Periodontology 2000, Vol. 65, 2014, 107133 2014 John Wiley & Sons A/S.
y & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Treatment of aggressive
periodontitis
WIM TEUGHELS, RUTGER DHONDT, CHRISTEL DEKEYSER & MARC QUIRYNEN
Aggressive periodontitis comprises a group of rapidly
progressing forms of periodontal disease that occur
in otherwise clinically healthy individuals. It is
accepted that, compared with patients with chronic
periodontitis, patients with aggressive periodontitis
show a more rapid attachment loss and bone
destruction that occurs earlier in life. The patients
age when attachment loss is detected is often the
criterion used by clinicians to diagnose aggressive
periodontitis and to distinguish aggressive periodon-
titis from chronic adult periodontitis [reviewed by
Albandar in this volume of Periodontology 2000 (3)].
Typically, aggressive periodontitis runs in families
(familial aggregation), pointing towards a genetic
predisposition. These three features (i.e. rapid
attachment loss, bone destruction that occurs early
in life and familial aggregation) are considered to be
the primary features of this disease. In the Workshop
for a Classication of Periodontal Diseases and Con-
ditions, the secondary features of aggressive period-
ontitis were identied as (i) relatively low amounts
of bacterial deposits despite severe periodontal
destruction, (ii) presence of hyper-responsive macro-
phage phenotypes, and (iii) increased portions of
Aggregatibacter actinomycetemcomitans and Porphy-
romonas gingivalis (46). Recently an entire volume of
Periodontology 2000 was devoted to the differences
in clinical (5) and histopathological (93) features,
epidemiological patterns (24), microbiological (4) and
immunological (29, 81) aspects, and genetic and envi-
ronmental risk factors (94) between aggressive peri-
odontitis and chronic periodontitis. From these
reviews it becomes clear that there are indeed
major differences between aggressive periodontitis
and chronic periodontitis. Despite these major
differences, it is not always easy to differentiate these
two disease entities clinically. However, from a
research perspective, it is essential that these diseases
can be, and are, clearly distinguished in order to gain
PERIODONTOLOGY 2000
a complete understanding of their etiology and
pathogenesis (5). Also, as pointed out throughout
this review, from a treatment perspective, distinction
is of major importance. Additionally, patients with
aggressive periodontitis are often diagnosed as having
a localized form or a generalized form of disease.
Each form has its own typical clinical features. The
relative lack of clinical inammation, often associated
with the localized molar-and-incisor form of
aggressive periodontitis, has been recognized for
almost 100 years. It is generally accepted that
this form of the disease is most often associated with
a thin biolm, at least in its early stages. In con-
trast, the presence of clinical inammation in gener-
alized aggressive periodontitis appears to be similar
to that observed in chronic periodontitis. In this
situation, age of onset and familial aggregation are
important additional criteria for either diagnosis or
classication. It is also becoming more commonly
recognized that chronic periodontitis may occur
simultaneously with both localized and generalized
forms of aggressive periodontitis (reviewed in refer-
ence 5).
The overall treatment concepts and goals in
patients with aggressive periodontitis are not mark-
edly different from those in patients with chronic
periodontitis. Therefore, the different treatment
phases (systemic, initial, re-evaluation, surgical,
maintenance and restorative) are similar for both
types of periodontitis. However, the considerable
amount of bone loss relative to the young age of
the patient and the high rate of bone loss warrants
a well-thought-through treatment plan and an
often more aggressive treatment approach, in order
to halt further periodontal destruction and regain
as much periodontal attachment as possible. The
ultimate goal of treatment is to create a clinical
condition that is conducive to retaining as many
teeth as possible for as long as possible.
107
Teughels et al.
Diagnosis and treatment planning
Given the rapid progression of the disease and the
high degree of difculty in gaining control of the
disease, diagnosis and treatment of aggressive peri-
odontitis should preferably be carried out by a peri-
odontist. However, the general practitioner does play
an essential role in the early detection of patients
who potentially have aggressive periodontitis. For a
proper diagnosis, a thorough review of the patients
medical history, medications, family history and
social history is required. In addition to an anamne-
sis, screening tests can be performed to establish
systemic modifying factors such as diabetes and
hematological conditions. Should a systemic disease
be present, for instance poorly controlled diabetes,
specialist medical consultation should be sought.
Furthermore, risk factors, such as smoking and stress,
must be identied.
The diagnosis should be made based on the above-
mentioned criteria and considerations, together with
a thorough mapping of the periodontal condition,
which includes the recording of probing pocket
depths, clinical attachment levels, bleeding on prob-
ing, furcation involvement, suppuration and tooth
mobility, and an assessment of the patients level of
oral hygiene. These data, together with a radiological
analysis, are of utmost importance for screening and
for establishing the proper diagnosis and a differen-
tial diagnosis. The diagnosis will also be a clear start-
ing point for proper treatment planning, for
evaluating and explaining treatment effects to the
patient and for patient education.
It is important to realize that even the most aggres-
sive and advanced cases of periodontitis are treatable.
Case reports have been published with a follow-up of
up to 19 years for patients with localized aggressive
periodontitis (65) and a follow-up of up to 40 years
for patients with generalized aggressive periodontitis
(67). However, it is essential for the patient to be
highly compliant and highly motivated to do his part
in order to gain control of the disease. A concerted
effort must therefore be made by the clinician to
inform the patient about the severity of the disease
and the risk factors, and the role of the patient in the
treatment. Also, the patient must be instructed very
precisely about the necessary oral-hygiene measures.
Furthermore, the clinician must assist the patient in
controlling risk factors, such as smoking.
Considerable evidence points to a familial aggrega-
tion of aggressive periodontitis [discussed by Vieira &
Albandar in this volume of Periodontology 2000 (104)].
Therefore, it is the practitioners duty to inform the
108
patient of this aspect and at least suggest screening
other family members once the diagnosis has been
established. The patient should be asked about the
periodontal condition of their close relatives and, if
possible, these relatives should seek consultation with
a periodontist (11, 68).
Initial phase
Treatment of aggressive periodontitis starts with
patient education and ensuring patient compliance.
A considerable amount of time should be invested in
establishing a good patientclinician relationship.
The time devoted to this, before commencing any
form of active treatment and during the whole pro-
cess of periodontal therapy, will have an impact on
treatment success that should not be underestimated.
The patient should be clearly informed about the dis-
ease process, contributing factors, the different
phases and goals of the treatment, the predictability
of treatment success and the patients own crucial
role in the treatment. The patient should be aware
that, for success, it is essential for optimal compliance
in plaque control and maintenance and for possible
modiable risk factors to be addressed. If the clinician
doubts the compliance of the patient, several pre-
treatment visits could be included in the treatment
plan, in which compliance with oral-hygiene instruc-
tions can be monitored and enhanced, together with
compliance towards, for example, a smoking-cessa-
tion protocol.
Owing to the aggressive nature of the disease, clini-
cians are often faced with teeth that are severely peri-
odontally compromised. The prognosis of these teeth
needs to be discussed with the patient when setting
up a treatment plan (8). One of the most difcult
aspects is whether or not to extract a tooth. It is often
stated that retention of hopeless teeth, but also of
teeth with a doubtful prognosis, can compromise the
treatment outcome. Leaving residual pockets of
 6 mm is a risk factor for the progression of peri-
odontal disease after active treatment (57). Residual
deep pockets are niches in the mouth where consid-
erable numbers of pathogenic bacteria can remain,
even after treatment. Earlier studies have reported
the disappearance of pathogenic bacteria from the
mouth after extraction of compromised teeth, thus
preventing recolonization of other teeth (19). A pro-
tective effect of extracting such compromised teeth
has been identied in young children (78). It is there-
fore suggested that a more radical extraction protocol
is justied when treating patients with aggressive

