1992; 3(1):9-16. It is easy to understand why genetics studies of this common problem have been neglected. A possible role for a mutation in this gene has also been reported in patients with generalized nonsyndromic. The defects may be a combination of vertical and horizontal defects (Figures 4(a) and 4(b)). Prior to finalizing any treatment plan, periodontists should consider the risk of disease progression and subsequent tooth loss as well as which option (ie, implant placement versus preservation of natural teeth) is likely to result in a better prognosis with fewer complications, is preferred by the patient, and is economically justifiable.7. 2016;95(1):43-49. } 2014;93(1):19-26. else { window.dataLayer.push({ target_offset = target_offset + 1000; J Med Case Rep. 2015;9:211. doi: 10.1186/s13256-015-0677-6. The prevalence in African populations and their descendants is between 1% and 5%, whereas it is 0.1% to 0.2% for Caucasians living in North America.19, Treatment of aggressive periodontitis is aimed at reducing chronically inflamed tissue and the number of microbes in the deep vertical periodontal pockets. if ( $(this).offset().top >= target_offset ) { 2004;19(Suppl):150-154. Clin Oral Implants Res. Individuals with type IV, like those with type VIII, also have AD inheritance.62 The presence or absence of type III collagen abnormalities has been taken to be a differentiating factor between the two types, with EDS type IV showing abnormal type III collagen. } They concluded that there was no evidence in these twins for significant heritability of any of these dental parameters. Because several forms of early-onset periodontitis (e.g., localized prepubertal periodontitis, localized juvenile periodontitis [JP], and generalized JP) can be found in the same family, the expression of the underlying genetic etiology appears to have the potential to be influenced by other genetic factors.58, Progress has been made in the study of rare genetic conditions or syndromes that can predispose to periodontal disease or have periodontal disease as a relatively consistent component of their pleiotropic effect. $('div#article-content > p.body').each(function(){ 12. For cost-effective, positive outcomes, periodontists should adopt a balanced approach between placing implants and employing regenerative periodontal therapy in which patients are assessed for the appropriateness of each on a case-by-case basis. Lang NP, Berglundh T, Heitz-Mayfield LJ, et al. Clin Oral Implants Res. Investigation by Kornman and colleagues into the association of different polymorphisms of inflammation-mediating genes and periodontal disease in adult nonsmokers indicated that interleukin 1α and 1β (IL-1α and IL-1β) genotypes may be a risk factor.51 The IL-1β polymorphism was IL-1β + 3953 and the IL-1α polymorphism was IL-1α -889. 24. Antibiotic therapy combined with local débridement appears to be an effective treatment regimen. In addition, there was bone loss of a lesser magnitude associated with tooth No. In addition, it is accepted that antibodies to Aa have been found in all patients with juvenile periodontitis at levels significantly greater than those of the controls (Genco and Slots, 1984). if(parent.attr('ccposition')){ Such a complex disease shows both inflammatory and degenerative pathologic features. 'IDCategory2': "", However, this association has been seen in other,53 but not all, populations.52-55 Greenstein and Hart noted that the relationship of specific IL-1 genotypes and the level of crevicular fluid IL-1β is not clear, and that the ability of the genetic susceptibility test for severe chronic periodontitis, based on the findings of Kornman and colleagues, to forecast which patients will develop increased bleeding on probing, periodontitis, loss of teeth, or need for dental implants is ambiguous.56 This illustrates the complexity of genetic association studies, and genetic counseling is based on a marker that accounts for only a portion of phenotypic variations. Lorne D. Koroluk, in Diagnosis and Treatment Planning in Dentistry (Third Edition), 2017. 'IDCategory3': "", 4. } 23 had improved and that tooth No. Most genetics studies of a trait make use of families with multiple affected individuals or twins. Localized Aggressive Periodontitis, also known as LAP, is a rare type of inflammatory periodontal disease. In addition to consistent early-onset periodontal disease, patients with EDS type VIII have variable hyperextensibility of the skin, ecchymotic pretibial lesions, minimal bruising, minimal to moderate joint hypermobility of the digits, and “cigarette paper” scars. Donos N, Laurell L, Mardas N. Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma. $(this).after( ad_content ); It is characterized by more pronounced systemic antibody titers against periodontal pathogens than are found in patients with GAP. var that = $($(this).children()[0]); 23 and 24 would require a greater volume of bone and gingiva; therefore, the existing site was not favorable for implant placement. In advance of the procedure, the patient was premedicated with 250 mgs of metronidazole and 500 mgs of amoxicillin 3 times a day for 2 weeks. 2. Aggressive periodontitis may cause bad breath. 12 Carbon Steel Scalpel Blades, Benco Dental). The diagnosis "Aggressive Periodontitis", defined by the International Workshop for Classification of Periodontal Diseases and Conditions in 1999, refers to the multifactorial, severe, and rapidly progressive form of Periodontitis, which primarily – but not exclusively – affects younger patients. } The dental hygienist must always be aware that periodontal disease is not necessarily an "adult" disease process. Copyright © 2021 Elsevier B.V. or its licensors or contributors. Neutrophil migration through the gingival crevice appears to be abnormal. 12 scalpel blade (No. if ( found == false && typeof last_found !== 'undefined' ) { Successful regenerative periodontal therapy requires access to the root and osseous defect to enable proper diagnosis and debridement. This article describes a case of severe, localized periodontal disease in which the patient rejected a recommendation to undergo extraction followed by implant placement and restoration in favor of receiving regenerative periodontal therapy to save the natural tooth. Localized Aggressive Periodontitis. }); Some 75% of patients with the classical localized juvenile periodontitis appeared to suffer from a peripheral blood neutrophil chemotactic abnormality (Cianciola et al., 1977). pos = parent.attr('ccposition'); Aggressive periodontitis have localized and generalized forms. The authors state that from 38% to 82% of the periodontal disease identified in these twins was attributable to genetic factors. } 'PageType': "Single", Along with hypophosphatasia, prepubertal periodontitis appears to be the most commonly encountered cause of premature exfoliation of the primary teeth, especially in girls (Fig. Nitric oxide (NO) and its enzyme, nitric oxide synthase (NOS), have been suggested to be involved in chemotaxis. Abnormalities in host defenses (e.g., leukocyte chemotaxis), extensive proximal caries facilitating plaque retention and bone loss, and a family history of periodontitis have been associated with LAP in children.56 As the disease progresses, the child’s periodontium shows signs of gingival inflammation, with gingival clefts and localized ulceration of the gingival margin. Fardal Ø, Grytten J. } Bacteria, such as Aggregatibacter actinomycetemcomitans, have been implicated in its development and progression, as well as a neutrophil function disorder in the inflammatory response. Localized aggressive periodontitis (LAP), previously localized juvenile periodontitis GAP is a severe form of generalized periodontitis affecting young adults (less than 30 years of age). The flap elevation enabled access to the granulation tissue occupying the defect, and the subsequent removal of the granulation tissue allowed visualization of the defect, which measured 5 mm × 8 mm. A comparison of implant treatments rendered by different types of practitioners found that the survival rate of implants placed by inexperienced practitioners was 73.0% whereas the survival rate of implants placed by implant specialists was 95.5%.11 To aid in the decision of whether or not to extract a tooth and place an implant, Pjetursson and Heimisdottir offer a system to classify teeth as secure, doubtful, or irrational to treat.12 Overall, dentists should attempt to retain natural teeth whenever possible. ad_content = ad_content.replace("SCRIPTEND", "' + ad_content + ''; The bone loss often exhibits a vertical pattern in the first molar region and a horizontal pattern in the incisor region. The patient was later referred to an orthodontist for consultation. A review of the literature was performed since the last official classi-fication in 1999 was developed using the keywords; “Aggressive Periodontitis,” “Severe Periodontitis,” “Juvenile Periodontitis,” “Localized Juvenile It can occur localized or generalized in an otherwise clinically healthy patient but with probable selective immune dysfunction. This rare AR disorder is characterized by oculocutaneous hypopigmentation, severe immunologic deficiency with neutropenia and lack of natural killer cells, a bleeding tendency, and neurologic abnormalities. A possible role for a mutation in this gene has also been reported in patients with generalized nonsyndromic aggressive periodontitis.67, Early-onset periodontitis may occur in the primary dentition (prepubertal periodontitis), may develop during puberty (JP), or may be characterized by exceedingly rapid loss of alveolar bone (rapidly progressive periodontitis). ad_content = ad_content.replace("SCRIPTEND", "' + ad_content + ''; The most common form of gingivitis, and the most common form of periodontal disease overall, is in response to bacterial biofilms (also called plaque) that is attached to tooth surfaces, termed plaque-induced gingivitis.Most forms of gingivitis are plaque-induced. pos = that.attr('ccposition'); It is usually accompanied by mild to moderate inflammation, and heavier than average plaque deposits may be visible. 