Periodontology Case Key Points 34 year old female patient Ref by

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Dentinal Tubules Study Club – Case 1

Periodontology Case

Key Points

34 year old female patient

Ref by: GDP in 2009 – Pus exudate from UL1 – Seen by specialist? in March 2010 with no presenting complaints.

HPC: Pt ref to periodontology clinic in June 2009 – Seen by undergraduate and underwent RSD under LA in all quadrants. Then ref to post-graduate clinic for mgt of periodontal disease.

RMH: Fit and well – No allergies.

SH: Works at retail outlet. Stopped smoking 2 year prior to presentation – Smoked roll ups for 15 years.

DH: Irregular attender. XGA all 8’s in Jan 2009.

OH: Brushes 2xday – Oscillating electric toothbrush. Uses interproximal brushes.

E/O: NAD – High lip line when smiling – Vertical maxillary excess – Shows gingival margins


Dentition: Minimally restored. No overt TSL.

OH: Scattered deposits of interproximal plaque present – localised to lower molar teeth. Rough deposits on root surfaces. O'Leary Plaque Control Index: 4%

Periodontal tissues: Marginal tissue inflammation. Gingival Bleeding Index: 40%. Thin gingival biotype. Deep probing range affecting anterior & posterior teeth (5-9mm).

Mobility: Grade I – UL7, UR7, LL6,7

Grade II – UL4









  • Severe generalised aggressive periodontitis

Aggressive periodontitis:

Three primary features (1999 International workshop for the classification of periodontal diseases and conditions):

  1. Rapid loss of attachment and tooth-supporting bone

    • Need to take baseline radiographs to compare against

    • Age is not necessarily an indicator of aggressive perio as you may have a periodontitis-sensitive patient may have neglected their OH over a decade. Conversely severe attachment loss in an elderly patient may not be the result of year long-lasting neglect.

  1. The patient is healthy and is not suffering from any systemic disease that could lead to periodontitis.

    • Systemic diseases can lead to altered host response to periodontal pathogens – “Periodontitis as a manifestation of systemic disease”

  1. Familial aggressive periodontitis

Secondary features but not universally necessary to diagnose:

  • Low amounts of etiological factors (plaque) combined with pronounced tissue destruction

  • Strong colonisation of A.actinomycetemcomitans and P.gingivalis

Generalised aggressive periodontitis (GAP)

Age of onset: Often in young patients >35 – But found in all ages

Often a familial link

Destruction pattern: Generalised interproximal attachment loss – 3 or more teeth (excluding 1st molar/incisors)

Serum Ab response against pathogens – Poor

↑Perio susceptibility + ↓Host Response = Disease not limited in extent GAP

Aggressive Periodontitis subtypes

Localised aggressive periodontitis (LAP)

Age of onset: Circumpubertal

Destruction pattern: Local attachment loss – Incisors and 1st molars. Interproximal attachment loss at 2 or more permanent teeth – one of which 1st molar and 2 or less other teeth (excluding 1st molar/incisors).

Vertical loss of alveolar bone around 1st molars and incisors – begins at puberty in healthy teenagers – Classic diagnostic signs of LAP.

Serum Ab response against pathogens – More pronounced systemic Ab titres against periodontal pathogens than in GAP. Stronger humoral response (natural killer T cells).

↑Perio susceptibility + ↑Host Response = Disease limited in extent LAP


Given that the patient has aggressive periodontitis – response to conventional periodontal therapy will be unpredictable and the overall prognosis will be poorer in comparison to chronic perio cases. Overriding success of treatment will be down educating the patient about the disease and stressing the importance of the patient’s role in success of treatment.

  1. Preliminary phase - Emergency treatment

    • Patient not in pain and no sign of acute infection

    • Extraction of hopeless teeth and provisional replacement? – Poor prognosis of UL4 due to grade II mobility. Check for fremitus on all mobile teeth. Options: Delay xla until after tx is completed, XLA and leave gap, essix retainer with tooth, single tooth denture, bridge, implant once periodontially stable? (Saving questionable teeth may jeopardise adjacent teeth and lead to loss of bone needed for implants)

  1. Nonsurgical phase (Phase 1 Therapy) – Arrest disease progression

    • Supportive periodontal therapy – every 3 months to maintain good OH. Modified bass technique and use of interproximal cleaning aids. Patient may be cleaning prior to appointments as 40% bleeding may indicate neglect on other occasions

    • RSD on sites >4mm pocketing – Patient has already undergone full mouth RSD, has it been successful? If not, why not? Vertical bone defects difficult to clean.

    • Full yearly 6PPC – Establish baseline *Check furcation involvement with Nabers Probe)

    • Diet control

    • Reinforce smoking cessation – ensure patient aware of risks if she begins smoking again

    • Prescribe local antimicrobial therapy – Systemic use of combined Amoxicillin (500mg 3xday/5 days) and Metronidazole (200mg, 3xday/5days). Or systemic Tetracycline (250mg, 4xday/14 days).

    • Adjunctive antimicrobial photodynamic therapy.

  1. Evaluation of response to NSPT

    • R/v Plaque and Bleeding indices – every 3 weeks.

    • Recheck pocket depths after RSD – 8-12 weeks to allow full healing

  1. Surgical phase (Phase 2 Therapy) – Correct anatomic defects

    • Deep periodontal pockets will be difficult to instrument. High prevalence of vertical defects that need to be resolved.

    • Regenerative therapy – BioOss/Emdogain to repair bony defects.

      • Open-flap surgical debridement, RSD, application of tetracycline solution), allo/xenogenic bone graft (human/porcine). Modified Widman Flap used – Expose interproximal bone – Replace flap margins at new level of bony crest to reduce pocket.

  1. Restorative phase (Phase 3 Therapy) – Replace missing teeth

    • Oral rehabilitation and implant therapy – Limited data on stronger link between aggressive perio and peri-implantitis as compared to chronic perio patients.

    • Thin biotype = Thin buccal plate. Therefore atraumatic extraction technique to be used for ridge preservation.

    • Periodontal examination and response to restorative treatment

  1. Maintenance phase (Phase 4 Therapy)

    • Periodic rechecking of plaque and calculus indices, pocketing, tooth mobility, fixed/removable restorative treatment, and any other pathological changes.

    • Full mouth PAs to be taken every 6 months as per FGDP Selection Criteria for Dental Radiography given that the patient is a high risk perio pt.

    • Monitor UL1 – Reduced sensibility – monitor as it may be become non-vital.

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