Diagnosis, Treatment and Maintenance of a Heavy Smoking ... · Diagnosis, Treatment and Maintenance of a Heavy Smoking Patient with Chronic Periodontitis – a Case Presentation Maria

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CASE REPORT

A 55-year-old patient was referred to the clinic inthe Department of Periodontology and FixedProsthodontics, University of Berne, Switzerland.The treatment plan suggested by the referring den-tist foresaw the incorporation of a removable par-tial denture in the maxilla in order to replace themissing teeth. The patient’s wish, however, was tobe treated for his periodontal problems and tohave the gaps in the lateral regions of the upperand lower arches closed by means of a fixed re-construction (Figs. 1a, b and Figs. 2a, b).

Medical History

The patient was healthy and did not take any med-ications. However, he was a heavy smoker havingsmoked one to two packs of cigarettes a day forthe past 30 years (at least 40 pack-years). He wasa journalist and as such was not willing to reduceor quit his smoking habits because of work-relatedstress. Also, he habitually drank 5 to 6 cups of cof-fee a day.

Dental History

The patient had been previously treated for peri-odontal disease in 1997, but without any surgicalinterventions. In the following three years, he hadbeen in recall every 4 months for supportive peri-odontal care. Hence, his most recent tooth clean-ing had been performed four months before his at-tendance at the clinic. The referring dentist had no-ticed a slow progression of periodontitis despitethe maintenance program instituted. He then in-formed the patient about the possibility of an an-tibiotic therapy and referred him to the clinic. Oneweek before he came to the clinic he had his lastvisit with the referring dentist where tooth 17 wasextracted for endodontic reasons. Subsequently,the patient complained about impaired chewingfunction, especially after the extraction of tooth 17.The other missing teeth also had been lost becauseof endodontic and periodontal problems.

Oral Hygiene

The patient indicated that he cleaned his teethtwice a day for 2 minutes with an electric tooth-brush and occasionally used dental floss for the in-terdental spaces (Figs. 3a, b).

Diagnosis, Treatment and Maintenance of aHeavy Smoking Patient with ChronicPeriodontitis – a Case Presentation

Maria Kandylaki, Niklaus P. Lang

This case presentation illustrates the systematic treatment and follow-up of a 55-year-old heavysmoker with advanced chronic periodontitis. The goal of the treatment was to arrest the progres-sion of periodontitis and the restitute of normal function by reconstructing the occlusion. After theinitial phase of treatment a surgical phase with hemisections and extractions of teeth was per-formed. The fixed prosthetic rehabilitation of the case was implemented without the use of dentalimplants. Patient follow-up was documented for two years after completion of therapy.

Key words: chronic periodontitis, furcation treatment, smoking, maintenance

Examination

Extraoral Examination

No abnormalities such as indurations, ulcerationsor tumors were detected extraorally.

Intraoral Examination

Similarly, no pathological findings were diagnosedon the oral mucosa, the tongue and the sublingualmucosal area. The salivary secretion rate ap-peared high and the saliva was very serous.

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Kandylaki and Lang · Diagnosis, Treatment and Maintenance of a Heavy Smoking Patient with Chronic Periodontitis

Figs. 2a, b The missing teeth on the lateral sides caused impaired chewing function.

Fig. 1a 55-year-old patient with a low smile line andsatisfied with his esthetics.

Fig. 1b The patient is a heavy smoker. There were littlesigns of inflammation on the gingiva.

Figs. 3a, b Staining and abrasions may be seen on the intra-oral views of the upper and lower arches.

a b

a b

a b

Dental Examination

The patient had a dentition with 23 teeth. In the up-per jaw, teeth 18, 17, 24, 26, 27 and 28 weremissing. In the lower jaw, teeth 36, 46 and 48were missing. Teeth 16, 15, 22 and 25 had beentreated endodontically. All other teeth respondedpositively to the vitality test with compressed CO2.Teeth 16, 25, 35, 37 and 38 had amalgam fill-ings. Secondary caries was found at teeth 37 and38. Composite fillings were present on 12, 13,14, 23, 44 and 47, respectively. The distal as-

pect of tooth 23 had an initial carious lesion. Agold crown was present on tooth 15 and a porce-lain crown on tooth 22 (Figs. 4a, 4b and Fig. 5).

Periodontal Screening

The basic periodontal screening examination (BPE)(Table1) revealed a Code of 4 in all sextants ex-cept for the upper left lateral sextant where a Codeof 3 was recorded. Furcation involvements of all re-maining molars were marked with an asterisk(Table 2)

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Figs 4a, b The amount of occlusal wear because of the loss of posterior support and bruxism was remarkable. Oldrestorations were present on the upper and lower arches.

