Journal of Indian Society of Periodontology

: 2019  |  Volume : 23  |  Issue : 4  |  Page : 371--376

Aggressive periodontitis with a history of orthodontic treatment

Vivek Vijay Gupta, Srinivas Sulugodu Ramachandra 
 Faculty of Dentistry, SEGi University, Selangor, Malaysia

Correspondence Address:
Dr Vivek Vijay Gupta
Faculty of Dentistry, SEGi University, No. 9, Jalan Teknologi, Taman Sains, Petaling Jaya, Kota Damansara, Selangor


This report presents a 29-year-old aggressive periodontitis patient from Morocco with a history of orthodontic treatment. Despite all the first molars showing advanced bone loss, the maxillary anterior teeth did not show any periodontal destruction. The scientific literature rarely reports cases of aggressive periodontitis without involving maxillary anterior teeth. The treatment provided includes extraction of hopeless tooth, removal of overhanging restoration, scaling, root debridement, and regenerative periodontal therapy. The discussion highlights the dilemma during diagnosis of the case as either “iatrogenic periodontitis due to orthodontic treatment” or “localized aggressive periodontitis.” The age group of 15–35 years is the common age group for patients' seeking orthodontic treatment and the occurrence of aggressive periodontitis. Sound knowledge of periodontitis and identification of early signs of aggressive periodontitis through meticulous periodontal examination may help in earlier identification and minimalistic treatment. Education regarding periodontitis, especially aggressive periodontitis, is essential among orthodontists and general dentists. This case report aims to discuss the dilemma involved during diagnosis of localized aggressive periodontitis.

How to cite this article:
Gupta VV, Ramachandra SS. Aggressive periodontitis with a history of orthodontic treatment.J Indian Soc Periodontol 2019;23:371-376

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Gupta VV, Ramachandra SS. Aggressive periodontitis with a history of orthodontic treatment. J Indian Soc Periodontol [serial online] 2019 [cited 2021 Feb 26 ];23:371-376
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Aggressive periodontitis commonly occurs in the age group of 15–35 years.[1] Rapid loss of attachment, family history of periodontitis, early age of onset, and good systemic health are the primary features in the diagnosis of aggressive periodontitis.[1] The American Academy of Periodontology updated the classification of aggressive periodontitis by the addition of the criterion of mismatch between the amount of local factors and the degree of periodontal destruction.[2] Despite these guidelines and updates, diagnosis of aggressive periodontitis remains a challenge.[3] Coincidentally, majority of patients receiving orthodontic treatment are in the same age group of 15–35 years.[4] Changes in the microbial flora and increase in the levels of the cytokines (interleukin-1 β, tumor necrosis factor-alpha) may initiate periodontitis during orthodontic treatment.[4] A busy orthodontist may overlook/or fail to diagnose early signs of periodontitis in these patients resulting in significant damage to the periodontal structures. This article reports a case of aggressive periodontitis with a history of orthodontic treatment. The article aims to discuss the dilemma in diagnosing a case of aggressive periodontitis and the devastating effect of orthodontic therapy in a case of aggressive periodontitis.

 Case Report

A 29-year-old patient from Morocco reported to the Oral Health Centre with a chief complaint of mobile teeth in the right and left upper back teeth region from the past 6 months. The patient, a student, was systemically healthy, nonsmoker, and did not provide any family history of periodontitis. The dental history revealed a patient had undergone fixed orthodontic treatment for 1 year in Saudi Arabia around 4 years back for esthetic purposes. The patient had Damon ® braces in the maxillary teeth and conventional braces in the mandibular teeth. Orthodontic treatment plan included extraction of the mandibular right central incisor (tooth 41). The patient discontinued orthodontic treatment upon advice from another general dental practitioner (GDP) on possible damage caused to the periodontium due to the orthodontic treatment. Further, attempts to gain treatment records from the orthodontic clinic in Saudi Arabia were unsuccessful. Temporomandibular joint examination revealed clicking on the right side of the mandible with deviation to the left on opening. Hard tissue examination revealed Ellis Class I fracture in relation to maxillary left central incisor (tooth 21). Mandibular right first molar showed a composite restoration on the occlusal surface.

