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Parameters of Care
Supplement
Parameter on “Refractory” Periodontitis*

The American Academy of Periodontology has developed the following parameter on the treatment of “refrac-
tory’’ periodontitis. Patients should be informed of the disease process, therapeutic alternatives, potential com-
plications, expected results, and their responsibility in treatment. Consequences of no treatment should be
explained. No treatment is very likely to result in further progression of the disease and eventual tooth loss.
Given this information, patients should then be able to make informed decisions regarding their periodontal
therapy. J Periodontol 2000;71:859-860.
KEY WORDS
Disease progression; periodontitis/complications; patient care planning; periodontitis/therapy.

CLINICAL DIAGNOSIS be non-responsive to treatment; e.g., refractory chronic

Definition periodontitis and refractory aggressive periodontitis.
“Refractory periodontitis” is not a single disease entity.
The term refers to destructive periodontal diseases in Clinical Features
patients who, when longitudinally monitored, demon- The primary feature of “refractory” periodontitis is
strate additional attachment loss at one or more sites, the occurrence of additional clinical attachment loss
despite well-executed therapeutic and patient efforts after repeated attempts to control the infection with
to stop the progression of disease. These diseases conventional periodontal therapy. The diagnosis of
may occur in situations where conventional therapy “refractory” periodontitis should only be made in
has failed to eliminate microbial reservoirs of infec- patients who satisfactorily comply with recommended
tion, or has resulted in the emergence or superinfec- oral hygiene procedures and follow a rigorous pro-
tion of opportunistic pathogens. They may also occur gram of periodontal maintenance. “Refractory” peri-
as the result of a complexity of unknown factors which odontitis is usually diagnosed after the conclusion of
may compromise the host’s response to conventional conventional active therapy.
periodontal therapy. Such conventional therapy fre- This diagnosis is not appropriate for patients who:
quently includes most, but not necessarily all, of the 1. Have received incomplete or inadequate con-
following: ventional therapy.
1. Patient education and training in personal oral 2. Have identifiable systemic conditions that may
hygiene; behavior modification. increase their susceptibility to periodontal infections
2. Thorough scaling and root planing to remove such as diabetes mellitus, immunosuppressive dis-
microbial deposits and eliminate anatomical root features orders, certain blood dyscrasias, and pregnancy.
that might act as reservoirs for microbial infection. 3. Have localized areas of rapid attachment loss
3. Use of local and/or systemic antimicrobial agents. which are related to factors such as: root fracture,
4. Elimination or correction of defective restora- retrograde pulpal diseases, foreign body impaction, or
tions and other local factors that might interfere with various root anomalies.
oral hygiene efforts or act as retention sites for peri- 4. Have recurrence of progressive periodontitis after
odontal pathogens. many years of successful periodontal maintenance.
5. Surgical therapy.
6. Extraction of severely involved teeth. THERAPEUTIC GOALS
7. Occlusal therapy. The goal of therapy for “refractory” periodontitis is to
8. Periodontal maintenance and re-evaluation. arrest or slow the progression of the disease. Due to the
The “refractory’’ designation can be applied to all complexity and many unknown factors, control may
forms of destructive periodontal disease that appear to not be possible in all instances. In such cases a rea-
sonable treatment objective is to slow the progression
* Approved by the Board of Trustees, American Academy of
Periodontology, May 1998.
of the disease.

