Aggressive Periodontitis
Ian Dunn
I am delighted to be posting my first PLOG, or Perio Blog, for GDPUK and look forward to penning further PLOGS over the coming months. I hope you find them of some use and will gladly take suggestions on perio related topics that people would like covered.

Our indemnity companies tell us that Perio is one of the main areas for litigation and payouts, leading to a significant upwards trend in our indemnity costs. When we look at the breakdown of the main causes of litigation in perio, DDU figures from 2014 show that 75% of perio cases were centred around failure to diagnose and failure to appropriately treat periodontitis. We are seeing average payouts to patients of around £30K for the failure to diagnose and treat chronic periodontitis and figures upwards of £100K for failing to diagnose and treat aggressive periodontitis. It is the latter that I would like to focus this PLOG on.

Aggressive Periodontitis is the contemporary name for the group of diseases that many of us would have been taught as Early Onset Periodontitis and included Localised Juvenile Periodontitis, Rapidly Progressive Periodontitis and Pre-Pubertal Periodontitis. Many of us will have entered our perio vivas remembering that Localised Juvenile Periodontitis affected central incisors and first molars in patients around the ages of puberty.

Whilst still relatively rare, affecting around 0.1% of the Caucasian population but as high as 2.5-5% of the Asian/Afro-Caribbean population, it can be a devastating disease and we owe it to our patients not to miss it. The diagnosis of aggressive periodontitis should significantly change your management as it may not respond to good plaque control and debridement alone. Right diagnosis, right treatment, wrong diagnosis, wrong treatment……poor outcomes.

The features of Aggressive Periodontitis are:

  • Strong family history
  • Young patients ( tend to be under 35 )
  • Good oral hygiene
  • Rate of progression is disproportionate to the levels of plaque and oral hygiene
  • Otherwise healthy patients
  • Increased prevalence of vertical bone loss.

Above is a case of a 25 year old Caucasian lady who presented to me after attending a walk in centre with a periodontal abscess and being told that she had the worst periodontal disease they had ever seen in someone so young. At presentation, her oral hygiene was above average and she was aware that her father had worn dentures from a very early age. She told me she had been to the dentist every 6 months, the same practice since she was 16 years old, something that was later proved to be true. I diagnosed her with Generalised Aggressive Periodontitis. It is important to note that Aggressive Periodontitis does not mean “untreatable” periodontitis ( Refractory Periodontitis as some used to call it). Interestingly, it is often the opposite and can be quite predictable to treat as we are usually not having to manage the lifestyle issues that that are often associated with Chronic Periodontitis. The patient above is now 34 and we have only lost 5 teeth, the four lower incisors and the LR8 that developed mesial caries. Whilst many implant dentists might be thinking about a clearance in this case followed by some sort of immediate full arch loading or All on Four type treatments, we have good data that shows periodontal patients have higher rates of peri-implantitis and the more aggressive the disease the higher the rate of peri-implant disease. The British Society of Periodontology, in their Parameters of Care document, recommends that Aggressive Periodontitis is a Complexity 3 case and should mostly be referred to Specialist care. This is an important dento-legal point in that you should offer any patients that you suspect of having Aggressive Periodontitis a referral to a Specialist Periodontist. Do not worry about how far away the Specialist is, how expensive they are or that the patient really wants you to treat them, offer them a referral, document their response and ,if they are turning it down on any grounds, please make sure that they understand the potential consequences of not accepting the referral. The defence societies call this Informed Refusal. We do not have have the time or space to do justice to the treatment of this disease but it regularly includes the use of systemic antibiotics at an appropriate time to complement the non-surgical phase of treatment and surgical techniques may need to be employed including pocket reduction surgery or newer techniques such as guided tissue regeneration in areas of vertical bone loss. The sooner this is spotted, the sooner it is treated and the less damage is done, so screen every patient at every examination even if they “don’t look like a perio patient” and if in doubt, refer it out!
Dr Ian Dunn BChD MFGDP (UK) MSc (Perio) Specialist Periodontist
  • Ian qualified from Leeds University in 1998. In 2001, he passed the examination for Membership of the Faculty of General Dental Practitioners at the Royal College of Surgeons. Following this achievement, Ian pursued a broad range of postgraduate courses and in 2003 completed the year long Restorative Certificate at St. Annes Dental Education Centre, allowing me to provide a very high standard of general dentistry for all of my patients.
  • Whilst enjoying all aspects of general dentistry, Ian developed a particular interest in Periodontics.
  • Ian is originally from Liverpool and has recently moved back to the area, with his wife, Paula and daughters, Charlotte and Jasmine.

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