A Case Report Using Regenerative Therapy for Generalized Aggressive Periodontitis

CASE REPORT

A Case Report Using Regenerative Therapy for GeneralizedAggressive Periodontitis

Robert G. Schallhorn*

Introduction: Control of aggressive periodontitis (AgP) is considered to be less predictable than that of chronic peri-odontitis because of its complex etiology and possible esthetic complications. This case report uses combined regenerativetechniques in conjunctionwith antimicrobial therapy to control and reverse the disease by regaining lost tissues and enhancedesthetics.

Case Presentation: This patient presented with advanced generalized AgP (GAgP) coupled with tooth splaying, ad-verse esthetics, and ulcerative colitis. After evaluation, additional diagnostic measures, and consultation with her gastroen-terologist, an aggressive treatment plan was pursued to regenerate lost tissues, eliminate pathogens, and help hermaintain oral health. Her response was favorable with elimination of the multiple osseous defects and esthetic improvementwith elevated self-esteem. The result was maintained for 12 years.

Conclusions: This case report presents the successful management of a 27-year-old female with GAgP. The treatmentprovided was evidence based, which included a combined regenerative approach in conjunction with both systemic antimi-crobial and conventional therapies and subsequentmaintenance care for 12 years. Of particular interest was the enhancementto prognosis effected through regeneration, which is in contrast to other approaches that strictly focus on arresting the diseaseand as such may lead to recession and diminished esthetics. Clin Adv Periodontics 2013;3:149-157.

Key Words: Aggressive periodontitis; esthetics, dental; maintenance, periodontal; regeneration, periodontal; sensitivity andspecificity, antibiotic.

BackgroundAggressive periodontitis (AgP) encompasses distinct types ofperiodontitis that affect people who, in most cases, appearotherwise healthy and have a rapid rate of disease progression.Generally, but not unusually, the amounts of microbialdeposits are inconsistent with the severity of periodontaltissue breakdown.LocalizedAgPusually has a circumpubertalonset with periodontal damage being localized to permanentfirst molars and incisors. The disease is frequently associated

with Aggregatibacter actinomycetemcomitans and neutrophilfunction abnormalities. Generalized AgP (GAgP) usuallyaffects people

periodontal support. Initial periodontal therapy alone isoften ineffective and may be contraindicated, particularlyif the goal is to regenerate the lost attachment apparatus.Microbiologic identification and antibiotic sensitivity test-ing should be considered to optimize anti-infective effortswith targeted systemic antimicrobial agents. Regenerationof the periodontal attachment apparatus, when feasible,should be considered1 as the ideal goal of treatment for ad-vanced forms of periodontitis not only to alter or eliminatethe microbiologic etiology and contributing risk factors,thereby arresting the progression of disease, but to regen-erate the lost periodontium, restoring the dentition to anoptimal state of health, function, comfort, and esthetics.Moreover, these efforts should also help to prevent recur-rence of the disease. This case report illustrates the success-ful treatment of a patient diagnosed with GAgP usingregenerative techniques in conjunction with targeted anti-microbial therapy and other conventional measures ofperiodontal care and maintenance.

Clinical PresentationA27-year-oldwhite femalewith ahealthhistory ofmigraineheadaches and possible ulcerative colitis was referred byher general dentist for a comprehensive periodontal evalua-tion. She presented to the authors private practice (Aurora,Colorado), which is limited to periodontics, on August 12,1999, for the examination along with the exposure of afull-mouth series of radiographs. She was taking oral con-traceptives and medication for migraines as needed. Thepatient was being evaluated by her physician and was sub-sequently confirmed for ulcerative colitis with no otherunderlying systemic disease causalities uncovered. She de-nied any social history of smoking and was unaware ofthe dental status of her parents or siblings.Her dental history included: 1) regular dental visits since

childhood; 2) no caries or dental restorations except for acomposite bonding buildup on the facial aspects of maxil-lary central incisors; 3) attempted orthodontic therapywith removable appliances during her early teens; 4) re-moval of all third molars; and 5) dental prophylaxis every6 months until 2 years before this visit when she wasadvised by her general dentist that she had suddenly devel-oped periodontal disease. A deep cleaning was accom-plished, and she subsequently changed dentists, had noother treatment, and was referred by her new dentist.Her dental complaints included: 1) malocclusion, in-

cluding recent anterior splaying of teeth #9 and #10; 2)bleeding gums; 3) frequent episodes of gingival enlarge-ment; 4) localized food impaction; 5) frequent aphthousulcers in varying locations; and 6) dissatisfaction and em-barrassment with her oral esthetic appearance (placingher hand over her mouth when smiling or keeping her lipsclosed). She expressed a fear of losing her teeth, a low painthreshold, and a poor rating for previous dental treatment.Her daily oral hygiene included brushing with a fluoridedentifrice, flossing, anduse of a perio-aid andmouthwashes.

