300
Osseo-Integrated Implant Treatment of a Patient With Rapidly Progressive Periodontitis. A Case Report* Hans S. Malmstrom, Michael E. Fritz, David P. Timmis, and Thomas E. Van
Dyke
placement of osseointegrated fixtures in a of with a probable history rapidly progressive Periodontitis. A 12-year history is patient The post-operative sequelae of placing fixtures in a fully edentulous maxilla presented. and partially edentulous mandible were the worst seen by the Implant Team at Emory University. The hypothesis presented is that patients with aggressive forms of periodontal disease should be subjected to appropriate mechanical and antimicrobial therapy to produce a healthy oral flora before any implants are placed. / Periodontol 1990;61:300304. The
case report presented describes
Key Words: Periodontitis, rapidly progressive; implants, osseointegrated;
case
reports.
Rapidly progressive Periodontitis (RPP) as originally described by Page et al.1 is characterized by an age of onset between puberty and age 35, and lesions which are generalized, affecting most of the teeth without any consistent pattern of distribution. It is not clear whether some, but not
all of the patients, had juvenile Periodontitis previously. Suzuki2 describes two types of RPP (A and B) based upon age of onset and previous localized juvenile Periodontitis (LJP). The distinction was further defined by Van Dyke et al.3 into RPP and generalized juvenile Periodontitis (GJP), the former having later onset and no systemic or immunological defects associated with the clinical condition. In both RPP and GJP, there is evidence of severe and rapid bone destruction, and during the active phase the gingival tissue is acutely inflamed, with marginal proliferation during the arrested phase. The amounts of microbial deposits are highly variable, and approximately 83% of the patients have functional defects in neutrophils or monocytes. The disease sometimes, but not always, has systemic manifestations including weight loss, mental depression, and generalized malaise. Some individuals are markedly responsive to treatment by scaling and root planing coupled with antibiotic administration. A case report presented here describes a patient who was initially examined in 1977, was treated by periodontal surgical therapy twice in 10 years with no definitive results, had microbial culturing performed, with a subsequent diagnosis consistent with either GJP or RPP, and was treat"Emory Dental Research Center, Emory University School of Postgraduate Dentistry, Atlanta, GA.
Figure
1:
Panographic radiograph of the patient,
1977.
ment planned for osseo-integrated implants. The course of his treatment and sequelae are presented here. There is little
known of the suitability of patients with aggressive forms of periodontal disease for implant therapy. This is particularly true in the partially edentulous patient.
CASE REPORT The patient presented to Emory University School of Dentistry in 1977. He was 28 years of age at that time. His medical history was unremarkable except for mild hypertension not being treated by medication and cigarette use. Pocket depths ranged from 3 mm to 9 mm and there was bleeding on probing throughout the mouth. A diagnosis of severe generalized Periodontitis was made at the time. Radiographs are displayed (Fig. 1). Due to economic and general attitude considerations, the treatment was to extract
Volume 61 Number 5
teeth # 5, 7, 9, 10, 12 and perform root canal therapy on # 4, 6, 11, and 16; perform osseous periodontal surgery, and fabricate a maxillary overdenture. For the mandibular arch, tooth #18 was extracted, a bridge was fabricated from #17 to 20, and teeth # 23 through 26 were temporarily splinted with wire and composite. Periodontal osseous surgical therapy was instituted prior to restorative dental therapy and after extraction of the teeth and the appropriate root canal procedures. Therapy was completed in June 1978 (Fig. 2) and the patient was assigned to the recall program. Pocket depths were no greater than 3 mm on completion of therapy. The patient was seen on 3 month examinations from 1978 through 1981. Many notations were made in the chart regarding periodontal abscesses during this time (these were incised and drained) and very red and irritated gingival tissue. Radiographs during this time revealed continuous loss of attachment (Fig. 3). This was especially notable on the remaining teeth on the maxillary arch. In the latter part of 1981, teeth # 4, 6, 11, and 16 were extracted and a conventional denture fabricated because of the advanced periodontal disease with recurring abscesses. The patient was lost to follow up for approximately 2 years and presented again in 1983 to Emory University School of Dentistry. Readmission workup at this time included tests for chemotactic