Oral cavity showed minimal amounts of plaque and calculus. Basic periodontal examination scores for the patient were 4, 2, 4 (right to left) for the maxillary sextants and 4, 2, 4 (right to left) for the mandibular sextants.[5] Comprehensive periodontal examination revealed deep periodontal pockets up to 10 mm around the maxillary and mandibular first molars. Clinical attachment loss in relation to right maxillary first molar: mesial 10 mm, buccal 12 mm, distal 10 mm, palatal 10 mm, and right mandibular first molar: mesial 8 mm, buccal 6 mm, distal 4 mm, and lingual 6 mm was recorded [Figure 1]. Clinical attachment loss in relation to left maxillary first molar: mesial 8 mm, buccal 7 mm, distal 4 mm, palatal 7 mm, and left mandibular first molar: clinical attachment loss: mesial 8 mm, buccal 7 mm, distal 5 mm, and lingual 6 mm was recorded [Figure 2]. Maxillary right first molar was grade III mobile. Maxillary first molars (tooth 16 and 26) had grade III furcation involvement (mesial, buccal, and distal furcations). Mandibular first molars (tooth 36 and 46) had grade II furcation involvement (buccal and lingual furcations). The patient was not having bruxism or trauma from occlusion. Orthopantomogram (OPG) revealed advanced bone loss extending from the distal area of the maxillary right second premolar to the mesial aspect of the maxillary right second molar [Figure 3]. Maxillary left first molar showed a similar pattern of bone loss. Mandibular first molars revealed similar pattern of bone loss, although the mesial aspects of the first molar showed pronounced bone loss [Figure 3]. OPG also showed horizontally impacted mandibular right third molar and mesioangular impaction of mandibular left third molar. Intraoral periapical radiographs provided more focused view of the bone loss, especially around the first molars [Figure 4]. Maxillary anterior sextant showed the absence of bone loss [Figure 5]. All the involved molars were responsive to cold and electric pulp sensitivity tests. The differential diagnoses for the case were localized aggressive periodontitis and iatrogenic periodontitis due to orthodontic treatment. Provisional diagnosis was localized aggressive periodontitis based on the age of the patient, pattern of bone loss, minimal amount of local factors, and patient being systemically healthy. A treatment plan was formulated that included removal of the composite restoration on the mandibular right first molar, extraction of the maxillary right first molar, scaling and root debridement, adjunctive antimicrobial therapy, periodontal regenerative therapies around the remaining first molars, and replacement of the maxillary first molar (following its extraction). Clinicians obtained informed consent from the patient after explaining the planned treatment.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

Treatment in the emergency phase included extraction of the maxillary right first molar due to grade III mobility. Phase I therapy included removal of the composite restoration on mandibular right first molar, followed by scaling and root debridement. Adjunctive antibiotics included combination of amoxicillin (500 mg thrice daily for 5 days) and metronidazole (400 mg twice daily for 5 days). One month following phase I periodontal therapy, reevaluation of the case showed residual periodontal pockets. Regenerative periodontal therapy including bone grafts (CompactBone ® B, Dentegris, Germany) was performed on the maxillary left first molar [Figure 6] and [Figure 7] and mandibular first molars [Figure 8] and [Figure 9]. Clinician provided postsurgical instructions and stressed the need for frequent maintenance visits. To assist the patient in the maintenance of oral hygiene and interdental brushes was prescribed, and oral hygiene instructions were reemphasized.{Figure 6}{Figure 7}{Figure 8}{Figure 9}

At the 3-month follow-up visit, the patient received oral prophylaxis. Follow-up of the patient 3 months following periodontal therapy was uneventful with significant reductions in the probing depth, gingival recession, and gain in clinical attachment level with clinical attachment loss around mandibular right first molar (mesial 5 mm, buccal 4 mm, distal 3 mm, and lingual 4 mm without bleeding on probing) [Figure 10]. Clinical attachment loss around maxillary left first molar: mesial 6 mm, buccal 4 mm, distal 3 mm, and palatal 4 mm; clinical attachment loss around mandibular left first molar: mesial 5 mm, buccal 3 mm, distal 3 mm, and lingual 3 mm) was recorded [Figure 11]. Unfortunately, the patient was lost to follow-up, which could be considered as a limitation of this case report.{Figure 10}{Figure 11}


