Aggressive Periodontitis & Multiple Supernumerary Teeth - A Rare Presentation

INTRODUCTION

Aggressive periodontitis comprises a group of rare, often severe, rapidly progressive form of periodontitis with a distinct tendency for familial aggregation. It is characterized by the presence of rapid attachment & bone destruction affecting systemically healthy individuals under the age of thirty years and lack of consistency in clinically visible microbial deposits and severe periodontal destruction.¹

Supernumerary teeth means teeth more than the normal number of the full complement of teeth in the primary or permanent dentition.² They are twice more common in the permanent than in the primary dentition.³ Supernumerary teeth may be single, multiple, unilateral or bilateral, erupted or unerupted either in the maxilla, mandible or both. Their shape and size may resemble the group of teeth at the site where they are found in the jaws or there may be little or no resemblance at all.⁴ Prevalance of supernumerary teeth was 2.97% as reported by Acikgoaz et al.in 2005. Supernumerary teeth may lead to various pathological conditions like de l ayed e ruption or non- e ruption, displacement of permanent teeth, resorption or malformation of adjacent roots and (rarely) cystic formation.⁵

Presence of multiple supernumerary teeth is a rare condition. Most cases are found in association with syndromes such as Gardner's syndrome, cleidocranial dysostosis, and cleft lip and palate. It has been reported that the prevalence for nonsyndromic multiple supernumerary teeth is less than 1% with male:female ratio 9:2.⁶

In non-syndromic multiple hyperdontia cases (five or more teeth), supernumerary teeth are more often seen in the mandible, in the premolar region to be more specific, as opposed to one- to- four supernumerary teeth, which are located in the anterior-superior and molar region of the maxilla.⁷

However, concerning the cases of simultaneous presence of multiple supernumerary teeth with generalized aggressive periodontitis, the literature available is scanty. In most of the previous reports, the teeth associated with aggressive periodontitis were supernumerary premolars. They were supernumerary molars in only one case.⁸ Here we report a rare case of generalized aggressive periodontitis associated with multiple supernumerary permanent teeth in relation to molars and highlight the possibilities of biologic association.

DESCRIPTION OFCASE

An eighteen yearold male reported to the department of Periodontics, P.M.N.M. Dental College & Hospital, Bagalkot with a complaint of mobile teeth in the lower front and right back region of jaw since one month. One week before his presentation, neighboring mobile tooth in anterior region was exfoliated due to trauma. He did not have any relevant family history, was a nonsmoker and systemically healthy with noncontributory medical history.

Intraoral examination revealed a full complement of permanent teeth, except a clinically exfoliated mandibular right permanent central incisor. In addition, a lingually erupting horizontally inclined paramolar supernumerary tooth was seen in relation to mandibular right 1^st molar. All teeth were in normal alignment with minimal deposits of plaque and calculus. Generalized gingiva appeared soft and edematous with smooth and shiny surface texture and pus exudation on palpation. Probing elicited bleeding along with the presence of deep periodontal pockets. Many teeth showed Millers grade I& II mobility, whereas the mandibular left central incisor showed grade III mobility. There was grade II furcation involvement in maxillary left 1^st molar and grade III furcation involvement in mandibular right 1^st molar (Photograph 1,2).

Radiographic screening revealed genera lized, moderate horizontal, vertical and arc shaped pattern of bone loss limited to few teeth. Panoramic radiography also showed three impacted supernumerary teeth: two in the mandible and one in maxilla, located in between root apices of molars in each quadrant except maxillary right (Photograph 3).

Since multiple impacted supernumerary teeth were present, a clinical examination was done to rule out syndromes associated with multiple impacted supernumerary teeth. Patient's sibling and parents were also examined clinically and radiographically, but they did not show any pathological periodontal alterations, including supernumerary teeth. Complete Haemogram revealed no significant findings. Based on clinical and radiological findings, the patient was diagnosed with generalized aggressive periodo ntitis with multiple impacted supernumerary teeth.

The patient was informed about his oral condition and a comprehensive treatment plan was explained to him. Mandibular permanent right lateral and left central incisors were extracted, and full-mouth scaling and root planing were performed under local anesthesia. Systemic antibiotics were prescribed to add benefits over the conventional therapy to improve the prognosis considering the risk factors like generalized aggressive periodontitis with multiple mobile teeth and furcation involvement (Photograph 4).

