Читать книгу Clinical Cases in Periodontics - Группа авторов - Страница 102

Periodontitis is a debilitating disease that is very prevalent and which can significantly impair quality of life, with the potential to negatively affect multiple systemic conditions. Early diagnosis and treatment has been shown to improve considerably the oral health of patients, and also biomarkers associated with their overall well‐being. This disease is diagnosed based on the clinical signs of inflammation and clinical evidence of periodontal tissue destruction. Radiographs also help to determine the extent of bone loss. According to the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions (https://www.perio.org/2017wwdc) [1], periodontitis has been identified in three distinct forms: periodontitis; periodontitis as a direct manifestation of systemic diseases; and necrotizing periodontitis. This case has focused on periodontitis, since this is the most prevalent form of this disease, and corresponds to what has been previously classified as either chronic or aggressive periodontitis.

Periodontitis is distinguished from gingivitis primarily on the basis of the presence of loss of attachment and resorption of alveolar bone. Therefore, in addition to common signs found in gingivitis, such as redness, swelling, bleeding tendency, and possibly suppuration, the diagnosis of periodontitis requires the presence of periodontal pockets associated with clinical loss of attachment. Alveolar bone loss is also a hallmark of the pathology and can be detected radiographically. It is not uncommon to detect extensive accumulation of dental plaque and calculus, although this can also be found in gingivitis [2]. According to the 2017 World Workshop, the severity and complexity of periodontitis can be categorized into a staging system that ranges from stage I to IV, from the least to the most complex conditions. The distinctions between these stages are clearly provided in the published proceeding of the 2017 World Workshop, and consider parameters such as interdental CAL, bone loss, tooth loss due to periodontitis, PD, furcation involvement, ridge defects, and masticatory dysfunctions. The stage can also be described in terms of its extent and distribution as localized (<30% of teeth involved) or generalized (≥30%), and/or molar/incisor pattern [3]. The extension should be assessed after the stage has been determined, and it should refer to the stage that captures the overall severity and complexity of the case [4]. This classification system also categorizes the case in a grade system based on historical disease progression and risk for potential continuation, including the factors that modify progression of the disease such as diabetes and smoking burden (grade modifiers). In this way the provider and the patient can have a clearer idea of the aggressiveness of the manifestation of periodontal disease, the likelihood of successful outcomes with most modalities of treatment, and the impact of the disease on systemic health. Other than the grade modifiers (smoking and diabetes), the primary factors considered in establishing the grade include direct and indirect evidence of progression, such as longitudinal bone loss or CAL, percentage bone loss/age, and case phenotype (level of destruction proportional to magnitude of local factors, such as biofilm and calculus). The grades are described as A, B or C, in which grade A represents the lowest risk of progression and grade C the highest risk.

Figure 1.6.5 Periodontal chart three months after therapy.

Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

Figure 1.6.6 Clinical presentation of the case one year after therapy.

Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

Based on the criteria established by this current classification, the present case would be diagnosed as periodontitis stage III, localized, grade C. A brief discussion of this diagnosis follows.

 Periodontitis case: periodontitis was defined based on the presence of two or more nonadjacent teeth with CAL >2 mm, associated with bone loss and periodontal pockets. The case is not associated with necrosis of gingival tissues or with rare forms of systemic disease that severely affect periodontal tissues.

 Stage III: most of the teeth present with bone loss extending to the middle of the root, CAL is more than 5 mm for multiple teeth, and more than one site presents with PD >6 mm. However, there is no tooth loss due to periodontitis, neither is any tooth expected to be extracted because of it, and apparently there is no significant need of complex rehabilitation.

 Localized extension: less than 30% of teeth were affected at the stage III level, as the chart and radiographs show. Of the 28 teeth present, eight (28.5%) had CAL >5 mm.Figure 1.6.7 Periodontal chart one year after periodontal therapy.Source: courtesy of Dr. Eduardo Sampaio and Dr. Marcelo Faveri.

