Managing aggressive periodontitis
The following case report describes the management of a patient with generalised aggressive periodontitis, combining non-surgical/surgical periodontal therapy, regenerative procedures, orthodontic and restorative treatment to address inadequate aesthetics.
Female patient, 42 years of age, referred by her general dental practitioner for the assessment and treatment of her periodontal condition. Main complaints for the last two previous years were:
Bleeding on brushing
The patient had been an irregular attendee to GDP in previous years. This has improved in the last six months. The current oral care regime consisted of tooth brushing and the use of interdental brushes three to four times a day. No previous HPT for her periodontal disease.
Fit and healthy 42-year-old female. No reported allergies. Non smoker and moderate alcohol consumption (16 units/week).
Competent lips with a medium-high upper lipline showing full crown length of maxillary central and lateral incisor teeth when smiling, without any gingival display.
Otherwise, nil of note.
Soft tissues were moist and healthy. Oral hygiene was adequate with minimal isolated supragingival plaque deposits, mainly located in the posterior interdental areas. There was no evidence of supragingival calculus, but there were generalised deposit of subgingival calculus.
Gingivae appeared generally erythematous and there was brisk bleeding on probing (BoP). Probing depths ranged between 3mm and 9mm. The majority of the dentition exhibited increased mobility and furcation involvement was evident in relation to the molar teeth. These findings are shown in Figure 1.
The dentition was heavily restored, predominantly with amalgam. Tooth 22 was restored with an all-ceramic crown. Tooth 12 appeared discoloured at the disto-incisal area due to the presence of a cingulum amalgam restoration. Tooth 46 presented with fracture of the amalgam restoration.
Class one incisal relationship in a skeletal class one. The maxillary incisor teeth were proclined with a presenting overjet of 4mm on tooth 12 and 3.5 mm on tooth 21, they also had a triangular shape and were spaced out approximately 1mm to 1.5 mm between all anterior teeth.
The maxillary tooth 21 was over erupted approximately 1mm. Dental maxillary and mandibular midlines were displaced by approximately 1.5mm to the left side and not coincident with the facial midline.
Full periodontal examination (Figure 1).
Full mouth periapical radiographs (Figure 2).
The following findings were observed:
– Generalised moderate horizontal bone loss, ≥ 50 per cent, of the root length in both maxillary and mandibular arches. More advanced horizontal bone loss, ≥ 75 per cent, in the maxillary left quadrant.
– Vertical bone defects mesial aspect of teeth 37 and 42.
– Evidence of furcation bone loss present on the maxillary molar teeth and tooth 46.
– Evidence of endodontic treatment of tooth 22 with adequate apical obturation. This tooth was restored with a customised post-core of adequate width and length. There was no evidence of periapical pathology associated with this tooth.
– Tooth 46 showed evidence of endodontic treatment with inadequate root preparation and inadequate obturation. Both the mesial and distal roots had poorly condensed root fillings that were more than 15mm short of the radiographic apex. Periapical pathology was evident on the mesial root.
Generalised aggressive periodontitis
Chronic periapical periodontitis due to failed endodontic treatment
Failed restoration of mandibular tooth 46
General dental practitioner to assess tooth 46 for repeat root canal treatment and full coverage restoration
Hygiene phase therapy
Open root surface instrumentation as indicated
Orthodontic-restorative Treatment for aesthetic improvement
Supportive periodontal therapy.
Hygiene phase therapy
Hygiene phase therapy was completed over eight visits. During this time, the patient developed generalised mild dentine hypersensitivity that was treated with a combination of topical application of desensitising agent with high content of sodium fluoride and prescription of high content of sodium fluoride dentifrice for daily use.
At re-evaluation after non-surgical hygiene therapy, the main complaints were:
Generalised cervical sensitivity
Generalised gingval recession.
Intraoral examination revealed excellent oral hygiene, with no supra gingival plaque deposits detected. Gingivae appeared pink and moist, with good tissue tone and evidence of generalised gingival recession of 2-3mm (Figure 3). Periodontal examination demonstrated residual probing depths of 5-6mm with increased mobility of several teeth as seen in the pocket chart shown in Figure 3. Slight improvement in the general sensitivity had been noticed since the high- fluoride desensitising agent had been applied.
The areas with persistent pockets were treated surgically. The grade two buccal furcation of tooth 16 also required regeneration with xenograft material (Bio-Oss, Geistlich) and a resorbable collagen membrane (Bio-Gide, Geistlich. The muco-periosteal flap was coronally advanced and sutured with polypropylene monofilament suture.
Four weeks after surgical instrumentation of the mandibular right molar area, the patient developed a lateral periodontal abscess. It was drained under local anaesthesia and a three-day course of Metronidazole 400mg was prescribed in conjunction with analgesia as required and chlorhexidine rinse twice a day.
