.

an easy task and requires highly skilled and well‐trained individuals. Residual pockets should be carefully reinstrumented, and this step should involve as many sessions as needed. A new period of three months of healing should be given before an assessment of the outcome of this new cycle of SRP is conducted. Clinicians should keep in mind that there is very little risk to the patient in delaying a possible surgical phase of treatment to make every effort to guarantee an optimal outcome of the anti‐infective therapy.

      E. Although the presence of residual pockets has been demonstrated as a good predictor of future attachment loss [20], clinicians should interpret this information with caution. Several other clinical aspects will impact the prognosis of the case. such as the level of plaque control by the subject, the presence of BOP, and the presence of furcation defects. Further, one must keep in mind that periodontal surgical procedures involve nonaffected periodontally diseased sites adjacent to residual pockets. If residual pockets are isolated nonbleeding lesions, they present a very low risk of progression and can be easily addressed with SRP during supportive periodontal therapy. Conversely, if residual pockets cluster around a few adjacent teeth and BOP is a recurrent finding over several sessions of maintenance, a surgical approach seems adequate. Periodontal surgery in the absence of proper plaque control exposes the periodontal patient to the risk of accelerated attachment loss [21] and should be avoided at all costs.

Case 1.7 Local Anatomic Factors Contributing to Periodontal Disease

      CASE STORY

A 63‐year‐old woman was referred for evaluation of periodontal condition on tooth #19. The patient reported tenderness around tooth #19 from time to time when she applied pressure on the buccal gingiva (Figures 1.7.1 and 1.7.2).

Figure 1.7.1 Clinical presentation of tooth #19.

Figure 1.7.2 Radiographic presentation of tooth #19.

      LEARNING GOALS AND OBJECTIVES

       To be able to identify local anatomic factors that may contribute to periodontal disease

       To understand the anatomy of the furcation and root

       To be able to diagnose a furcation invasion using a furcation classification system

Medical History

      The patient’s medical history was not significant. The patient reported no allergies to any medication, latex, metal, or food.

Review of Systems

       Vital signsBlood pressure: 119/71 mmHgPulse rate: 56 beats/minuteRespiratory rate: 15 breaths/minute

Social History

      The patient denied smoking, occasionally drank alcohol during social events, and denied the use of recreational drugs. The patient was a yoga instructor and claimed that she had a very healthy lifestyle.

Oral Hygiene Status

      The patient brushed twice a day with electric toothbrush and flossed every day.

Extraoral Examination

      No significant findings were present.

Intraoral Examination

       Soft tissues including buccal mucosa, hard and soft palate, floor of the mouth, and tongue were all within normal limits.

       There was generalized gingival recession, although most teeth still had adequate amounts of attached keratinized gingiva.Figure 1.7.3 Periodontal probing depth measurements during initial visit.

       Refer to Figure 1.7.3 for the periodontal charting.

       Tooth #19 exhibited a probing depth of 8 mm on the midbuccal aspect and clinically had grade II furcation invasion. No significant mobility was detected.

       A cervical enamel projection (CEP) was detected at the buccal furcation area below the gingival margin on #19.

Occlusion

      No occlusal interferences were detected.

Radiographic Examination

      Periapical radiograph of tooth #19 did not show a significant amount of bone loss around the furcation area. Cone beam computed tomography (CT) was used to further examine the periodontal condition of tooth #19 and showed evidence of bone loss over the buccal furcation area (Figure 1.7.2).

Diagnosis

A diagnosis of stage III grade B periodontitis was made based on the clinical and radiographic examinations with respective to the severity of furcation involvement (grade II) and the rate of progression of bone loss (<2 mm over five years). The attachment loss and grade II furcation invasion on tooth #19 required definitive periodontal treatment. The prognosis of #19 was questionable because the grade II furcation made the patient’s daily oral hygiene maintenance in this area very difficult [1].

Figure 1.7.4 Cervical enamel projection (CEP) on buccal of tooth #19 (left); CEP removed (right).

Treatment Plan

      The treatment plan and sequence were as follows.

       Diagnostic phase: comprehensive dental and periodontal examination, radiographic examination.

       Disease control phase: oral hygiene instruction, adult prophylaxis, localized scaling, and root planing of the buccal furcation of tooth #19.

       Reevaluation phase: periodontal reevaluation of tooth #19, oral hygiene evaluation and reinforcement.

       Surgical phase: open flap debridement and removal of the CEP on the buccal aspect of tooth #19.

       Maintenance phase: regular three‐month periodontal maintenance visits.

Treatment

Localized scaling and root planing of tooth #19 was performed using a Cavitron and hand instruments. After a healing period of six weeks, periodontal reevaluation revealed a probing depth of 8 mm with bleeding on probing on the midbuccal of #19. The treatment plan at this point included surgical treatment to remove the CEP. An intrasulcular incision was made from the distal