + 25.53, where A = Age in years, P = Periodontosis height x 100/root height, and T = Transparency height x 100/root height), Lamendin et al. were able to estimate age at death with a mean error of +/- 10 years on their working sample and +/- 8.4 years on a forensic control sample. Lamendin found this technique to work well with a French population, but did not test it outside of that sample area. This study tests the accuracy of this adult aging technique on a more diverse skeletal population, the Terry Collection housed at the Smithsonian's National Museum of Natural History. Our sample consists of 400 teeth from 94 black females, 72 white females, 98 black males, and 95 white males, ranging from 25 to 99 years. Lamendin's technique was applied to this sample to test its applicability to a population not of French origin. Providing results from a diverse skeletal population will aid in establishing the validity of this method to be used in forensic cases, its ideal purpose. Our results suggest that Lamendin's method estimates age fairly accurately outside of the French sample yielding a mean error of 8.2 years, standard deviation 6.9 years, and standard error of the mean 0.34 years. In addition, when ancestry and sex are accounted for, the mean errors are reduced for each group (black females, white females, black males, and white males). Lamendin et al. reported an inter-observer error of 9+/-1.8 and 10+/-2 sears from two independent observers. Forty teeth were randomly remeasured from the Terry Collection in order to assess an intra-observer error. From this retest, an intra-observer error of 6.5 years was detected.

Development of a classification system for periodontal diseases and conditions

Classification systems are necessary in order to provide a framework in which to scientifically study the etiology, pathogenesis, and treatment of diseases in an orderly fashion. In addition, such systems give clinicians a way to organize the health care needs of their patients. The last time scientists and clinicians in the field of periodontology and related areas agreed upon a classification system for periodontal diseases was in 1989 at the World Workshop in Clinical Periodontics. Subsequently, a simpler classification was agreed upon at the 1st European Workshop in Periodontology. These classification systems have been widely used by clinicians and research scientists throughout the world. Unfortunately, the 1989 classification had many shortcomings, including: (1) considerable overlap in disease categories, (2) absence of a gingival disease component, (3) inappropriate emphasis on age of onset of disease and rates of progression, and (4) inadequate or unclear classification criteria. The 1993 European classification lacked the detail necessary for adequate characterization of the broad spectrum of periodontal diseases encountered in clinical practice. The need for a revised classification system for periodontal diseases was emphasized during the 1996 World Workshop in Periodontics. In 1997 the American Academy of Periodontology responded to this need and formed a committee to plan and organize an international workshop to revise the classification system for periodontal diseases. The proceedings in this volume are the result of this reclassification effort. The process involved development by the Organizing Committee of an outline for a new classification and identification of individuals to write state-of-the-science reviews for each of the items on the outline. The reviewers were encouraged to depart from the preliminary outline if there were data to support any modifications. On October 30-November 2, 1999, the International Workshop for a Classification of Periodontal Diseases and Conditions was held and a new classification was agreed upon (Figure 1). This paper summarizes how the new classification for periodontal diseases and conditions presented in this volume differs from the classification system developed at the 1989 World Workshop in Clinical Periodontics. In addition, an analysis of the rationale is provided for each of the modifications and changes.

Analysis of human gingival tissue and gingival crevicular fluid beta-glucuronidase activity in specific periodontal diseases

BACKGROUND

Beta-glucuronidase (betaG) is one of the enzymes involved in the destruction of non-collagenous components of the extracellular matrix. It is also considered an indicator or predictor of periodontal disease activity. The present study was conducted to determine the presence and the levels of betaG activity in gingival tissue and gingival crevicular fluid (GCF) in periodontal disease and health status. The validity of 2 expressions of data, total betaG activity versus betaG concentration, and the correlations between clinical periodontal status and betaG profile was also evaluated.

METHODS

betaG activities in gingival tissues and GCF samples from 57 individuals, divided into 3 equal groups of adult periodontitis (AP), early-onset periodontitis (EOP), and periodontally healthy subjects were spectrophotometrically examined.

RESULTS

Both patient groups had higher betaG levels in both gingiva and GCF than controls. Significant differences were observed among all groups when total GCF betaG activities were examined (P <0.05). However, the difference between AP and controls was not significant when concentration values were compared (P >0.05). The highest GCF betaG activity, with both expressions, was detected in EOP group. No absolute correlations between clinical parameters and betaG activity were observed, except for random correlations in the patient groups with mean total betaG activities. Also GCF/gingiva betaG levels and the 2 expressions did not show absolute correlations.