function and microbial culturing. The patient was placed in a protocol of scaling and tetracycline therapy every 6 weeks. The laboratory tests revealed a chemotactic defect in the patient's neutrophils. In 1984, the patient was treated surgically in the mandibular arch and teeth # 17, 20, 23, 25 and 26 were extracted due to advanced periodontal disease and a bridge placed from #21 through 28 (Fig. 4). The patient moved from Atlanta from 1985 through February 1987, at which time he appeared for a consultation with the Implant Team at Emory University School of Dentistry. Radiographs again displayed bone loss (Fig. 5), there was some edematous tissue present, and pockets ranged from 2 mm to 5 mm on the mandibular arch. The Implant Team at that time treatment planned the patient for 6 osseointegrated fixtures to be placed on the maxilla and 3 fixtures on the mandibular left. It was decided to make the patient part of a research protocol which addressed itself to what would happen to patients who had a history of GJP and/or RPP and were now treated with osseo-integrated implants. Intraoral examination revealed a plaque score of 75% and a gingival score of 8.3% of all surfaces. The chemotactic defect was still present, and microbiological culture revealed high percentages of Wolinella recta and E. corrodens (Table 1). The patient's laboratory profile (SMA 22) was within normal limits except for slightly elevated triglycéride levels. Clinical preoperative photographs of the patient are shown in Figures 6A-E. The patient was given a course of scaling and, after obtaining clinical gingival health, was appointed for implant surgery. It was felt that antibiotic coverage was not indi-
IMPLANTS IN RAPIDLY PROGRESSIVE PERIODONTITIS
301
Figure 2: Panographic radiograph of the patient, 1978. Selective extractions and periodontal osseous surgery have been performed.
Figure 3: Panographic radiograph of the patient, 1981. Note the dramatic periodontal breakdown seen around tooth numbers 4, 6, and 11.
Figure
4:
Periapical radiographs,
1984. A mandibular fixed prosthesis
has been constructed.
Figure 5: Panographic radiograph, 1987.
J Periodontol
302
MALMSTROM, FRITZ, TIMMIS,
May
VAN DYKE
1990
Table 1: Culture From Periodontal Pocket Tooth #31
Bacteria
% 0.5
Osseo-Integrated Implant Treatment of a Patient With Rapidly Progressive Periodontitis. A Case Report* Hans S. Malmstrom, Michael E. Fritz, David P. Timmis, and Thomas E. Van
Dyke
placement of osseointegrated fixtures in a of with a probable history rapidly progressive Periodontitis. A 12-year history is patient The post-operative sequelae of placing fixtures in a fully edentulous maxilla presented. and partially edentulous mandible were the worst seen by the Implant Team at Emory University. The hypothesis presented is that patients with aggressive forms of periodontal disease should be subjected to appropriate mechanical and antimicrobial therapy to produce a healthy oral flora before any implants are placed. / Periodontol 1990;61:300304. The
case report presented describes
Key Words: Periodontitis, rapidly progressive; implants, osseointegrated;
case
reports.
Rapidly progressive Periodontitis (RPP) as originally described by Page et al.1 is characterized by an age of onset between puberty and age 35, and lesions which are generalized, affecting most of the teeth without any consistent pattern of distribution. It is not clear whether some, but not
all of the patients, had juvenile Periodontitis previously. Suzuki2 describes two types of RPP (A and B) based upon age of onset and previous localized juvenile Periodontitis (LJP). The distinction was further defined by Van Dyke et al.3 into RPP and generalized juvenile Periodontitis (GJP), the former having later onset and no systemic or immunological defects associated with the clinical condition. In both RPP and GJP, there is evidence of severe and rapid bone destruction, and during the active phase the gingival tissue is acutely inflamed, with marginal proliferation during the arrested phase. The amounts of microbial deposits are highly variable, and approximately 83% of the patients have functional defects in neutrophils or monocytes. The disease sometimes, but not always, has systemic manifestations including weight loss, mental depression, and generalized malaise. Some individuals are markedly responsive to treatment by scaling and root planing coupled with antibiotic administration. A case report presented here describes a patient who was initially examined in 1977, was treated by periodontal surgical therapy twice in 10 years with no definitive results, had microbial culturing performed, with a subsequent diagnosis consistent with either GJP or RPP, and was treat"Emory Dental Research Center, Emory University School of Postgraduate Dentistry, Atlanta, GA.