Dental/oral examination findings were generally withinnormal limits and included a high (forced) smile line

FIGURE 1 Pretreatment image showing anterior sextant. Generalizedinflammation is suggested particularly between teeth #7 and #8, whichhave a magenta-colored papilla. The diastema between teeth #9 and #10is prominent.

FIGURE 2 Pretreatment radiographs suggest early moderate bone loss with isolated areas of severe bone loss.

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150 Clinical Advances in Periodontics, Vol. 3, No. 3, August 2013 Regenerative Therapy for Aggressive Periodontitis

revealing gingival tissues and a diastema between teeth #9and #10 with their flaring (Fig. 1). Localized supragingivalplaque and calculus accumulations were light. Parafunctionalhabits of occasional bruxing/clenching were reported, andfremitus was noted.

Periodontally, multiple sites of edematous magenta-colored papillae could be seen, and probing depths (PDs)/clinical attachment levels (CALs) of 5 to 8mmwere pre-sent in all sextants. Friable gingival tissues were noted atteeth #21 through #27,with root prominences and suspected

FIGURE 3a Pretreatment image of the 7-mm AL mesial to tooth #10. 3b Full-thickness flap with papilla preservation shows severe bone loss present witha shallow osseous crater defect. 3c After root debridement, EDTA treatment was performed, and EMD and DFDBA were placed, followed by an ePTFEbarrier that was positioned to the cemento-enamel junction (CEJ) to facilitate coronal attachment apparatus formation. 3d Exposure of the site at 7 weeksafter surgery. The barrier was removed, and a rapid healing pattern was suggested to the area with tissues extended 2 mm from the CEJ. 3e Twelve yearsafter regenerative therapy, the tissue appeared healthy and probed 2 mm. Substantial CAL was gained. 3f Pretreatment periapical radiograph of thelesion at teeth #9 and #10. 3g A 12-year postoperative radiograph of teeth #9 and #10 suggests substantial supracrestal attachment apparatusregeneration.

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Schallhorn Clinical Advances in Periodontics, Vol. 3, No. 3, August 2013 151

underlying bony dehiscences. Radiographically, there wasearly bone loss with localizedmoderate and severe horizon-tal bone loss and localized moderate-to-severe angularbone loss (Fig. 2).

The plaque index (PI) using a modified OLeary assess-ment4 was calculated at 59% effectiveness, and bleedingon probing (BOP) was observed in 60% of the interprox-imal sites. Based on her history, age, and periodontal

FIGURE 4a Two-wall/3-wall intrabony and lingual dehiscence lesion at the distal aspect of tooth #20, and 2-wall intrabony and lingual dehiscence lesion at thedistal aspect of tooth #21 before regenerative materials were placed. 4b Area of teeth #19 through #21 exposed 7 weeks after barrier placement. A normalhealing pattern to regenerative care is noted. This newly forming granulation tissue was completely covered by the flap to prevent its loss. 4c Pretreatmentbitewing radiograph indicates that intrabony lesions are present at the distal aspects of teeth #13 and #18 through #21. 4d At 12 years after regenerativetherapy, the lesions were completely filled. The bone was more consistent with it being turned over to host bone in which DFDBAePTFE combination therapywas used versus the distal aspect of tooth #13 where P-15/hydroxyapatite graft was placed.

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FIGURE 5a Surgical image depicts a 3-mm-deep 2-wall lesionbetween teeth #26 and #27. 5b Combination therapy has been usedafter root debridement. Again, DFDBA has been covered by ePTFE.5c At 7 weeks after surgery, the area demonstrated rapid healing ofthe lesion with complete fill. Again, the newly formed tissues werecompletely covered to nurture their optimal maturation. 5d At 12 yearsafter treatment, the PD of 2 to 3 mm was consistent with maintaininghealth. 5e Preoperative radiograph of the moderate lesion suggestedbetween teeth #26 and #27. 5f At 12 years after treatment, the lesion wassuggested to be completely regenerated.

