Q U I N T E S S E N C E I N T E R N AT I O N A L
PERIODONTOLOGY
Management of localized aggressive periodontitis:
A 30-year follow-up
Catherine Petit, DDS1/Olivier Huck, DDS, PHD2/Salomon Amar, DDS, PHD3/Henri Tenenbaum, DDS, PHD4
This case report describes the long-term follow-up of a patient
with localized aggressive periodontitis over a 30-year period. A
16-year-old woman was referred for periodontal assessment
after starting orthodontic treatment. The patient was treated
initially by combined nonsurgical and antimicrobial therapy,
and autotransplantation of maxillary third molars in place of
Key words: Aggregatibacter actinomycetemcomitans, aggressive periodontitis, autotransplantation, implant,
nonsurgical
Over the years, various terms have been used to
describe periodontal disease in the younger population,
such as periodontosis, juvenile periodontitis, early onset
periodontitis, and more recently aggressive periodonti-
tis.1 Aggressive periodontitis (AgP) has been defined as
1
Assistant Professor, Department of Periodontology, Dental Faculty, University of
Strasbourg, Strasbourg, France; and Department of Periodontology, Medicine
and Buccodental Surgery, University Hospitals of Strasbourg (HUS), Strasbourg,
France.
2
Professor and Chair, Department of Periodontology, Dental Faculty, University of
Strasbourg; and Department of Periodontology, Medicine and Buccodental
Surgery, University Hospitals of Strasbourg (HUS), Strasbourg, France; and
Regenerative Nanomedicine (RNM), UMR 1260, INSERM (French National Institute
of Health and Medical Research), FMTS, Strasbourg, France.
3 Provost for Biomedical Research/Chief Biomedical Research Officer, Touro College;
and University System, Professor of Pharmacology, Professor of Microbiology
and Immunology, New York Medical College, Valhalla, NY, USA.
4
Emeritus Professor, Department of Periodontology, Dental Faculty, University of
Strasbourg, Strasbourg, France; and Regenerative Nanomedicine (RNM), UMR
1260, INSERM (French National Institute of Health and Medical Research), FMTS,
Strasbourg, France.
Correspondence: Prof Henri Tenenbaum, Department of Periodontology,
Dental Faculty, 8 rue Sainte-Elisabeth, 67000 Strasbourg, France. Email:
htenen@gmail.com
VOLUME 49 • NUMBER 8 • SEPTEMBER 2018
Catherine Petit
maxillary first molars, followed by a regular supportive peri-
odontal treatment program. This challenging case demonstrat-
ed that elimination of putative bacterial pathogens and
long-term supportive periodontal treatments provide an effec-
tive treatment modality for localized aggressive periodontitis.
(Quintessence Int 2018;49:615–624; doi: 10.3290/j.qi.a40660)
a rapid form of periodontal destruction that develops
early in life in otherwise healthy individuals.2 The dis-
ease is classified as localized and generalized forms.
Both localized and generalized AgP share certain fea-
tures in common, ie, rapid loss of attachment and bone
destruction, and a tendency to familial aggregation.
The reported prevalence of AgP is relatively low in
adolescents, from 0.1% in Europe3 to 3.4% in Africa.4
The prevalence increases with age, up to 10% for those
between 18 and 20 years old.5,6 The rapid rate of alveolar
bone resorption may induce bone defects, progressing
to more than two-thirds of the root lengths within a few
years. A distinct radiographic feature of the localized
aggressive form of periodontal destruction is the angu-
lar bony defects at the first permanent molars and cen-
tral incisors.7 Localized AgP patients often have small
amounts of bacterial plaque associated with the affected
teeth. In the definition of localized AgP, Aggregatibacter
actinomycetemcomitans is considered as causative bac-
teria and its incidence is characteristically increased.8,9
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Petit et al
a b
a b
Figs 2a to 2c (a and b) Clinical views at age 13 before starting orthodontic treatment. (c) Panoramic radiograph during orthodontic
treatment after extraction of the four first premolars.
a probing.
