A Rose by Any Other Name: The Long Intricate History of Localized Aggressive Periodontitis

Abstract

This review addresses the recent World Workshop Consensus Conference (WWCC) decision to eliminate Localized Aggressive Periodontitis (LAgP) in young adults as a distinct form of periodontitis. A "Consensus" implies widespread, if not unanimous, agreement among participants. However, a significant number of attendees were opposed to the elimination of the LAgP classification. The substantial evidence supporting a unique diagnosis for LAgP includes the (1) incisor/molar pattern of disease, (2) young age of onset, (3) rapid progression of attachment and bone loss, (4) familial aggregation across multiple generations, and (5) defined consortium of microbiological risk factors including Aggregatibacter actinomycetemcomitans. Distinctive clinical signs and symptoms of LAgP are presented, and the microbial subgingival consortia that precede the onset of signs and symptoms are described. Using Bradford-Hill guidelines to assess causation, well-defined longitudinal studies support the unique microbial consortia, including A. actinomycetemcomitans as causative for LAgP. To determine the effects of the WWCC elimination of LAgP on research, we searched three publication databases and discovered a clear decrease in the number of new publications addressing LAgP since the new WWCC classification. The negative effects of the WWCC guidelines on both diagnosis and treatment success are presented. For example, due to the localized nature of LAgP, the practice of averaging mean pocket depth reduction or attachment gain across all teeth masks major changes in disease recovery at high-risk tooth sites. Reinstating LAgP as a distinct disease entity is proposed, and an alternative or additional way of measuring treatment success is recommended based on an assessment of the extension of the time to relapse of subgingival re-infection. The consequences of the translocation of oral microbes to distant anatomical sites due to ignoring relapse frequency are also discussed. Additional questions and future directions are also presented.

Keywords: Aggregatibacter actinomycetemcomitans; aggressive periodontitis; consensus conferences; damage/response framework; microbiome consortia; treatment success.

Figure 1

Illustration of the Golden and Albino Hamster experiments showing transmission from mother to child. Golden Hamster Dame (caries positive) is on the left, and Albino Hamster Dame (caries negative) is on the right side. Hamster pups are delivered in a sterile chamber by cesarian section under sterile conditions, and then albino pups are put in the cage of the Golden Hamster pups to be suckled by the Albino Dame (bottom right side of illustration) while the albino pups are suckled by the Golden Hamster Dame (bottom left side of the illustration). As shown, the Golden pups have no caries now (bottom right), while the albino pups have caries (bottom left).

Figure 2

Illustration of the experimental gingivitis model. Panel Upper Left: illustration of pre-experimental gingival health of a student prior to abstaining from oral hygiene. Panel Lower Left: Gingival indices indicate punctate areas of redness around marginal ginigivae, especially in the upper premolar and molar areas 21 days after abstaining, while incisors show minimal inflammation. Panel Upper Right: Plaque disclosure seven days following abstaining from oral hygiene using erythrocin staining. Note minimal levels of plaque around the gingival margin of the teeth. Panel Lower Right: Plaque disclosure 21 days after abstaining from oral hygiene. Note the increased intensity of erythrocin staining, which illustrates increased plaque thickness, and how upper anterior teeth show less staining, i.e., less plaque accumulation.

Figure 3

Diagram of Damage/Response. The solid upper line represents a normal healthy host response. At day zero an infection occurs driven by either a bacterial or viral challenge to the host. Following the microbial challenge after some delay the disease develops and the host response occurs. Disease resolves and the host response tapers to avoid furter tissue damage. The bolded straight line on the bottom represents an inadequate host response. Here tissue damage continues until an adequate host response occurs. Thus the bolded bottom line represents a muted host response and continued tissue damage.

Figure 4

Radiographs of a patient with significant pocket depth and bone loss. Shows loss of two mandibular incisors and extensive bone loss in the first molar region,. Note the lack of carious lesions on radiographs throughout the dentition.

Figure 5

Panoramic radiographs of cases of aggressive periodontitis in adolescents. Panel (A) shows a panoramic view of excessive bone loss in the first molars and no carious lesions. Panel (B) shows more extensive disease in an adolescent with bone loss around the molars and missing molars and incisors with occlusal, but proximal decay is related to a blow-out occlusal lesion in the mandibular right second molar.