|Year : 2021 | Volume
| Issue : 1 | Page : 83-88
The assessment of aggressive periodontitis at Kuantan, Pahang: A retrospective study
Nurul Farahin binti Fazid1, Siti Mahirah binti So’odi2, Munirah Yaacob3, Juzaily Hussain3, Suhaila Muhammad Ali3
1 Klinik Pergigian Tanjung Malim, Tanjung Malim, Malaysia
2 Klinik Pergigian Selayang Baru, Batu Caves, Malaysia
3 Periodontic Unit, Restorative Department, Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan, Malaysia
|Date of Submission||12-Nov-2019|
|Date of Decision||20-Jul-2020|
|Date of Acceptance||01-Aug-2020|
|Date of Web Publication||28-Jan-2021|
Dr. Munirah Yaacob
Kulliyyah of Dentistry, International Islamic University Malaysia, Kuantan Campus, 25200 Kuantan.
Source of Support: None, Conflict of Interest: None
Aim: Aggressive periodontitis (AgP) is a less common but rapidly destructive form of periodontitis. Literature is scarce regarding the prevalence and characteristics of the disease in Malaysia. This study was conducted to assess the prevalence of AgP and its correlation with sociodemographic, risk factors, and clinical presentations. Materials and Methods: This retrospective cross-sectional descriptive study of AgP includes patients who had attended the IIUM Dental Clinic from the year 2014 up to June 2017. The data regarding the characteristics of AgP were extracted from patients’ case records systematically using a standard data extraction form. Descriptive analysis, independent t-test, and χ2 test were conducted using IBM SPSS, version 24.0 software. Results: Of 262 periodontitis cases, 11 were confirmed to have AgP, giving a prevalence of 4.2%. Seven of them had the generalized form of AgP with a mean (±SE) age of 36.4 (±6.99) years. Eight of them were female, the majority were Malay, and four of them claimed of having familial aggregation. The localized form had significantly deeper pocket depth of at least 6 mm. However, the percentage of bleeding on probing and plaque scores were significantly higher in the generalized form of the disease (P < 0.05). First molars showed the highest frequency of tooth loss and clinical attachment loss. Conclusion: The prevalence rate of AgP in a specified population in Kuantan was found at 4.2%, affecting younger age group compared to chronic periodontitis. Age, the percentage of bleeding on probing, plaque score, and deep pockets were significantly associated with the types of AgP.
Keywords: Aggressive Periodontitis, Malaysia, Prevalence, Risk Factors, Sociodemographic
|How to cite this article:|
Fazid NF, So’odi SM, Yaacob M, Hussain J, Muhammad Ali S. The assessment of aggressive periodontitis at Kuantan, Pahang: A retrospective study. J Int Oral Health 2021;13:83-8
|How to cite this URL:|
Fazid NF, So’odi SM, Yaacob M, Hussain J, Muhammad Ali S. The assessment of aggressive periodontitis at Kuantan, Pahang: A retrospective study. J Int Oral Health [serial online] 2021 [cited 2021 Mar 5];13:83-8. Available from: https://www.jioh.org/text.asp?2021/13/1/83/308365
| Introduction|| |
Aggressive periodontitis (AgP) is a severe form of periodontitis with rapid destruction of the inflammatory periodontal tissue which is made worse by loss of tissue attachment and bone, leading to early tooth loss., Plaque biofilm is directly associated with disease severity, although in the localized form of AgP, studies have suggested no correlation between plaque levels and the presence of disease. Furthermore, there is strong evidence showing familial aggregation in young patients with early expression of aggressive periodontal disease. In addition, smoking increases the severity of both chronic periodontitis and AgP (because of their young age, the effect on the localized form of AgP is not apparent). Nibali et al. had reported that the average tooth loss per patient per year was 0.09 teeth where they calculated that one-third of patients with AgP (38%) seemed to account for the most teeth lost (91%).
A review reported that 0.1–0.2% of the European population was affected by AgP, and Africa recorded the highest percentage in the world, which is 3.4%. A recent study in a Romanian population attending a prosthodontic clinic revealed a higher prevalence of 11.4%. However, a limited number of studies have been retrieved on the prevalence of AgP in Southeast Asia (SEA). A study in an Indonesian population showed a prevalence of 3.13%, while only one study found for a Malaysian population depicted prevalence of 5.3%, and the highest prevalence reported for SEA was 9.6% from an Indian population in Hyderabad. The prevalence reported by Prathypaty et al. and Yee et al. seems to be the highest in SEA and they had similar study populations, which consisted of newly referred patients in periodontal specialist government clinics.