Given the early onset and rapid progression of this
disease, rapid support is essential. The treatment of
advanced periodontal destruction in AgP patients rep-
resents a significant challenge for the periodontist
because it is sometimes difficult to compensate for the
lost tissues. Treatment objectives include controlling
infection, stopping disease progression, correcting ana-
tomical defects, and maintaining periodontal health in
the long term. In the present case report, the 30-year fol-
low-up of a patient affected by localized AgP is described.
CASE PRESENTATION
A 16-year-old systematically healthy woman of North-
African origin who had just finished orthodontic treat-
ment was referred to the Department of Periodon-
tology at the Dental Faculty, University of Strasbourg,
616
Figs 1a and 1b Radiographs at age 13
before starting orthodontic treatment;
note the slight bone destruction on the
mesial aspects of the maxillary right first
molar and mandibular left first molar.
c
Figs 3a and 3b (a) Clinical view at the
end of orthodontic treatment before
removal of the appliances. (b) Clinical view
with a periodontal probe showing a disto-
buccal pocket of 11 mm on the maxillary
left central incisor without bleeding on
France, in 1986. The orthodontic treatment had been
started 3 years previously, at age 13. Figure 1 shows the
endodontic treatments on the maxillary right first molar
and mandibular left first molar (teeth 16 and 36, accord-
ing to FDI notation), and slight bone destruction on the
mesial aspects of both teeth, which had been present
before orthodontic treatment and unfortunately was
not detected. Orthodontic treatment was performed
with extraction of the four first premolars (Fig 2).
Complete medical and dental history was recorded
including clinical periodontal parameters such as Plaque
Index (PI),10 Gingival Index (GI),11 bleeding on probing
(BOP), pocket probing depth (PPD), recession (R), clinical
attachment level (CAL), mobility, and furcation involve-
ment. Measurements of PPD and CAL were performed
at six sites for each tooth using a PCPUNC 15 periodon-
tal probe (Hu-Friedy) with an accuracy of 0.5 mm.
VOLUME 49 • NUMBER 8 • SEPTEMBER 2018

Fig 4 Periodontal charting with probing
depths on six sites per tooth at baseline
(performed using periodontalchart-online,
www.periodontalchart-online.com; print-
ed with permission of the Department of
Periodontology, University of Bern, Swit-
zerland).
The clinical examination revealed localized inflam-
mation amplified by the presence of orthodontic appli-
ances but without BOP (Fig 3). The mean PPD was
3.02 mm with nine sites from 5 to 6 mm and nine sites
≥ 7 mm out of 144 (12.5%) (Fig 4). The maxillary left
central incisor had a grade I mobility. No mobility and
no furcation lesions were detected on the molars.
Radiographic examination revealed severe osseous
defects around all the first molars, particularly in the
maxilla, and one maxillary central incisor (Fig 5). The
maxillary incisors also presented root resorption related
to the orthodontic treatment, which may affect the
long-term prognosis.
In 1986, based upon the clinical and radiographic
evaluations, a diagnosis of juvenile periodontitis was
established. That diagnosis was also suggested by the
age of the patient, her ethnicity, the low amount of
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clinically visible plaque deposits (PI = 0.63), the normal
appearance of the gingival tissues, and the specific
localization of the periodontal lesions mainly at molars
and incisors.
Unlike many cases of localized AgP that do not have
associated tooth decay, this patient was obviously sus-
ceptible to cavities that led to endodontic treatment of
the maxillary first molars and second premolars, and
the mandibular left first molar (teeth 16, 15, 25, 26, and
36). Otherwise, amalgams were present on the maxil-
lary right second molar (tooth 17, with another caries
lesion distally), and the maxillary first molars and sec-
ond premolars, maxillary left second molar, mandibular
left first molar and second premolar, and mandibular
right first and second molars (teeth 16, 15, 25, 26, 27,
36, 35, 46 and 47).
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Petit et al
a b
d e
g h
j k
Figs 5a to 5l Clinical views and radiographs at age 16 before starting the periodontal treatment.
