Читать книгу Clinical Cases in Periodontics - Группа авторов - Страница 105

A. Incidental loss of attachment associated with mechanical trauma has distinct clinical features that make it clearly distinguishable from infection/inflammation‐induced attachment loss. It tends to be circumscribed to buccal surfaces, particularly in areas of a very thin soft tissue, and the neighboring papilla present normal height. The tissue surrounding the recession has a very healthy appearance, and it is not uncommon to have toothbrush abrasion associated with the gingival recession. The collapse of gingival tissues on buccal surfaces can also be associated with marginal gingival inflammation, but in this case the presence of plaque and calculus is not an uncommon finding and the tissues surrounding the gingival recession tend to show clinical signs of inflammation.

B. The distinction between the two diagnoses can be difficult at times. The differences are typically determined by the age of onset, rate of progression, and the patterns of bone loss. In general, periodontitis starts at age 30–35 years and progresses in random bursts in different sites throughout life. If the disease presents in younger patients or can be documented to have occurred in a short period, it tends to be classified as of more aggressive nature, increasing the grading of the case for periodontitis, or considering the possibility of a systemic disease that may have major impact on periodontal tissues. Both forms of periodontitis can occur in a localized or generalized pattern. Familial aggregation is one of the features of many forms of aggressive patterns of periodontitis; therefore, if this is suspected, the clinician should inquire about the periodontal status of close relatives or suggest they receive an oral examination. Many common chronic diseases, such as diabetes, may affect the course of periodontitis, or at least are intrinsically associated with it, but do not necessarily have a distinguishable phenotype, and thus the diagnosis still is of periodontitis. However, a careful review of the medical history is imperative, including referral for further evaluations or consultations for any systemic comorbidities, including rare medical disorders that may have major impact on the periodontal tissues. Those medical evaluations should confirm the periodontal diagnosis and direct the treatment plan. Because of the much higher prevalence of periodontitis compared with other aggressive forms associated with rare systemic diseases, this will be the most prevalent diagnosis, but the potential for the latter should not be dismissed [18].

C. Although it is not the intent here to address therapy, which is discussed extensively in other chapters of the book, the relevance of the distinction between different aggressive forms of periodontitis, especially considering the grading system of the new classification, depends on the assumption that these clinical forms of the disease would require specific types of treatment. Classical literature has indicated that subjects with different aggressive forms of periodontitis (aggressive forms compared to “chronic periodontitis” in previous classifications) with comparable extent and severity of the conditions tend to respond similarly to periodontal therapy [19]. This would imply that the prognosis of the case would depend more on the extent and severity (staging) of the periodontal disease, and also the progression and risk factors associated with it (grading). Therefore, the new classification system could be helpful in establishing different treatment protocols according to the combination of the findings already discussed. A general dentist should be especially mindful in consulting a periodontist whenever the diagnosis reaches stage III or grade B, and potentially other dental and healthcare providers the diagnosis reaches stage IV or grade C, or if the case presents with other signs of potential aggressiveness or major complexity.

D. In these circumstances, the clinician should confirm the grading of the case, ruling out any systemic causes for the disease (risk factors such as smoking or uncontrolled diabetes, immunocompromise, endocrine disorders, or syndromes). The next thing to check is the efficiency of the patient’s plaque control. This can be easily ascertained by the gingival and plaque indices. In the presence of large amounts of plaque, reinfection of pockets occurs fast and healing is compromised. Once the level of oral hygiene of the patient has been assessed, provided it was not the problem, the next steps will depend greatly on the level of periodontal training of the therapist. If the clinician is an experienced periodontist, the chances are that therapy was properly executed and there is very little room for improvement. The clinician might be dealing with a rare case of refractory periodontitis, where the subject does not respond to conventional therapy. The next step would be to consider adjunctive or complementary approaches such as systemic antibiotics and/or periodontal surgery. If a less experienced clinician is involved, the fair assumption is there was failure in calculus removal to a level compatible with resolution of the periodontal condition. Particularly for severe generalized forms (higher staging) of the disease this should not be a surprise because subgingival debridement of deep pockets is not an easy task and requires highly skilled and well‐trained individuals. Residual pockets should be carefully reinstrumented, and this step should involve as many sessions as needed. A new period of three months of healing should be given before an assessment of the outcome of this new cycle of SRP is conducted. Clinicians should keep in mind that there is very little risk to the patient in delaying a possible surgical phase of treatment to make every effort to guarantee an optimal outcome of the anti‐infective therapy.

E. Although the presence of residual pockets has been demonstrated as a good predictor of future attachment loss [20], clinicians should interpret this information with caution. Several other clinical aspects will impact the prognosis of the case. such as the level of plaque control by the subject, the presence of BOP, and the presence of furcation defects. Further, one must keep in mind that periodontal surgical procedures involve nonaffected periodontally diseased sites adjacent to residual pockets. If residual pockets are isolated nonbleeding lesions, they present a very low risk of progression and can be easily addressed with SRP during supportive periodontal therapy. Conversely, if residual pockets cluster around a few adjacent teeth and BOP is a recurrent finding over several sessions of maintenance, a surgical approach seems adequate. Periodontal surgery in the absence of proper plaque control exposes the periodontal patient to the risk of accelerated attachment loss [21] and should be avoided at all costs.