Perio Contest 2018/ 19 April 2018/

Case 43 | Perio Contest 2018 | Russia

Dr Catherine Kuletskaya

Generalized severe chronic periodontitis second to diabetes mellitus – Dr. Kate Kuletskaya, Russian Federation

Case description

The following is a case that involves the multidisciplinary approach with significant periodontal component.

06.04.2015
A 73-year-old woman was referred by the general dentist to the Department of Periodontology at Moscow State University of Medicine and Dentistry (MSUMD) with complaints on loose teeth, oral malodor, bleeding during toothbrushing and presence of gingival suppuration in the mandibular anterior region during palpation.

The patient noticed some discomfort and periodic bleeding when brushing over the last 1-2 years. Therefore she was advised to use Lacalut Active or Parodontax toothpaste for short periods of time. She began to notice her teeth were shifting about 6 month ago. Periodontal treatment was never performed before.

Medical history
The patient was asked to complete a health questionnaire (“yes or no” format), in which she noted the presence of type 2 diabetes mellitus (DM) and hypertension. She is 159 cm tall and weighs 61 kg, her body mass index (BMI) is 24,13.
The patient was diagnosed with the type 2 diabetes 10 years ago. At that time her HbA1c was 7,5%. Familial tendency wasn’t revealed. At first she took metformin for 2 years, and now it’s been 7 years since she takes the combination of Metformin 1000/Sitagliptin 50 mg once a day in the morning. She is under the care of a physician, her HbA1c is 6,4%, representing improved metabolic control.
To correct the high blood pressure 160/90 she takes Edarby (ARBs, azilsartan) 40 mg once a day. At this time her pressure is 130/80.
She doesn’t have any allergy and is a nonsmoker.

Dental history
The last dental visit was 2 weeks ago to another clinic, where supragingival calculus deposits were removed. The patient had a regular dental follow-up every 6 month in the past five years. The oral hygiene regimen included toothbrushing with a manual toothbrush, twice a day.
There were no significant findings on the extraoral examination. Muscles of mastication and facial expression were all within normal limits. The function of the temporomandibular joints was within normal limits. The intraoral examination (Figure 1) of the soft tissues, including the tongue, floor of the mouth, hard and soft palate and buccal mucosa, did not reveal any abnormalities. The oral cancer screen was negative.
Presence of plaque was diagnosed on the lingual surface of the lower anterior teeth, subgingival calculus was present throughout.
The patient was partially edentulous, missing teeth: 15, 14, 24, 25, 37 and 47. Diastemas were present between the maxillary incisors. The maxillary and mandibular incisors displayed extrusion, rotation and facial flaring (Figure 1). Porcelain bridges on teeth: 13 -16, 23- 26 and ceramic crown on mandibule first left molar were installed more then 15 years ago. Crowns demonstrated poor margins, gingival recession exposing the crown margins but without secondary caries.
Endodontically treated teeth: 23, 32 and 41.
Caries or endodontic lesions.
No carious lesions were observed. The mandibular left first molar demonstrated the endodontic-periodontal lesion.
Occlusal relationships.
The canine relationship was Class I (right side) and Class II (left side) Angle’s classification. The occlusal scheme observed was anterior guidance in protrusion and group function on lateral movements. Premature contacts were observed on the teeth: 41 and 43. The tooth 17 is severe extruded from the upper dental arch.

Periodontal examination
To assess the extent of the periodontal disease, a full periodontal examination was accomplished. The examination included pocket probing and evaluation of gingival recession, furcation involvement and tooth mobility (Figure 1-3).

Clinical signs of periodontal inflammation: the gingiva was cyanotic, bluish red, swelling, bleeding on probing, by texture it was smooth and shiny. Suppuration was observed when probing of periodontal pockets of teeth 32-43 and tooth 36. Periodontal pockets ranged from 4 to 9 mm. The majority of the anterior teeth presented with recession that measured 2 mm.
Determination of the degree of teeth mobility.
The maxillary second right molar presented with grade-three mobility. Other teeth demonstrated grade-one: 13,11,21,22,32,42,43,46 and grade-two: 12, 36, 31, 41 mobility.
The degree of furcation involvement (Hump et al. 1975)
The maxillary first molars demonstrated class 2 furcation involvement; the mandibular right and left first molars had class 3 and class 2 furcation involvement, respectively.