Fig. 5 Clinical dental ex-amination and tooth vitality.

a b

Table 2

On the basis of the BPE it was decided to performa comprehensive periodontal charting and to ob-tain a full mouth set of periapical radiographs.

Periodontal ExaminationThere were only moderate signs of inflammation inthe gingival tissues. The periodontal chart showedprobing pocket depths (PPD) up to 8 mm (Fig. 6).Teeth 16 and 37 had trough and trough furcationinvolvements (Grade 3, per Hamp et al, 1975Classification). Teeth 14, 47 and 28 had grade 1furcation involvements. Tooth mobility was grade 1

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Fig. 6 Initial periodontal chart. The prob-ing pocket depths ≥ 4mm are marked inred color. The open circles represent thestart of a furcation involvement (< 3 mm).The black circles (•) represent a furcationinvolvement of ≥ 3 mm.

Score 0: Probing depth ≤ 3 mm, absence of cal-culus, absence of overhanging recon-structions, absence of bleeding on prob-ing

Score 1: Probing depth ≤ 3 mm, absence of cal-culus, absence of overhanging recon-structions, but bleeding on probing

Score 2: Probing depth ≤ 3 mm, presence of cal-culus and/or presence of overhangingreconstructions, bleeding on probing

Score 3: Probing depth >3 mm – 5 mmScore 4: Probing depth > 5 mm* : Furcation involvement, mobility, mucogingival prob-lems, recessions

Table 1 The Basic Periodontal Examination (BPE)Measurements are made at two sites (mesial, distal) pertooth with a graduated periodontal probe (3, 5, 7, 10mm) at a pressure of 0.25 N. The highest score in eachsextant is noted.

4* 4 3

4* 4 4*

(Ramfjord and Ash, 1979) for teeth 16, 14 and37. Tooth 15 had grade 2 mobility. The bleedingon probing (BOP) percentage was 64% and thePlaque Control Record index was 61% (O’Leary etal, 1972).

Radiological ExaminationThe radiological examination showed that tooth48 was impacted (Fig. 7). The endodontic treat-ments at teeth 16, 15, 12 and 15 were incom-plete. There was a generalized horizontal boneloss and angular bony defects at teeth 14 (distally)and 23 (mesially).

Functional Analysis

The screening test for functional disturbances(Shore, 1959; Jenni, 1988) revealed that the pa-

tient had no pain or discomfort in the temporo-mandibular joints or related structures. The maximalopening of the mouth was 55 mm. The overbiteand the overjet were within normal range. The pa-tient had a neutral class I on both sides. There wereno prematurities in centric relation and consequent-ly no ‘slide in centric’. The working side yielded agroup function on both sides. The patient admittedto chewing his pencils while working. The occlusalsurfaces of the teeth showed marked abrasions be-cause of the bruxism and loss of posterior support.

Diagnosis

Due to the findings of the examination the patientwas classified to have ‘generalized chronic peri-odontitis with furcation involvement’ (Armitage etal, 1999). Other diagnoses included caries at

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Fig. 7 Initial radiographic examination. Tooth 48 is impacted.

9.11.00 26.10.00 26.10.00 29.8.00 29.8.00

26.10.00 26.10.00 29.8.00 26.10.00 26.10.00

29.8.00 29.8.00

teeth 23, 37, 38, incomplete endodontic treat-ments at teeth 16, 15, 12, 25, and parafunctionand loss of posterior support.

Etiology

Obviously, the primary etiological factors consistedof supra- and subgingival plaque and calculus. Thepatient’s smoking habit was considered as a mod-ifying factor. Caries and defective fillings were con-tributing as secondary etiological factors.

Prognosis

A pre-therapeutic single-tooth prognosis (Table 3)was established. Based on the periodontal, en-dodontic and functional status every tooth was

evaluated and attributed to one of the followingcategories: teeth with secure prognosis, doubtfulprognosis, and teeth irrational to treat. Teeth thatcould be maintained without major therapeutic ef-forts were considered in the first category. Teeththat required major therapeutic efforts were includ-ed in the second category. The final category in-cluded teeth considered to be irrational to treatand where extraction was the only logical treat-ment option.

Pre-therapeutic Prognosis for Single TeethTooth 48 was classified as being ‘irrational totreat’. Teeth 16, 15, 14, 22, 23, 25, 47, 37 and38 were given a doubtful prognosis because of furcation involvements, angular bony defects and/or incomplete root canal fillings. The remainingteeth were considered to have a secure prognosis (Table 4).