periodontitis. However, the use of high-sensitivity
bacterial-detection techniques has indicated that
even after a full-mouth tooth extraction, periodontal
pathogens remain in the mouth. Van Assche et al.
(100) performed a full-mouth tooth extraction in nine
patients and took microbial samples of subgingival
plaque, the tongue dorsum and the saliva before
extraction, and samples of the tongue dorsum and
the saliva 6 months after extraction. Using a quantita-
tive PCR analysis, the authors showed that, although
tooth extraction resulted in signicant reductions in
the numbers of periodontal pathogens, it failed to
eliminate the pathogenic species from the mouth
(100). A study by the same authors investigated the
microbial ecology in the newly formed pockets
around implants placed in patients 36 months after
a full-mouth tooth extraction. They showed that as
soon as 1 week after abutment connection, the detec-
tion frequencies of pathogenic bacteria around the
newly placed implants had risen to detection fre-
quencies comparable with those before extraction.
The bacterial numbers, however, were lower than
before extraction (77). As a full-mouth extraction of
periodontally compromised teeth does not result in
the elimination of pathogens from the mouth, the
extraction of compromised teeth in the dentate
patient will probably not result in sufcient protec-
tion from recolonization around other teeth. Thus,
extraction of teeth should not be advocated for pre-
venting colonization around other teeth in the
mouth.
Although the ultimate goal in the treatment of
aggressive periodontitis is to create a clinical condi-
tion that is conducive to retaining as many teeth as
possible for as long as possible, this is obviously dif-
cult because patients with aggressive periodontitis
are considerably younger than the average patient
with chronic periodontitis. This age aspect interferes
with treatment and treatment planning at different
levels, some of which are not often considered.
One level is the psychological impact of the mes-
sage that multiple teeth need to be extracted in young
patients. Whilst there are currently no studies that
address this aspect in patients with aggressive peri-
odontitis, there are some indications that the impact
of tooth loss on people and their lives should not be
underestimated. Davis et al. (20) reported that in a
cohort of 94 fully edentulous patients, 45% reported
retrospectively to have experienced difculties in
accepting their tooth loss. In the cohort of Naik & Pay
(66), which comprised 400 fully and partially edentu-
lous patients, only 25% of the patients reported hav-
ing difculties in accepting the loss of their teeth. One
Aggressive periodontitis treatment
of the major differences between both studies was the
age of the patients, which was above 60 years in the
study by Naik & Pay (66) but of a wider range
(31 years and older) in the study by Davis et al. (20).
It cannot be directly derived from the latter paper
whether younger patients experience more coping
problems than do older patients, but it could be a
reasonable hypothesis. Additionally, one should take
into account that the patients attitude toward tooth
loss might be different in different parts of the world.
Similarly, one could hypothesize that the compro-
mised esthetics after periodontal therapy might have
a signicant effect on the general and psychological
well-being, self-esteem and daily social life of younger
patients.
Another level on which age impacts treatment in
aggressive periodontitis is the prosthetic rehabilita-
tion. Obviously, when teeth are extracted, the
patient will seek adequate prosthetic rehabilitation.
Although teeth can have a life expectancy of over
80 years, there is currently no single type of pros-
thetic device with a similar life expectancy. This
means that the age of the patient when a tooth/
teeth are extracted can play a decisive role in the
patients quality of life. Early extraction of a puta-
tively questionable tooth in a 40-year-old patient
with a life expectancy of 80 years could mean the
start of time-consuming and expensive prosthetic
treatment for the next 40 years (30, 51, 74). How-
ever, when considering that several studies have
demonstrated that compromised teeth can survive
for decades, given that a proper maintenance pro-
gram is followed. In this regard, Graetz et al. (30)
followed 34 patients with aggressive periodontitis
and 34 patients with chronic periodontitis, who
had two or more teeth with alveolar bone loss of
 50%, for 15 years. After 15 years they found that
in the patients with aggressive periodontitis, 88.2%
of the teeth with a questionable prognosis and
59.5% of the teeth with a hopeless prognosis had
survived (30). These authors did not nd any sig-
nicant difference in tooth-survival rate between
patients with aggressive periodontitis and patients
with chronic periodontitis. It has been suggested
that teeth with a predicted questionable prognosis
as a result of severe bone loss should not be trea-
ted periodontally, but rather extracted early to
avoid possible involvement of neighboring teeth. In
regard to this aspect, it has been shown that long-
term preservation of hopeless teeth is an attainable
goal with no detrimental effect on the adjacent
teeth (53). The treatment of periodontally compro-
mised teeth that have advanced bone loss is a
109
Teughels et al.
meaningful, therapeutic approach to prevent tooth
loss with the consequence of prosthetic rehabilita-
tion. Several studies have been performed in which
the prognosis of dental implants in periodontally
healthy subjects has been compared with the prog-
nosis of dental implants in subjects with aggressive
periodontitis. De Boever et al. (21) placed implants
in, and followed up, 110 patients. Sixty-eight of
these patients had suffered from chronic periodon-
titis and 16 from generalized aggressive periodonti-
tis. After a follow-up period of 100 months in
which the patients were enrolled in a maintenance
program, there was a signicant difference in
implant survival between the chronic periodontitis
and generalized aggressive periodontitis groups,
with implant-survival rates of 96% and 80%,
respectively (21). Swierkot et al. (96) evaluated the
prevalence of mucositis and peri-implantitis,
implant success and implant survival in patients
treated for generalized aggressive periodontitis,
over a period of 516 years, comparing them with
periodontally healthy subjects. They found that
patients with generalized aggressive periodontitis
had a ve times greater risk of implant failure, a
three times higher risk of developing mucositis and
a 14 times greater risk of developing peri-implantitis
(96). Similarly to these studies, Mengel & Floris-
de-Jacoby (60) studied 39 patients over a 3-year per-
iod following implant placement: 15 patients were
treated for generalized aggressive periodontitis, 12
for chronic periodontitis and 12 patients were peri-
odontally healthy. The results showed that the
increase in pocket depth and attachment loss was
greater, and the implant-survival rate was lower, for
subjects with generalized aggressive periodontitis
than for periodontally healthy subjects or patients
with chronic periodontitis (60). From the aforemen-
tioned studies it can be concluded that implant sur-
vival in patients with generalized aggressive
periodontitis is lower than in periodontally healthy
subjects, or even in patients with chronic periodon-
titis. For localized aggressive periodontitis speci-
cally there is very little evidence on which to base
any conclusions. Clinicians should be aware of this
when they consider implant-supported restorations
for replacing teeth in patients with aggressive peri-
odontitis, especially as patients with aggressive
periodontitis are generally of a younger age than are
patients with chronic periodontitis. This means that
dental restorations need to remain functional and
retain good esthetics for a longer period of time in
these patients. Consulting with other dental special-
ists to assess the strategic restorative value of
110
certain teeth or to assess alternative restorative
options, such as orthodontic treatment, might help
in the nal decision of whether to extract or to
retain.
Active periodontal treatment
Despite better insights into the etiology of aggressive
forms of periodontitis, initial treatment is directed
toward the bacterial load in the periodontal pockets.
As such, there is no difference between the treatment
concepts used for treating chronic periodontitis
or aggressive periodontitis. However, the clinical
response to nonsurgical therapy is much less docu-
mented for aggressive periodontitis than for chronic
periodontitis. The number of studies assessing the
effect of periodontal treatment on aggressive peri-
odontitis is limited and they often report on only a
small number of patients. This primarily relates to the
low prevalence of this disease, and this hampers the
execution of comparative clinical trials.
Nonsurgical therapy
Although the effect of nonsurgical treatment on
chronic periodontitis is well documented (39), its effect
on aggressive periodontitis is much less clear. In rela-
tion to the effect of nonsurgical therapy alone as a
treatment for aggressive periodontitis, two aspects
seem of importance. The rst aspect relates to the
question of whether, and to what extent, scaling and
root planing alone can result in the desired clinical
changes, such as probing pocket-depth reduction, gain
in clinical attachment and reduction in bleeding on
probing. Ideally, this aspect is derived from data on
the magnitude of the effect on the clinical parameters
(e.g. the amount of probing pocket-depth reduction)
combined with data on the predictability (e.g. the pro-
portion of patients responding to treatment). Unfortu-
nately, the latter is often not reported. The second
aspect relates to the long-term stability of the results
obtained. For this, longitudinal data are necessary.
For localized aggressive periodontitis, the effect of
nonsurgical therapy alone can be derived from stud-
ies in which scaling and root planing represent the
rst phase of a staged combination therapy. In this
regard, Slots & Rosling (92), evaluated 20 deep pock-
ets in six patients with localized aggressive periodon-
titis and reported a small reduction of 0.3 mm in the
probing pocket depth 16 weeks after scaling and root
planing. However, this reduction was accompanied
by a small average loss, of 0.05 mm, in clinical

attachment. Similarly to these observations, Korn-
man & Robertson (44) reported an average probing
pocket-depth reduction of 0.1 mm in eight patients,
2 months after scaling and root planing. This virtual
absence of clinical response is, however, contradicted
by data from comparative studies in which scaling
and root planing alone represented the control treat-
ment of the study. Reporting on 19 patients with
localized aggressive periodontitis, Palmer et al. (72)
showed an average reduction of approximately
0.8 mm in probing pocket depth and an average gain
in clinical attachment of approximately 0.3 mm for
the affected teeth, 3 months after scaling and root
planing. Also, a reduction in bleeding on probing was
observed. Asikainen et al. (6) even reported an aver-
age probing pocket-depth reduction of 1.4 mm in
eight patients, 2 months after scaling and root plan-
ing. Unfortunately, none of the above-mentioned
studies performed a statistical analysis of the
observed effects. However, Unsal et al. (99) analyzed
the clinical effect of scaling and root planing alone in
nine patients with localized aggressive periodontitis
included in the control group of their study. Three
months after performing scaling and root planing,
pocket-depth reduction of 1.8 mm and clinical
attachment gain of 1.2 mm was recorded. These
effects were accompanied by a signicant reduction
in bleeding on probing, from 47.1% to 10.1%.
Although the average probing pocket depth was not
provided by Saxe n et al. (83), it is interesting to note
that the four patients with localized aggressive peri-
odontitis in the control group of the study who did
not receive surgery, showed a signicant reduction in
the percentage of sites with a probing pocket depth of
>4 mm, from 19.4% at baseline to 2.8% 20 months
after scaling and root planing. These ndings are in
line with those reported by Gunsolley et al. (35), who
recalled 19 treated and 21 untreated patients with
localized aggressive periodontitis, approximately
4 years after initial therapy. Some of the treated
patients also received open ap curettage but,
according to the authors, there was no signicant dif-
ference in response between both groups of treated
patients. Although no statistical comparison between
the baseline and the recall data (approximately
4 years after baseline) was performed, the clinical
data show, for the treated patients, a reduction in
probing pocket depth of 0.2 mm and a gain in clinical
attachment of 0.3 mm. Interestingly, probing pocket
depth was increased by an average of 0.2 mm, and an
additional loss of attachment of 0.3 mm was recorded
for the untreated patients with localized aggressive
periodontitis.
Aggressive periodontitis treatment
These limited data and statistical analyses on the
effect of scaling and root planing in patients with
localized aggressive periodontitis hamper a solid con-
clusion on its effectiveness and long-term stability.
However, based on these data, it seems that scaling
and root planing improves the clinical parameters in
patients with localized aggressive periodontitis, which
contradicts the reports from the 1980s. Its predictabil-
ity is unknown, but the clinical effects can be
recorded for up to 3 years after treatment.
The effect of root planing alone on generalized
aggressive periodontitis is much better documented,
although only one study has been specically
designed to assess the effect on clinical parameters.
Hughes et al. (38) re-evaluated 79 patients with gen-
eralized aggressive periodontitis, 10 weeks after scal-
ing and root planing. They reported statistically
signicant mean changes in overall probing pocket
depth of 0.4  1.7 mm, and of 2.1  2.0 mm for ini-
tially deep pockets. An overall gain in clinical attach-
ment of 0.2  1.93 mm was also recorded, and for
deep sites this was 1.77  2.15 mm. The percentage
of bleeding on probing was reduced by 34%. Interest-
ingly, the authors reported that 32% of the patients
did not respond to treatment. Probably, this large
proportion of nonresponders can explain the large
standard deviation values observed in this study. The
nonresponding patients were primarily smokers. The
observation that scaling and root planing indeed
reduces clinical probing pocket depth and bleeding
on probing, and results in a gain of attachment, is
also conrmed by several comparative studies inves-
tigating the adjunctive effect of antimicrobials where
the control group was treated with scaling and root
planing alone (1, 7, 12, 34, 36, 37, 62, 76, 82, 88, 103,
106, 107) (Table 1). These studies show average
whole-mouth probing pocket-depth reductions rang-
ing from 0.7 to 1.5 mm, and average gains in clinical
attachment ranging from 0.2 to 1.4 mm. For the
majority of these studies the clinical changes were
statistically signicant. These results conrm the
effectiveness of scaling and root planing in patients
with generalized aggressive periodontitis, at least for
the short term. In most of these studies the outcome
of scaling and root planing was assessed, for the rst
time, 26 months after the baseline measurements
had been performed. However, some studies followed
the clinical results over time, up to 24 months after
scaling and root planing, and the data from these
studies can provide important information on the sta-
bility of the clinical results obtained. The majority of
these studies show that the probing pocket-depth
reductions (1, 12, 36, 37, 88, 103, 107) and gains in
111
 Table 1. Summary table of comparative studies using adjunctive systemic antibiotics in patients with generalized aggressive periodontitis