Plaque control history:
The patient used a medium brush twice a day, standart technique without any adjunctive devices.

Radiographic examination:
The panoramic radiograph (30.03.2015) presented generalized severe horizontal alveolar bone loss was verified by a radiographic examination (>50% the root length). The mandibular first molars presented mesial angular bone defect and furcation involvement. Extensive vertical bone defects were diagnosed at teeth 36 and 43 as well. Loss of cortical density and alterations in the trabecular pattern of bone were observed (Fifure 1-4).

Diagnosis:
Generalized severe chronic periodontitis second to diabetes mellitus. Partial edentulism, chronic apical periodontitis of tooth 36.
Diabetes mellitus-associated periodontitis, (AAP/EAP classification, 1999).

The goals of periodontal treatment were to preserve the natural dentition, to improve periodontal health, to eliminate occlusive trauma, to improve comfort, esthetics and function, considering systemic factors and the age of the patient. Thus, the aim of our intervention was to enhance the quality of life of the patient.

Scientific rationale for the treatment plan:
1) Diabetes and periodontitis are chronic noncommunicable diseases with a bidirectional relationship (Consensus reports and guidelines of EFP/ IDF workshop in 2017 and EFP/AAP workshop in 2012).
2) Elevated levels of proinflammatory mediators in poorly controlled diabetes of people with diabetes play a role in the observed increased periodontal destruction (Polak & Shapira, 2017).
3) Periodontal therapy may improve serum HbA1C levels in patients with diabetes (Polak & Shapira, 2017).
4) The strategy of One-Stage Full-Mouth Debridement was chosen to prevent the crosscontamination of adjacent areas (Quirynen et al. 2006).

Treatment plan:
I Initial therapy
1) Motivation and instruction in oral hygiene measures.
2) Scaling and root planing under the antibiotic coverage.
3) Diagnostic testing:
• Microbial analysis of samples obtained from a patient’s periodontal pockets.
• Biochemical assessment (HbA1c, Vitamin D25OH, Ca total and ionized, PTH)
4) Extraction of the tooth 17.
5) Therapist consultation.
6) Orthodontist consultation.
II Second evaluation of periodontal status after the nonsurgical stage of therapy
1) Nonsurgical treatment of residual pockets.
2) Correction of individual oral hygiene.
III Orthodontic treatment
IV Endodontic treatment of the teeth 21, 31 and 36 endodontic retreatment of the teeth 32 and 41
V Retention of the results of orthodontic treatment by splinting of the mobile teeth.
VI Orthopedic consultation treatment.
VII Restorative treatment.
VII Final assessment of periodontal status.
IX Periodontal maintenance phase.

Initial therapy
Oral hygiene instruction comprised recommendations on using soft
toothbrush (the Bass tooth brushing method), interdental tooth brushes and irrigator.

Microbiological testing was carried out at the Department of Microbiology of MSUMD. The following results were obtained in two weeks (20.04.2015):

Representatives of parodontopathogenic flora: α- and β-hemolytic streptococci in association with parodontopathogenic species – Aggregatibacter Actinomycetemcomitans in an insignificant amount sensitive to penicillins, fluoroquinolones and tetracyclines of a wide spectrum of action.

Recommendations (options to choose from):
1. Avelox (Moxifloxacin) 400mg once a day for 7 days;
2. Doxycycline 1 capsule – 100 mg for 7 days. On the 1st day of treatment, a daily dose of 200 mg (once). In the following days – 100 mg per day.
3. Amoxiclav 625 mg 1 tablet 2 times a day for 7 days.

20.04.2015
According to the obtained results and scientific evidence the course of Amoxiclav was prescribed: 625 mg two times daily for 7 days.

The mouthrinse for local use at home: 0,2% solution of Chlorhexidini 4 times daily for 14 days.