The patient is from Morocco, a North African nation wherein, high prevalence of aggressive periodontitis is noted.[6],[7] The increased presence of JP2 clone of the Gram-negative rod Aggregatibacter actinomycetemcomitans among adolescents living in the North and Western Africa results in significantly increased the risk of periodontal attachment loss.[5] The past dental history states orthodontic treatment (including extraction of mandibular right central incisor) lasting for 1 year which the patient subsequently discontinued. Increasing the vertical dimension of occlusion was probably the reason for the placement of an overlay-type of composite restoration on the mandibular right first molar. Further, attempts by the patient and us to retrieve his previous orthodontic treatment records from Saudi Arabia were not fruitful. Access to previous radiographs and treatment details improves the patient care.[8]

Localized aggressive periodontitis and iatrogenic periodontitis due to orthodontic treatment were the differential diagnoses for the case. Patient's young age, minimal amount of local factors, rapid attachment loss, and absence of any systemic disease are few of the factors favoring the diagnosis of localized aggressive periodontitis.[1],[2] According to the recently released classification of periodontitis, the case would be considered as localized stage III, grade C periodontitis. An additional descriptor of early-onset disease (molar/incisor pattern) can be added based on the indirect evidence of progression.[9]

The recent classification of periodontitis removed the preexisting category of “aggressive periodontitis.”[10] The rationale for the removal was the lack of sufficient evidence to consider chronic and aggressive periodontitis as two pathophysiologically distinct diseases.[10] Difficulty in obtaining a comprehensive supporting family history and the need for well-maintained clinical and radiographic records to support the rapidity of periodontal destruction was the main reason for the removal of aggressive periodontitis as a separate category.[10] In addition, the mismatch between the amount of local factors and that of periodontal destruction (a key supporting feature used in the diagnosis of aggressive periodontitis) was subjective and could differ according to the individual views of the clinicians.[11] Furthermore, on the patient being referred after completion of initial periodontal therapy, information regarding amount of local factors was lost, resulting in difficulties in differentiating cases of chronic from aggressive periodontitis.[11] Despite all the above-mentioned points, cases of advanced periodontal destruction in young individuals are noticed, which cannot be comprehensively explained with the current periodontitis model. Fine et al. suggested aggressive periodontitis to be an “orphan disease” in the United States and most of the less densely populated countries.[12] Authors suggested longitudinal data to be generated from countries wherein, the disease is prevalent such as the Arab region and Northern African countries like Morocco, wherein the prevalence of aggressive periodontitis is comparatively higher.[12] Cases like these may support the persistence of aggressive periodontitis and provide impetus to long-term studies on aggressive periodontitis.

Improper use of orthodontic elastic bands has been associated with periodontal destruction around incisors and maxillary first molars.[13],[14] The studies report a significant alveolar bone loss on the mesial tooth surface of the maxillary first molars following orthodontic treatment.[14] In this particular case, mesial areas of all the first molars showed the increased bone loss. Lin et al. listed the pain, isolated pyogenic granuloma such as lesions, deep probing depth along with rubber band, converging roots, diverging crowns, and intact interdental bone as common features in cases involving elastic band abuses resulting in localized periodontal destruction.[13] The absence of pain, minimal amount of gingival inflammation, diverging roots, loss of interradicular bone with furcation involvement in all the first molars are few of the additional features favoring the diagnosis of the case as localized aggressive periodontitis.

A peculiar feature noticed in the case is the absence of periodontal disease in the maxillary anterior sextant. Distolabial migration of the maxillary anterior is one of the hallmarks of aggressive periodontitis.[1] Ramachandra et al. staged the cases of aggressive periodontitis into three stages based on severity.[15] The particular case would be a stage II aggressive periodontitis owing to the presence of at least two sites with clinical attachment loss > 6 mm, bone loss of 50%–70%, the presence of both horizontal and vertical bone defects, having one tooth indicated for extraction or with a hopeless prognosis. Despite the case being in stage II, the maxillary anterior teeth are unaffected by the disease process. Kanas and Kanas reported a new entity titled “localized aggressive multiparous periodontitis” which occurred in females with children and the cases showed lack of involvement of maxillary anterior teeth.[16] However, in our case, the patient is a male. Currently, scientific literature lacks documentation of cases of aggressive periodontitis with noninvolvement of maxillary anterior teeth. Cases of aggressive periodontitis continue to show peculiar variations underscoring the complex facets of the disease.[3]