CONCLUSIONS

The findings of the present study confirm the relationship between betaG activity and periodontal diseases. The differences in data concerning GCF total betaG activity and betaG concentration may suggest that they are not matching measures. Data presentation seems to be an important factor in GCF/enzyme profile studies.

Early-onset periodontitis

In 1993, the 1st European Workshop on Periodontology explicitly recognized that there was insufficient knowledge to differentiate truly different forms of periodontal disease from differences in the presentation/severity of the same disease. In spite of recent progress in our understanding of periodontal diseases, the issue is far from having been resolved. Classification of periodontal diseases, therefore, remains based upon the definition of specific clinical syndromes. Early-onset periodontitis (EOP) is one such syndrome and comprises a group of pathological conditions leading to loss of periodontal tissues early in life. The notion that classifies periodontitis syndromes as "early-onset" or "adult" is primarily epidemiological in nature and is based on the observation that periodontitis is rather infrequent in children and young adults. Nevertheless, considerable epidemiological evidence indicates that periodontitis does affect children and young adults to a level of severity that may lead to premature exfoliation of primary and/or permanent teeth. Clinical presentation of periodontitis early in the life of an individual is thought to indicate that the etiologic agents have been able to cause considerable tissue damage over a relatively short period of time. It also implies either infection with highly virulent bacteria and/or a highly susceptible subject. The purpose of this review is to discuss the criteria generally utilized to classify EOP, provide the rationale to designate EOP as a distinct disease entity, and to review the evidence justifying a subclassification into particular subgroups of EOP.

Periodontitis

The purpose of this review was to assess the scientific and clinical bases for the proposed classification of periodontitis. The clinical and histopathological signs and the etiology of periodontitis were described. Cross-sectional studies were analyzed to determine when onset of periodontitis most frequently occurs in adults. In addition, the progression rates of periodontitis have been assessed from longitudinal studies. No clinical, histopathological, or microbiological features could be identified that would characterize different disease entities of chronic periodontitis. The prevalence, extent, and severity of periodontitis were found to increase continually with higher age and there was no age when onset of disease would most likely occur. The rate of periodontitis progression varies largely between patients and there is no natural threshold for distinguishing various rates of disease progression. The incidence of periodontitis unresponsive to treatment depends on pretreatment progression rate, extent and severity of disease, tooth type, smoking, high levels of putative periodontal pathogens, a deficient immune response, and the type of therapy provided. There is no scientific basis for the classification "adult periodontitis" and "refractory adult periodontitis." Extensive clinical examinations are required for the diagnosis of "rapidly progressive adult periodontitis." It appears unrealistic that these examinations can be performed routinely in clinical practice. Therefore, the classification proposed by the Organizing Committee to define adult, rapidly progressive, and refractory periodontitis as specific disease entities was replaced with a simplified classification of periodontitis based on the scientific data available.

Clinical features of early-onset periodontitis

The authors estimate the prevalence of early-onset periodontitis, or EOP, in U.S. adolescents and describe the clinical features that occur at an early stage in those who have EOP. In 1986 and 1987, about 10.0 percent of African-American, 5.0 percent of Hispanic and 1.3 percent of white U.S. adolescents had EOP. Clinical features that may be useful in the early detection of EOP include overt gingival inflammation, dental calculus and a high rate of caries, restorations and tooth loss.

Putative periodontal pathogens in subgingival plaque of young adults with and without early-onset periodontitis

This study assessed the associations between putative periodontal pathogens and early-onset periodontitis (EOP) in a population of 248 subjects, 13 to 19 years of age at baseline, derived from a representative sample of U.S. young adults. The subjects were selected based on the presence or absence of attachment loss at baseline. The attachment level was assessed clinically at baseline and at a 6-year follow-up examination, and the presence of 7 bacterial species was assessed at follow-up using DNA probes. The individuals were classified into generalized, localized, incidental EOP, and no-periodontitis groups based on the extent and severity of attachment loss; and classified as having rapid, moderate, slow, and no progression based on the rate of periodontal progression during the 6 preceding years. In the EOP groups there were significantly higher percentages of individuals with detectable levels of Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, Campylobacter rectus, and Treponema denticola. In addition, the EOP group had significantly higher levels of these 5 microorganisms compared to the no-periodontitis group. There were also higher percentages of individuals with these species and higher levels of bacteria in the group showing disease progression than the group without progression. In a descending order of importance, P. gingivalis, T. denticola, and P. intermedia were the microorganisms significantly associated with the generalized and/or rapidly progressing disease. F. nucleatum and C. rectus were also associated with EOP, but to a lesser degree. In the present population Actinobacillus actinomycetemcomitans was not significantly associated with EOP, though it was recovered more often from subjects with localized EOP. Eikenella corrodens was present equally in subjects with and without disease. The results show that several bacterial species are associated with EOP, and that P. gingivalis and T. denticola are of particular importance and may play a significant role in the more severe and progressive forms of EOP.

