Clinical Success in Management of Advanced Periodontitis (eBook)

Severity Criteria

Periodontal disease is an inflammatory disease caused by a bacterial infection. It is characterized by a progressive destruction of the dental attachment tissues. Left untreated, it may lead to complete loss of dental attachment structures and subsequently loss of teeth.

The primary objective of treatment is to arrest the progressive destruction of periodontal tissue and thus to arrest loss of attachment structures. However, the infectious process involved in periodontal disease is complex. Host susceptibility and the presence of pathogenic bacterial species, whether exogenous or commensal, interact and either promote or hinder the progression of the disease. Simultaneously, numerous local or environmental factors exert an influence on the etiologic agents and the course of disease. Because of its multifactorial nature, periodontal disease is difficult to manage. In formulating treatment strategies, both the patient’s periodontal susceptibility and the amount of periodontal destruction need to be taken into account. Repair and regeneration have become realistic objectives in the current context of periodontal therapeutics. For this reason, a methodic assessment of severity factors is a crucial step in treatment planning.

Severe periodontal disease is characterized by:

• Destruction of periodontal attachment tissue exceeding one third of the root’s length

• Class II or III furcation invasion

• Probing depths exceeding 6 mm

• Attachment loss exceeding 4 mm

Some teeth have already been lost or are unlikely to be maintained. The indication of prosthetic restorations for the replacement of missing teeth denotes the irreversible aspect of treatment in the periodontal patient. However, prosthetic rehabilitation may seem a risky endeavor in the context of uncontrolled periodontal disease. This raises several questions concerning both the disease itself and the global treatment strategy:

• Is infection control possible in all forms of periodontitis?

• Are there severity factors? How can they be detected? Can they be eliminated?

• What are the risk factors?

• What would be the best treatment strategy?

• To what extent can a conservative approach be applied?

• What are the different criteria that indicate the decision to extract?

• When should the decision to extract be made?

• What is the prognosis for the remaining teeth?

• Is it possible to place implants in the context of advanced periodontal disease?

• Should we carry out periodontal treatments less often and place implants more often?

• What are the optimal conditions for successful therapy?

In the 1990s, the strategy consisting of root debridement with scaling and planing with or without surgical techniques and followed by periodontal maintenance every 3 to 6 months was considered the best treatment for the majority of periodontal diseases (Goodson 1994). However, the so-called refractory forms emerged; these were characterized by poor response to treatment (Figs 1-1a and 1-1b). In these specific cases, antibiotic therapy was recommended. Since then, however, progress in microbiologic knowledge no longer limits the use of antibiotic therapy to the refractory forms of periodontal disease. Taken together, these elements demonstrate the need for a sound understanding of the complex microbiology of periodontal disease in clinical practice.

A better understanding of the etiology and pathogenesis of periodontal diseases has allowed for the development of new guidelines for management and treatment; this represents a major step toward carrying out treatment strategies better suited to individual patients. An increasingly specific approach, taking into account factors such as patient susceptibility, features of periodontal infection, and individual severity factors, will no doubt lead to a reduction of the number of refractory forms and lay out a clinical context favorable to tissue response.

The American Academy of Periodontology’s 2000 classification now serves as a reference. Periodontal disease treatments should be carried out in accordance with the diagnostic criteria specified in this classification. Advanced periodontitis is most often observed in younger patients, though it does not represent a distinct clinical subset; it is observed in chronic and aggressive forms of periodontal disease, both of which represent the principal subunits of the new classification. In the case of chronic periodontitis, treatment is relatively straightforward: the infection is characterized by a significant amount of plaque buildup and features a predominant commensal bacterial population with local aggravating factors. In the case of aggressive periodontitis, a more specific protocol must take into account the involvement of a more complex bacterial flora, specific patient susceptibility factors, and additional risk factors. Here again, formulating a precise diagnosis is a crucial step in patient management.

Defining treatment success in periodontal practice represents a difficult task. It implies both complete elimination of infectious processes and associated inflammation as well as durable prevention of recurrence in all previously pathologic periodontal sites. Infection control is the key to success, though it is the aspect of treatment that is most difficult to accomplish. The ultimate goal is durable restoration, both esthetic and functional, while attempting to avoid the use of partial dentures.

Currently, there is a strong incentive toward the application of evidence-based solutions and techniques. However, statistical analysis is more difficult to carry out in the clinical setting than in the context of pure research. Clinical practice can therefore demonstrate its efficacy and ultimately point out elements of scientific truth through interpretation of scientific information.

Among these indicators of clinical proof are the following:

• Continuous, progressive loss of periodontal support is a significant and undesirable clinical proof.

• Durable elimination of clinical signs of inflammation and long-term maintenance of periodontal support structures are significant positive clinical proofs.

• Attachment gain and reduced probing depths are significant, ideal clinical parameters that indicate long-term clinical success.

Prevalence of Periodontal Disease

Periodontal disease predominantly affects the adult population. The overall prevalence of periodontitis is high. According to some authors, 90% of the general population have signs of periodontitis and 50% of individuals aged 15 to 19 years have at least one periodontal pocket (Waerhaug 1975; Sheiham 1978). An analysis of the natural history of the disease is informative and shows that there are several periodontal disease subtypes.

A first longitudinal study, carried out in a tea-picking community of Sri Lanka (Loë et al 1986), studied a group of individuals who were relatively well isolated from dental care over a period of 15 years. At the end of the study, the authors defined three groups:

• The first group represented 8% of all studied individuals and was characterized by the presence of a rapidly progressing form of periodontal disease. Approximately 20 teeth had been lost for periodontal reasons before the age of 40 years, and all teeth were generally lost at the age of 45 years (Figs 1-2a and 1-2b).

• The second group represented 81% of all studied individuals; this group featured a moderate form of periodontitis and an average of 7 teeth lost for periodontal reasons at age 45 years (Figs 1-3a and 1-3b).

• The third group represented 11% of the study group and was characterized by the absence of periodontitis; no teeth were lost to periodontal disease, and despite the presence of gingivitis, no evidence of periodontal destruction was observed (Figs 1-4a and 1-4b).

The results of this study were confirmed in other population groups. This distribution is considered valid in various populations, regardless of geographic localization.

In Western Europe, a study of nonedentulous individuals aged 45 to 54 years showed that 36% presented with a severe form of periodontitis, 31.9% had a moderate form of periodontal disease, and 32% presented no signs or symptoms of periodontal destruction (Ainamo et al 1982). It is noteworthy that edentulous cases were not taken into account. In France, according to a study by the Institut National de la Santé et de la Recherche Médicale (INSERM), 90% of the general population presents with various degrees of periodontal pathology (INSERM 1999).

In Sweden, 13% of individuals examined in 1973 and reexamined between 1988 and...