One of the significant reasons for dilemma in the diagnosis is the age of the patient. The age group that seeks orthodontic treatment is generally 15–35 years.[4] Coincidentally, aggressive periodontitis occurs in the same age group.[4] Maxillary and mandibular first molars are the initial teeth to erupt into the oral cavity. Coincidentally, the first molars are the teeth considered for anchorage or leverage purposes by the orthodontist during either removable or fixed orthodontic therapy.[4] Even though orthodontic therapy may not initiate aggressive periodontitis, it may aggravate the periodontal destruction. Orthodontic treatment in the patient could have resulted in the accumulation of plaque and calculus, especially in the first molar area. In the absence of previous records, it could be speculative to suggest whether periodontitis was existing before orthodontic treatment or periodontitis occurred during orthodontic treatment. The preventive recommendations proposed by Hazan-Molina et al. regarding the need for an approval of periodontal health by an interdisciplinary dental team before and during orthodontic treatment is encouraging.[4] Advices include use of proper periodontal examination, a blood IgG antibody titer analysis and microbiologic examination for periodontal pathogens during diagnosis of periodontitis.[17] Ishihara et al. recommended use of the above-mentioned criteria to determine the correct timing of initiation of orthodontic treatment in aggressive periodontitis.[17]

However, it is necessary to highlight the correct advice provided by the GDP in Saudi Arabia to discontinue with orthodontic therapy, following the identification of periodontitis in the patient. Speculating the exact stage or amount of periodontal destruction at which, the GDP alerted the patient to discontinue with orthodontic treatment does not serve any purpose. Reasons for identification of aggressive periodontitis at a late stage include failure to diagnose and consequent misdiagnosis by dentists.[18] Studies show low confidence among GDP, especially in diagnosing and treating aggressive periodontitis.[19],[20],[21],[22] Ercan et al. suggested ≥50% GDP were not knowledgeable in the diagnosis and treatment of aggressive periodontitis.[19] Authors stressed periodontal education among GDP to increase the awareness regarding periodontitis.[19] Knowledge about aggressive periodontitis was found to be inadequate among dentists in Nigeria, a country which is neighbor of Morocco (the patient is a native of Morocco).[20] Among GDPs in Victoria, Australia, confidence in the diagnosis and treatment of aggressive periodontitis was 62% and 52%, respectively.[21] Suggestions to decrease variation among dentists about diagnosis ultimately benefitting patient care include increased use of accepted practice guidelines and consensus building opportunities.[22] Berlin-Broner et al. advocated orthodontists to increase their awareness on periodontitis and commitment toward instructing patients' to maintain good oral hygiene during orthodontic therapy, thereby decreasing the chances of caries and periodontitis.[23] In the present case, the gingival recession noted on maxillary molars is possibly due to the thin gingival biotype. A fragile/thin gingival biotype could trigger gingival recession during orthodontic therapy. Detecting and controlling mucogingival risk factors could help the orthodontist to avoid gingival recession thus preventing periodontitis.[24] The use of adjunctive antibiotics helps in control of tissue invasive bacteria including A. actinomycetemcomitans and Porphyromonas gingivalis (causative organisms for localized and generalized aggressive periodontitis, respectively).[25] Literature supports the use of a combination of amoxicillin and metronidazole in the adjunctive treatment of aggressive periodontitis.[25]


The diagnosis of aggressive periodontitis (molar/incisor pattern of periodontitis) can be challenging, especially in cases wherein, the previous dental records are unavailable. Orthodontic therapy can initiate and aggravate periodontitis in young individuals. Constant monitoring of periodontal health of orthodontic patients is important before, during, and after orthodontic therapy. Regular evaluation of periodontal health in these patients may help in retention of teeth and prevent advanced periodontal destruction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.


We would like to thank Mr. Matthias Matthes of Dentegris International, Germany for providing us with samples of CompactBone ® B. We would like to thank the Datuk Dr. Khairiyah Abd Muttalib, Dean, Faculty of Dentistry, SEGi University for considering this case as “academic interest” and waiving off the charges of surgical periodontal therapies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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