The positive identification of A actinomycetemcomi-
tans was performed at three levels. Periodontal plaque
samples were cultured on A actinomycetemcomitans
selective medium,12 and star-shaped colonies typical of
A actinomycetemcomitans were obtained. Further bio-
chemical identification of A actinomycetemcomitans
was confirmed using ApiSystem (BioMérieux). Finally,
gingival biopsies taken at sites 16 and 26 during surgi-
618
c
f
i
l
cal treatment were prepared for cryosections and posi-
tively immunostained with an antibody directed
against A actinomycetemcomitans (Fig 6).13
There was no known family history of periodontitis
and no outstanding findings in the family medical histo-
ries. Most of the relatives were living in Morocco, there-
fore it was not possible to clinically assess their periodon-
tal conditions. Routine blood investigations were
VOLUME 49 • NUMBER 8 • SEPTEMBER 2018

performed with standard results. The patient was a non-
smoker and remained in this state for the next 30 years.
Active periodontal therapy (APT)
In 1986, APT comprised the following:
• an explanation of the etiology of the disease, with
detailed oral hygiene instructions
• scaling and root planing (SRP) in two sessions asso-
ciated with systemic antibiotherapy using doxycy-
cline (1 capsule of 100 mg twice a day for 15 days)
• reevaluation after 2 months.
Oral hygiene instructions consisted of explanations
related to the bacterial etiology of the disease, and
instruction to achieve an optimal plaque control using
a soft toothbrush, fluoride toothpaste, and interdental
flossing. The patient was advised to use 0.1% chlorhexi-
dine mouthwash twice daily for 15 days.
Given the dental and periodontal status of the two
maxillary first molars, these teeth were considered as
hopeless and planned for extraction. Both maxillary
third molars were easily accessible and had a favorable
radicular evolution to consider transplantation.
For the mandibular molars, the dental and peri-
odontal status was slightly less degraded, and espe-
cially the accessibility of the third molars was more
problematic to consider a transplant. Therefore, these
teeth were preserved.
Three months after starting APT, the transplanta-
tions of the maxillary third molars to replace the
extracted first molars were performed under local anes-
thesia strictly following the protocol described by
Andreasen et al.14 The surgical procedure was per-
formed using careful atraumatic dissection, and transfer
of the tooth to the prepared new recipient socket was
done preserving the maximum periodontal ligament
on the root surface. The extraoral phase between
extraction and transplantation was kept as short as pos-
sible to ensure maintenance of periodontal membrane
vitality. The immediate transplantation procedure was
realized. The donor teeth were placed lightly and gently
into the recipient socket to avoid occlusal interferences
without trimming (Fig 7). Preoperative antibiotic pro-
phylaxis was used starting the night before (500 mg
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Fig 6 Aggregatibacter actinomycetemcomitans immunostaining
(arrows) from gingival biopsy taken during surgery at tooth 16.
BM, basement membrane; CT, connective tissue; Ep, epithelium.
macrolide, 2 g/day). Antibiotic coverage was carried out
for an additional 5 days. An analgesic (paracetamol) and
0.1% chlorhexidine mouthwash were also given. The
suspended sutures were removed after 10 days.
Supportive periodontal treatment (SPT)
The initial treatment was followed by marked clinical
improvement (Fig 8) and the patient proved highly
motivated, and was placed on SPT that was performed
every 3 months during the first year, every 4 months for
the next 4 years, and every 6 months until the last exam-
ination 30 years after APT. SPT consisted of qualitative
evaluation of the oral hygiene and reinstruction of
adapted techniques when required. During the 30 years
of follow-up, PI was measured on a regular basis. When
significant increase of plaque was observed, oral
hygiene reinstruction procedures included explanation
regarding the importance of maintaining a low amount
of plaque on long-term periodontal stability, visualiza-
tion of plaque deposits by the patient after staining, and
demonstration of adapted tooth-brushing techniques,
and use of interdental devices. SRP of residual pockets
with PPD > 3 mm was then performed.
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a b
Figs 7a to 7d Clinical views before extraction of tooth 16 and after replacement by the third molar transplant.
Periodontal events during SPT
No treatment other than SRP of residual pockets with
PPD > 3 mm at SPT appointments was performed until
2011 (25 years after APT). At that time, recurrence of
pockets was detected on the mesial aspects of the
mandibular first molars (teeth 36 and 46), and two
regenerative procedures using enamel matrix deriva-
tives (EMD) (Emdogain, Straumann) were performed.