  Grade C (rapid rate of progression): percentage bone loss/age was more than 1.0 (50%/43 years).

Although the diagnosis of periodontitis for cases such as the one presented here is straightforward, the determination of cases at the beginning of the disease process and the distinction between severe generalized cases and more aggressive forms of periodontitis is not always easy. The new classification system presents numerous tools to help clarify such distinctions. Such understanding is very valuable in determining prognosis and establishing a treatment plan and guiding the follow‐up on these cases. Although this classification is fairly new, some recent longitudinal data has validated its staging and grading parameters for long‐term prognosis and outcomes following treatment of periodontal patients [5,6]. However, clinical technical issues still exist, especially in the distinction between early signs of periodontitis and more advanced forms of gingivitis, complicated by difficulties in determining initial clinical attachment loss in the absence of clear radiographic evidence of alveolar bone loss, mainly in areas where severe gingival inflammation causes hyperplasia of the gingival margin.

Clinicians should also be careful while distinguishing between patients with periodontitis and those presenting with areas of incidental attachment loss not caused by the bacterial‐induced inflammation characteristic of periodontitis – what is currently described as “reduced periodontium in non‐periodontitis patient” [7]. For instance, isolated sites of gingival recession caused by toothbrush trauma should not be confused as a sign of periodontitis. These lesions are easily distinguishable from recession of the gingival margin as a consequence of periodontitis on the basis of their clinical features. They involve primarily the buccal surface of teeth, with no loss of adjacent interproximal tissue, and are primarily associated with teeth with thin buccal soft tissues such as maxillary canines and premolars – what is described as “periodontal phenotype.” The presence of these isolated lesions is not sufficient for the diagnosis of periodontitis, even though they are associated with attachment and alveolar bone loss. However, if lesions such as these present with CAL ≥3 mm and PD >3 mm in two or more teeth, especially in the context of plaque and gingival inflammation, then the diagnosis of periodontitis would be more likely and therefore recommended [8].

Other common examples of incidental attachment loss lesions include the bone loss associated with restorations invading the biologic width and defects on the distal aspect of second molars caused by the malposition of unerupted or partially erupted third molars. The mesial tipping of teeth can also lead to a clinically deepened sulcus and a radiographic image suggestive of a vertical bone loss. This appearance is the consequence of the apical displacement of the mesial CEJ and should not lead to the erroneous diagnosis of periodontitis. It should be noted, however, that a condition such as this may predispose the site to greater accumulation of plaque, and therefore greater risk of development of any form of periodontal disease. As one can see, there are several circumstances where the early diagnosis of periodontitis can be complicated.

The distinction among more aggressive manifestations of periodontitis, what previously was differentiated as chronic and aggressive periodontitis, can also be difficult. These two conditions have since been understood as one single disease – periodontitis – as no significant evidence could corroborate a distinct etiologic or pathologic process for each of the former [3,9,10]. Such distinctions now are helped by the use of the grading system and among other features aim to find aggressive manifestations, i.e. those that show a faster rate of tissue loss and a greater risk for further progression. However, clinicians rarely have the opportunity to measure rates of disease progression, and therefore indirect measures may assist in this understanding, especially using the percentage bone loss/age formula incorporated in the grading. Although periodontitis can affect individuals of any age, chronological age remains an essential component of the natural progression of periodontitis if left untreated. If a younger individual presents with advanced attachment and bone loss, it is concluded that these subjects are presenting a faster rate of progression.

Although the description of a specific disease called “aggressive periodontitis” is no longer adopted, the classical presentation of several clinical features that made it easily distinguishable, such as age of onset, primarily incisors and firsts molars affected by the disease (including a tendency to manifest infrabony angular defects around these molars), and an overall lack of clinical signs of inflammation and minimal amounts of gross plaque and calculus accumulation despite severe bone loss around the affected teeth is accounted for by the new grading system, especially the grade C pattern.