In view of both studies, we hypothesized a high prevalence of AgP among patients with periodontitis attending our dental clinic. However, the human population across various cultures and geographic regions may show different prevalence and risks for AgP. Therefore, there is a need to undertake studies examining the characteristics of patients with AgP among the different populations across the country. With this aim in mind, the present study describes the patterns and characteristics of AgP disease from a population in Kuantan, Malaysia.
| Materials and Methods|| |
Setting and design
The present study is a retrospective, cross-sectional descriptive design of treatment records of patients with periodontitis. This convenient sample consisted of patients who had been diagnosed with periodontitis at IIUM Dental Clinic, Kuantan, Pahang, Malaysia from the year 2014 up to June 2017.
There were three sources of name list of patients with periodontitis included in the study: from the periodontal specialist clinic list, the students’ waiting list, and the students’ log book. Therefore, a master list of names of patients with periodontitis was developed. It combined the names from those three sources to ensure no redundancies before their treatment records were retrieved from the Treatment Records Unit. The exclusion criteria in this study were treatment records of periodontitis cases with incomplete details of periodontal information (such as incomplete periodontal charting) and cases that had sought periodontal treatments at IIUM Dental Clinic, Kulliyyah of Dentistry earlier than the year 2014.
For AgP cases, the patients’ periodontal records were further scrutinized to confirm the diagnosis that has been made based on the case definition recommended by Armitage. Armitage stated that the diagnosis of AgP is made based on clinical, radiographic, and historical findings which show rapid attachment loss and bone destruction, and possible familial aggregation of the disease.
The sample size was calculated based on the prevalence of AgP among patients with periodontal disease reported by Yee et al. It was estimated 5.3%, with the worst acceptable rate of 5% and a confidence interval of 99.9%. Therefore, to be able to estimate at least a 5.3% prevalence of AgP among patients with periodontal disease, this study needed a minimum sample size of 217 of treatment records of patients with periodontitis.
Data extraction forms and analysis
Data extraction forms were used to systematically collect the required information. It consisted of three parts: the first part of data collection concentrated on patients’ basic information such as name, age, date of birth, race, gender, and occupation. The second part was on the etiology of the disease including familial aggregation, environmental factors such as smoking status (number of cigarettes and duration of smoking), oral hygiene status and practice, history of stress, history of systemic diseases, and medication intake. The third part focused on the clinical presentation of the disease, including plaque score, bleeding on probing (BOP), mobility of tooth, probing pocket depth (PPD), recession, and clinical attachment loss (CAL).
Two examiners (NF and SS) were responsible to develop the master list consisted of names of patients with periodontitis and retrieved the case notes from the Treatment Records Unit. Three periodontists (MY, JH, and SA) further scrutinized the treatment records of AgP cases to confirm the AgP diagnosis by examining the available periodontal information and they also excluded files with incomplete periodontal information. Any issues were resolved by discussion. Of this pool of patients with periodontitis, 11 patients were confirmed to be diagnosed with AgP and all eligible cases data were extracted by two examiners (NF and SS).
The data were analyzed using Statistical Package for Social Sciences (SPSS) software, version 24.0, released 2016, for Windows (IBM, Armonk, New York). Descriptive statistics, independent t-test, and χ2 test were used to analyze the differences between the localized and generalized forms of AgP in relation to sociodemographic and periodontal parameters. The significance level was set at P < 0.05.
| Results|| |
From the 3 years of records, 262 periodontitis cases were identified. Eleven of them had been diagnosed with AgP which gives a prevalence of 4.2% that affects patients with a mean age (±SE) of 33.09 (±3.09) years, while the diagnosis of chronic periodontitis affects older patients with a mean age (±SE) of 49.06 (±0.78) years [Table 1].