Clinical classification of periodontitis in adolescents and young adults

THE AIM OF THIS STUDY was to determine the degree to which clinical classifications based on cross-sectional assessments endure in the course of development of early-onset periodontitis (EOP), and to introduce new criteria which might improve the clinical classification of these diseases. Subjects with EOP and a matched group without EOP were identified within a national probability sample examined during the 1986/87 survey of US schoolchildren. Of these, 265 subjects (mean age 16 years) were re-examined during the 1992/93 school year. The clinical attachment level of teeth was assessed, and the individuals were classified into localized juvenile periodontitis (LJP), generalized juvenile periodontitis (GJP), incidental attachment loss (IAL), and no-periodontitis groups using three classification methods previously described. A fourth method that considered the extent and severity of attachment loss and the number of missing teeth was introduced to classify the individuals at baseline and at follow-up as having localized, generalized, or incidental EOP, and no-periodontitis groups. Furthermore, the individuals were classified using criteria based on the rate and pattern of change in attachment loss during 6 years. The results showed low correlations between the baseline classifications and the classifications at the 6-year follow-up examination, irrespective of the method used. In addition, the cross-sectional classifications were not predictive of the rate of progression of periodontal disease in these subjects. In the generalized disease group, two-thirds of the individuals exhibited moderate/rapid disease progression, while one-third had slow or no progression. In the localized disease group, one-half of the individuals had moderate/rapid disease progression and one-half had slow or no progression. In the incidental disease group one-fourth of the individuals had moderate/rapid disease progression and three-fourths had slow or no progression. We propose that the term early-onset periodontitis be used as a generic term to describe periodontal disease before its normal onset. In addition, we suggest that incidental, localized, and generalized EOP are heterogenous groups comprising rapidly and slowly progressing forms within each classification. The findings suggest that a classification system in which subsets of the disease that are defined according to a combination of cross-sectional criteria and the disease progression may be useful in studies of EOP. Furthermore, the findings suggest that clinical classifications of EOP be used as generic descriptors until a full understanding of the pathogenesis of this disease is accomplished.

Early-onset periodontitis: progression of attachment loss during 6 years

We studied the pattern of progression of early-onset periodontitis and the change in the extent and severity of the periodontal condition in adolescents who were followed for 6 years. In a national survey of the oral health of U.S. children, 14,013 adolescents were examined clinically in 1986/1987 to assess the periodontal attachment loss of teeth. Individuals with early-onset periodontitis within this population were identified and classified into localized juvenile periodontitis (LJP), generalized juvenile periodontitis (GJP), and incidental attachment loss (IAL) groups. Ninety-one subjects, 13 to 20 years old at baseline, were examined 6 years later. They included 51 males and 40 females; and 72 Blacks, 6 Hispanics, and 13 Whites. They were clinically re-examined and then reclassified according to their periodontal status at follow-up. The severity and extent of these diseases continued to increase during the study period. In teeth that were affected at baseline, the lesions had progressed to include deeper portions of the periodontium, and more of the teeth unaffected at baseline exhibited periodontal attachment loss at follow-up, thus changing the disease characteristics and the basis for the clinical classification. Of the individuals classified with LJP at baseline, 62% continued to have LJP 6 years later and 35% developed GJP. Of those classified with GJP initially, all but two (82%) continued to have GJP at follow-up. Among the IAL group, 28% of subjects developed LJP or GJP, and 30% were reclassified in the no attachment loss group. Molars and incisors were the teeth most often affected in all three groups. The mean change in attachment loss over 6 years in the LJP, GJP, and IAL groups was 0.45, 1.12, and 0.13 mm, respectively. The present findings demonstrate the limitations of the currently used morphological criteria in the classification of early-onset periodontitis. The findings also suggest that the difference between LJP and GJP is in the number and type of teeth involved, and that the two classifications progress similarly, with some cases of LJP developing into GJP.