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examination, a preliminary diagnosis of GAgP was madewith other issues and complications as noted above.Additional diagnostic measures recommended and pur-

sued included genetic testing, subgingival microbial anal-ysis with antimicrobial sensitivity testing, and medicalconsultation and clearance.The genotype test was negative. Microbial analysis re-

vealed several significant pathogens, including Tannerellaforsythia, Campylobacter species, Fusobacterium species,and Parvimonas micra. Although confirmatory evidenceof A. actinomycetemcomitans and P. gingivalis was notpresent, their absence did not exclude a diagnosis of AgP.

Case ManagementTreatment included initial plaque control refinement untilPI was >85% effective, occlusal adjustment for fremitus,and fabrication of a night guard if bruxism persisted. Inview of the severe involvement in the anterior sextantscoupled with her high smile line, initial root planing wasdeferred as a result of anticipated recession of the edema-tous papillae with ensuing esthetic problems.After presurgical treatment, exploratory surgery with

regenerative therapy was performed in conjunction withantimicrobial therapy based on microbial analysis andconsultation with her gastroenterologist (250 and 125mg amoxicillin and clavulanate potassium, respectively,three times daily, 250 mg metronidazole three times dailywith double doses for an initial 3 days for a total of 12days, followed by 100 mg doxycycline daily for 7 weeksto suppress the crevicular bacteria challenge and mem-brane contamination/wicking that may occur during al-tered oral hygiene). The surgery, after informed written andverbal consent was obtained, included: 1) flap reflection us-ing full papillary retention and distal wedge procedures inall second molar regions for pocketing and hyperplastictissues; 2) debridement and root planing as appropriate;

3) osteoplasty in areas with shallow osseous cratering and/or osseous ledging; and 4) regenerative therapy that included24% EDTA root preparation, topical application of enamelmatrix derivative (EMD),x intramarrow penetration anddemineralized freeze-dried bone allograft (DFDBA) useat multiple sites, with anorganic bone/hydroxyapatite{ useat tooth #13 along with expanded polytetrafluoroethylene#

(ePTFE) and titanium-reinforced ePTFE depending on theamount of spacemaintenance needed. The flapswere reposi-tioned or coronally positioned as needed for full coveragewith ePTFE or collagen sutures. At one point, the patientdeveloped a postoperative problem (nausea, gastritis, bloat-ing)with her systemic antibiotics,which requiredmodifyingthis protocol in concert with her gastroenterologist.The postoperative protocol was to see the patient weekly/

biweekly until membrane and remaining suture removal at7 weeks postoperatively and subsequently weekly/biweeklyfor postoperative care for an additional 3 months. Gingivalaugmentation was performed at teeth #21 through #27.Periodontal maintenance therapy was recommended

at 2- to 3-month intervals. This was followed with somevariability in the interval between visits. Fluctuations inplaque indexing for oral hygiene effectiveness also war-ranted continual reinforcement.

Clinical OutcomesAt the time of ePTFE membrane removal, all sites had suc-cessful fill of the intrabony defects, coverage of the dehis-cence defects, and restoration of normal architecture withvarying amounts of crestal apposition. The underlying tissue

FIGURE 6 Post-treatment radiographs exposed 12 years after treatment suggest good osseous fill of the angular lesions. It is difficult to detect previous boneloss because the trabecular pattern is suggestive of host bone with the exception of the distal aspect of tooth #13.

PST Genetic Test, Interleukin Genetics, Waltham, MA. PrefGel, Straumann, Andover, MA.x Emdogain, Straumann. OraGraft, LifeNet Health, Virginia Beach, VA.{ PepGen P-15, DENTSPLY International, York, PA.# W.L. Gore & Associates, Flagstaff, AZ.

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at the time ofmembrane removal varied froma rapid healingpattern to a typical healing pattern as reported previously.5

Representative presurgical/surgical areas, removal of ePTFEmembranes in regenerative sites, and 12-year postoperativetreatment areas are presented along with their companionradiographs in Figures 3 through 5.After treatment, sites probed 1 to 3 mm, including all re-

generative sites with no BOP. Radiographically, evidenceof bone fill of intrabony defects was suggested becauseDFDBA is radiolucent until mineralization occurs. More-over, crestal apposition after regenerative treatment (Fig. 6)was suggested at teeth #6 to #7/8, #9 to #10/11, #26 to#27, and #29 to #30.