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Supplement
TREATMENT CONSIDERATIONS gins T, Stoll J. Metronidizole in periodontitis. I. Clinical
Once the diagnosis of “refractory” periodontitis has and bacteriological results after 15 to 30 weeks. J Peri-
odontol 1984;55:325-335.
been made, the following steps may be taken: 10. Magnusson I, Clark WB, Low SB, Maruniak J, Marks
1. Collection of subgingival microbial samples from RG, Walker CB. Effect of non-surgical periodontal ther-
selected sites for analyses, possibly including antibi- apy combined with adjunctive antibiotics in subjects
otic-sensitivity testing. with refractory periodontal disease. I. Clinical results.
2. Selection and administration of an appropriate J Clin Periodontol 1989;16:647-653.
11. Lundström Å, Johansson L-Å, Hamp S-E. Effect of
antibiotic regimen. combined systemic antimicrobial therapy and mechan-
3. In conjunction with the administration of an ical plaque control in patients with recurrent periodontal
antimicrobial regimen, conventional periodontal ther- disease. J Clin Periodontol 1984;11:321-330.
apies may be used. 12. Hirschfeld L, Wasserman B. A long-term survey of
4. Reevaluation with microbiological testing as tooth loss in 600 treated periodontal patients. J Peri-
odontol 1978;49:225-237.
indicated. 13. McFall WT Jr. Tooth loss in 100 treated patients with
5. Identification and attempt to control risk fac- periodontal disease. A long-term study. J Periodontol
tors (e.g., smoking). 1982;53:539-549.
6. Intensified periodontal maintenance program 14. Slots J, Rams RE. New views on periodontal microbiota
which may include shorter intervals between appoint- in special patient categories. J Clin Periodontol 1991;
18:411-420.
ments with microbiologic testing if indicated (Param- 15. Pertuiset JH, Saglie FR, Lofthus J, Rezende M, Sanz M.
eter on Periodontal Maintenance, pages 849-850). Recurrent periodontal disease and bacterial presence
in the gingiva. J Periodontol 1987;58:553-558.
OUTCOMES ASSESSMENT 16. Adriaens PA, De Boever JA, Loesche WJ. Bacterial
1. The desired outcome for patients with “refractory” invasion in root cemetum and radicular dentin of peri-
periodontitis includes arresting or controlling the disease. odontally diseased teeth in humans: A reservoir of peri-
2. Due to the complexity and many unknown fac- odontopathic bacteria. J Periodontol 1988;59:222-230.
17. Telsey B, Oshrain HI, Ellison SA. A simplified labora-
tors of “refractory” periodontitis, control may not be tory procedure to select an appropriate antibiotic for
possible in all instances. In such cases, a reasonable treatment of refractory periodontitis. J Periodontol 1986;
treatment objective is to slow the progression of the 57:325-327.
disease. 18. Fine DH. Microbial identification and antibiotic sensi-
tivity testing, an aid for patients refractory to peri-
SELECTED RESOURCES odontal therapy. J Clin Periodontol 1994;21:98-106.
1. The American Academy of Periodontology. Periodon- 19. Hernichel-Gorbach E, Kornman KS, Holt SC, et al.
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In: Proceedings of the World Workshop in Clinical Peri- periodontitis. J Periodontol 1994;65:8-16.
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ogy; 1989:I/23-I/31. bination therapy to eliminate Porphyromonas gingivalis in
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cotherapeutics. Ann Periodontol 1996;1:491-566. 21. Nyman S, Lindhe J, Rosling B. Periodontal surgery in
3. Consensus report on non-surgical pocket therapy: plaque-infected dentitions. J Clin Periodontol 1977;
Mechanical, pharmacotherapeutics, and dental occlu- 4:240-249.
sion. Ann Periodontol 1996;1:581-588. 22. Wilson TG, Glover ME, Malik AK, Schoen JA, Dorsett
4. Oshrain HI, Telsey B, Mandel ID. Neutrophil chemo- D. Tooth loss in maintenance patients in a private peri-
taxis in refractory cases of periodontitis. J Clin Peri- odontal practice. J Periodontol 1987;58:231-235.
odontol 1987;14:52-55. 23. Haffajee AD, Socransky SS, Dzink JL, Taubman MA,
5. Magnusson I, Marks RG, Clark WB, Walker CB, Low Ebersole JL. Clinical, microbiological and immuno-
SB, McArthur WP. Clinical, microbiological and immuno- logical features of subjects with refractory periodontal
logical characteristics of subjects with refractory peri- diseases. J Clin Periodontol 1988;15:390-398.
odontal disease. J Clin Periodontol 1991;18: 291-299. 24. Listgarten MA, Lai CH, Young V. Microbial composition
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microbiota associated with refractory periodontitis. J microbial samples from patients with refractory peri-
Periodontol 1990:61:692-698. odontitis. J Periodontol 1993;64:155-161.
7. Gordon J, Walker C, Hovliaras C, Socransky S. Efficacy 25. Slots J, Emrich LJ, Genco RJ, Rosling BG: Relation-
of clindamycin hydrocloride in refractory periodontitis: 24- ship between some subgingival bacteria and peri-
month results. J Periodontol 1990;61:686-691. odontal pocket depth and gain or loss of periodontal
8. Kornman KS, Karl EH. The effect of long-term low- attachment after treatment of adult periodontitis. J Clin
dose tetracycline therapy on the subgingival microflora Periodontol 1985;12:540-552.
in refractory adult periodontitis. J Periodontol 1982;53: 26. Armitage GC. Development of a classification system
604-610. for periodontal diseases and conditions. Ann Periodontol
9. Loesche WJ, Syed SA, Morrison EC, Kerry GA, Hig- 1999;4:1-6.

860 Parameter on ‘‘Refractory’’ Periodontitis Volume 71 • Number 5 (Supplement)