The periodontal tissues including the alveolar bone, the periodontal ligament, cementum and gingiva are the battleground upon which is staged an intricate assault by micro-organisms and a clever defense by the host’s immune system. As Napoleon wrote, “Victory belongs to the most persevering.” When defended effectively, and reinforced by appropriate oral hygiene and professional prophylaxis, the host benefits from oral health and preservation of periodontal structures. When the host is compromised by systemic conditions and/ or inadequate local plaque removal, it leaves the battleground vulnerable to bleeding, suppuration, loss of architecture and irreversible destruction. The purpose of this article is to demonstrate, as illustrated by a case report, the importance of professional prophylaxis in maintaining “peace” in the periodontal regions.
Case Report
A 61-year-old Caucasian female presented to the Reconstructive Periodontics and Implant Surgery Clinic (RPISC) with “loose front teeth”. She had been referred by her general dentist to specifically investigate the recent drifting of teeth 11, 12, and 13. According to the patient, she had noticed swelling about four months earlier and noticed that her front teeth were moving while chewing. As reported by the patient, she noticed an increased amount of swelling and bleeding in the area over the past several months. She also realized that the space between her front teeth had markedly increased over the same time period.
The patient had periodontal surgery 25 years prior to her presentation to RPISC for “pyorrhea”. Since then she has been maintained by her general dentist, who saw her every six months for a periodontal prophylaxis. According to the patient, the duration of each appointment was approximately 30 minutes. Her home care routine consisted of brushing twice daily with a manual toothbrush and flossing 2-3 times per week.
Medical History
The patient had a significant history including an aortic valve replacement, asthma, type II diabetes and hypertension. Her daily medications included Metformin, Warfarin, Metoprolol, Ferrous Gluconate and Norvasc. The swelling of the periodontal tissues became apparent about two months following institution of daily administration of Norvasc. Her blood pressure upon presentation was 145/89 and her glycated hemoglobin was within normal limits. She reported a high level of dental anxiety.
Clinical Examination
The patient was referred specifically for examination of teeth 11, 12, and 13. Clinical examination of these teeth revealed hyperplastic exophytic gingival tissues, M1 mobility, significant root roughness, fremitus and probing depths of 4-10mm. There was a 6mm space between teeth 11 and 21. (Figure 1).
A cursory examination of other areas was performed and it was determined that the periodontal disease was not limited to teeth 11, 12 and 13.
As such, a comprehensive investigation revealed 115 sites measured between 4 and 6mm and 19 sites had a probing depth greater than 6mm (see baseline row in Table 1). Over 90% of sites exhibited bleeding upon probing.
Radiographic Examination
A full mouth series (Figures 2-4) revealed salient findings including generalized moderate to severe bone loss, angular defects at 11, 16 and 47, a periapical radiolucency at 26 with 100% bone loss, widened periodontal ligament spaces at 21, as well as generalized calculus deposits. Root trunk length was unfavourable for molar teeth.
Diagnosis
Generalized chronic moderate to severe periodontitis modified by local factors, occlusal trauma, systemic conditions (diabetes) and medications.
Gingival hyperplasia related to calcium channel blocker:(Norvasc).
Combined endodontic/periodontal lesion, tooth 26.
Risk Assessment
According to the Periodontal Risk Assessment criteria the patient was found to have a high periodontal risk score1 (Figure 5).
Prognosis
The following prognosis was assigned to individual teeth:
Irrational to treat: 26
Doubtful: 16, 13, 12, 11, 21, 22, 23, 27, 37, 47
Secure: All other teeth not listed above.
Treatment
Oral decontamination through exhaustive sanative therapy was prescribed. This comprised of two hours of scaling and root planing under profound dental anaesthesia performed by an experienced dental hygienist assisted by surgical loupes and fiber-optic head lighting. Both ultrasonic and hand instruments were utilized. The patient was instructed on the use of a powered toothbrush, a floss technique suitable for her dexterity and TePe interproximal brushes (TePe Munhygienprodukter, Malmˆ, Sweden). Her general dentist removed tooth 26 without complications.
Follow-up
The patient presented eight weeks following the definitive sanative therapy with significant improvement (Figure 6). A co-management of the patient’s periodontal condition was now instituted.2 The patient alternates between her general dentist and the RPISC every three months.
Two years after treatment, the patient has only six sites that measure between 4-6mm. No sites measure greater than 6mm. The mobility of her maxillary anterior teeth has decreased, as has the swelling. The spacing between the central incisors has decreased by 50% (3mm) (Figure 7). Of note is the radiographic appearance of the alveolus at the mesial aspect of tooth 27 suggesting regeneration after the removal of tooth 26 (Figure 8).
Discussion
Clinicians are constantly inundated by novel options to treat periodontal disease. Lasers, photodynamic approaches, irrigation and the local delivery of antibiotics are approaches that are heavily marketed to aid the clinician in treating patients with periodontal lesions. Soft tissue management programs designed by practice management consultants are also often used in general practices as a blanket approach for patient care. None of these approaches or options is effective for the patient if the clinician loses sight of the fundamental underlying pathophysiology of periodontal disease. The removal of local factors must be achieved to facilitate resolution of the inflammatory process.
Definitive sanative therapy by way of scaling, root-planing and the appropriate use of ultrasonic instrumentation is the most effective first line treatment in removing sub-gingival deposits. This is a labour intensive process requiring skill by the clinician. It also requires the use of carefully sharpened instruments, adequate anaesthesia, and enough time to complete the task. At the RPISC we allocate approximately 5-7 minutes of time per tooth for instrumentation for initial sanative therapy, and two minutes per tooth for regular periodontal prophylaxis.