Initial therapy
22.04.15- 23.04.15.
Full mouse debridement was performed on the 3rd and 4th days of taking antibiotics within the period of 24 hours. The strategy of One-Stage Full-Mouth Debridement was chosen to prevent the crosscontamination of adjacent areas (Quirynen et al. 2006).

Ultrasonic debridement (EMS Piezon Master 600) was followed by hand scaling and root planing (Depeller Gracey curets) of all teeth surfaces.
The first appointment was scheduled for 16 p.m. on April 22, when all the teeth on the lower jaw were cleaned. Next visit took place at 10 a.m. on April 23: all the teeth were cleaned on the upper jaw.

Recommendations: In case of temporal dentin hypersensitivity to brush with toothpaste for sensitive teeth, if symptoms persist, notify the dentist.
One week later the tooth 17 was extracted.

Second evaluation of periodontal status (03.06.2015)

The periodontal reevaluation was carried out within 6 weeks after initial periodontal therapy (scaling/root planing). The patient’s compliance was excellent. Her motivation remained stable and consistent. A new periodontal chart reveals an important reduction in probing pocket depth and reduced number of sites with bleeding on probing (Figure 2-1).

Scaling and root planning was performed in areas where pocket probing depth of 5 mm or more remained. Favorable response to the nonsurgical phase permitted the initiation of the orthodontic therapy.

Orthodontic treatment (08.2015- 06.2016)

The orthodontist was asked to assess the possibility of orthodontic treatment in the anterior region to restore a normal occlusal plane and thus reestablish the contacts. Orthodontic plates were used for this purpose. The total duration of the orthodontic therapy was 11 months. Only light orthodontic forces were applied (Figure 3).
During the orthodontic therapy phase, the patient was seen every 2-3 months for periodontal evaluation.

Endodontic treatment of the teeth 21, 31 and 36 endodontic retreatment of the teeth 32 and 41 (07.2016).
Splinting of the mobile teeth (07.2016)
Maxillary anterior teeth were splinted from lateral incisor to lateral incisor. In the mandible all teeth were splinted.

Prosthetic treatment (10 – 11.2016)
Restorative treatment (12.2016)
Final assessment of periodontal status (11.2017)

One year after the end of restorative treatment, a new periodontal recording was obtained. The result of these examinations presented a stable and healthy periodontal status (Figure 4)

Periodontal maintenance therapy

Maintenance visits were scheduled at regular intervals varying between 3 and 4 months and included hygiene control, probing and prophylaxis.
During the each maintenance visit, all teeth were polished with Airflow Perio Plus powder. In addition, the teeth were fluoridated topically with Duraphat® varnish.

High-quality performance of Scaling & Root planing with continuous maintenance therapy has made it possible to achieve an excellent result in treatment of patient with chronic periodontitis second to type two diabetes.

References

1. Chapple, I. L. C., & Genco, R. (2013). Diabetes and periodontal diseases: Consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. Journal of Clinical Periodontology, 40(Suppl. 14), 106–112.

2. Polak, D., & Shapira, L. (2017). An update of the evidence for pathogenic mechanisms that may link periodontitis and diabetes. Journal of Clinical Periodontology, https://doi.org/10.1111/jcpe.12803.

3. Sanz M, Ceriello A, Buysschaert M, et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. J Clin Periodontol. 2018;45:138– 149.

4. Quirynen M, De Soete M, Boschmans G, Pauwels M, Coucke W, Teughels W, van Steenberghe D. Benefit of ”one-stage, full-mouth disinfection” is explained by disinfection and root planing within 24 hours: a randomized controlled trial. J Clin. Periodontol 2006; 33: 639–647.

Figure 1-1. Facial view of the teeth before treatment. Periodontal disease with pathologic migration of the anterior teeth.

Figure 1-2. Facial view of the teeth. Initial situation. The gingiva looks cyanotic and swollen.

Figure 1-3. Periodontal Chart. Initial situation.

Figure 1-4. A panoramic radiograph. Initial situation.

Figure 2-1. Periodontal Chart. Reevaluation (six weeks after the initial therapy). Favorable response to the nonsurgical phase permitted the initiation of the orthodontic therapy.