112
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
Teughels et al.

number) initial baseline baseline baseline

treatment and
retreatment

Sigusch et al. Generalized Scaling and Full-mouth Control 10 Probing depth 5.9  0.7 5.5  0.7 4.6  1.0 5.2  0.7
2001 (88) aggressive root planing root planing (mm)
periodontitis in four in two sessions
Probing depth 8.2  1.0 8.1  0.1 5.9  1.2 7.0  1.0
to ve within 48 h (3
deep (mm)
sessions weeks after
completion Clinical 6.3  0.8 6.0  0.9 5.7  1.0 5.9  0.8
of initial attachment
therapy) level (mm)

Bleeding on Not Not Not Not

probing (%) determined determined determined determined

Doxycycline 8 days 12 Probing depth 5.5  0.6 5.4  0.6 3.9  0.8 4.2  1.1
(200 mg/ (mm)
day)
Probing depth 8.6  1.2 7.8  1.1 5.2  0.8 6.6  0.9
deep (mm)

Clinical 6.0  1.1 5.9  1.0 4.8  0.8* 5.1  0.9

attachment
level (mm)

Bleeding on Not Not Not Not

probing (%) determined determined determined determined

Metronidazole 8 days 15 Probing depth 5.8  0.7 5.8  1.0 3.6  0.8* 3.2  0.7
(1000 mg/day) (mm)

Probing depth 8.1  1.1 7.6  1.0 3.6  1.1* 3.3  1.1
deep (mm)

Clinical 6.2  1.0 6.0  0.7 4.3  0.7* 4.0  1.1

attachment
level (mm)

Bleeding on Not Not Not Not

probing (%) determined determined determined determined

Clindamycin 8 days 11 Probing depth 5.7  1.1 5.6  0.8 3.5  1.0* 3.4  0.8
(600 mg/day) (mm)

Probing depth 8.4  0.8 8.0  1.0 4.2  1.1* 3.6  1.0
deep (mm)

Clinical 6.1  1.0 6.4  0.8 4.4  1.0* 4.2  0.9

attachment
level (mm)

Bleeding on Not Not Not Not

probing (%) determined determined determined determined
 Table 1. (Continued)
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
number) initial baseline baseline baseline
treatment and
retreatment

Guerrero et al. Generalized Scaling and Placebo 7 days 21 Probing depth Data not
2005 (34) aggressive root planing (mm) included
periodontitis in 1 day + as they
Probing depth
chlorhexidine report
deep
rinse twice on
(mm)
daily for changes
14 days Clinical
attachment
level (mm)

Bleeding on
probing (%)

Metronidazole 7 days 20 Probing depth

(1500 mg/day) (mm)
Amoxicillin
Probing depth
(1500 mg/day)
deep (mm)

Clinical
attachment
level (mm)

Bleeding on
probing (%)
Aggressive periodontitis treatment

113
 Table 1. (Continued)

114
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
Teughels et al.

number) initial baseline baseline baseline

treatment and
retreatment

Xajigeorgiou Generalized Scaling Ultrasonic Control 11 Probing depth 4.2  0.7 3.2  0.6* 3.5  0.8* Data
et al. 2006 aggressive and root debridement (mm) derived
(106) periodontitis planing in (6 weeks after from
Probing depth Not Not Not
four visits completion of graphs.
deep (mm) determined determined determined
scaling and root Additional
planing) Clinical 4.6  0.7 3.8  0.6* 4.1  0.6* data were
attachment provided
level (mm) as changes

Bleeding on 78  37 33  24* 15  25*

probing (%)

Metronidazole 7 days 10 Probing depth 4.6  1.0 3.4  0.5* 3.1  0.7*
(1500 mg/day) (mm)
Amoxicillin
Probing depth Not Not Not
(1500 mg/day)
deep (mm) determined determined determined

Clinical 5.0  1.0 4.3  0.9* 4.0  1.3*

attachment
level (mm)

Bleeding on 87  21 22  18* 15  14*

probing (%)

Doxycycline 14 days 10 Probing 4.2  0.6 3.5  0.7* 3.4  0.8*

(200 mg on depth (mm)
day 1;
Probing depth Not Not Not
100 mg/day
deep (mm) determined determined determined
thereafter)
Clinical 5.0  1.4 4.4  1.7* 4.2  1.9*
attachment
level (mm)

Bleeding on 81  25 24  23* 14  22*

probing (%)

Metronidazole 7 days 12 Probing depth 4.7  0.6 3.5  0.5*(a) 2.9  0.6*(a)
(1500 mg/day) (mm)

Probing depth Not Not Not

deep (mm) determined determined determined

Clinical 5.4  1.3 4.6  1.1* 4.1  1.3*

attachment
level (mm)

Bleeding on 80  36 29  15* 21  31*

probing (%)
 Table 1. (Continued)
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
number) initial baseline baseline baseline
treatment and
retreatment

Haas et al. Generalized Scaling and Placebo 12 Probing depth Not Not Not
2008 (36) aggressive root planing in (mm) determined determined determined
periodontitis four to six
Probing depth 7.5  0.4 5.3  0.4* 4.8  0.4* 5.1  0.4*
sessions
deep (mm)
within 14 days
Clinical Not Not Not Not
attachment determined determined determined determined
level (mm)

Bleeding on Not Not Not Not

probing (%) determined determined determined determined

Azithromycin 3 days 12 Probing depth Not Not Not Not

(1500 mg/day) (mm) determined determined determined determined

Probing depth 7.3  0.6 4.9  0.4* 3.9  0.5* 4.3  0.4*
deep (mm)

Clinical Not Not Not Not

attachment determined determined determined determined
level (mm)

Bleeding on Not Not Not Not

probing (%) determined determined determined determined

Machtei et al. Five with Scaling and Doxycycline 30 days 15 Probing depth 4.09  0.1 3.37  0.1
2008 (54) localized root planing in (100 mg/day, (mm)
aggressive four sessions after a loading
Probing depth Not Not Not Not Not
periodontitis with weekly dose of 200 mg)
deep (mm) determined determined determined determined determined
and 24 with intervening
generalized intervals Clinical 4.93  0.3 4.02  0.2
aggressive under attachment
periodontitis coverage level (mm)
of antibiotics
Bleeding on Not Not Not Not Not
probing (%) determined determined determined determined determined

Metronidazole 14 days 14 Probing depth 4.29  0.2 3.53  0.2

(750 mg/day) (mm)
Amoxicillin
Probing depth Not Not Not Not Not
(1500 mg/day)
deep (mm) determined determined determined determined determined

Clinical 4.93  0.3 4.14  0.2

attachment
level (mm)

Bleeding on Not Not Not Not Not

probing (%) determined determined determined determined determined
Aggressive periodontitis treatment

115
 Table 1. (Continued)

116
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
Teughels et al.

number) initial baseline baseline baseline

treatment and
retreatment

Mestnik et al. Generalized Scaling and Placebo 14 days 15 Probing depth 4.1  0.6 3.2  0.6*(a)
2010 (62) aggressive root (mm)
periodontitis planing in
Probing depth Not Not
14 days +
deep (mm) determined determined
chlorhexidine
rinse twice Clinical 4.2  0.5 3.5  0.5*
daily for attachment
60 days level (mm)