For each surgical procedure, full-thickness flaps were
raised in regard of the lesion. SRP was performed with
ultrasonic and manual scalers till the obtainment of a
root surface exempt of bacterial biofilms. Following
620
c d
Fig 8 Periodontal charting with probing
depths on six sites per tooth at the end of
active periodontal therapy (APT) before
starting supportive periodontal treatment
(SPT) (performed using periodontal-
chart-online, www.periodontalchart-on-
line.com; printed with permission of the
Department of Periodontology, University
of Bern, Switzerland).
hemostasis, EMD was applied according to the manu-
facturer’s protocol. Flaps were then sutured with inter-
nal mattress and single sutures (5.0 vicryl sutures,
Ethicon). Sutures were removed 2 weeks later. Other-
wise, the periodontal status remained stable during the
follow-up period (Table 1). After 30 years, BOP was
detected in less than 10% of the sites.
Dental events during SPT
After 15 uneventful years, numerous recurrences of
caries appeared between 2001 and 2005 that led to
endodontic treatments on the maxillary right second
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Table 1 Evolution of the periodontal pocket depth and number of sites
over the 30 years of follow-up
Baseline 20 y
1 – 4 mm 126 (87.5) 143 (99.3)
No. of sites [n 5 – 6 mm 9 (6.25) 1 (0.7)
(%)] with PPD ≥ 7 mm 9 (6.25) 0 (0.0)
Total 144 144
Mean PPD (mm) 3.02 2.46
molar, and mandibular left second molar and right first
molar (teeth 17, 37 and 46), and amalgam and compos-
ite restorations on the maxillary right third molar (tooth
18; the one transplanted at the site of 16), right second
molar, both central incisors, and left second premolar,
and both mandibular first molars and left second molar
(teeth 17, 11, 21, 25, 37, 36, and 46).
The maxillary left third molar (tooth 28; the one
transplanted at the site of 26) had pulpal necrosis with
an apical periodontitis without any symptoms. It was
decided to follow the evolution without immediate
treatment. Finally, due to improvement in the patient’s
financial income, a metal-ceramic crown was placed on
the maxillary right second premolar (tooth 15).
In 2006, ie, 20 years after APT, the maxillary left central
incisor presented internal root resorption that indicated
extraction. A provisional partial denture was prepared
and placed immediately after extraction. It was replaced
2 months later by an implant, and after osseointegration
followed by an implant-supported metal-ceramic crown.
In the following years, endodontic treatment was
performed on the mandibular right second molar
(tooth 47). In 2009, a metal-ceramic crown was placed
on the mandibular left second molar (tooth 37), and
dental restorations needed to be replaced on the max-
illary right first molar and left second molar, and man-
dibular left second premolar and right second molar
(teeth 16, 27, 35, and 47). In 2011, a radicular fracture
was detected on the maxillary right second premolar
(tooth 15), which was extracted and replaced by an
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30 y
137 (95.1)
6 (4.2)
1 (0.7)
Fig 9 Periapical radiograph of teeth 15
144 and transplanted 18 in 2011 (after 25 years
of follow-up) before extraction of the frac-
2.66
tured premolar.
implant (Fig 9). In 2013, radicular caries appeared on
the mandibular left first and second molars (teeth 36
and 37). These teeth were also extracted and replaced
by two implants.
A complete examination with clinical assessment
and radiographic evaluation was performed after 30
years (Fig 10 to 12). Four teeth were lost during SPT for
reasons other than periodontal (0.13 teeth lost/year).
DISCUSSION
The present case report confirms that localized AgP can
be maintained over years with appropriate APT and
SPT.15 With the exception of recurrence of periodontal
pockets on the mandibular first molars (teeth 36 and
46) after 25 years, all the complications were related to
dental and not periodontal problems.
In contrast to some claims,16 regenerative surgical
treatment seems not always a requisite to ensure long-
term tooth stability. A conservative approach in associ-
ation with SPT provided significant improvement of
clinical parameters and long-term clinical stability. The
mean PPD decreased from 3.02 mm at baseline to
2.46 mm after 20 years and 2.66 mm after 30 years. It
should be noted that the mean PPD value at 30 years
included four implants whose mean PPD (4.0 mm for 24
out of 144 sites) was deeper than the tooth-related
mean PPD (2.39 mm for 120 sites).17
Four teeth were lost during SPT, representing a
mean tooth loss of 0.13 per year, higher than that
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Petit et al
a b
Figs 10a to 10c Clinical views after 30 years of follow-up.