24. var parent = that.parent(); }); Periodontal disease, also known as gum disease, is a set of inflammatory conditions affecting the tissues surrounding the teeth. pos = that.attr('ccposition'); Gingivitis is a non-destructive disease that causes inflammation of the gums. $(last_found).after( ad_content ); This enabled access to the root and osseous defect in the interproximal area between teeth Nos. Localized aggressive periodontitis Clinical view showing minimal plaque and inflammation Surgical appearance of the localized, vertical, angular bony defects affecting the mandibular incisors 12. The localized form typically has a circumpubertal onset. Localized aggressive periodontitis is a bacterial infection caused by the pathogens Aggregatibacter actinomycetemcomitans (Aa).The American Academy of Periodontology (AAP) classifies localized aggressive periodontitis as type III A. Albandar and colleagues, using data from a 1986-1987 survey, estimated the prevalence of aggressive periodontitis in adolescent schoolchildren in the United States to be 10% in African Americans, 5% in Hispanics, and 1.3% in whites.54. It is caused by mutations in the CHS1/LYST gene.64, Papillon-Lefèvre syndrome and Haim-Munk syndrome are two of the many different types of palmoplantar keratoderma, differing from the others by the occurrence of severe early-onset periodontitis with premature loss of the primary and permanent dentition. Kamil W, Al Bayati L, Hussin AS, Hassan H. Recon-struction of advanced bone defect associated with severely compromised maxillary anterior teeth in aggressive periodontitis: a case report. Effectiveness of implant therapy analyzed in a Swedish population: prevalence of peri-implantitis. 'ccSize': that.attr("ccsize"), This condition may occur even in the presence of good oral hygiene. } Secondary features include phagocyte abnormalities and a hyperresponsive macrophage phenotype.24 Aggressive periodontitis can be localized or generalized. }); The severity of the disease appears to be an exuberant reaction to a minimum amount of plaque accumulation and may result in early tooth loss. else { 24 suggested vertical and horizontal bone loss extending to the apical one-third of the root length. window.dataLayer.push({ var ad_content = ``; Although the centers for disease control and prevention has found that the incidence of periodontal disease increases with age (70.1% of adults age 65 and older are said to have the disease), aggressive forms of periodontitis can affect children and young adults who are otherwise healthy. These individuals are usually characterized by type III collagen abnormalities with hyperextensibility of the skin, ecchymotic pretibial lesions, easy bruisability, cigarette paper scars, joint hypermobility of digits, pes planus, and, of greatest concern, arterial and intestinal ruptures. The term “aggressive periodontitis” has replaced the term “early-onset periodontitis.” Aggressive periodontitis is subclassified into localized aggressive periodontitis and generalized aggressive periodontitis. } While rare, its presentation can have severe implications for those affected. 'ccPosition': pos, Periodontitis can be further subcategorized into three broad classes based on radiographic, laboratory, and clinical features: chronic periodontitis, aggressive periodontitis, and periodontitis due to a systemic condition. 5 Poorly designed implant-supported prostheses are not conducive to the patient's performance of oral hygiene, which can lead to the presence of disease around a dental implant and eventually cause peri-implantitis. The periodontal disease state is often described as a local inflammatory disease with possible underlying systemic factors. 'IssueDate': "March 2020", 5-10).62. Localized aggressive periodontitis (LAP) can affect both the primary and permanent teeth. It occurs in children without evidence of systemic disease. Steven J. Challacombe, Penelope J. Shirlaw, in Mucosal Immunology (Third Edition), 2005. The considerable overlap in phenotype of these two types warrants careful family and clinical evaluation, and biochemical studies of collagen when a patient with features of EDS and periodontal disease is evaluated.63, Chédiak-Higashi syndrome has frequently been linked with severe periodontitis. else { Aggressive periodontitis can be viewed as two categories of periodontitis that may have overlapping etiologies and clinical presentations: (1) a localized form (localized aggressive periodontitis [LAP]) and (2) a generalized form (generalized aggressive periodontitis [GAP]). Localized aggressive periodontitis affects the first molar teeth and/or incisors. if ( $(this).offset().top >= target_offset ) { Individuals with GAP exhibit marked periodontal inflammation and have heavy accumulations of plaque and calculus. J Clin Periodontol. 