Treatment PrognosisThe patient was interested in having periodontaltreatment and appeared to be very motivated.Unfortunately, despite prompting, he did not evenappear to want to consider a reduction in his smok-ing habits. The periodontal situation of teeth 16and 37 and their response to therapy was, there-fore, crucial from a prosthetic point of view.Because of his heavy smoking habit the use of den-tal implants appeared risky. Assuming good com-pliance and collaboration, the prognosis for the re-mainder of the dentition appeared good.

Treatment Planning

The treatment plan consisted of four phases:1. Systemic phase 2. Hygiene phase3. Corrective phase 3.1. Surgical interventions3.2. Reconstructive interventions4. Maintenance phase.

In the systemic phase, there was no need for furtherexaminations of the patient’s medical condition.Smoking counseling had been planned. The pa-tient was also to be informed about the effects ofhis smoking on the treatment outcome and the risksin case of implant placement. A testing of the IL-1gene complex polymorphism status was considered

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Teeth irrational to treatPeriodontal criteria• Attachment loss to the apex• Perio-endodontal lesions• Repeated periodontal abscesses

Endodontal criteria• ‘fausse route’ in the apical portion of the root

Dental criteria• Vertical root fractures• Fracture in the middle third of the root• Caries in the root canal• Functional reason (third molars without antago-

nists, etc.)

Teeth with doubtful prognosisPeriodontal criteria• Furcation involvement• Infrabony defects• Horizontal loss > 2/3 of the root

Endodontal criteria• Incomplete endodontic treatment• Periapical lesion• Big screw/post in the canal

Dental criteria• Deep root caries

Table 3 Classifying criteria for the pre-therapeutic sin-gle-tooth prognosis

in case of implant therapy (Feloutzis et al, 2003).The plan for the hygiene phase consisted of moti-vation, instruction in the Bass technique and of theuse of interdental brushes. Debridement of all teethunder local anesthesia (scaling and root planing)was to be performed in a systematic way.Provisional fillings were planned for teeth 37 and38. The loss of periodontal support was compati-ble with the age of the patient, the oral hygieneand his smoking history. Hence, no microbial test-ing was planned before or after the hygiene phaseand no use of antibiotics was considered. The re-evaluation was planned to take place 8 weeks af-ter the completion of the hygiene phase. In the corrective phase additional therapy was an-ticipated. Two main treatment options were con-sidered, namely: tooth-supported or implant-sup-ported reconstructions (especially in the secondand in the fourth quadrants). Because of his smok-ing status the treatment plan was performed withthe focus on the maintenance of the strategic teeth16 and 37. For the surgical aspect, an access flap (modifiedWidman flap) was planned from tooth 14 to tooth

16 with an amputation of the distobuccal root oftooth 16. The extraction of tooth 16 and the place-ment of an implant following elevation of the sinusfloor were not considered as an option because ofthe smoking issue. In the third quadrant, there weretwo possibilities: to maintain a premolar occlusion(extraction of 37 and 38), or to perform a hemi-section on tooth 37 in order to use the mesial rootas an abutment for a fixed partial denture 35 x 37,combined with the extraction of tooth 38. In thefourth quadrant, tooth 48 was planned to be ex-tracted during access surgery at tooth 47. No im-plant placement was considered in the third quad-rant. In the second and fourth quadrants, implantplacement would have been an alternative to theclosure of the gaps.For the reconstruction of the dentition a singlecrown on tooth 15 and splinted crowns on thepalatal and the mesiobuccal roots of tooth 16 (fol-lowing endodontic re-treatment of tooth 16) wereplanned. In the second quadrant, a fixed partialdenture from tooth 23 to 25 or a single implant(24) was considered. Due to the additional finan-cial cost and the risks involved, the nature of the re-

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Table 4 Pre-therapeutic single tooth prognosis

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Teeth irra-tional to betreated

Doubtfulteeth

X X X X X X

Secure teeth X X X X

Secure teeth X X X X X X X X X X

Doubtfulteeth X X X

Teeth irra-tional to betreated

X

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

construction was still to be decided in the thirdquadrant. In the fourth quadrant, a fix partial den-ture from tooth 47 to 45 or a single implant (46)was planned. Because of the bruxism the patientwas to be provided with a Michigan splint for theupper jaw to be used at night. The maintenance visits were initially scheduledevery 3 months.

Treatment Sequence

As indicated in the treatment plan the treatmentcould be scheduled as planned and hence, the firsttwo therapeutic phases followed a sequence iden-tical to that of the treatment plan.