Influence of smoking and race on immunoglobulin G subclass concentrations in early-onset periodontitis patients

Recent data indicate that smoking is an important risk factor for the development of periodontitis. Smoking is also known to reduce serum immunoglobulin G (IgG) levels. Interestingly, patients with the localized form of early-onset periodontitis (LJP) have elevated levels of serum IgG2, and those who smoke are not clinically different from nonsmoking LJ subjects. In contrast, patients with the generalized form of early-onset periodontitis (G-EOP) who smoke have more extensive destruction than their nonsmoking counterparts. Given the effects of smoking on EOP and the association of IgG2 with less severe disease, we hypothesized that smoking might reduce serum IgG2 and that this might be most apparent in G-EOP. We therefore examined the effects of smoking on serum IgG subclass concentrations in race-matched groups: LJP, G-EOP, and age-matched periodontally healthy controls (NPs). Smoking status was established from serum cotinine levels, and serum IgG subclass concentrations were determined by using radial immunodiffusion. The data indicated that the effects of smoking were remarkably selective with respect to both IgG subclass and race. Smoking did not appear to have any effect on the concentration of IgG1 or IgG3 in either black or white subjects. In contrast, smoking was associated with depressed serum IgG2 concentrations in both white NP and G-EOP subgroups. Serum IgG2 levels in black subjects did not appear to be depressed by smoking, with the single striking exception of the black G-EOP subgroup which also had depressed serum IgG4 levels. The results here confirm that smoking has effects on serum immunoglobulin levels, but the effects were both race and serum IgG subclass specific. Furthermore, the periodontal diagnosis of EOP subjects appeared to be important, as indicated by the fact that IgG2 and IgG4 levels were reduced in smoking black G-EOP subjects whereas the IgG2 and IgG4 levels in black LJP and NP subjects were not reduced by smoking.

Differential diagnosis in clinical trials of therapy for periodontitis

For purposes of clinical trials of therapies for periodontitis, it is recommended that population samples be identified as adult periodontitis (systemically modified or not systemically modified), early onset periodontitis (localized or juvenile, generalized or rapidly progressive, or associated with systemic disease), or necrotizing ulcerative periodontitis, avoiding overlapping criteria. Population samples of adult or early onset periodontitis modified by or associated with systemic conditions should be used in clinical trials only when the intent is to study effect on the specifically modified condition. Objective identification of the modifying systemic condition should be required for all subjects in such trials. Population samples should be homogeneous for the diagnosis, whether systemically modified or not. Refractory periodontitis, prepubertal periodontitis, and periodontitis associated with systemic disease are not recommended as useful descriptors of population samples without discrete identification of underlying systemic abnormality for all included subjects. Definition of population sample by a bacteriological or a host response feature is not recommended unless the trial is specifically aimed at that feature and the sample is homogeneous for it. All trials of efficacy should include physical or radiographic measurement of attachment level or bone height as a critical outcome variable. Results from trial in one form of periodontitis should not be applied directly to other forms.

[The indications for the surgical treatment of chronic periodontitis of the permanent teeth in children and adolescents of different health groups]

Chronic granulating and granulomatous periodontitis of 250 permanent teeth was treated in children and adolescents aged 7 to 17, surgery had to be resorted to in 44 (18%) cases. Three groups of indications for radical treatment of chronic periodontitis in children were distinguished: difficulties in or impossibility of conservative treatment, inefficacy of conservative treatment, and somatic indications. The conservative and surgical methods together are most often indicated for patients in whom the adverse conditions of treatment (the first group of indications) are associated with an aggravated somatic status. Radical methods of treatment helped attain bone tissue recovery sooner (in 5-6 months) than after conservative therapy alone (in 8-9 months) and completely liquidate chronic foci of odontogenic infection.

Diagnosis of periodontal diseases

This paper reviews current (Fall, 1990) information related to the diagnosis of periodontal diseases. As background, principles of diagnostic decision-making and conceptual shifts during the 1970's and 1980's are reviewed in brief. "Diseases" that appeared in many classification schemes for periodontal diseases in the early 1970's--for example, "periodontosis" and "occlusal trauma"--do not appear in most current classifications. A recent (1989a) classification recommended by the American Academy of Periodontology holds that "periodontitis" includes several different diseases. There is, indeed, evidence for several different forms of periodontitis, but the AAP's classification does not conform to the principles of diagnostic decision-making because of the significant overlap between and heterogeneities within its suggested "diseases". An alternative classification is suggested, based on a concept that the periodontal diseases are mixed infections whose outcome is modified by relative effectiveness of host response. This view suggests that the most usual forms, gingivitis and adult periodontitis, normally occur in persons with essentially normal defense systems. Variation in extent or severity of disease can be understood as a function of the local infection in hosts with various degrees of compromised resistance to the infection. Early-onset periodontitis (EOP) cases could be accounted for by those where host response is abnormal to some significant degree. The greater the abnormality, the greater the extent and severity of disease might be. Localized EOP cases would be those where a relatively effective specific response intervenes to ameliorate progress of disease after the initially rapid progression. Other issues are detection of disease activity and assessment of risk for disease progression. Non-cultural bacteriological tests are available, but have not yet been shown to detect or predict activity or risk. One difficulty in reaching such proof for those or other tests has been the lack of an appropriate "gold standard" for disease activity or progression. This is being remedied by development of improved automated probes and imaging technologies. Considerable effort is being devoted to determining whether factors in gingival crevicular fluid may have diagnostic utility. More evidence is needed before clinical utility is known, but several enzymes and cytokines have potential for aiding diagnostic decisions.