Bleeding on 63.6  21.3 12.5  11.7*

probing (%)

Metronidazole 14 days 15 Probing depth 4.3  0.7 2.7  0.5*(a)

(1200 mg/day) (mm)
Amoxicillin
Probing depth Not Not
(1500 mg/day)
deep (mm) determined determined

Clinical 4.5  0.8 3.2  0.5*

attachment
level (mm)

Bleeding on 77.7  19.7 12.2  13.0*

probing (%)

Yek et al. Generalized Scaling and Placebo 7 days 16 Probing depth 3.7  0.7 2.5  0.5* 2.5  0.5* Data
2010 (107) aggressive root (mm) derived
periodontitis planing in from
Probing depth Not Not Not
two visits graphs
deep (mm) determined determined determined

Clinical 3.3  1.3 2.30  1.16* 2.4  1.1*

attachment
level (mm)

Bleeding on Not Not Not

probing (%) determined determined determined

Metronidazole 7 days 12 Probing depth 4.06  0.6 2.7  0.5* 2.6  0.4*
(1500 mg/day) (mm)
Amoxicillin
Probing depth Not Not Not
(1500 mg/day)
deep (mm) determined determined determined

Clinical 3.8  1.1 2.7  1.1* 2.8  1.3*

attachment
level (mm)

Bleeding on Not Not Not

probing (%) determined determined determined
 Table 1. (Continued)
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
number) initial baseline baseline baseline
treatment and
retreatment

Baltacioglu Generalized Scaling and Placebo 12 Probing depth 4.9  0.3 4.2  0.2*(a,b) 2 months
et al. 2011 (7) aggressive root planing (mm) instead of
periodontitis in 24 h 3 months
Probing depth Not Not
deep (mm) determined determined

Clinical 5.5  0.5 4.7  0.6*(a,b)

attachment
level (mm)

Bleeding on 95.0  0.1 37.7  0.1*

probing (%)

Metronidazole 10 days 14 Probing depth 4.9  0.7 3.4  0.4*(a,c)

(750 mg/day) (mm)
Amoxicillin
Probing depth Not Not
(750 mg/day)
deep (mm) determined determined

Clinical 5.3  0.8 4.0  0.5*(a,c)

attachment
level (mm)

Bleeding on 93.6  0.1 25.2  0.1*

probing (%)

Doxycycline 14 days 12 Probing depth 5.0  0.6 4.0  0.3*(b,c)

(200 mg (mm)
on day 1;
Probing depth Not Not
100 mg/day
deep (mm) determined determined
thereafter)
Clinical 5.7  0.8 4.6  0.4*(a,c)
attachment
level (mm)

Bleeding on 95.2  0.1 36.6  0.2*

probing (%)
Aggressive periodontitis treatment

117
 Table 1. (Continued)

118
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
Teughels et al.

number) initial baseline baseline baseline

treatment and
retreatment

Heller et al. Generalized Scaling and Placebo 10 days 15 Probing depth 4.9  0.2 3.5  0.2* 3.5  0.2*
2011 (37) aggressive root (mm)
periodontitis planing
Probing depth Not Not Not
(one-stage
deep (mm) determined determined determined
full-mouth
disinfection) Clinical 5.2  0.2 4.4  0.2* 4.4  0.2*
in 24 h + attachment
within level (mm)
1 week start
additional scaling Bleeding on 83.6  4.4 54.0  6.4* 69.0  5.3*
and root planing probing (%)
over 4-6 weeks
Metronidazole 10 days 16 Probing 5.2  0.2 3.3  0.1* 3.2  0.1*
(750 mg/day) depth (mm)
Amoxicillin
Probing depth Not Not Not
(1500 mg/day)
deep (mm) determined determined determined

Clinical 5.6  0.3 4.1  0.2* 4.1  0.3*

attachment
level (mm)

Bleeding on 85.0  3.1 45.0  3.7* 60.0  4.7*

probing (%)

Varela et al. Generalized Scaling and Placebo 10 days 15 Probing depth 4.2  0.2 3.3  0.1* 3.3  0.1*
2011 (103) aggressive root planing (mm)
periodontitis (one-stage
Probing depth Not Not Not
full-mouth
deep (mm) determined determined determined
disinfection)
in 24 h + Clinical 4.6  0.3 4.0  0.2* 3.9  0.2*
within attachment
1 week level (mm)
start
additional Bleeding on 81  4.9 50.9  3.8* 57.9  4.9*
scaling and probing (%)
root
Metronidazole 10 days 16 Probing depth 4.3  0.2 3.1  0.1* 2.9  0.1*
planing
(750 mg/day) (mm)
over 4-6
Amoxicillin
weeks Probing depth Not Not Not
(1500 mg/day)
deep (mm) determined determined determined

Clinical 4.9  0.3 3.8  0.2* 3.8  0.2*

attachment
level (mm)

Bleeding on 85.7  3.6 41.4  2.7* 45.1  4.2*

probing (%)
 Table 1. (Continued)
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
number) initial baseline baseline baseline
treatment and
retreatment

Aimetti et al. Generalized Scaling and Placebo 7 days 20 Probing depth 4.5  1.1 3.4  0.8*(a) 3.3  0.8*(b)
2012 (1) aggressive root planing (mm)
periodontitis (one-stage
Probing depth Not Not Not
full-mouth
deep (mm) determined determined determined
disinfection)
in 24 h + Clinical 5.0  1.2 4.0  1.1* 4.0  1.0*(c)
chlorhexidine attachment
rinse twice level (mm)
daily for 60
days Bleeding on 56.2  18.2 16.6  5.0*(d) 15.5  3.8*(e)
probing (%)

Metronidazole 7 days 19 Probing 4.3  1.1 2.8  0.6*(a) 2.7  0.6*(b)

(1500 mg/day) depth (mm)
Amoxicillin
Probing depth Not Not Not
(1500 mg/day)
deep (mm) determined determined determined

Clinical 4.7  1.1 3.4  0.8* 3.3  0.6*(c)

attachment
level (mm)

Bleeding on 61.5  17.7 9.3  0.8*(d) 9.4  0.6*(e)

probing (%)
Aggressive periodontitis treatment

119
120
Teughels et al.

Table 1. (Continued)
Study Type of Initial Retreatment Treatment Duration Number Clinical data
(author, patient treatment using a staged groups of patients
year and approach per group Variable Baseline Retreatment 3 months after 6 months 12 months 24 months Remarks
reference (time between baseline after after after
number) initial baseline baseline baseline
treatment and
retreatment

Casarin et al. Generalized Scaling and Placebo 7 days 12 Probing depth 5.2  0.3 3.5  0.7* 3.7  1.1*
2012 (12) aggressive root moderate (mm)
periodontitis planing in
Probing depth 7.5  0.6 4.5  0.8* 4.1  0.9*
1 day
deep (mm)

Relative clinical 7.8  1.0 6.6  1.0* 6.8  1.4*

attachment
level moderate
(mm)

Relative clinical 10.0  1.3 7.8  1.3* 7.5  1.2*

attachment
level deep (mm)

Bleeding on 34.3  6.1 11.7  2.9* 11.0  3.0*

probing (%)

Metronidazole 7 days 12 Probing depth 5.1  0.2 3.2  0.6* 3.5  0.6*
(750 mg/day) moderate (mm)
Amoxicillin
Probing depth 7.7  0.9 3.8  1.1 * 3.6  1.4*
(1125 mg/day)
deep (mm)

Relative clinical 7.5  1.9 6.4  2.1* 6.8  1.4*

attachment level
moderate (mm)

Relative clinical 9.9  1.6 7.4  2.1* 7.7  2.6*

attachment level
deep (mm)

Bleeding on 39.3  6.5 11.1  3.3* 10.3  2.0*

probing (%)

Data are presented as mean  standard deviation.

(a), (b), (c), (d), e) Statistically signicant intergroup difference.
*Statistically signicant difference from baseline.

