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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 122-125

Rehabilitation of dentition affected by stage IV periodontitis through an interdisciplinary approach


1 Consultant Periodontist, Mar Baselios Dental College, Kothamangalam, Kerala, India
2 Department of Prosthodontics, Mar Baselios Dental College, Kothamangalam, Kerala, India
3 Consultant Endodontist, Kerala, India

Date of Submission08-Apr-2019
Date of Acceptance16-Jul-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Jimmy George
Department of Prosthodontics, Mar Baselios Dental College, Kothamangalam - 686 691, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_13_19

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   Abstract 


Rehabilitation of periodontally compromised dentitions is always challenging in order to restore the masticatory function as well as to prevent future disease progression. This case report discusses an interdisciplinary approach for managing a case of Stage IV periodontitis in a female patient who presented with multiple mobile furcations involved posterior teeth. By a combined endo-perio-prosthetic effort, the retention and rehabilitation of majority of her teeth was achieved.

Keywords: Aggressive periodontitis, furcation, interdisciplinary approach, root resection


How to cite this article:
Abraham AS, George J, Thomas D, Cherian B. Rehabilitation of dentition affected by stage IV periodontitis through an interdisciplinary approach. J Interdiscip Dentistry 2020;10:122-5

How to cite this URL:
Abraham AS, George J, Thomas D, Cherian B. Rehabilitation of dentition affected by stage IV periodontitis through an interdisciplinary approach. J Interdiscip Dentistry [serial online] 2020 [cited 2021 Apr 17];10:122-5. Available from: https://www.jidonline.com/text.asp?2020/10/3/122/304149




   Clinical Relevance to Interdisciplinary Dentistry Top


  • The ultimate goal of periodontal therapy is to preserve the natural dentition.
  • The goal is not only to maintain the natural dentition, but also to restore lost periodontium.
  • Hence, for rehabilitation of periodontally compromised teeth an interdisciplinary approach with proper diagnosis and treatment planning is essential for its success.



   Introduction Top


Aggressive periodontitis is a stand out disease in the entire spectrum of periodontal pathologies in terms of etiology, clinical presentation, therapeutic modalities, and maintenance. Significant strides have been made in the surgical management and correction of defects seen in aggressive periodontitis, especially in the localized version. In reality, however, patients often present at a stage where regenerative surgical therapy is no longer possible, and the teeth are deemed for extraction. In the most recent revision of the classification of periodontal diseases, the existing diagnostic categories of chronic and aggressive periodontitis have been replaced by a new system of staging and grading of periodontitis.[1] Accordingly, cases that have been previously diagnosed as moderate to advanced generalized aggressive periodontitis are most likely to be included under Stage IV periodontitis. A major challenge in these situations is the rehabilitation for restoring occlusal function. Fixed replacements are seldom sought, mostly due to insufficient number and periodontal support of the abutment teeth, and many a times, patients have to be content with the removable prosthesis. In routine practice, fixed partial dentures are considered only to be tooth replacements, but from a periodontal standpoint, they are the most effective means of splinting mobile teeth. This case report presents the rehabilitation of a comparatively young patient diagnosed with generalized aggressive periodontitis or Stage IV periodontitis with coordinated periodontal, endodontic, and prosthetic management.


   Case Report Top


A 40-year-old female patient reported to the outpatient department of periodontics of our institution, with the chief complaint of the mobility of the upper left back teeth noticed for 6 months. The patient gave a history of undergoing fixed orthodontic treatment 4 years ago [Figure 1]. No attributable medical history was reported. On clinical examination, fair oral hygiene was observed. Teeth numbers 16, 26, and 27 showed recession with deep periodontal pockets and Grade III furcation involvement. On radiographic assessment, generalized bone loss was seen in the maxillary and mandibular arch with advanced bone loss in relation to 16, 26, and 27. These teeth also showed interradicular bone loss suggestive of furcation involvement. Teeth 16 and 26 showed Grade II mobility and 27 showed Grade III mobility. Considering the age, oral hygiene status, and examination findings, a provisional diagnosis of generalized aggressive periodontitis was made. As per the new classification, a diagnosis of generalized Stage IV Grade C periodontitis was applied since there were (a) interdental attachment loss of more than 5 mm; (b) radiographic bone loss extending up to apical third of the root; (c) Grade II mobility, secondary occlusal trauma, and masticatory dysfunction; and (d) percentage bone loss/age of >1. Hopeless prognosis was assigned to 27, and it was advised extraction.
Figure 1: Preoperative picture

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The patient was informed regarding the doubtful prognosis of 17, 16, 25, and 26 and the possible need for extracting them too in the future. However, the patient was desirous of retaining them. Hence, an interdisciplinary treatment plan was formulated in consultation with the endodontic and prosthodontic departments, which was approved by the patient. Initially, 27 was extracted. During the phase I therapy, 25, 26, and 28 were given a temporary splint using wire and composite. Endodontic treatment was done in relation to 17,16, and 26. Following this, the patient underwent full mouth flap surgery along with regenerative procedures in the indicated areas [Figure 2]. Furcation involved 16 and 26 were managed by resection of their mesiobuccal roots [Figure 3]. Postsurgery, the patient was kept under regular maintenance for 6 months. At 6-month review, mobility of 16 and 26 was found to be considerably reduced. It was decided to proceed with the prosthetic rehabilitation of the maxillary posteriors by means of fixed prostheses [Figure 4]. A fixed dental prosthesis was made including 17, 16, and 15 and similarly in relation to 25, 26, 27, and 28 ensuring adequate scope for interdental cleansing. The patient is presently under supportive therapy, and the treatment results have been maintained to date [Figure 5].
Figure 2: Root resection performed in relation to 16 and 26