After six weeks, the patient was reexamined clinically. Because of the persistence of periodontal pockets, he was advised to undergo surgical therapy (Photograph 5). Periodontal flap surgery was carried out to provide access to instrumentation and regenerative therapies. Until sufficient healing after surgery; intermediate removable partial denture was fabricated and inserted in relation to 41, 31, and 32 due to aesthetic reason. He is under periodontal maintenance for the past three months. The patient was also informed about the presence of multiple impacted supernumerary teeth , related possible complications, and available treatment modalities. At present, the patient has preferred to remain under observation (Photograph 6).

Formerly in 1989 AAP World workshop in clinical periodontics, aggressive periodontitis was classified under the category of early onset periodontitis comprising of prepubertal, juvenile and rapidly progressive form of periodontitis. In 1999 International Workshop for the Classification of Periodontal Disease, it was reclassified as a distinct disease category presenting following characteristics: 1) Otherwise clinically healthy patient, 2) Rapid attachment loss and bone destruction, 3) Amount of microbial deposits inconsistent with disease severity. 4) Familial aggregation of diseased individuals.

Clinical forms of aggressive periodontitis include localized and generalized variants. The features of generalized aggressive periodontitis are: (1) it usually affects persons who are under thirty years of age, but may also affect older persons; (2) it is characterized by a generalized interproximal attachment loss that affects at least three permanent teeth in addition to the first molars and incisors; (3) it is characterized by a pronounced episodic nature of the attachment and alveolar bone destruction; and (4) it leads to poor serum antibody  response to infectious agents.⁹

According to the 1999 International Workshop for the Classification of Periodontal Disease, all the listed features need not be present for the diagnosis of aggressive periodontitis, and that clinical, radiological, and historical data alone can be used to differentiate aggressive periodontitis from chronic periodontitis.⁹ Based on this our case was diagnosed as generalized aggressive periodontitis.

Some of the intraoral disease entities associated with supernumerary teeth can be summarized as follows: in 84.2% of cases it is believed that the subjects have no associated dental problems; in 8.1% it is associated with delayed eruption; in 3.4% displacement of adjacent teeth; in 2.1% enlargement of follicular epithelium; and in 1.3% with median diastema.¹⁰ Generalized aggressive periodontitis is rarely seen in association with multiple supernumerary teeth.

First study comparing the possible connection between supernumerary teeth and aggressive periodontitis was a case report published by Kaslick & Chasens in 1968 including the study of twenty seven black patients. ¹¹However, Eley 1974 was first to describe the possible association with the finding of four supernumerary fourth molars described in a Black female with juvenile periodontitis.¹² Since then, very few researchers have reported such phenomenon, including a total of six case studies and one retrospective study till today.

Rubin et al 1981 described two identical black twins with LJP, multiple supernumeraries and no dental caries. Four supernumeraries were present in one twin, three of which were supplemental mandibular premolars, and two mandibular supplemental premolars were present in the second twin. All the supernumerary teeth were oriented for eruption with complete crown formation, but no premolar root resorption was noted.¹³ Mendieta 1988 reported a Black female with seven supernumerary teeth, three at the apices of maxillary premolars and four below mandibular premolars. Crowns of these supernumerary teeth were completely formed with normal premolar morphology to peg-shaped forms.¹⁴ In a retrospective study by Acikgoaz out of one hundred seventy four subjects having supernumerary teeth only three patients were diagnosed with aggressive periodontitis. Supernumerary teeth were seen in incisor and premolar region.¹⁰ Verma et al 2010 reported mesiodens located in the mandible of a twenty five year old male diagnosed with localized aggressive periodontitis.¹⁵ Recently Salman et al 2012 reported a case of generalized aggressive periodontitis with six impacted supernumerary teeth; two supplemental premolars in the maxilla and four distomolars, one in each quadrant.⁸

The etiology of supernumerary teeth still remains unclear. Although many theories for explanation of the development of this anomaly have been proposed, localized and independent hyperactivity of the dental lamina is the most generally accepted cause for the development of supernumerary teeth. Their development may be influenced by a combination of hereditary and environmental factors.⁶

Both supernumerary teeth and aggressive periodontitis are uncommon but have shown familial inheritance pattern. In 1995 Odell and Hughes hypothesized on the possible association, but defined this possibility as speculative.¹⁶ Although genetic heterogeneity makes it hard to determine genetic basis for their association and the exact explanation remains unclear, concomittent presence of both generalized aggressive periodontitis & multiple supernumerary teeth is definitely rare one. Both are consistent with multifactorial and multigenic etiology with modifying environmental factors.

CONCLUSION

In the present case, three impacted supernumerary teeth observed in aggressive periodontitis is definitely a rare one. It calls for further detailed genetic study based on large population to explain whether this association is by chance or has biological rationale.