Perils of periodontitis
Areas of destruction most often display an uneven distribution in advanced periodontitis. Sites associated with higher risk for recurrence are those areas exhibiting poor response to periodontal surgery, even though overall improvement may have occurred.
These sites become potential reservoirs for pathogenic bacteria. Subgingival recolonisation from these sites increases the chance for disease recurrence or progression. In addition, plaque control cannot be carried out appropriately and durably in these sites. Finally, when the balance between pathogenic and beneficial bacteria is unfavourable, these sites continue to undergo attachment loss. Adequate adjunctive treatment should be initiated.
There are three distinct types of risk sites:
- Deep pockets
- Interradicular lesions
- Mobile teeth.
Residual deep pockets are usually associated with the presence of bony lesions that have responded poorly to initial therapy. Specific adjunctive therapy consists of carrying out reparative surgery through guided tissue regeneration or bone grafting. Numerous different grafting materials have been assessed in clinical studies: these include autogenous graft tissues, decalcified and calcified allografts, xenografts (purified bovine-derived enamel matrix components), and alloplastic bone substitutes (synthetic hydroxyapatite, tricalcic phosphates and bioactive ceramic materials). Most of these materials serve as guides for the regeneration of bone tissue.
The goal of periodontal regeneration techniques is the restoration of connective attachment tissue and enhancement of the growth of new cementum tissue, periodontal ligament and bone tissue. Regeneration of interproximal bone defects can only be performed through guided tissue regeneration using resorbable or non-resorbable membranes.
Results are difficult to predict. Membranes are frequently distorted, particularly in large lesions: this reduces the regeneration rate. In addition, when the membrane is exposed, it is highly susceptible to colonisation by plaque; this delays proper healing and may even compromise the overall outcome.
Prognosis is better for deep, narrow lesions than for shallow, wide lesions such as osseous craters.
Treatment of an osseous lesion with bone grafting and regeneration.
- Fig 1: A 55-year-old female patient with aggressive periodontitis was referred by a
colleague for assessment and treatment.
- Fig 2: After four one-hour periodontal sessions for full mouth root surface debridement under local anaesthetic, a deep periodontal pocket persisted around her maxillary right canine.
- Fig 3: A periodontal flap was raised and the pocket further debrided and granulation tissue was removed. Attachment loss was estimated to be 14mm.
- Fig 4: Particles of Bio-oss mixed into the blood clot to form a firm coagulum that can be fitted to the destroyed septum. A resorbable membrane then was used to cover the site.
- Fig 5: Recorded pocket depth is 11mm post-operatively.
- Fig 6: Three years after surgery, periodontal tissue is healthy. Pocket reduction and gain of attachment are 9mm.
- Fig 7: Bone destruction reaches the periapical region (post-op radiograph).
- Fig 8: Outcome of the grafting procedure, three years after surgery. True regeneration was achieved.
For medical images, please see the printed magazine or view the PDF online here
About the author:
Dr Maxwell is a specialist in periodontics. He graduated from the University of Glasgow Dental School in 1982 and obtained his MGDS from the Royal College of Surgeons in Edinburgh in 1990.
After obtaining his MSc in periodontology in 1997 at the University of Bristol, he was accepted on to the specialist register in periodontology in 2000.
Dr Maxwell is now based on Mondays and Tuesdays at Care Dental Focus in Crieff (01764 655745) and on Wednesdays, Thursdays and Fridayss at the Scottish Centre for Excellence in Dentistry (0141 427 4530), working as a periodontal specialist. He undertakes all aspects of treatment within his field, with a major focus on regenerative therapy and cosmetic periodontal surgery.
Dr Maxwell is a member of the British Society of Periodontology and has had his work published regularly in a number of leading dental journals. He also served as an examiner with the Royal College of Surgeons in Edinburgh and lectures to general dental practitioners and dental hygienists on a regular basis.