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Figure 3: Review after 2 weeks

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Figure 4: Prosthetic rehabilitation done in relation to first and second quadrants ensuring proper interdental cleansing

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Figure 5: Preoperative panoramic radiograph showing extensive bone loss and postoperative panoramic radiograph after prosthetic rehabilitation

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   Discussion Top


The long-standing diagnostic dilemma of differentiating between chronic and aggressive periodontitis has been solved in the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions,[1] wherein the exact periodontal status of the patient is described under staging and grading of periodontitis. From the periodontal findings in the present case, it could be retrospectively diagnosed as generalized Stage IV Grade C periodontitis, which implies a severe disease with a risk of future progression and the need for complex rehabilitation.

Among the commonly observed types of periodontal diseases, generalized aggressive periodontitis is generally attributed a poor prognosis, mainly attributed to the rapid rate of progression and inability to mount adequate immune response.[2] The often-delayed clinical presentation further jeopardizes the possibility of salvaging the affected teeth. In the present case, the maxillary posteriors were severely compromised requiring extractions. However, the periodontal status of the adjacent teeth precluded any kind of fixed replacement leaving the only option of a removable prosthesis, to which the patient disagreed. In the present day scenario, implants have become the standard of tooth replacement and are no longer contraindicated in aggressive periodontitis patients. Kim and Sung[3] in a systematic review of the outcomes of dental implant treatment in patients with generalized aggressive periodontitis reported up to 96% survival rates of implants after 5 years. However, the feasibility of implant-supported restoration in the present case was limited, considering the severe bone loss that was present and the proximity to the maxillary sinus. Hence, it was decided to proceed with the retention of the teeth.

Along with the severe attachment loss, an additional complicating factor was the presence of multiple furcation involvements. Proximal furcations of maxillary molars are rather challenging to manage, where regenerative procedures often fail. Root amputation or resection is the only option in these situations. Maxillary root resection was first reported in the literature by Hiatt[4] in 1963. In the era of advanced regenerative procedures and implants, the use of resective procedures in general has become limited, yet root amputation procedures still hold good in the management of furcation involvement. Carnevale et al.[5] evaluated 488 root-resected teeth for a period of 3–11 years and reported only 6% tooth loss. Apart from the periodontal management, endodontic and restorative considerations are also critical while planning for root resection. Proper endodontic treatment must be performed in the roots to be retained prior to resection, and in case of vital root resection, endodontic treatment should not be prolonged for more than 2 weeks. During the resection procedure, it must be ensured that residual ridges, furcation flutes, and root concavities are corrected, so as to prevent plaque retention. It is also important to keep the tooth out of occlusion during the healing period.

The critical aspects while restoring a root-resected tooth are (i) flat emergence profile from the preparation margin to facilitate plaque control, (ii) narrow occlusal table buccopalatally, and (iii) reduced cuspal inclines so as to minimize occlusal overload.[6] Occlusal narrowing can be accomplished by reducing mandibular lingual cusps and maxillary buccal cusps.[7]

In the present case, the treated maxillary posteriors were given fixed dental prosthesis. There is a general tendency to avoid fixed dentures in periodontally compromised cases. However, it has to be reiterated that a fixed prosthesis is the best periodontal splint. Fixed prostheses provide better rigidity and a more favorable force distribution compared to other types of splinting. The mobility of periodontally compromised teeth is reduced, thereby promoting better healing and providing better patient comfort and acceptance. A close association between the prosthodontist and periodontist is essential while restoring periodontally compromised teeth to ensure proper design features conducive for adequate plaque control and maintenance.


   Conclusion Top


A case report highlighting the role and outcome of interdisciplinary management in a patient with generalized aggressive periodontitis/Stage IV periodontitis has been presented. The rendered treatment may be less than ideal; yet, the untimely loss of multiple posterior teeth in a young patient could be at least postponed by the reported treatment approach combining periodontal, endodontic, and prosthetic procedures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, et al. A new classification scheme for periodontal and peri-implant diseases and conditions-Introduction and key changes from the 1999 classification. J Clin Periodontol 2018;45 Suppl 20:S1-8.  Back to cited text no. 1
    
2.
Carranza F, Newman M, Takei H, Carranza's Clinical Periodontology. 10th ed. St. Louis, Mo.: Elsevier Saunders; 2006.  Back to cited text no. 2
    
3.
Kim KK, Sung HM. Outcomes of dental implant treatment in patients with generalized aggressive periodontitis: A systematic review. J Adv Prosthodont 2012;4:210-7.  Back to cited text no. 3
    
4.
Hiatt W, Amen C. Periodontal pocket elimination by combined therapy. Dent Clin North Am 1964;133:44.  Back to cited text no. 4
    
5.
Carnevale G, Di Febo G, Tonelli MP, Marin C, Fuzzi M. A retrospective analysis of the periodontal-prosthetic treatment of molars with interradicular lesions. Int J Periodontics Restorative Dent 1991;11:189-205.  Back to cited text no. 5
    
6.
Newell DH. The diagnosis and treatment of molar furcation invasions. Dent Clin North Am 1998;42:301-37.  Back to cited text no. 6
    
7.
Basaraba N. Root amputation and tooth hemisection. Dent Clin North Am 1969;13:121-32.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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