ABSTRACT:The treatment and 2-year outcome of the case presented here was completed in the University of Toronto Graduate Periodontic Department. A graduate periodontal resident in training provided active treatment. This case details current concepts and treatment of advanced periodontitis and outlines a new classification of periodontal diseases.; Periodontal surgery will fail or is of little value in patients with poor oral hygiene who are not seen on regular recalls.
A 36-year-old Chinese female patient presented to the University of Toronto Faculty of Dentistry with the chief complaint of bleeding gums every time she brushed her teeth.
In Hong Kong, she had received regular dental care and then had a 3-year hiatus due to lack of dental insurance. When she returned, her dentist discovered that she had experienced a severe amount of attachment loss during a 36-month period. Arriving in Canada, she started to experience intermittent spontaneous pain in the upper left quadrant. Subsequently, at an emergency visit, 26 and 27 were extracted and she was referred to the Graduate Periodontics Clinic.
Her medical history was non-contributory; she denied a history of smoking or drinking. Extra-oral examination revealed no significant findings. Her face was symmetrical with a straight profile. Intra-oral examination revealed that she had good oral hygiene. There were minimal plaque and calculus deposits. The gingiva was pink and firm in appearance with most papilli intact (Fig. 1). However, few papilli were erythematous in addition to multiple gingival sites with edema and bleeding upon probing. All teeth tested vital.
Clinical examination revealed that 12.8% of her pockets were greater than 6 mm, 17.9% were between 4-6mm, and 56.4% of her pockets were 1-3mm (Graph 1). Areas of concern included 16 & 17, 22 & 23 and 46. These areas had deep pockets, increased mobility and furcation involvement.
Review of the full mouth series revealed that 16 and 17 had greater than 50% bone loss. Between 23 and 24, there was moderate vertical bone loss. 46 had about 30-40% bone loss with furcation involvement.
Occlusal analysis, among other findings, revealed that she had a Class I relationship with an anterior crossbite (42 and 43), minimal overjet and overbite with no signs of fremitus. The maxillary anterior teeth were crowded. 17 had overerupted due to the missing 47.
Occlusal analysis revealed group function on the right side and canine guidance on the left side without interferences in lateral excursions. In protrusion, she had mild anterior guidance but several posterior teeth maintained contact. The patient denied any history of shifting teeth. Therefore, the misaligned anterior teeth were not caused by pathological migration.
Microbiological testing revealed that high levels of periodontal pathogens, P.g., P.i., B.f., and spirochetes. The diagnosis of early-onset periodontitis (Page, 1983) was established. Her overall prognosis was poor. Even though she was young to have such advance attachment loss, her keen motivation and compliance did improve her prognosis.
Initial therapy included oral hygiene instructions, scaling and root planing with local anaesthesia and a regiment of metronidazole (500mg bid for 1 week). Re-evaluation and microtesting were done six weeks after initial therapy.
Upon reevaluation, the initial therapy effectively reduced the levels of periodontal pathogens. Only P.i. was reported to be at very low levels. The other pathogens were undetectable. There was a dramatic decrease in mobility and probing depth reduction. The frequency distribution of the pockets greater than 6mm decreased from 12.8% to 5.6% (Graph 1).
Open flap debridement and pocket reduction surgery was completed around 16 and 17. Full thickness flaps and distal wedge with inverse bevel incisions were used to gain access to the Class II furcations (Fig. 2). In addition to debridement and minor osseous recontouring, thorough root planing was completed. The flaps were then apically repositioned.
Upon raising the flap, there was a two-wall defect with intact buccal and palatal plates between 22 and 23 (Fig. 3). Guided tissue regeneration was attempted in this region. Full thickness flaps with sulcular incisions were used to gain access to the two-wall defect. After debridement and root planing, the defect was filled with bioactive glass (Perioglas, Block Drug Company (Canada) Ltd, Mississauga, ON, Canada) and covered with a resorbable membrane (Atrisorb, Block Drug Company (Canada) Ltd, Mississauga, ON, Canada). The flaps were coronally repositioned and the patient was prescribed a regiment of doxycycline 100mg once per day for one week.
Upon reflection of the flap, a Grade II cervical enamel projection (CEP) was noted on the buccal of 46 (Fig. 4). Enameloplasty was performed to remove the CEP.
After completion of active phase of periodontal treatment, the patient was placed on a 3-month recall maintenance and monitoring program. A two-year reevaluation was performed. The frequency distribution of pockets shifted to predominantly shallow pockets of 1-3mm. Only 6.3% of the pockets were 4-6mm and 0% were greater than 6mm (Graph 1). Furthermore, the pockets that initially were deep decreased to 3mm (Graph 2). There was 1-3mm gain of attachment in the deep pockets (Graph 3) with 1-2mm increase in recession (Graph 4).
This clinical case reviews many basic concepts in treatment of periodontal disease. First, it illustrates the strength of initial therapy of oral hygiene instruction, thorough scaling and root planing with local anaesthesia and antibiotic therapy. Many studies have demonstrated the effectiveness of antibiotic therapy combined with scaling and root planing such as the randomized double-blinded placebo controlled trials of Loesch (1991) and Soder (1990). There are numerous regiments for antibiotic therapy which include use of tetracycline, doxycycline or combination of metronidazole and amoxicillin. Studies have shown that any of these regiments have been effective in reduction of periodontal pathogens.
