Clinical Cases in Periodontics. Группа авторов

in the response of periodontitis to anti‐infective therapy

Medical History

      There were no significant medical problems, and the patient had no known allergies. He had been previously hospitalized for a day surgery to remove polyps from his vocal cords. At the time of his first appointment he was not taking any medication.

Review of Systems

       Vital signsBlood pressure: 120/75 mmHgPulse rate: 70 beats/minute (regular)

Social History

      The patient was a 43‐year‐old white man, originally from Texas, but had been living in Massachusetts for the past 10 years. He drank alcohol socially, quit smoking 10 years ago, and reported not consuming recreational drugs. He was a musician, divorced, and had no children. His mother had heart disease, and his father died of lung cancer.

Extraoral Examination

      His extraoral examination was unremarkable: skin, head, neck, temporomandibular joint, and muscles were all within normal limits.

Intraoral Examination

The oral cancer screen was negative. His gingiva was pink, firm, with pointed papillae on the buccal aspect (Figure 1.6.1). However, the lingual and palatal aspects presented with signs of inflammation, with erythematous and edematous gingival margins. Adequate amounts of attached tissue were present around most teeth. Gingival recession was present at several sites (see periodontal chart for details). Supragingival and subgingival calculus could be detected on several tooth surfaces, particularly on the buccal surface of upper molars and lingual surfaces of lower incisors. There was generalized plaque accumulation. Saliva was of normal flow and consistency.

The periodontal chart presented in Figure 1.6.2 includes the following periodontal parameters: (i) probing pocket depth (PD) in millimeters; (ii) measurement from the cementoenamel junction (CEJ) to the free gingival margin (FGM) in millimeters (gingival recession was recorded as a positive value); (iii) clinical attachment level (CAL), which was calculated by adding the CEJ–FGM distance to the PD; and (iv) presence (1) or absence (blank) of bleeding on probing (BOP). Each clinical parameter was measured at six sites per tooth excluding third molars. Probing values were colored in black and red to highlight shallow (<4 mm), and intermediate to deep (≥4 mm) pockets. BOP was detected in 68% of sites, and the mean values for full‐mouth PD and CAL were 3.2 mm and 2.7 mm, respectively.

Figure 1.6.1 Clinical presentation of the case at initial visit.

      Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

Figure 1.6.2 Periodontal chart at initial visit.

      Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

Occlusion

      There were no signs of trauma from occlusion, no major occlusal discrepancies and interferences, and no significant mobility.

Radiographic Examination

A full‐mouth set of radiographs (Figure 1.6.3) was exposed. There was generalized moderate to severe horizontal bone loss, consisting of more than 50% loss of the original bony support. There was furcation involvement seen in teeth #1, #2, #3, #14, #15, #16, #18, #19 and #30. There was a periapical radiolucency noted on tooth #5. There were root canal treatments seen on teeth #5 and #12. There were several amalgam restorations and recurrent decay noted on tooth #13.

Diagnosis

      Periodontitis stage III, localized, grade C.

Treatment Plan

      The treatment plan for this case consisted primarily of four to six sessions of scaling and root planing (SRP) accompanied by oral hygiene instructions for the complete dentition. A reassessment of the case was planned for three months after the completion of this initial phase when the need for additional therapy would be decided.

Treatment

      After the patient’s initial examination, radiographs, and charting (Figures 1.6.1–1.6.3), a comprehensive treatment plan was presented and agreed upon. The first session involved full‐mouth gross scaling and oral hygiene instructions on the proper toothbrushing technique and use of dental floss. Due to the presence of large amounts of subgingival calculus, the patient required six sessions of subgingival SRP under local anesthesia (one sextant of the mouth was instrumented per session). During this active phase of anti‐infective therapy, previously instrumented sextants were constantly reexamined for residual supragingival and subgingival calculus, and whenever detected, residual calculus was removed. Every SRP session was accompanied by reinforcement of the oral hygiene instructions.

Three months after the last SRP session, the patient was reexamined (Figures 1.6.4 and 1.6.5), residual pockets ≥4 mm received additional SRP, a full‐mouth plaque removal was performed, and oral hygiene instructions reinforced. Mean full‐mouth PD and CAL were reduced to 2.3 and 2.4 mm, respectively, and there was a reduction in BOP to 13%. At that time no additional periodontal therapy was deemed necessary. The patient was placed in a recall system for supportive periodontal therapy every three months. Figures 1.6.6 and 1.6.7 illustrate the clinical presentation and the periodontal parameters one year after completion of SRP.

Figure 1.6.3 Full‐mouth periapical radiographs of the case at initial visit.

      Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

Figure 1.6.4 Clinical presentation of the case three months after therapy.

      Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

Discussion

      Periodontitis is a debilitating disease that is very prevalent and