Fig 11 Radiographs after 30 years of follow-up.
described by Nibali et al18 in localized AgP (0.05 per
patient per year). However, the maximal duration of the
studies included in the systematic review by Nibali et
al18 was 19 years whereas the four tooth losses ob-
served in the present case, all for reasons other than
periodontal, happened after 20 years of follow-up. In
this context, the role of regular SPT during this long-
term follow-up should be emphasized. It has been
demonstrated, in the context of chronic or aggressive
periodontitis, that patients more compliant with SPT
have reduced risk of tooth loss.19,20 In the present case,
recall frequency was adapted in function of the evolu-
tion of periodontal parameters, especially PPD and PI,
and motivation regarding oral hygiene was performed
accordingly.
A actinomycetemcomitans has been implicated in
the pathogenesis and progression of localized AgP.21,22
Therefore, APT was directed at reducing the levels of
this pathogen and PPD. The use of systemic antibiotics
622
c
in conjunction with SRP offers benefits over SRP alone
in terms of CAL and PPD, and reduces risk of additional
attachment loss.23
Additionally, the elimination of putative periodontal
pathogens such as A actinomycetemcomitans is of par-
ticular importance as AgP patients were also reported
to present a hyperinflammatory response to bacterial
lipopolysaccharides.24 Finally, the combined treatment
has also demonstrated superior clinical results in sys-
tematic reviews.25,26
An established protocol and the use of a specific
antibiotic for localized AgP treatment have not yet
been determined in the literature.16,27 Mechanical
debridement before antibiotic administration has
been recommended because the disorganization/
reduction of subgingival biofilms enhances the effi-
ciency of antimicrobials.28 In localized AgP patients,
administration of antibiotics immediately after the
mechanical debridement has resulted in greater
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Fig 12 Periodontal charting with prob-
ing depths on the same six sites after 30
years of follow-up (performed using peri-
odontalchart-online, www.periodontal-
chart-online.com; printed with permission
of the Department of Periodontology,
University of Bern, Switzerland).
reductions of PPD and CAL compared with SRP alone
or the administration of antibiotics at a later time after
APT or along with SPT.27,29
In the present case, the risk of developing caries
lesions had not been sufficiently taken into account
before the orthodontic treatment. In 1986, five teeth
were hopeless or questionable (teeth 16, 21, 26, 36, and
46). The two maxillary first molars were extracted
during APT and replaced by transplanted maxillary
third molars. Transplantation was followed by com-
plete periodontal regeneration around the trans-
planted teeth. These teeth are still present 30 years
later (100% survival rate), but with a caries lesion on 16
and an apical periodontitis on 26.
In a study on tooth autotransplantation,30 in which
these two transplanted third molars were included, the
long-term survival rate for transplants observed after at
least 10 years was 96%. Nevertheless, the cumulative
complication rate after an observation period of 10 to
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Peti t et al
20 years was 38.9%. Several other studies obtained
survival rates of 83% to 97% for transplanted teeth.
Czochrowska et al31 described a success rate of 79%
with a mean observation time of 26.4 years and a mini-
mum follow-up of 17 years. Survival and success of
autotransplantation are similar to those of dental
implants and may be proposed when the conditions of
root evolution and availability of the teeth to be trans-
planted are favorable.
Transplanted teeth have the same risks as natural
teeth, and periodic follow-up should be carried out
with the same frequency as for the other teeth in the
mouth to ensure positive long-term results.
CONCLUSION
Long-term management of localized AgP is challenging
and several treatment options have been proposed
over time. In the present case, a conservative approach
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Petit et al
led to the long-term persistence of teeth even in the
presence of severe periodontal disease. This article
emphasizes the importance of regular SPT and shows
how developments in implantology changed the treat-
ment approaches. This case also demonstrates that
regular monitoring should not only concern periodon-
tal tissues, but also focus on the caries risk, and caries
prevention when present.
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