|Table 1: Prevalence of periodontitis cases at IIUM Dental Clinic and the mean age of the group (n = 262)|
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[Table 2] presents that seven patients with AgP were diagnosed with the generalized form with a mean (±SE) age of 36.4 (±6.99) years, whereas the localized form affected a younger age group of 27.3 (±0.5) years. A significant difference in mean age was found between the two groups (P = 0.002). Five cases of generalized form were female with the majority being of Malay race. It was also observed that one of the patients with generalized AgP had mental retardation. Four patients described the same occurrence among family members, with three of them having the generalized form of AgP. One of the patients with AgP had the habit of smoking tobacco. Patients with poorer oral hygiene were found higher among generalized AgP cases compared to localized AgP, with rates of 36.4% and 27.3%, respectively.
|Table 2: Sociodemographic and oral health variables associated with patients with aggressive periodontitis (n = 11)|
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Clinical features exhibited by patients with AgP are given in [Table 3] [Figure 1] and [Figure 2]. Mean (±SE) percentage of PPD at least 6 mm for localized AgP in comparison to generalized AgP showed a significant difference (P = 0.023), with values of 8.48% (±16.57) and 4.65% (±3.28), respectively. Patients with the generalized form of AgP showed significantly higher percentages of BOP and plaque score compared to patients with the localized form (P < 0.05). First molars had the highest CAL which was 4.6 mm and the highest frequency of tooth loss. Meanwhile, second premolars exhibited the lowest CAL which was 1 mm and lateral incisors had the lowest tendency for tooth loss.
|Table 3: Periodontal parameters of aggressive periodontitis (AgP) patients|
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|Figure 1: Mean clinical attachment loss (CAL) for each tooth in aggressive periodontitis. M2 = second molar, M1 = first molar, P2 = second premolar, P1 = first premolar, C = canine, I2 = lateral incisor, I1 = central incisor|
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|Figure 2: Number of missing teeth among patients with aggressive periodontitis. M2 = second molar, M1 = first molar, P2 = second premolar, P1 = first premolar, C = canine, I2 = lateral incisor, I1 = central incisor|
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| Discussion|| |
This study showed a prevalence of 4.2% of AgP cases in the selected study population that is slightly lower than the rate reported in a study with a similar population by Yee et al. There were no other published studies found from a comparable population in Malaysia. Both prevalence rates were higher than the actual incidence reported from the general population elsewhere. However, the prevalence is slightly lower when compared to a recent study conducted in India (9.6%) that had assessed 10 years of treatment records. The latter study determined the periodontitis diagnosis based on similar classification used by our study; however, the longer timespans from which the records were retrieved increase the sample size, detection rate of periodontitis cases, and the reliability of the prevalence. The limitation of any study examining previous records is always related to retrieval bias, especially of missing records. Nevertheless, retrospective data are still relevant as the basis for further exploration of any issues. From the literature search, the highest reported prevalence for AgP of 11.4% was seen from a convenience sampling of patients who attended a prosthodontic clinic in Romania. However, the authors had highlighted the drawback of the study where their diagnosis was not based on the classification of periodontal and dental conditions, but was based on panoramic radiographs only without any information on the pocket depth or level of inflammation.
According to the American Academy of Periodontology in the update of the 1999 classification, AgP affects younger patients compared to chronic periodontitis. Patients’ age and medical status have been thought of as the second essential key of general features in distinguishing between chronic periodontitis and AgP. The present study showed that AgP affects younger adults with a mean age of 33.09 (±3.09) years; on the other hand, chronic periodontitis affects older patients with a mean age of 49.06 (±0.78) years. These findings concurred with a study conducted at a periodontal specialist clinic in Malaysia (34.9 years). Further analysis found that the mean age for localized and generalized AgP was 27.3 and 36.4 years, respectively. This substantiates the current literature which reports that the localized form of AgP usually affects younger adults, whereas the generalized form affects patients in their 30s. Other studies conducted in Asian regions stated that 0.6% of 13- to 19-year-old school children in Ankara, Turkey, 0.13% of 15- to 18-year-old school children in Tehran, Iran, and 0.15% of 15- to 39-year-old participants in India were affected by AgP.
The present study showed that AgP is seen more commonly in females compared to males (ratio of 3:1), but the finding was statistically insignificant. A similar result was reported by Yee et al. and Baer.13] A larger study by Hørmand and Frandsen also concluded that AgP affects females more than males with a ratio of 5:2 after examining 156 patients with AgP. The authors had suggested that the earlier eruption of first molars and incisors in females predisposes them to the higher occurrence of AgP., In contrast, two surveys reported significantly higher disease prevalence rates in males than in female subjects., Nevertheless, data from any specific population should always be interpreted with caution while considering the population size, study design, and the fact that females have a higher tendency to attend dental checkups rather than males. The biological plausibility behind this is still scarce though the emergence of gender medicine is trying to explore this.