Ten weeks after the surgical therapy was completed, the patient was reassessed. Complaints at this stage were:
Generalised cervical gingival recession
Large interdental spaces present in the maxillary anterior sextant.
Intraorally, the oral hygiene and supragingival plaque control was excellent. Minimal supragingival calculus deposits had reformed lingual to the mandibular incisal teeth. The periodontal examination of the full dentition revealed no pathological probing depths, no bleeding on probing and isolated increased mobility as shown on the pocket chart shown in Figure 4.
There was clinical evidence of a good response to surgical therapy with reduction in periodontal probing depths, mild gain of attachment, reduction of tooth mobility and improvement in the areas of furcation involvement.
Supportive phase therapy
The patient was placed on a supportive phase therapy programme with a dental hygienist on a three-monthly basis, with instruction to re-instrument deep pockets of ≥ 4mm that bled on probing. This can be a sign of re-colonisation of pockets. In addition, re-enforcement of the importance of good supragingival plaque control with daily use of interdental brushes.
At the eight-month review, patient’s main concern was the large interdental “gaps” present in the maxillary anterior sextant. The periodontal condition was good and stable as seen from the pocket chart in Figure 5. It was felt that the patient would benefit at this stage from a labial acrylic gingival veneer in order to address her aesthetic concerns.
The result is acceptable considering the lack of contact points present between the lateral and central incisor teeth and thus the impossibility of filling the whole interdental space with the acrylic material. This was an interim measure prior to the orthodontic assessment and treatment (Figure 6).
During a tailored periodontal maintenance programme, the patient maintained excellent oral hygiene with a stable periodontal condition as seen from the pocket chart dated 20-10-09 (Figure 7). Tooth 17 showed isolated distal and buccal pockets of 5-6mm requiring additional non-surgical re-instrumentation under LA. Teeth 24 and 25 exhibited increased mobility of grade 1 requiring removal of the occlusal interference adjusting the occlusion in lateral excursions. Taking into account the excellent motivation of the patient and medium-term periodontal stability, an orthodontic opinion was sought to assess suitability for treatment.
Following an orthodontic assessment, the patient received maxillary and mandibular fixed appliances with additional interproximal stripping to reduce the interdental spaces in both arches, retrocline the maxillary anterior sextant to create contact points and intrude maxillary tooth 21 to align the incisal edge with the contralateral incisor tooth.
The patient was aware of the need of permanent retention in the form of palatal bonded wire. It was also made clear that, due to the shape of her maxillary teeth and the gingival recession as a result of the periodontal treatment received to date, orthodontic treatment alone would not remove the “black triangles”. For that reason, restorative treatment in the form of composite additions mesial and distal to the central and lateral maxillary incisor teeth, plus replacement of the all ceramic crown of maxillary tooth 22, should follow to obtain an overall better result.
Or, alternatively, continue with the labial gingival acrylic veneer (Figure 8a). Additional hygiene support was provided to avoid any relapse of the periodontal disease during orthodontic treatment.
Appraisal of the treatment outcomes
One of the keys for success in periodontal treatment is to make sure that the patient understands the etiological cause and evolution of his/her disease and the role that he/she has in it. Spending time at the first visit with the patient and giving them adequate time to process the information received will allow them to ask appropriate questions that concern them.
The patient must demonstrate good motivation, and maintain excellent supragingival plaque control to achieve periodontal stability overtime before the aesthetic and mobility concerns could be reviewed.
The maxillary molar teeth were treated differently. There is good evidence to support buccal furcation class two in molar teeth responding well to regenerative techniques. This is not the case for molar proximal furcations class two. In this case, the left maxillary molar teeth did not receive additional treatment after the surgical instrumentation. The proximal furcations were left to heal by repair. A targeted supportive therapy programme will guarantee the long-term stability of the periodontal disease for the molar teeth.
The provision of the labial acrylic veneer involving six units, although not ideal because of the proclined position of the maxillary teeth and the lack of contact points, has proved to be successful in addressing and improving the aesthetics of the maxillary anterior sextant as an interim measure.
A more pleasing result to attempt infill of the interdental spaces has required a combined orthodontic-restorative approach. Full commitment of the patient understanding the length of time that this type of approach involves and maintaining excellent oral hygiene during the orthodontic phase is paramount. Patients suffering from aggressive periodontitis must be closely monitored. If reinfection occurs, disease tends to have a more rapid progression than any other periodontal condition.
A tailored maintenance programme is of great importance to arrest at early stages any occurring reactivation that might take place. A three- monthly appointment seems to be an adequate regime.
About the author
Dr Jose Armas MBBS, BDS, MFDS (Glas). MRD (Perio). Specialist periodontist practicing at Somerset Place Consulting and consultant in periodontics at Glasgow Dental School and hospital.