DiscussionThis case presents the successful treatment and long-termmanagement of a patient diagnosed with GAgP. The es-thetic outcome has been favorable with no recession andclosure of the diastema and flare of teeth #9 to #10 resultingfrom the resolution of the inflammation and increased boneapposition (Fig. 7) and without orthodontic or restorativemeasures. All this has pleased the patient because her smilewas markedly improvedwith a natural smile versus her pre-treatment forced smile (Fig. 8).Much of the treatment for AgP has centered around

evidence-based therapies.6,7 Although a myriad of newbiologics, barriers, and grafts have been introduced,

they are of little value if the basics in management of causalfactors, root debridement, and follow-up maintenance arenot properly applied. In particular, maintenance on a regularbasis is essential in both the perioperative and early phasesof healing8 and after the completion of care9 if the resultsto treatment are to remain stable, particularly because thesepatients could be quite susceptible to disease recurrence.Of particular interest was the enhancement affected

by regenerative therapy in contrast with other approachesthat strictly focus on arrestment of disease in which reces-sion can occur, leading to less favorable esthetic results. n

FIGURE 7 Maxillary anterior sextant 12 years after the completion of care.The gingival architecture and consistency appear healthy, with papillaefilling the interproximal spaces.

FIGURE 8a Pretreatment image depicting the patients high smile line withinflammation and severe erythema visibly seen. 8b Smile at 12 years aftertherapy demonstrates that control of the inflammation has allowed forclosure of the diastema. Removal of the facial composite buildups on teeth#8 and #9 has also enhanced their esthetics. The patient was happy withthe esthetic results of her care.

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Summary

Why is this case new information? j Uses three regenerative techniques that have demonstrated histologicproof-of-principle alone or in combination with each other

j Illustrates the potential for clinical success with combinedregenerative techniques and targeted antimicrobial therapy incomplex intrabony, dehiscence, and supracrestal lesions with stabilityover 12 years

What are the keys to successfulmanagement of this case?

j Correct diagnosisj Identifying etiologic factors that can be eliminated or reduced belowa threshold value

j Coordinated treatment with the patients physician to minimizeadverse non-dental conditions

j Attention to detail in all aspects of therapyj Continual evaluation of the response during therapy for possiblemodifications, etc.

j Critical reevaluation after therapy for possible needed refinement,adjunctive care, etc., and to confirm that treatment goals andobjectives have been achieved

j Patient acceptance and compliance as a cotherapist and maintainingeffective plaque control and maintenance recommendations

j Ongoing assessment during maintenance therapy with potentialintervention, diagnostic testing, etc., to intercept any adversechanges to maintain periodontal health

What are the primary limitations tosuccess in this case?

j Foremost, patient acceptance and compliance with plaque controland other recommendations

j Patients healing capacityj The nature of defectsj Accessibility, etc., for proper instrumentation, which frequently canonly be determined during surgical exploration

j Possible undiagnosed endodontic problemsj Response to antimicrobial therapyj Patients susceptibility to recurrence and/or other systemic factors

AcknowledgmentsThe author thanks Drs. Pamela McClain (private practice,Aurora, Colorado), Rachel Schallhorn (private practice,Aurora, Colorado), and Paul Rosen (private practice, Yard-ley, Pennsylvania) for their help in the preparation of thismanuscript. The author reports no conflicts of interest re-lated to this case report.

CORRESPONDENCE:Dr. Robert George Schallhorn, 22591 E. Long Dr., Aurora, CO 80016.E-mail: [email protected].

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References1. American Academy of Periodontology. Glossary of Periodontal Terms,

4th ed. Chicago: American Academy of Periodontology; 2001:39-40.

2. American Academy of Periodontology. Parameter on aggressive peri-odontitis. J Periodontol 2000;71(Suppl. 5):867-869.

3. American Academy of Periodontology. Parameter on refractory peri-odontitis. J Periodontol 2000;71(Suppl. 5):859-860.

4. OLeary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol1972;43:38.

5. Schallhorn RG, McClain PK. Clinical and radiographic healing patternobservations with combined regenerative techniques. Int J PeriodonticsRestorative Dent 1994;14:391-403.

6. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, GunsolleyJC. The efficacy of bone replacement grafts in the treatment of peri-odontal osseous defects. A systematic review. Ann Periodontol 2003;8:227-265.

7. Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatmentof periodontal intrabony and furcation defects. A systematic review. AnnPeriodontol 2003;8:266-302.

8. Westfelt E, Nyman S, Socransky S, Lindhe J. Significance of frequency ofprofessional tooth cleaning for healing following periodontal surgery. JClin Periodontol 1983;10:148-156.

9. Cortellini P, Tonetti MS. Long-term tooth survival following re-generative treatment of intrabony defects. J Periodontol 2004;75:672-678.

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A Case Report Using Regenerative Therapy for Generalized Aggressive Periodontitis

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