clinical attachment (1, 12, 34, 36, 37, 88, 103) remain
stable or improve, up to 6 months after the initial
therapy (Table 1). However, in some studies, there is
already a small relapse in probing pocket-depth
reduction (34, 82, 106) or a gain in clinical attachment
(82, 106, 107) between 3 and 6 months after scaling
and root planing. Studies with longer follow-up (36,
88) show that after 6 months, probing pocket depths
start to increase and the obtained gain in clinical
attachment starts to decrease (Table 1). These nd-
ings are again in agreement with those reported by
Gunsolley et al. (35) who recalled 28 treated and 20
untreated patients with generalized aggressive peri-
odontitis, approximately 4 years after initial therapy.
Although no statistical comparison was performed
between the baseline data and the recall data, the
clinical data show an increase in probing pocket
depth of 0.3 mm and a loss in clinical attachment of
0.4 mm for the treated patients.
Based on these observations, it seems that general-
ized aggressive periodontitis responds well to scaling
and root planing in the short term (up to 6 months).
However, after 6 months, relapse and disease pro-
gression is reported, despite frequent recall visits and
oral-hygiene reinforcements.
Systemic antibiotics
Treating patients with aggressive periodontitis is
challenging. The disease responds less predictably
to conventional mechanical periodontal therapy
than chronic periodontitis (11, 90), the disease pro-
gression is rapid and severe and patients are gener-
ally of a younger age. Hence, scientists and
clinicians have been exploring adjunctive treat-
ments to enhance the outcome, stability and pre-
dictability of conventional mechanical therapy. In
view of the specic microbiological nature of both
types of aggressive periodontitis, the use of chemo-
therapeutics and, more specically, of systemic
antibiotics, could play an important role in the
treatment of these diseases.
Although it is currently well established that anti-
biotics should not be administered without prior
disruption of the bacterial biolm (64), at least two
studies have evaluated the effect of systemic antibiot-
ics as the sole form of therapy in patients with local-
ized aggressive periodontitis (17, 69, 70). These
studies show that tetracycline, systemically adminis-
tered over a period of at least 6 weeks, in combina-
tion with supragingival plaque control, decreased the
probing pocket depths and resulted in gains in clini-
cal attachment for up to at least 24 months. In addi-
Aggressive periodontitis treatment
tion, this regimen may lead to some repair of the
alveolar bone defects. These data were largely
conrmed by Slots & Rosling (92) who administered
1 g of tetracycline for 2 weeks after completion of an
initial phase of scaling and root planing. The scaling
and root planing reduced the total subgingival bacte-
rial counts and the proportions of certain gram-nega-
tive bacteria, but no periodontal pocket became free
of A. actinomycetemcomitans, and the study reported
small clinical changes after debridement. However,
the administration of tetracycline, 6 weeks following
scaling and root planing, and in the absence of a new
phase of instrumentation, resulted in a gain in clinical
attachment level of 0.27  0.45 mm and suppression
of A. actinomycetemcomitans, Capnocytophaga and
spirochetes to low or undetectable levels in all test
periodontal pockets. Although these were important
observations in relation to our understanding of
aggressive periodontitis, and although they were
recently conrmed in patients with chronic periodon-
titis using metronidazole and amoxicillin (50), newer
data do not validate the treatment approach that was
used in the latter study. There is currently a clear con-
sensus that mechanical instrumentation must always
precede antimicrobial therapy. One should rst
mechanically reduce the subgingival bacterial load,
which might otherwise inhibit or degrade the antimi-
crobial agent. Furthermore, one should mechanically
disrupt the structured bacterial aggregates that can
protect the bacteria from the agent (64). Insufcient
concentrations of the active agent may favor the
emergence of resistant bacterial strains.
Surprisingly, little investigation has been carried
out into the adjunctive effect of systemic antibiotics
on the outcome of mechanical instrumentation in
patients with localized aggressive periodontitis. The
rst reports can be traced back to the end of the
1970s (91); however, few studies have focused speci-
cally on localized aggressive periodontitis. It is obvi-
ous that this hampers our current understanding of
the use of systemic antibiotics in the treatment of this
patient group. Furthermore, the approach, in terms
of the set-up of the studies, the combination of differ-
ent treatments used and the way of reporting data,
was markedly different in these older papers from
what is now considered to be the standard. Even
more importantly, the development and the expo-
nential increase of antibiotic resistance over the past
two decades should increase our awareness that the
antibiotic regimens used then might no longer be as
effective. It must be considered that the absence of
clinical trials addressing the issue of adjunctive sys-
temic antibiotics in the treatment of localized
121
Teughels et al.
aggressive periodontitis does not reect a lack of
interest in this disease. However, the low prevalence
of localized aggressive periodontitis makes it hard to
nd sufcient numbers of patients, which might be a
reason for this lack of new studies. On the other hand,
this lack might reect a publication bias owing to the
absence of any signicant adjunctive effect of sys-
temic antibiotics. There is therefore an urgent need
for new clinical trials addressing this issue.
Although the adjunctive effect of tetracycline on
scaling and root planing was observed by Slots et al.
in 1979 (91), the limited number of patients in the
study does not allow a denitive conclusion to be
reached. Kornman & Robertson (44) reported on the
administration of systemic tetracycline (1 g/day for
28 days) as an adjunct to scaling and root planing,
starting on the rst day of scaling and root planing. It
is assumed from their article that scaling and root
planing was completed within the 28-day period in
which the patients were taking the systemic antibiot-
ics. Although this study was not placebo controlled,
the eight patients included served as their own
controls because they received scaling and root plan-
ing without tetracycline 2 months before receiving
scaling and root planing supplemented with systemic
tetracycline. The authors concluded that scaling
and root planing alone had essentially no effect on
either clinical or microbiological parameters. The
mean probing pocket depth was reduced from
8.0  1.1 mm to 7.9  1.1 mm in this study. How-
ever, when scaling and root planing was repeated in
conjunction with systemic tetracycline, an additional
mean reduction in probing pocket depth to
6.4  1.3 mm was recorded.
Despite several reports on the adjunctive use of sys-
temic antibiotics during periodontal treatment
(including surgery) of localized aggressive periodonti-
tis (45, 56, 84), none of these studies actually evalu-
ated the effect of antibiotics relative to scaling and
root planing alone. The rst actual randomized pla-
cebo-controlled study was published by Asikainen
et al. in 1990 (6). Sixteen patients were randomized
into a placebo group and a group that received sys-
temic doxycycline at a loading dose of 200 mg and
doses of 100 mg daily for 14 days thereafter. All
patients received scaling and root planing as part of
their treatment. Scaling and root planing was per-
formed over an 8-week period, although the systemic
antibiotic or placebo was only used during the rst
2 weeks of the scaling and root planing. No signi-
cant differences were found between groups in prob-
ing pocket depth and bleeding on probing, during
and at the end of the study.
122
These results encouraged the researchers to explore
the effect of other systemic antibiotics. Saxe n &
Asikainen (83) randomized 27 patients into a placebo
group, a tetracycline group (1 g/day for 12 days) and
a metronidazole group (600 mg/day for 10 days).
Scaling and root planing was performed at baseline
and was repeated at 3 months. At 6 months postop-
eratively, the periodontal condition had improved in
all groups. However, in the metronidazole group
the percentage of pockets deeper than 4 mm was
reduced more than in the other groups. Additionally,
only one patient was still positive for A. actinomyce-
temcomitans, whereas in the tetracycline and control
groups, four and six patients, respectively, were still
positive for the bacterium. Whilst no statistical analy-
sis was performed, the authors concluded that there
was a higher predictability of the treatment results of
scaling and root planing when the treatment was per-
formed with adjunctive use of metronidazole than
with tetracycline.
In contrast to these results, Palmer et al. (72) evalu-
ated the effect of adjunctive tetracycline (1 g/day for
14 days) in 38 patients. Scaling and root planing was
performed within 7 days, and the antibiotics were
administered starting from the last scaling and root
planing session. Three months after baseline the
improvements in probing pocket depth, clinical
attachment level and bleeding on probing were sig-
nicantly better in the tetracycline group. These
results, in relation to the whole study, which also
included a surgical phase, led the authors to conclude
that systemically administered tetracycline is a useful
adjunct in the nonsurgical treatment phase of local-
ized aggressive periodontitis. However, administering
the antibiotic at the surgical phase did not provide
any further, statistically signicant, advantage.
Tinoco et al. (98) evaluated the effect of metronida-
zole (750 mg/day for 8 days) combined with amoxi-
cillin (1500 mg/day for 8 days) as an adjunct to
scaling and root planing in a randomized, placebo-
controlled study involving 20 patients with localized
aggressive periodontitis. Although 1 year after treat-
ment, both groups showed signicant clinical bene-
ts, patients who had received systemic antibiotics
adjunctively showed better results regarding probing
pocket depth, clinical attachment level, gingival
bleeding index and radiological bone ll.
As it seems, from the above-mentioned studies,
that adjunctive systemic antibiotics improve the clini-
cal outcome in patients with localized aggressive peri-
odontitis, the question arises of whether the type of
antibiotic is of importance. This aspect was addressed
by Akincibay et al. (2), who compared the clinical