Second, there are limitations to nonsurgical therapy if one wants to achieve further pocket reduction and attachment gain. Treatment of class II furcations in maxillary teeth such as 16 and 17 is difficult. Molars with furcation involvement generally have a poor prognosis (Becker 1984, Hirshfeld & Wasserman 1978, McFall 1982, Ramfjord 1987) and not all surgical therapies are effective in those regions.
In a randomized controlled, blinded longitudinal study, Fleischer (1989) demonstrated that calculus removal is less effective with closed scaling and root planing than open flap debridement in deep pockets and furcations. Furthermore, numerous controlled randomized split-mouth design studies have shown that there is no difference between open flap debridement and guided tissue regeneration in maxillary class II furcations (Metzler 1991, Mellonig 1994, Pontoriero & Lindhe 1995). Therefore, if the intent was to save the teeth, treatment of maxillary Class II furcation should be approached in a conservative surgical manner ie. surgical debridement and pocket reduction. Access to the furcations with a proxabrush or sulca brush for self-maintenance can be achieved.
However, with the success of dental implants, a different perspective must be considered. A clinician must now determine which treatment to apply: a) saving a tooth with an advanced furcation defect or b) extracting the tooth for implant placement. The treatment of choice must be determined by the predictability of treatment outcome.
Third, depending on the type of defect, guided tissue regeneration techniques can be successfully performed. For example, the two-wall defect between 22 and 23 was treated by the use of graft material in conjunction with membrane. Studies have shown guided tissue regeneration to be effective in gain of vertical and horizontal attachment and reduction in probing depths (Zamet 1997, Garret 1997, Lovelace 1998)
Fourth, enamel extending into the furcal area is known as a cervical enamel projection (CEP). CEPs occur primarily on buccal surfaces of molars (28.6% mandibular, 17% maxillary) and are classified from Grade I to III (Masters & Hoskins 1964). Grade III is the most severe where the CEP extends well into the furcation. Statistically, there is significant relationship between molars with CEPs and furcation defects (Swan & Hurt 1976). Treatment of CEPs involve enameloplasty where the enamel projection is removed from the root surface.
Fifth, as seen in many studies such as Kaldahl (1996) and Philstrom (1983), deeper sites tend to have the most dramatic improvement in response to any periodontal treatment. These studies show a gain in attachment and decrease in probing depths at the expense of an increase in gingival recession. The expected amount of recession has to be carefully considered prior to surgery. If the projected post-surgical root exposure is not desirable or unacceptable to the patient, one should carefully consider and discuss corrective restorative procedures.
Sixth, success of any periodontal therapy depends on the maintenance of the patient. Periodontal surgery will fail or is of little value in patients with poor oral hygiene who are not seen on regular recalls (Nyman 1977, Becker 1984).
Finally, appropriate treatment is based on accurate diagnosis. In this clinical case, one can argue for either early-onset periodontitis or rapidly progressive periodontitis. These two diagnostic entities have been used for the last two decades. Based on the accumulation of research data during this period of time, it appears that there are clear shortcomings for the current classification. For one, there are considerable overlap in disease categories. Second, the issue of age of onset and rate of progression is unclear. (Armitage 1999). This had led to a new classification system by the American Academy of Periodontology.
The age-dependent nature of periodontitis designation has been eliminated. The term "adult periodontitis" is now replaced with "chronic periodontitis", and "early-onset periodontitis" is replaced with "aggressive periodontitis". More detailed description and discussion of the new classification can be found in Annuals of Periodontology 1999, Volume 4.
r. Lai, a University of Pennsylvania dental graduate, has received his M.Sc. in Periodontology at the University of Toronto. His specialty practice of periodontics and implant surgery is located in Central Toronto.
Oral Health welcomes this original article.
Armitage G. 1999. Ann Periodontol 4:1-6.
Becker W, Becker B, Berg, L. 1984. J Perio 55:505-509.
Fleischer H, Melonig J, Gray J, Barnett J.1989. J Perio 60:402-409.
Garret S, Polson AM, Stoller, NH. 1997. J Perio 68:667-675.
Hirschfeld L, Wasserman B. 1978. J Perio 49:225-237
Kaldahl WB, Kalkwarf KL, Patil KD. 1996. J Perio 67:93-102.
Loesch WH, Schmidt E, Smith BA. 1991. J Perio 62:247-257.
Lovelace Lovelace TB. Mellonig JT. 1998. J Perio 69:1027-1035.
Masters DH, Hoskins SW. 1964. J Perio 35:49-53.
McFall W. 1982. J Perio 53:539-549.
Mellonig Mellonig JT. Seamons BC. 1994. Int J Perio Restor 14: 254-71.
Metzler D, Seamons B, Mellonig J, 1991. J Perio 63:353-360.
Nyman S, Lindhe J, Rosling B. 1977. J Clin Perio 4:240-249.
Page R, Altman L, Ebersole J. 1983. J Perio 54: 197-209.
Philstrom B, McHugh R. Oliphant T. 1983. J Clin Perio 10:524-541.
Pontoriero R, Lindhe J. 1995. J Clin Perio 22: 756-63.
Ramfjord SP. 1987. J Clin Perio 14: 433-437
Soder PO, Frithiof L, Wikner S. 1990. J Perio 61: 281-8.
Swan RH, Hurt WC. 1976. J Am Dent Assoc 93:342-345.
Zamet JS, Darbar UR. 1997. J Clin Perio 24: 410-8
(Nyman 1977, Becker 1984)