The frequency of periodontal prophylaxis does not take the place of thoroughness. In the case presented, the patient attended her dentist’s office faithfully every six months for periodontal maintenance. Reportedly, the duration of the appointment was a mere 30-minute. During a 30 minute appointment time needs to be allocated for seating the patient, updating the medical history, addressing any patient concerns, evaluating the condition of the teeth and periodontium, discussing any treatment required, dismissing the patient and then preparing the operatory for th
e next patient. This leaves very little time for actual scaling and root planing, polishing and oral hygiene instructions in the 30-minute window. When this cycle repeats over several appointments over several years, the deterioration of the periodontium is expected and should come at no surprise. When other factors such as diabetes, ineffective home care and medications weaken the host defenses, the host becomes compromised and the destruction of the periodontal tissues ensues.
Gingival Hyperplasia
Amlopidine (Norvasc) belongs to a class of drugs called calcium channel blockers. These medications inhibit the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. By relaxing coronary arteries, amlodipine is useful in preventing chest pain resulting from coronary artery spasm or angina. A known dental side effect of amlopidine is gingival hyperplasia.3 Usually it develops as an enlargement of the interdental papilla. The enlargement can extend over the teeth and crowns and presents in a lobulated or nodular arrangement. Effective oral hygiene helps to minimize gingival overgrowth associated with calcium channel blockers.
Some other medications that can potentially cause gingival hyperplasia include
Adderal, Caduet, Cellcept, Coreg, Cyclosporine, Dilantin, Diovan, Nifedipine, Phyenytoin, Pulmicort, Tegretol and Valproate. As demonstrated in this case report, hyperplasia is sometimes reversible by removing local factors and significantly improving oral hygiene.
Risk Assessment for Recurrence
Lang & Tonetti published a method for periodontal risk assessment that evaluates a patient’s risk profile on the basis of a number of clinical conditions.1 These include the level of infection, prevalence of residual periodontal pockets, tooth loss, an estimation of the destruction of the periodontal support in relation to the patient’s age and environmental, behavioural and systemic conditions.
In calculating the patient’s individual periodontal risk assessment, a functional interpretation of their disease is shown on a “spider web” diagram. The Periodontal Risk Assessment can be assessed using an online program at www.dental-education.ch/riskassessment from the University of Bern.4 (Figure 5) demonstrates the Risk Assessment at initial presentation.
Movement of Teeth Following Treatment
The closure of the diastema by 3mm following oral decontamination was an unexpected positive outcome for the patient. By eliminating subgingival calculus the tissues responded by a significant reduction in inflammation. The inflamed, edematous periodontal ligament and gingival tissues responded to the definitive sanative therapy by a marked reduction in inflammatory parameters allowing the teeth to return to their initial position in the alveolus. A decrease in tooth mobility is not uncommon after sanative therapy.
Conclusion
Between 5-20% of any population suffers from severe chronic generalized periodontitis.5 This population would likely benefit from the co-management by the general dentist and the periodontist (Academy Report, July 2006). Identifying patients with severe periodontitis or a deteriorating risk profile is an essential first step in developing a strategy to return the patient to stable periodontal health. These patients require far more professional support than those without the disease. The role of the clinician is to act as the commander that reinforces the defenses of the patient with all available resources to fend the attack by micro-organisms and inflammatory products in the battle constantly raging against the periodontium.
“The battlefield is a scene of constant chaos. The winner will be the one who controls that chaos, both his and the enemies.” Napoleon Bonaparte
OH
Peter Fritz is a certified specialist in Periodontics and is in full-time private practice in Fonthill, Ontario.
Donna Lavoie is a Registered Dental Hygienist and is in full-time private practice in Fonthill, Ontario.
Wendy Ward is a tenured professor in the Department of Nutritional Sciences in the Faculty of Medicine at the University of Toronto.
Peter Birek is a tenured Associate Professor at University of Toronto. He also maintains a practice of Periodontics and Implant surgery in Toronto.
Oral Health welcomes this original article.
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Table 1.
Periodontal parameters over treatment time. Note that all parameters have improved at 8 weeks post-treatment; continued improvement followed in three of the four parameters over 2 years. The plaque index remained at 30%. |
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O’Leary Plaque Score
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BOP Sites
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Sites measuring 4-6 mm
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Sites measuring > 6 mm
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|
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Baseline
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100% |
140 |
115 |
19 |
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8 weeks post-sanative therapy
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20% |
4 |
24 |
2 |
|
6 months post-sanative therapy
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30% |
2 |
9 |
0 |
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1 year post-sanative therapy
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30% |
1 |
6 |
0 |
|
2 years post-sanative therapy
|
30% |
1 |
6 |
0 |
References
1. Oral Health Prev. Dent. 2003;1(1):7-16. Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Lang NP, Tonetti MS.
2. J Periodontol. 2006 Sep;77(9):1607-11. Guidelines for the management of patients with periodontal diseases. Krebs KA, Clem DS 3rd; American Academy of Periodontology.
3. J Periodontol. 2000 May;71(5 Suppl):876-9. Parameter on periodontitis associated with systemic conditions. American Academy of Periodontology.
4. Clinical Research Foundation, Periodontal Risk Assessment V3.1. Christoph A. Ramseler, University of Bern
5. J Periodontol. 2005 Aug;76(8):1406-19. Position paper: epidemiology of periodontal diseases. Burt B; Research, Science and Therapy Committee of the American Academy of Periodontology.