outcome of systemic doxycycline vs. systemic metro-
nidazole combined with amoxicillin during scaling
and root planing. They randomly divided 30 patients
into two treatment groups. The rst group received
100 mg of doxycycline for 10 days and the second
group received 375 mg of amoxicillin and 250 mg of
metronidazole three times a day for 10 days. They
found that both groups showed signicant improve-
ments in plaque index, gingivitis index, periodontal
probing depth and clinical attachment level values.
The metronidazole plus amoxicillin group showed
signicantly more improvement in plaque index and
gingivitis index. Although the authors reported no
statistically signicant differences in probing pocket
depths and attachment levels between both groups at
the end of the study, there was at least a clear ten-
dency for more improvement in the metronidazole
plus amoxicillin group.
In contrast to localized aggressive periodontitis, the
effect of systemic antibiotics as an adjunct to scaling
and root planing in generalized aggressive periodon-
titis has been subjected to many more randomized,
placebo-controlled studies. Among a variety of anti-
biotics that can be used and have been tested as
adjuncts in generalized aggressive periodontitis, the
combination of amoxicillin and metronidazole is
becoming advocated to an increasing extent. The
rationale behind combining both antibiotics has
found its origin in the observation that A. actinomyce-
temcomitans was resistant to tetracycline, the antibi-
otic of choice in the 1990s (83, 105). The failure of
tetracycline to suppress A. actinomycetemcomitans,
together with in-vitro data showing the synergistic
effect of metronidazole and amoxicillin on A. actino-
mycetemcomitans (73) instigated van Winkelhoff et al.
(101) to study the efcacy of this antibiotic combina-
tion to eliminate A. actinomycetemcomitans from
subgingival sites. The combination of 250 mg of metro-
nidazole and 375 mg of amoxicillin, three times a day
for 7 days, as an adjunct to scaling and root planing,
was found to be very effective in suppressing subgin-
gival A. actinomycetemcomitans (101). Both microbio-
logical and clinical effectiveness of this combination
therapy has been shown for patients with chronic
periodontitis (86). Recently, Sgolastra et al. (87) per-
formed a meta-analysis of the effectiveness of the
adjunctive use of amoxicillin and metronidazole in
patients with generalized aggressive periodontitis and
included six randomized, placebo-controlled clinical
trials (7, 34, 62, 103, 106, 107) published up to Sep-
tember 2011. The study results clearly showed an
adjunctive effect of the amoxicillinmetronidazole
combination in patients with generalized aggressive
Aggressive periodontitis treatment
periodontitis. Despite the fact that the majority of the
included studies individually failed to show a statisti-
cally signicant effect, signicant mean differences in
clinical attachment gain of 0.42 mm, pocket-depth
reduction of 0.58 mm, bleeding on probing changes
of 14.95% and gingival bleeding changes of 21.44%
were calculated in favor of the antibiotics. It is inter-
esting to note that the mean differences for clinical
attachment gain, probing pocket-depth reduction
and bleeding on probing in patients with aggressive
periodontitis were higher than the mean differences
reported in another meta-analysis by the same
authors, which investigated the adjunctive effect
of the amoxicillinmetronidazole combination in
patients with chronic periodontitis (86). This may
suggest that patients with generalized aggressive
periodontitis benet more from an adjunctive combi-
nation therapy than do patients with chronic peri-
odontitis. Since September 2011, two additional
randomized, placebo-controlled clinical trials have
largely conrmed the outcome of the meta-analysis
of Sgolastra et al. (1, 12). It should be noted that in
these studies, a variety of dosages for both antibiotics
were used (between 750 mg and 1500 mg/day), as
were a variety of administration regimens in terms of
duration (between 7 and 14 days) and how scaling
and root planing was performed (see Table 1). As no
comparative data are available, it is currently impos-
sible to dene a clear protocol. However, data are
available on the optimal timing of the use of amoxicil-
lin and metronidazole in relation to nonsurgical
therapy. It has been suggested that patients with
aggressive periodontitis should initially be treated
with scaling and root planing alone and then be clini-
cally monitored, and only in refractory cases should
systemic antimicrobial therapy be used as an adjunct
to re-instrumentation (91). Thus, antimicrobials are
more likely to be used at the retreatment visit rather
than as part of the initial therapy (31). Although this
is a reasonable approach, it can only hold if patients
who receive antibiotics at the retreatment show at
least the same benets compared with those who
receive the same regimen at the initial therapy.
Recently, in a retrospective study (43) as well as in a
prospective study (31), it has been shown that there is
a clear clinical benet of using antibiotics at the initial
therapy compared with using them at retreatment.
Despite the fact that the combination of metroni-
dazole and amoxicillin has shown additional clinical
benets beyond those of scaling and root planing
alone in patients with generalized aggressive peri-
odontitis, it is still not clear whether this combination
is more effective than other antibiotics because few
123
Teughels et al.
comparative studies have been performed. Sigusch
et al. (88) compared the effects of metronidazole,
clindamycin and doxycycline with a control group
treated without antibiotics. It should be noted that
the antibiotics were used at retreatment as an initial
scaling and root planing procedure had been per-
formed 3 weeks before re-instrumentation and anti-
biotic administration. The authors reported that the
use of metronidazole or clindamycin was more effec-
tive in reducing probing pocket depth and gaining
attachment compared with the control or the use of
doxycycline, indicating the superiority of these two
antibiotics. Similarly, also using a retreatment
approach, 6 weeks after initial therapy, Xajigeorgiou
et al. (106) assessed the effect of adjunctive use of
metronidazole plus amoxicillin, metronidazole alone
or doxycycline alone, compared with a control group.
Presumably owing to the small number of patients in
each group, no statistically signicant differences
could be shown. However, it is interesting to note that
for probing pocket-depth reduction and clinical
attachment gain, the largest additional benet after
retreatment was seen for the metronidazole alone
and metronidazole plus amoxicillin groups. A smaller
benet was noted for the doxycycline group, and no
benet of retreatment was seen for the control group
(106). Similar results, albeit reaching statistical signi-
cance, were recently obtained by Baltacioglu et al. (7)
when the antibiotics were administered at initial ther-
apy. In a study comparing the effectiveness of the
adjunctive use of metronidazole plus amoxicillin,
doxycycline, or scaling and root planing alone, the
authors found that the combination of metronidazole
plus amoxicillin resulted in a signicantly greater
probing pocket-depth reduction and gain in clinical
attachment compared with the use of doxycycline or
with the control treatment. However, doxycycline
also showed a statistically signicant additional prob-
ing pocket-depth reduction and clinical attachment
gain vs. the control. In contrast to these studies,
Machtei & Younis (54) could not nd differences in
clinical outcome between patients receiving either
metronidazole combined with amoxicillin or doxycy-
cline as adjuncts to rst-phase therapy. In their study,
24 patients with generalized aggressive periodontitis
and ve patients with localized aggressive periodonti-
tis were divided over the two test groups. Patients
received a quadrant-wise scaling and root planing at
weekly intervals and were given oral-hygiene instruc-
tions. They were placed into one of two treatment
groups: 1500 mg/day of amoxicillin and 750 mg/day
of metronidazole for 14 days; or a 200-mg load-
ing dose of doxycycline followed by 100 mg of doxy-
124
cycline, daily, for 30 days. During the 3-month
follow-up period, patients were recalled biweekly for
oral-hygiene reinforcement and motivation. The
authors found that under these conditions, both
regimes provided clinical improvements and that the
differences in the results between both groups were
not signicant. However, it should be borne in mind
that the duration of the doxycycline therapy was
much longer than for the regimen with other anti-
biotics.
Taking this limited number of comparative studies
together, it appears that the adjunctive use of metro-
nidazole plus amoxicillin, metronidazole alone or
clindamycin in patients with generalized aggressive
periodontitis results in more pronounced clinical
improvements when compared with the use of doxy-
cycline for a similar amount of time or with scaling
and root planing alone.
Recently, the effectiveness of azithromycin in the
treatment of aggressive periodontitis was also tested.
Compared with other antibiotics, azithromycin has
the advantage of having a long half-life. As azithromy-
cin only needs to be administered once a day for
3 days, one could assume that patient compliance
would be better compared with other antibiotic regi-
mens. Compliance to an adjunctive antibiotic regi-
men seems to be an important aspect for the clinical
outcome in aggressive periodontitis. In a retrospec-
tive analysis, Guerrero et al. (33) demonstrated that
incomplete adherence to a metronidazole plus amox-
icillin regimen resulted in signicantly less probing
pocket-depth reduction and less gain in clinical
attachment. Therefore, Haas et al. (36) compared the
clinical effect of the adjunctive use of azithromycin
with scaling and root planing in aggressive periodon-
titis. One year after treatment, a signicant additional
1 mm reduction in probing pocket depth and 0.7 mm
gain in attachment was evident, which shows the
potential of azithromycin in the treatment of aggres-
sive periodontitis. In this study, localized and general-
ized periodontitis patients were pooled.
Local antimicrobials
Although there is a clear rationale for the use of local
antimicrobials, which is based on the emerging anti-
biotic resistance, the possibility to achieve maximum
antibacterial concentrations and the reduction of sys-
temic side effects, the effectiveness of local antimicro-
bials in aggressive periodontitis has barely been
investigated. However, especially for localized aggres-
sive periodontitis, the localized character and limited
number of diseased sites would in theory favor their