Figure
1:
Panographic radiograph of the patient,
1977.
ment planned for osseo-integrated implants. The course of his treatment and sequelae are presented here. There is little
known of the suitability of patients with aggressive forms of periodontal disease for implant therapy. This is particularly true in the partially edentulous patient.
CASE REPORT The patient presented to Emory University School of Dentistry in 1977. He was 28 years of age at that time. His medical history was unremarkable except for mild hypertension not being treated by medication and cigarette use. Pocket depths ranged from 3 mm to 9 mm and there was bleeding on probing throughout the mouth. A diagnosis of severe generalized Periodontitis was made at the time. Radiographs are displayed (Fig. 1). Due to economic and general attitude considerations, the treatment was to extract
Volume 61 Number 5
teeth # 5, 7, 9, 10, 12 and perform root canal therapy on # 4, 6, 11, and 16; perform osseous periodontal surgery, and fabricate a maxillary overdenture. For the mandibular arch, tooth #18 was extracted, a bridge was fabricated from #17 to 20, and teeth # 23 through 26 were temporarily splinted with wire and composite. Periodontal osseous surgical therapy was instituted prior to restorative dental therapy and after extraction of the teeth and the appropriate root canal procedures. Therapy was completed in June 1978 (Fig. 2) and the patient was assigned to the recall program. Pocket depths were no greater than 3 mm on completion of therapy. The patient was seen on 3 month examinations from 1978 through 1981. Many notations were made in the chart regarding periodontal abscesses during this time (these were incised and drained) and very red and irritated gingival tissue. Radiographs during this time revealed continuous loss of attachment (Fig. 3). This was especially notable on the remaining teeth on the maxillary arch. In the latter part of 1981, teeth # 4, 6, 11, and 16 were extracted and a conventional denture fabricated because of the advanced periodontal disease with recurring abscesses. The patient was lost to follow up for approximately 2 years and presented again in 1983 to Emory University School of Dentistry. Readmission workup at this time included tests for chemotactic function and microbial culturing. The patient was placed in a protocol of scaling and tetracycline therapy every 6 weeks. The laboratory tests revealed a chemotactic defect in the patient's neutrophils. In 1984, the patient was treated surgically in the mandibular arch and teeth # 17, 20, 23, 25 and 26 were extracted due to advanced periodontal disease and a bridge placed from #21 through 28 (Fig. 4). The patient moved from Atlanta from 1985 through February 1987, at which time he appeared for a consultation with the Implant Team at Emory University School of Dentistry. Radiographs again displayed bone loss (Fig. 5), there was some edematous tissue present, and pockets ranged from 2 mm to 5 mm on the mandibular arch. The Implant Team at that time treatment planned the patient for 6 osseointegrated fixtures to be placed on the maxilla and 3 fixtures on the mandibular left. It was decided to make the patient part of a research protocol which addressed itself to what would happen to patients who had a history of GJP and/or RPP and were now treated with osseo-integrated implants. Intraoral examination revealed a plaque score of 75% and a gingival score of 8.3% of all surfaces. The chemotactic defect was still present, and microbiological culture revealed high percentages of Wolinella recta and E. corrodens (Table 1). The patient's laboratory profile (SMA 22) was within normal limits except for slightly elevated triglycéride levels. Clinical preoperative photographs of the patient are shown in Figures 6A-E. The patient was given a course of scaling and, after obtaining clinical gingival health, was appointed for implant surgery. It was felt that antibiotic coverage was not indi-
IMPLANTS IN RAPIDLY PROGRESSIVE PERIODONTITIS
301
Figure 2: Panographic radiograph of the patient, 1978. Selective extractions and periodontal osseous surgery have been performed.
Figure 3: Panographic radiograph of the patient, 1981. Note the dramatic periodontal breakdown seen around tooth numbers 4, 6, and 11.
Figure
4:
Periapical radiographs,
1984. A mandibular fixed prosthesis
has been constructed.
Figure 5: Panographic radiograph, 1987.
J Periodontol
302
MALMSTROM, FRITZ, TIMMIS,
May
VAN DYKE
1990
Table 1: Culture From Periodontal Pocket Tooth #31
Bacteria
% 0.5