'ccZoneID': that.attr("cczoneid"), } Chronic periodontitis, on the other hand, usually affects all the adult teeth. The exact defect in the system is absence of the sialyl Lewis x (SleX) structure antigens, which are important ligands for selectin on the leukocyte, which leads to a profound defect in leukocyte rolling, the first step in the adhesion cascade. Consensus statements and recommended clinical procedures regarding implant survival and complications. There was no bleeding on probing, the probing depth was 3 mm, and there was no tooth mobility or open contact. A review of the literature was performed since the last official classification in 1999 was developed using the keywords; “Aggressive Periodontitis,” “Severe Periodontitis,” “Juvenile Periodontitis,” “Localized Juvenile Periodontitis,” “Periodontosis,” “Early Onset Periodontitis,” and “Rapidly Aggressive Periodontitis.” Aggressive periodontitis describes a type of periodontal disease and includes two of the seven classifications of periodontitis as defined by the 1999 classification system: ad_content = ad_content.replace("SCRIPTEND", "' + ad_content + ''; last_found = $(this); Aa produces a powerful leucotoxin and neutralizing activity against this toxin is present in the serum of patients with juvenile periodontitis (Genco and Slots, 1984). In its more serious form, called periodontitis, the gums can pull away from the tooth, bone can be lost, and the teeth may loosen or fall out. Ahmad Soolari, DMD, MS $(last_found).after( ad_content ); 'ContentOutput': "Editorial", In this case, regenerative periodontal therapy was able to produce a remarkable regainment of bone (ie, 8 mm) within 3 years. 24 and tooth No. Pjetursson BE, Heimisdottir K. Dental implants - are they better than natural teeth? Stephen J. Challacombe, ... Martin H. Thornhill, in Mucosal Immunology (Fourth Edition), 2015. StenbergJr., Alexander Alcaraz, in Pediatric Dentistry (Sixth Edition), 2019. } Early-onset periodontal disease may also be found in patients with EDS type IV. $('div#article-content > p.body').each(function(){ 24 was fully functional and had no more mobility, no widened periodontal ligament, and no diastema (Figure 8). } The disease is most commonly manifested in the molar area, where localized, usually bilaterally symmetric loss of attachment occurs (Fig. Holm-Pedersen P, Lang NP, Müller F. What are the longevities of teeth and oral implants? found = true; As is true for dental caries, periodontal disease is common; occurs with a continuum of expressivity; and is greatly influenced by environmental conditions, such as diet, occlusion, and oral hygiene habits. last_found = $(this); 2017 Feb;44(2):158-168. doi: 10.1111/jcpe.12640. The infectious episodes and the severity are much milder than those observed in LAD type I, and the only persistent clinical symptom is chronic severe periodontitis. 'ccZoneID': that.attr("cczoneid"), return false; aggressive periodontitis: the rapid destruction of the clinical periodontal attachment and the bone surrounding the tooth or teeth. Localized aggressive periodontitis (LAP) is usually found in younger individuals than GAP (see Figures 25-3 and 25-4). The patient accepted a treatment plan that included surgical regenerative periodontal therapy. 2015;86(2 Suppl):S105-S107. Once debrided, the osseous defect was filled with a particulate freeze-dried bone allograft (Cortical Bone, Maxxeus Dental) (Figure 6) and covered with a resorbable membrane (Bio-Gide®, Geistlich Biomaterials) that was trimmed and fitted to the interproximal area (Figure 7). FINEET AL. Aa produces a powerful leukotoxin, and neutralizing activity against this toxin is present in the serum of patients with juvenile periodontitis (Tsai et al., 1981). They concluded that early-onset periodontitis is a complex, oligogenic disorder (i.e., involving a small number of genes), with IL-1 genetic variation having an important but not exclusive influence on disease risk. Several factors must be taken into account. The patient was informed that the benefit of periodontal treatment, whether surgical or nonsurgical, can be short-lived without a commitment to regular periodontal maintenance visits. Long-term clinical response to treatment and maintenance of localized aggressive periodontitis: a cohort study. 