use. Surprisingly, hardly any study has investigated,
in a controlled manner, the possible adjunctive effect
of local antimicrobials in localized aggressive peri-
odontitis. To the best of our knowledge, only Unsal
et al. (99) have performed a comparative study. In
this study, 26 patients with localized aggressive peri-
odontitis were randomized, after scaling and root
planing, into a control group, a group receiving 1%
chlorhexidine gel (subgingivally administered) and a
group receiving a 40% tetracycline gel (subgingivally
administered). The local subgingival administration
of either of the two antimicrobial agents did not result
in a signicant additional improvement of the clinical
parameters in these patients after the 12-week obser-
vation period. The use of local antimicrobial agents
has also been tested in generalized aggressive peri-
odontitis. However, only one study actually compared
the adjunctive use of a local antimicrobial vs. scaling
and root planing alone (82). In this study, the effect of
tetracycline bers was investigated, in a split-mouth
design, over a 6-month follow-up period in 10
patients with generalized aggressive periodontitis.
The adjunctive use of tetracycline bers resulted in
statistically signicant additional probing pocket-
depth reductions of 0.6 mm and in gains of clinical
attachment of 0.7 mm, up to 6 months after therapy.
On the other hand, the effect of local antimicrobials
has been compared with the effect of systemic antibi-
otics in patients with generalized aggressive peri-
odontitis. Purucker et al. (76) compared the effect of
tetracycline bers with systemically administered
amoxicillin/clavulanic acid over a 52-week period in
28 patients. Both adjuvants were applied 15 weeks
after initial therapy (8 weeks after the completion of
initial therapy) without additional scaling and root
planing. Under these conditions, no statistically sig-
nicant differences between either treatment modali-
ties were recorded in probing pocket depth and
clinical attachment level. A signicant difference in
bleeding on probing was recorded at week 54 in favor
of the systemic antibiotic. The study authors stated
that, because of the relatively small number of
patients included, the claim that both antibiotic treat-
ment modalities are equivalent cannot be made.
Moreover, based on the data described above, the
timing of usage of both antibiotic modalities might
not have been optimal. Additionally, although the
data were not statistically analyzed in this way, when
the event of antibiotic application (week 15, 8 weeks
after completion of initial therapy) is used as the
baseline, there seems to be at least a numerical ten-
dency that the systemic antibiotic provided a better
clinical adjunctive effect for probing pocket depth,
Aggressive periodontitis treatment
clinical attachment level and bleeding on probing
compared with the local antibiotic modality. Simi-
larly, Kaner et al. (41) recently compared the effect of
a chlorhexidine chip with systemically adminis-
tered amoxicillin (1500 mg/day) plus metronidazole
(750 mg/day), both applied 1 week after the comple-
tion of scaling and root planing. Over the 6-month
observation period, the results show that scaling and
root planing plus adjunctive chlorhexidine chips pro-
vided clinical improvements, but these were not
maintained in full over the entire observation period.
In the chlorhexidine chip group, probing pocket
depth signicantly increased again between 3 and
6 months. Scaling and root planing plus systemic
amoxicillin/metronidazole was more effective with
regard to reduction of pocket depth and gain in clini-
cal attachment.
In conclusion, in patients with aggressive periodon-
titis, the adjunctive effects of local antimicrobials,
which have been reported in the literature, do not
seem to improve on the adjunctive effect of systemic
antibiotics. Only for generalized aggressive periodon-
titis has an adjunctive clinical effect for tetracycline
bers compared with scaling and root planing alone
been shown. How local antimicrobials compare with
systemic amoxicillin plus metronidazole with regard
to both costbenet and effectiveness is currently
unknown. Therefore, it seems plausible that the deci-
sion to use this type of treatment modality should be
made on an individual basis rather than be evidence-
based.
Surgical treatment of aggressive
periodontitis
The diagnosis of aggressive periodontitis is often
made at an advanced stage of the disease, which
means that clinicians will have to treat severely com-
promised teeth. Consequently, after initial nonsurgi-
cal therapy, residual pockets will remain, and these
may require surgical treatment. Surgery provides the
practitioner with direct access to root surfaces and
furcation areas, thus permitting a more thorough
debridement. It has also been suggested that because
A. actinomycetemcomitans can invade the pocket epi-
thelium, placing itself out of reach of scaling and root
planing, the removal of pocket epithelium can help
in controlling the disease. Furthermore, intrabony
defects can be addressed by either bone-recontouring
or regenerative techniques. Although few studies have
specically addressed surgery in aggressive periodon-
titis, those that have often report positive results. If
125
Teughels et al.
risk factors, such as smoking, can be controlled, the
level of maintenance therapy is high and the patient
is compliant, the outcome of periodontal surgery in
aggressive periodontitis can be comparable with that
in chronic periodontitis. Different surgical techniques
are possible in patients with aggressive periodontitis.
Access surgery
The effectiveness of a modied Widman ap proce-
dure in reducing probing pocket depths is shown in
several small-sample-size studies. Christersson et al.
(15) treated 25 deep periodontal lesions in seven
patients with localized aggressive periodontitis using
one of three treatments: scaling and root planing
alone; scaling and root planing with additional soft-
tissue curettage; or modied Widman ap surgery.
Microbiological and clinical effects were monitored
up to 16 weeks after treatment. The results showed
that scaling and root planing alone did not effectively
suppress A. actinomycetemcomitans in periodontal
pockets, whereas scaling and root planing combined
with soft-tissue curettage and modied Widman ap
surgery did. Furthermore, the clinical response to
treatment was signicantly better for scaling and root
planing combined with soft-tissue curettage and for
modied Widman ap surgery (16). Lindhe & Liljen-
berg (49) treated 16 patients with localized aggressive
periodontitis by means of tetracycline administration,
scaling and root planing and modied Widman ap
surgery, after which the patients were enrolled in a
maintenance program for 5 years. Lesions at rst
molars and incisors in a group of patients with
chronic periodontitis were treated in an identical
manner and served as controls. The treatment
resulted in the resolution of gingival inammation,
gain of clinical attachment and bone rell in angular
bony defects. The healing of the lesions in the
patients with aggressive periodontitis was similar to
the healing observed in patients with chronic
periodontitis (49). In another study, performed by
Mandell & Socransky (55), eight patients with local-
ized aggressive periodontitis were treated using modi-
ed Widman surgery and a doxycycline regimen.
Twelve months after surgery the treatment had been
effective in eliminating A. actinomycetemcomitans
from the pockets and obtaining mean probing
pocket-depth reductions of approximately 3.6 mm, as
well as a mean attachment gain of 1.3 mm (55). Aside
from these aforementioned studies there are many
case reports in which modied Widman surgery
helped to accomplish a stable periodontium (75, 80).
Buchman et al. (10) enrolled 13 patients with aggres-
126
sive periodontitis in a prospective case series and
reported gains in clinical attachment for up to 5 years
after initial treatment. Treatment consisted of a com-
bination of scaling and root planing, together with
access surgery, without osseous recontouring for
pockets deeper than 6 mm. All patients received
amoxicillin combined with metronidazole systemi-
cally. A signicant 2.3-mm gain in clinical attachment
was recorded 3 months after therapy. These improve-
ments were maintained for up to 5 years after treat-
ment during which the patients were enrolled in a
supportive periodontal-therapy program. In this
study, periodontal-disease progression was success-
fully arrested in 95% of the initially compromised
lesions, whilst 25% experienced discrete or recurrent
episodes of loss of periodontal support (10).
Regenerative surgery
An alternative to access surgery to resolve residual
periodontal pockets is the use of regenerative tech-
niques in an attempt to resolve intrabony defects.
Many different techniques (such as bone grafting,
guided tissue regeneration using membranes, the use
of biologic modiers and combinations of the above)
have been developed over the years to regenerate ver-
tical bone defects. These techniques were designed
for the regeneration of steep vertical defects and have
very specic indications, and their effectiveness is
dependent on the defect morphology, tooth mobility
and furcation involvement. Poor results are expected
in the treatment of horizontal bone loss, furcation
defects and increased tooth mobility (18).
Bone grafting
Bone grafting can lead to regeneration by providing a
scaffold for the ingrowth of bone. There are different
types of grafts. Autografts are grafts that are harvested
from the patients own body and as such do not cause
much tissue reaction during healing. Theoretically,
the autograft contains viable bone cells, giving it oste-
ogenic qualities aside from osteoconductive qualities.
However, it has been shown that few bone cells sur-
vive the harvesting procedure. The autograft is the
graft of choice when available, but there are limita-
tions in obtaining it. Alternatives are allografts (e.g.
freeze-dried bone allograft), xenografts (bovine or
corral derived) and alloplastic materials (e.g. bioactive
glass, hydroxyapatite and beta-tricalcium phosphate).
Although case reports have been published on their
utility in patients with aggressive periodontitis (22, 28,
95), very few controlled studies have been conducted
using adequate numbers of patients or in which