The treatment of periodontitis as discussed in later chapters depends on the ability of the clinician to remove plaque and calculus from the root surfaces, allowing for proper healing of the gingival tissues, and on the capacity of the patient to perform proper plaque control. These are the cornerstones of periodontal therapy. Although the focus of this case is the diagnosis, but not treatment, of periodontitis, it is important to emphasize that the results obtained with anti‐infective periodontal therapy will determine the long‐term prognosis of the case and the need for additional treatment. Therefore, it is essential that clinicians examine the outcome of the initial therapy before any additional decisions regarding the case can be made, and this reevaluation could be considered part of the diagnostic process.

Studies examining the prognostic ability of periodontal clinical parameters have demonstrated that the presence of plaque, BOP, and suppuration have very low positive predictive values but very high negative predictive values [11,12]. This indicates that sites without clinical signs of inflammation are at very low risk for disease progression and might not require additional therapy. In addition, the accumulation of information regarding the clinical parameters for a given site over time increases the prognostic value of these parameters. Sites with constant BOP have a much higher chance of progression than sites that bleed sporadically [12]. These findings support the notion that any site cleared of periodontitis, but still presenting with PD ≥4 mm and BOP should be carefully monitored during the maintenance phase [7]. It is also well established that the prognosis of periodontitis directly depends on the patient’s ability to control plaque accumulation. A longer follow‐up will afford the clinician a better assessment of the patient’s oral hygiene skills.

The presence of residual pockets after initial therapy, rather than the presence of deep pockets at the initial examination, is associated with an increased risk of future attachment loss [13]. This information is readily available to periodontists and can add great insights into the long‐term prognosis of the case. When clinicians are trying to assess the outcome of their initial periodontal therapy, another key piece of information is how much improvement one can anticipate. In other words, what should be the realistic expectation of a therapist regarding the treatment outcome? This clearly will depend on the severity and extent of the periodontal condition at the beginning of treatment, also understood by the given staging and grading of the case. A few clinical end points for the active phase of periodontal treatment have been recently suggested, such as the presence of at most four sites with PD ≥5 mm [14], absence of sites with PD ≥4 mm and bleeding on probing and <10% of sites with BOP in the mouth [7], and absence of sites with PD ≥5 mm with BOP and no sites with PD ≥6 mm [15]. All these authors have suggested that successful anti‐infective treatment should lead to a minimal number of deep pockets and of sites with BOP in the mouth after treatment.

In addition, several longitudinal studies have been conducted, and guidelines regarding the amount of pocket depth reduction and clinical attachment gains for each initial pocket depth are available and should be used to keep the outcome of treatment in perspective [16,17]. It is unrealistic, for instance, to expect a 9‐mm pocket to convert to a 3‐mm sulcus after SRP. The staging of the case may therefore allow a better understanding of what to expect of the case and what course of action a clinician should take. For example, a case described as periodontitis stage I/II will need anti‐infective therapies, but likely will not need any further treatment if this initial phase is successful. A periodontitis stage III is one where the patient may expect some teeth loss following long‐term care, but is likely to maintain most of the dentition, if not all, if proper anti‐infective treatment and good home care are maintained. However, because of the multiple complexities of such cases, they may benefit from a consultation with a periodontist, and may need adjunctive antimicrobials and periodontal surgery, especially those with a generalized extent. A periodontitis stage IV is one where the patient may expect complete loss of the dentition if appropriate treatment is not timely rendered, or if successful outcomes are not established. These cases would significantly benefit from multidisciplinary treatment, especially a team of professionals with advanced restorative/prosthodontic and periodontal skills. If part of the dentition remains, these cases may also benefit from adjunctive antimicrobials and periodontal surgery. The grading of the case may also help establish expectations and course of action. Especially in cases that have modifiers affecting the grade, such as diabetes and smoking, an integrative approach involving the medical care team in the management of the case would be of benefit to the outcomes of periodontal treatment and the overall health of the patient. Cases without known systemic conditions, but presenting with grade C features, may also benefit from a more careful analysis by such an integrated healthcare team, or at least may need more attention and special care from the dental providers.