24 with an angle of almost 45°. Aggressive periodontitis-1 is caused by mutation in the CTSC gene, which is also involved in Papillon-Lefèvre syndrome and Haim-Munk syndrome, while aggressive periodontitis-2 has been mapped to a different chromosomal location (1q25).69-71, Ralph E. McDonald, ... Vanchit John, in McDonald and Avery Dentistry for the Child and Adolescent (Ninth Edition), 2011, The generalized form of aggressive periodontitis occurs at or around puberty in older juveniles and young adults. 'IDCategory1': "Implantology", Moreover, the longevity of implants does not surpass that of compromised but successfully treated natural teeth,1 and biologic and prosthetic complications are common as implant cases age.2 Beyond these considerations, the successful placement of an implant and management of the space between teeth Nos. Periodontists suggest that there is evidence for the existence of several variant types of periodontal disease, generally subclassified by the age of onset, severity of bone loss, oral hygiene status, and the presence or absence of local factors. var last_found; In addition, it causes severe bone and attachment loss, specifically impacting the first molars and the incisors. Eur J Oral Sci. Tetracyclines are contraindicated. The teeth were scaled and root planed again to remove any remaining plaque and calculus. } LAgP starts at a much earlier age than CP, but it is not right to go to a... 3. }); Because of its wide distribution and rapid rate of alveolar bone destruction, the generalized form of aggressive periodontitis has also been referred to by the terms such as generalized juvenile periodontitis (GJP), severe periodontitis, and rapidly progressive periodontitis. Inclusion of smoking data along with the genetic analysis increased the heritable variance in severe chronic periodontitis from 18% to 52%, confirming smoking as an environmental causative factor that may act in addition to inherited susceptibility genes.57, Early-onset periodontitis has been the subject of most family studies. Not every tooth with a poor prognosis can be saved, but advances in regenerative periodontal therapy can sometimes enable dentists to avoid tooth extraction and implant placement, preserving the natural dentition. A genome-wide scan for chronic periodontitis found suggestive evidence of association for six genes, including NIN, NPY, and WNT5A for severe chronic periodontitis, and NCR2, EMR1, and chromosome location 10p15 for moderate chronic periodontitis. 7. This disease is often localized, affecting only a few teeth. } This causes a marked decrease in chemotaxis, accompanied by pronounced neutrophilia. Aggressive periodontitis refers to periodontal disease of an aggressive and rapid nature that usually occurs in patients younger than 30 years. Localized aggressive periodontitis (LAP) In 1989 the World Workshop in Clinical Periodontics, categorized this disease as:- “Localized juvenile periodontitis” (LJP) 15. An interesting finding is the demonstration that many patients have depressed neutrophil chemotaxis and phagocytosis. found = true; return false; Accessed January 9, 2020. // element is now visible in the viewport An interesting finding is the demonstration that many patients have depressed neutrophil chemotaxis and phagocytosis. Radiographic appearance of localized aggressive periodontitis showing the characteristic loss of bone around the primary molars. }); var offset = $('#article-content p:nth-of-type(5)').offset(); Localized Aggressive Periodontitis. Susanne Perschbacher, in Oral Radiology (Seventh Edition), 2014. It is commonly first diagnosed during the late primary dentition or early transitional dentition. found = true; 23 and 24 via a full-thickness flap that was raised beyond the mucogingival junction to facilitate the ridge-augmentation procedure. $(last_found).after( ad_content ); Some 75% of patients with the classical localized juvenile periodontitis appeared to suffer from a peripheral blood neutrophil chemotactic abnormality (Cianciola et al., 1977). Radiographic examination typically shows significant bilateral, symmetric bone loss in the permanent first molar and incisor regions. A clinical examination and periodontal evaluation (ie, assessment of mobility, probing depth, bleeding on probing, plaque score, and clinical attachment loss) revealed severe horizontal and vertical bone loss, deep probing depth with bleeding, class II mobility, a widened periodontal ligament, traumatic occlusion, and the formation of a diastema bet… First, the tissues around implants may be more susceptible to plaque-associated infections than the tissues around natural teeth.8 In a study involving beagle dogs, plaque was allowed to accumulate around natural teeth and dental implants to induce periodontal disease. An early onset of the breakdown of periodontal bone. Diplomate In this case, the prognosis for tooth No. if ( $(this).offset().top >= target_offset ) { Affected teeth harbor more nonmotile, facultative, anaerobic, gram-negative rods (especially Porphyromonas gingivalis) in GAP than in LAP. ad_content = ad_content.replace("SCRIPTEND", "' + ad_content + ''; In this patient the disease has not progressed to include the permanent teeth, as sometimes occurs. Alternatively, Michalowicz and colleagues published a large study (63 monozygotic and 33 dizygotic pairs) of adult twins (mean age, 40 years).50 Using elements of the Ramfjord index as criteria for diagnosis, they calculated heritability estimates. A 3-year postoperative photograph of the lower anterior ridge (Figure 9) demonstrates an improvement in the tissue's color, tone, and texture as well as a lack of edema. parent = parent.parent(); if(that.attr('ccposition')) { Abnormal probing depths with minor gingival inflammation, rapid bone loss, and minimal to various amounts of plaque have been demonstrated at the affected sites of the child’s dentition. ' + ad_content + ''; } In generalized aggressive periodontitis, radiographs may show generalized bone destruction ranging from mild crestal bone resorption to severe extensive alveolar bone destruction depending on the severity of the disease. There may be a relatively low amount of plaque accumulation despite severe periodontal destruction. Localized aggressive periodontitis is frequently associated with deficiencies in the neutrophilic function and with high serum antibody response against periodontopathogens; while generalized aggressive periodontitis is also associated with deficiencies in neutrophil function, but with low serum antibody response against periodontopathogens(31). A study in the beagle dog. $(this).after( ad_content ); Aggressive Periodontitis Periodontal Problems in Children and Adolescents. if ( found == false && typeof last_found !== 'undefined' ) { Nonsmokers aged 40 to 60 carrying the “2” allele (in either the homozygous or the heterozygous state) at both loci were observed to have nearly 19 times the risk of developing severe periodontitis as did those homozygous for the “1” allele at either or both of these loci. A defining quality of the disease is its ability to progress at an extremely fast rate. HartsfieldJr., in McDonald and Avery's Dentistry for the Child and Adolescent (Tenth Edition), 2016. 2012; 59(1):89-110. 10. The primary features of aggressive periodontitis include a history of rapid attachment and bone loss with familial aggre- gation. It often affects the entire periodontium of the dentition. They concluded that early-onset periodontitis is a complex, oligogenic disorder (i.e., involving a small number of genes), with IL-1 genetic variation having an important but not exclusive influence on disease risk. $(this).after( ad_content ); last_found = $(this); The cause of aggressive periodontitis is unknown; however, specific bacterial pathogens, especially Actinobacillus actinomycetemcomitans; functional defects of polymorphonuclear leukocytes; exuberant immune responses; and inheritable genetic factors have been implicated. Peri-implant diseases: consensus report of the sixth European workshop on periodontology. These findings suggest a role for neutrophils in normal protection, and suggest that this function is depressed, allowing for the overgrowth of organisms, particularly those such as Aa that produce leukotoxic factors. A familial tendency for aggressive periodontitis, and the fact that it can be found in conjunction with specific syndromes (palmar plantar hyperkeratosis or Papillon-Lefèvre syndrome) suggest a possible genetic basis for the condition. if ( found == false && typeof last_found !== 'undefined' ) { An advanced surgical reconstruction approach can yield a favorable long-term prognosis, maintain natural healthy dentition, and overcome the need for a prosthesis.3 Biological and technical complications can occur in as many as 50% of implants within 10 years of placement.4 In a discussion of technical factors (eg, occlusion, improper implant placement, angulation of implants, poorly planned prostheses, loading too early, etc) and biological factors (eg, poor oral hygiene, periodontal disease, systemic diseases, smoking, specific microbes causing peri-implantitis) that can affect the success of implants, it was noted that approximately 25% to 30% of the adult population have overt grinding or clenching bruxism and that this could contribute to implant failure if the implant-supported prosthesis has an inadequate occlusal design to address bruxism. }); Regenerative periodontal therapy offers alternative to extraction/implant placement. In addition to its antimicrobial effects, minocycline has been a useful treatment because of its inhibition of collagenase activity.26 In cases in which surgical intervention is indicated, periodontal regeneration has been shown to be effective.