treatments were compared. Using freeze-dried bone
allografts, Yukna & Sepe (108) reported an average
defect ll of 80% in 12 patients with localized aggres-
sive periodontitis at re-entry after 12 months. In addi-
tion to this study, using a split-mouth approach,
Mabry et al. (52) demonstrated signicantly greater
bone ll (mean = 2.8 mm) and resolution of osseous
defects (mean = 72.7%) in allogeneic freeze-dried
bone-grafted osseous bone defects in 16 patients with
localized aggressive periodontitis when compared
with defects that were treated with debridement only.
The best results were obtained when adjunctive sys-
temic tetracycline was administered using the surgi-
cal procedure. Evans et al. (27) evaluated a 4:1
(volume by volume) ratio combination of beta-trical-
cium phosphate/tetracycline, hydroxyapatite/tetracy-
cline or freeze-dried bone allograft/tetracycline in a
split-mouth study of 10 patients with localized
aggressive periodontitis. At re-entry, signicant
decreases in defect depth and pocket depth were
detected for each graft material. No signicant differ-
ences between the different grafting materials were
found in terms of hard-tissue or soft-tissue changes.
However, a greater percentage of defect ll was dem-
onstrated for hydroxyapatite/tetracycline compared
with beta-tricalcium phosphate/tetracycline. The
results of these studies show that the use of these
grafting materials in combination with tetracycline
can result in additional bone ll and resolution of the
residual osseous defects in patients with localized
aggressive periodontitis.
Guided tissue regeneration using
membranes
Membranes are used to inuence the ingrowth of dif-
ferent tissues into intrabony defects. By holding off
the ingrowth of epithelium and connective tissue,
cells from the periodontal ligament are allowed to
grow into the defect, resulting in regeneration of the
periodontal attachment. There are nonresorbable and
resorbable membranes. Nonresorbable membranes
provide a marginally greater attachment gain, but a
second procedure is necessary for removing them. Re-
sorbable membranes are biodegradable and do not
require a second procedure to remove them; however,
they do cause a greater inammatory response. The
use of nonresorbable expanded polytetrauoroethyl-
ene membranes has been shown to be effective for
regenerating intrabony defects in aggressive peri-
odontitis in case reports (25, 61, 89, 109).
Using a split-mouth approach, Sirirat et al. (89) com-
pared the effect of a polytetrauoroethylene mem-
Aggressive periodontitis treatment
brane with osseous surgery in six patients with
aggressive periodontitis. Whilst both treatments were
effective 1 year following surgery, probing
depth reduction and clinical attachment gain were
signicantly greater in the polytetrauoroethylene
membrane-treated defects than in the osseous
surgery-treated defects, reaching a mean probing
pocket-depth reduction of 2.6 mm and a gain in
clinical attachment of 2.2 mm. The base of the
polytetrauoroethylene membrane-treated defects
showed a signicant increase in bone ll. Zucchelli
et al. (109) treated similar intrabony defects in 10
patients with localized aggressive periodontits and in
10 patients with chronic periodontitis using titanium-
reinforced polytetrauoroethylene membranes. After
1 year there were no signicant differences in the
amount of clinical attachment gain, reduction of
probing pocket depth or increase in gingival recession
between chronic periodontitis and localized aggres-
sive periodontitis groups. DiBattista et al. (25) treated
seven patients with intrabony defects on rst molars
using surgical debridement, polytetrauoroethylene
membrane, polytetrauoroethylene membrane with
root conditioning or polytetrauoroethylene mem-
brane plus root conditioning and composite graft,
consisting of calcium-sulfate, freeze-dried bone allo-
graft and doxycycline. A signicant gain in attach-
ment and bone ll was observed for all techniques.
There were no signicant differences in results
between the techniques. The average gain in attach-
ment for all sites combined was 3.2 mm. The number
of patients in relation to the number of tested treat-
ments in this study is low and does not permit rea-
sonable conclusions to be made on the effect of the
separate techniques. Mengel et al. (61) performed a
comparative study on the regeneration of one- to
three-wall bony defects in 12 patients with general-
ized aggressive periodontitis using a bioresorbable
membrane or with bioactive glass. They treated 22
defects using a membrane and 20 defects using the
alloplastic graft. Both treatment modalities resulted
in signicant changes in probing pocket depth and in
clinical attachment gain of about 4 mm and 3 mm,
respectively. No signicant differences between the
two treatments were found.
Biological modiers
The use of enamel matrix proteins (amelogenin)
attempts to recreate the physiological environment
for the development of the periodontal ligament. This
allows the regeneration of new cementum and the
formation of new attachment in periodontal defects.
127
Teughels et al.
The use of enamel matrix protein results in more
attachment gain than open-ap debridement in
patients with chronic periodontitis (26). There is,
however, little evidence for an advantage in patients
with aggressive periodontitis. Most published articles
on the use of enamel matrix protein in patients with
aggressive periodontitis are case reports (9, 42). In
this regard, Vandana et al. (102) published a case ser-
ies involving four patients with chronic periodontitis
and four patients with aggressive periodontitis. Six-
teen intrabony defects were surgically treated with
either enamel matrix proteins or surgical debride-
ment alone using a split-mouth design. The mean
pocket-depth reduction and amount of defect ll
were signicant in both treatments, 9 months post-
surgery, in both groups of patients. No signicant dif-
ferences in mean pocket-depth reduction, clinical
attachment level gain, amount of defect ll or defect
resolution were detected between the two treatments,
in both groups of patients. This study failed to
demonstrate an advantage of using enamel matrix
proteins compared with surgical debridement alone.
Growth factors and differentiation factors also play
an import role in tissue development and healing and
are therefore used as tools for gaining attachment.
Mediators such as platelet-derived growth factor,
insulin-like growth factor, broblast growth factor,
bone morphogenetic protein and transforming growth
factor-beta have shown promising results in animal
studies and in vitro (71, 79, 97). Platelet-rich plasma
has been shown to improve clinical and radiographic
parameters for compromised teeth (58). Their disad-
vantages are the low tissue specicity and unknown
systemic effects. At present, their effectiveness in
patients with aggressive periodontitis is unknown
(23, 80). There is, however, a case series published by
Mauro et al. (58) on the regenerative surgery of intrab-
ony defects with platelet gel. Three patients, who had
shown a refractory response to previous treatments,
were treated and followed for 15 months. The oper-
ated sites showed a reduction of pocket depth and a
gain in attachment. Moreover, the effect remained sta-
ble during the 15-month follow up, whereas previous
treatments had not been as effective (58).
Maintenance therapy
Once treatment has resulted in a stable and healthy
periodontium, the patient should enter a mainte-
nance program. The purpose of this supportive peri-
odontal therapy is to ensure that periodontal health
is maintained after active therapy (40), so that no
128
additional teeth are lost and disease recurrence is
prevented. Supportive periodontal therapy should
therefore be directed towards risk factors for disease
recurrence and tooth loss. Several factors (such as
smoking, diabetes mellitus, age, irregular supportive
periodontal therapy and ineffective plaque control)
have been shown to increase the risk for tooth loss
during supportive periodontal therapy in patients
with chronic periodontitis (1315, 48, 59). A higher
risk for disease recurrence and tooth loss after active
periodontal therapy can be anticipated in patients
with aggressive periodontitis than in patients with
chronic periodontitis because of a higher susceptibil-
ity for disease progression in patients in the former
group. However, the risk factors for tooth loss and/or
recurrence of periodontitis in patients with aggressive
periodontitis have only recently been investigated.
Few studies have assessed the mean tooth loss in
patients with aggressive periodontitis during support-
ive periodontal therapy (8, 35, 85). The mean annual
tooth loss for these patients seems to range from 0.11
(85) to 0.29 (35) teeth, although in the latter study
also untreated patients were included. In the recent
retrospective study of Baumer et al. (8), tooth loss of
0.13 teeth/year was calculated in patients with
aggressive periodontitis. Interestingly, when the
authors differentiated between the different types of
aggressive periodontitis, patients with generalized
aggressive periodontitis exhibited a higher tooth loss,
of 0.14 teeth/year, whereas patients with localized
aggressive periodontitis only lost 0.02 teeth/year. An
additional analysis showed that patients with aggres-
sive periodontitis who followed the supportive peri-
odontal care regularly had a tooth loss of 0.075 teeth/
year, whereas patients with irregular periodontal care
had a tooth loss of 0.15 teeth/year, stressing the
importance of regular periodontal supportive ther-
apy. Age, low educational status and absence of the
interleukin-1 composite genotype were signicantly
correlated with tooth loss and could be dened as risk
factors. Nearly signicant correlations could be found
for smoking, type of aggressive periodontitis, irregular
supportive periodontal therapy and the plaque-con-
trol record. In terms of risk factors for disease recur-
rence (dened as the occurrence of probing pocket
depths of 5 mm or more at 30% or more of the teeth),
Baumer et al. (8) also identied smoking as the main
signicant risk factor, thereby conrming the data
from Kamma & Baehni (40). In the latter study, the
authors also identied stress as a signicant predic-
tive factor for future clinical attachment loss. The
type of aggressive periodontitis was a nearly signi-
cant risk factor for which patients with generalized

aggressive periodontitis showed an odds ratio of 35.2
for recurrence and which conrms the results of stud-
ies showing long-term stability of the disease in
patients with localized aggressive periodontitis (35,
65). Additionally, an elevated gingival bleeding index
and a high plaque-control record showed odds ratios
of 31.1 and 63.8, respectively, for disease recurrence.
No statistical analysis could be performed for sup-
portive periodontal treatment as a risk factor for
disease recurrence because none of the patients
receiving regular supportive periodontal therapy
experienced recurrence of the disease. However, this
stresses the effectiveness of this risk factor. In sum-
mary, age, educational status, generalized aggressive
periodontitis (vs. localized aggressive periodontitis),
absence of the interleukin-1 composite genotype,
irregular supportive periodontal therapy, smoking,
high mean gingival bleeding index and high plaque-
control records are important risk factors for disease
recurrence or tooth loss in patients with aggressive
periodontitis. Of these, maintenance of supportive
periodontal therapy, smoking, high mean gingival
bleeding index and high plaque-control records are
modiable risk factors, and the latter two are corre-
lated with the patients oral hygiene. Therefore, it
seems tempting to support the daily oral hygiene of
aggressive periodontitis patients with antiseptics as
part of the supportive periodontal therapy. To date,
only one trial, performed by Guarnelli et al. (32) in 18
patients, has evaluated the effect of an amine uo-
ride/stannous uoride-containing mouthrinse in
patients with aggressive periodontitis. In a cross-
over clinical trial this mouthrinse was effective for
reducing the amount of supragingival plaque depos-
its. However, there was no signicant difference com-
pared with the placebo mouthwash on the gingivitis
index. The impact of these results on disease progres-
sion and tooth loss has not been determined.
Regular supportive periodontal therapy has been
shown to be effective in controlling the progression
of aggressive periodontitis. Maintenance therapy is
considered to be a lifelong requirement, but the fre-
quency of recall visits is unclear. The use of many
different protocols is being reported in the litera-
ture. Deas & Mealey (23) stated that monthly intervals
are advisable during the rst 6 months of mainte-
nance. Some studies have reported an effective con-
trol of disease progression using three to four recall
visits per year. To date there are no studies compar-
ing the effect of different follow-up intervals in
patients with aggressive periodontitis. In order to
dene such intervals for patients with chronic peri-
odontitis, the periodontal risk assessment, which
Aggressive periodontitis treatment
estimates the patients risk prole for the progression
of periodontitis, based on six risk factors, was created
(47). Meyer-Baumer et al. (63) recently attempted to
conrm the prognostic value of the model in
aggressive periodontitis. When the interleukin-1
composite genotype was not taken into account, the
impact of this model could be shown to be statisti-
cally signicant and allowed patients with aggressive
periodontitis to be characterized into different risk
groups.
Finally, needless to say, each visit for supportive
periodontal treatment should consist of a thorough
medical review, an inquiry into recent periodontal
problems, an extensive oral examination, a renewal of
oral-hygiene instructions, debridement of residual
pockets and prophylaxis. Also, the need to control
modiable risk factors, such as smoking, must be
stressed to the patient.
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