Interdisciplinary Treatment Planning in Transitioning a Periodontally Hopeless Dentition: A Clinical Case Review
Bozidar “Bole” Kuljic, DDS
Treating patients with advanced periodontal disease may require staged treatment that utilizes various modalities. In this case report, a patient with a high-risk periodontal condition lacked the financial means to receive optimal treatment immediately. The interdisciplinary team was able to provide a solution that addressed immediate needs and provide stability in the short term by retaining teeth that could be maintained for a limited amount of time until a long-term solution using implant-retained prostheses could be provided.
Decreasing risk in a dentition with advanced periodontal disease presents a great challenge for both dentist and patient. For the patient, confronting the reality of transitioning from a natural, hopeless dentition to a removable prosthesis is likely the greatest oral change he or she will ever experience.1 Psychological distress and functional concerns due to the loss of teeth and the need to adapt to a new and diminished chewing system are compounded by additional challenges, such as a decreased sense of taste and temperature. It is critical that the treating clinician have a thorough and frank discussion with the patient explaining the differences between, the nuances of, and the expectations involved with chewing with natural teeth versus dentures.2 Additionally, a full understanding of the differences between tissue-borne and implant-retained dentures will help patients make an educated choice for their future.
The following case demonstrates a way of staging treatment by using different modalities to treat a patient with advanced periodontal disease. While reducing overall risk and improving the prognosis should always drive treatment decisions, orthodontics and restorative dentistry can provide a means to delay and stage the ultimate loss of periodontally involved teeth and provide acceptable interim outcomes.3
Clinical Case Review
Patient History and Chief Complaint
A 54-year-old woman presented with a chief complaint that she was unable to eat properly. She added that she was self-conscious of her upper teeth because they were shifting and moving, and was also concerned about a missing front tooth in her lower jaw (Figure 1 through Figure 3). As an employee at a local grocery store, she had a limited discretionary income. Throughout her life, she had irregular dental visits that were usually prompted by pain and often resulted in extraction.
The patient had been to the practice 1 year earlier to treat pain in tooth No. 21. The tooth was treated with root canal therapy, a core build-up, and a full-coverage crown. At the time, the patient was informed she had advanced periodontal disease and was advised to schedule a comprehensive treatment plan appointment to address the hopeless prognosis of numerous teeth (Figure 4 through Figure 6). She appeared to understand and stated that she was not surprised by the diagnosis; however, she did not return to the practice until 1 year later.
The patient was otherwise healthy without any medical conditions or contraindication to dental care, so her medical risk was deemed low and the prognosis good.
Diagnosis, Risk Assessment, and Prognosis
Periodontal: The examination revealed severe bleeding upon probing throughout the patient’s dentition. Probing depths were in the range of 5 mm to 8 mm around teeth Nos. 7 through 10 and 30. Radiographic bone loss greater than 4 mm existed throughout the mouth, with intrabony defects found on teeth Nos. 7 through 10, 28, and 30. Teeth Nos. 7 through 10 had Class 3 mobility, while teeth Nos. 6, 24, 28, and 30 exhibited Class 1 mobility. Gingival recession of more than 2 mm was noted on teeth Nos. 6 through 8, 11, 20, 22, 24, 28, and 30.
Prognosis: Poor, with teeth Nos. 7 through 10 and 30 hopeless
Biomechanical: Upon clinical examination, two acceptable amalgam restorations were found. The filling on tooth No. 28 had a small overhang, while tooth No. 30 had an extensive amalgam restoration that compromised the structural integrity of the tooth. There was no indication of active caries.
Functional: The patient had minimal attrition. Secondary occlusal traumatism was noted on teeth Nos. 22, 24, and 28. Clinical examination revealed the presence of a unilateral click on the right side upon opening. Due to the absence of the posterior teeth, the patient had developed a collapsed bite with a loss of vertical dimension (Figure 7). The initial diagnosis was occlusal dysfunction.
Dentofacial: In repose, teeth Nos. 7 and 8 were labially positioned in comparison to the adjacent teeth (Figure 8). The upper lip was found to have medium dynamics, whereas the lower lip exhibited high dynamics.
Risk: Medium to High