Early-onset periodontitis: radiographic patterns of alveolar bone loss in 55 cases from a selected Malaysian population

The objective of this report was to determine the radiographic patterns of alveolar bone loss in early-onset periodontitis (EOP) cases in a selected Malaysian population. The radiographs of 55 cases of EOP patients were examined and the radiographic patterns were classified as follows: Type I: bone destruction on first molars and/or incisors only; Type II: bone destruction on first molars and/or incisors and several additional teeth (less than 14 teeth); Type III: generalized bone destruction (greater than 14 teeth), but with involvement noticeably more extensive on the first molars and/or incisors; Type IV: generalized bone destruction (greater than 14 teeth), but with no more bone loss on the first molars and/or incisors than on other involved teeth. Sex, age, and missing teeth were also recorded. Out of 55 cases, 47 cases, 22 males and 25 females, were classified into the types mentioned above; the remaining 8 cases were excluded due to too many missing teeth. It was found that 7 (14.9%) were Type I; 12 (25.5%) were Type II; 7 (14.9%) were Type III; and 21 (44.7%) were Type IV. There was a predominance of first molar/incisor involvement in Types I, II, and III with the maxillary first molars most frequently involved followed by the mandibular central incisors. Type I occurred in the younger age group and Types II, III, and IV mainly in the older age group. It was concluded that EOP in this patient sample resembled that of western society.

Diagnosis and classification of the periodontal diseases

A classification for gingivitis and periodontitis has been proposed based on clinical observations and immunologic parameters (summarized in Table 10). Overlapping clinical situations and exceptions to the rule certainly exist and pose challenges to clinicians during diagnosis, prognosis, and treatment planning. The clinical significance of making the diagnosis of either rapidly progressive periodontitis, juvenile, or prepubertal forms of periodontitis compared with adult periodontitis must be considered. A diagnosis of early-onset disease may (1) modify the periodontal treatment plan and may include the use of systemic antibiotics (for example, tetracyclines) or antiplaque agents (for example, sanguinarine, chlorhexidine); (2) modify the prosthetic treatment plan and require longer periods of monitoring before extensive replacement or splinting is initiated; (3) increase the frequency of periodontal recall appointments (at least four to six times during the first year or two following peridontal therapy); (4) implicate a genetic basis for the disease with the possibility of peridontal involvement of other family members; (5) influence decisions on prognosis; and (6) alert the clinician for potential future rapid periodontal breakdown. Future studies will further define and characterize all forms of periodontal diseases. Clinical, microbial, and immunologic information may permit inclusion of the relatively rare forms of periodontitis such as ANUG periodontitis and refractory periodontitis. Understanding the underlying biologic mechanisms of the pathogenesis of the periodontal diseases, coupled with clinical observations, will permit improved clinical investigations that ultimately will improve therapeutic approaches.

Radiographic evaluation of juvenile periodontitis (periodontosis)

Of 49,380 male naval recruits who were screened for juvenile periodontitis (JP), 270 were clinically diagnosed as having the disease. Full-mouth radiographs identified 182 of these 270 patients as having JP with extensive bone loss on permanent first molars and/or incisors. These 182 patients, 137 (75.3%) of whom were black, were further classified into Type I: bone loss involving first molars and/or incisors and up to two additional teeth; Type II: involvement of first molars/incisors and several additional teeth; and Type III: generalized involvement (more than 14 teeth) but with bone loss notably more extensive on the first molars and/or incisors. Of the 182 patients, 129 (70.9%) were Type I; 43 (23.6%) were Type II, and 10 (5.5%) were Type III. The molars were involved more frequently than the incisors; more than one molar was always involved, with or without incisor involvement. Most cases had minimal or no radiographic caries, and 46% had demonstrable calculus. Of the remaining 88 cases from the 270 with the initial diagnosis of JP, 63 demonstrated severe bone loss on more than 14 teeth, with many of the teeth being involved to the same degree. These cases were termed rapidly progressive periodontitis. Six of the 88 cases had bone loss on only one tooth surface of the dentition. These cases were termed acute localized destruction of alveolar bone. The status of the other 19 cases could not be determined.