Current knowledge on AgP implicates linkage history of the same occurrence within AgP family as its etiology. The findings of this study showed that nearly half of patients with AgP had strong family linkage, with most of them exhibiting a generalized presentation of AgP. Indeed, an adequate study design is needed for exhaustive evaluation and testing to verify the validity of genetic inheritance. Nevertheless, Marazita et al. in a large-scale family genetic study had demonstrated that AgP shows inheritance related to the autosomal-dominant mode of transmission with 70% penetrance. In view of that, dentists ought to ask, advise, or screen family members of patients with AgP for the disease. Early detection with adequate treatment and proper management should be able to mitigate the severity of the disease among individuals and families as a whole.
Armitage and Cullinan reported on the accumulation of plaque and mentioned that patients with localized AgP showed thin plaque deposition with little or no calculus, whereas patients with chronic periodontitis exhibited thick and complex polymicrobial communities on the affected teeth. These findings corroborate the current study’s findings of fair plaque control and BOP in patients with AgP. Despite the low presence of plaque, evidence has shown that patients with AgP exhibit a rapid amount of bone loss and destruction., Thus, proper advice on oral health care and disease control remain critically important for patients with AgP to inhibit the accelerated progression of the disease.
In the present study, first molars consistently showed the highest frequency of tooth loss and a mean CAL of 4.6 mm. A meta-analysis of multiple studies has shown that molars have a higher risk and are more susceptible to loss compared to anterior teeth. The progression of the disease and tooth loss contributed by the susceptibility of patients was toward the disease. Yee et al. are in agreement that first molars and incisors had a hopeless prognosis and a high tendency of loss. He relates other external factors that can contribute to the loss of molars, such as difficulty in cleaning the posterior teeth and cracked roots. Nevertheless, a systematic review has concluded that despite the high prevalence of tooth loss found among patients with AgP, many studies report excellent long-term stability of treated AgP cases. It is concluded that early detection, treatment, and subsequent long-term follow-up of patients with periodontitis during the maintenance phase help to maintain periodontal health and prevent tooth loss in most patients.,
| Conclusion|| |
The prevalence of AgP cases among patients with periodontitis who have attended the IIUM Dental Clinic during the period of 3 years is 4.2%. The data from two studies conducted in two district clinics in Malaysia had proven that a high prevalence of patients with AgP exists among the disease-inflicted sample. Due to this high prevalence, awareness in diagnosing the cases among general dentists as a whole should be enforced as they are the primary care providers for oral health. The early identification and treatment of AgP are vital to prevent or reduce the incidence of tooth loss and subsequently for the improvement of patients’ quality of life. The high prevalence of AgP found in the current study may not reflect the actual incidence of AgP that can be directly inferred to Malaysia’s general population because of the use of convenience samples. Nevertheless, more explicit research needs to be conducted on a large scale to identify the associated risks and susceptibility factors that contribute to this high prevalence in Malaysia. A genetic study can also be conducted to analyze similarities of genes and traits carried by these group of patients with AgP.
We would like to acknowledge assistant professor Dr. Mohd Hafiz Arzmi for assisting in statistical analysis, the staff of IIUM Polyclinic for technical assistance, and direct and indirect parties for assistance and guidance.
Financial support and sponsorship
This study was supported by the IIUM Research Initiative Grant: RIGS17-088-0663.
Conflict of interest
There are no conflicts of interest.
All authors contributed to the design and implementation of the research. MY coordinated the research. NF and SM performed the screening of records, extracted the data from treatment records file, and processed the collected data. MY, JH, and SA scrutinized the specific data for patients with AgP and excluded the ineligible cases. NF, SM, and MY interpreted the results and worked on the manuscript. All authors discussed the results and commented on the manuscript.
Ethical policy and institutional review board statement
Ethical approval was obtained from IIUM Research Ethical Committee (IREC) with IREC No. 693.
Patient declaration of consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
The data set used in the current study is available on request from Dr. Munirah Yaacob at the e-mail address: [email protected].
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]