Aggressive periodontitis is considered as a multifactorial disease, comprising of a heterogeneous group of infectious diseases characterized by the complex host-microbial interaction in the periodontium. Aggressive nature and early onset of the disease have been found to depend with respect to bacterial etiology, host susceptibility, hereditary and environmental factors and often modified by behavioral factors.
The loss of attachment, or destruction of the periodontal ligament and loss of adjacent supporting bone, is seen in adult cases, as well as in early-onset disease, which affects young persons who otherwise appear healthy. The disease is often associated with severe congenital defects of hematological origin, alterations in neutrophil chemotaxis function, systemic conditions such as metabolic disorders (diabetes mellitus, female hormonal alterations), drug-induced disorders, hematologic disorders/leukemia, and immune system disorders.
As per the classification given by American Academy of Periodontology, periodontitis may be of three types i.e., aggressive periodontitis (AP), chronic periodontitis and periodontitis associated with systemic disease. This classification is based on difference in respect to bacterial etiology, host response and clinical disease progression. However the evidences suggest that underlying host susceptibility factors play a significant role in disease manifestation. Hereditary factors are also suggested to play an important role in comparison to environmental factors in manifesting the early onset of periodontitis. High prevalence of infection in siblings of affected individuals has also reported by many workers.
It is documented well now that smoking has a profound effect on the predisposition to periodontal diseases, independent of oral hygiene, age, or any other risk factor. However, it has also been documented that there is no difference between smokers and nonsmokers when compared in terms of amounts of plaque accumulation, in the prevalence of the principal bacteria, which are considered pathogenic for periodontitis.
But at the same time we also must note that reports suggests that smoking causes suppression in vascular reaction, which subsequently leads gingivitis, masking effect on the signs of inflammation, association between refractory periodontitis and a polymorphonuclear leukocyte defect in the peripheral blood.
Recently, an association of smoking with osteoporosis has shown, so dental surgeons have also tried to link it with dental alveolar bone loss. More than 500 bacteria have been identified within periodontal pockets, so it is next to impossible to say accurately that which particular species may have contributed in development of periodontal lesion.
However, a finite set of pathogenic bacteria, sometimes working alone, or in combinations, cause periodontal diseases in humans. Simple antimicrobial treatment is not enough to treat the aggressive periodontitis, since the presence of both gram-negative and positive anaerobic and facultative rods, gram positive anaerobic cocci, have been reported in the periodontal lesions. Most of them have shown a variety and variability in sensitivity to antibiotics.
Three pathogens have an especially strong association with the presence of progressive periodontal disease: Actinobacillus actinomycetemcomitans, spirochetes of acute narcotizing gingivitis, and Porphyromonas gingivalis . One potential virulence factor recently ascribed to P. gingivalis and A. actinomycetemcomitans, which is shared by a number of respiratory and enteric pathogens, is the ability to enter mammalian cells. These pathogens are very often the cause of continued loss of periodontal attachment despite diligent conventional mechanical periodontal therapy, as well as causing refractory periodontitis, localized juvenile periodontitis, and other types of early-onset periodontitis.
Evaluation of the patient’s periodontal status requires obtaining a relevant medical and dental history and conducting a thorough clinical and radiographic examination, with evaluation of extraoral and intraoral structures. A medical history should be taken and evaluated to identify predisposing conditions that may affect treatment, patient management and outcomes. Such conditions include, but are not limited to, diabetes, hypertension, and pregnancy. Factors, which may also play a role in treatment outcome, are smoking, substance abuse and medications.