Systemic Phase No further medical examinations were performed.The patient was informed about the effects of smok-ing on the periodontal treatment outcomes. Thespecific risks of an implant placement and the in-fluence of smoking and of the IL-1 status on thelong-term prognosis of an implant-supported recon-struction were also addressed. The patient found itimpossible to attend a smoking cessation program.

However, the patient was willing to reduce his to-bacco consumption, but with no guarantees ofsuccess. A testing of the IL-1 gene complex poly-morphism was postponed until after the completionof the hygiene phase.

Hygiene PhaseAt the beginning of the treatment the patient wasinformed about the etiology of periodontitis andcaries. The periodontal and reconstructive prob-lems were addressed with special focus on thesmoking issue and on the maintenance of thestrategically important teeth 16 and 37. The dif-ferent treatment options and the financial aspectswere also discussed. The importance of maintain-ing good oral hygiene, and complying with therecommendations made, was stressed for achiev-ing optimal treatment outcomes. The treatment sequence in the hygiene phase alsofollowed the treatment plan. Motivation of the pa-tient and instructions in the Bass technique and theuse of interdental brushes were performed. The de-bridement of all teeth took place during 3 ap-pointments under local anesthesia. Provisional fill-ings were placed on teeth 37 and 38. The patientwas very motivated and improved his oral hygiene

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Figs. 9a, b Lateral views after the hygiene phase.Provisional fillings are present on teeth 37 and 38.

Fig. 8 Frontal view after the hygiene phase. Somestaining is present because of rinsing with chlorhexidine(Hibitane®).

a b

successfully. As a result, the PlaqueControl Record (O’Leary et al, 1972)dropped to 10% from an initial 61%.During the hygiene phase the patientrinsed twice a day with a 0.1%Chlorhexidine solution (Hibitane®).The re-evaluation took place 8 weeksafter completion of the hygiene phase(Fig. 8 and Figs. 9a, b). A great re-duction in probing pocket depths tookplace following the instrumentation(Fig. 10). There were, however, stillsome residual pockets of 5 mm in theupper and lower molar regions. In thelower front region, from tooth 45 totooth 35, no probing pocket depthsgreater than 4 mm were present. BOPwas 29% (Lang et al, 1986) and thePlaque Control Record amounted to13%. The goals of the hygiene phaseto reduce pockets and inflammationhad been reached. According to thequality assessment of the Swiss Societyof Odontology (SSO 2000) (Table 5)a standard of A was reached becauseof the 5 residual pockets of 5 mm anda standard of B for the percentage ofBleeding on Probing (BOP) (Table 6).

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Fig. 10 Periochart after the hygienephase. There are still pockets of 5 mm inthe first and third quadrants. In the lowerfront, a great reduction of probing depthshas been achieved.

Quality assessment Description Patient of the tissues compliance

A + No probing depths > 4 mm Very good plaque controlMinimal bleeding Optimal collaboration on probing (<10%)No visible plaque/calculus Very motivated patient

A No probing depths > 5 m Good plaque controlModerate bleeding on The recall is almostprobing (<= 25 %) always followedPlaque Index < = 30% Reinforcement of motivation

B Residual probing depths Absence of motivation> 5 mmBleeding on probing Low level of collaboration> 25 %Plaque Index > 30%

C Abscesses, pus secretion No interest in the treatmentGeneralized bleeding Non-complaint patienton probingMassive plaque accumulation

Table 5 Quality assessment. Description of the tissues, patient compli-ance.

Corrective Phase Surgical InterventionsFurther therapy was indicated after successful com-pletion of the hygiene phase. The patient was stilla heavy smoker and had no intention of quitting.The different treatment options and risks involvedwith implant therapy and the extensive reconstruc-tions were discussed. The patient preferred tooth-supported reconstructions. Because of the decisionof not installing dental implants no testing for the IL-1 genotype was relevant. The patient clearly ex-pressed his wish to receive more teeth in the thirdquadrant than a premolar occlusion could offerhim. In order to use teeth 16 and 37 as abutmentsfor the fixed partial dentures in the first and thirdquadrants, additional therapy was needed.

The final plan for the prosthetic reconstruction wasas follows:

In the first quadrant: a single crown on tooth15, splinted crowns on thepalatal and mesiobuccalroots of tooth 16

In the second quadrant: a fixed partial denture from23 x 25 with a distal ex-tension

In the third quadrant: a fixed partial denture from35 x 37 to a hemisectedtooth 37

In the fourth quadrant: a fixed partial denture from45 x 47.

In the first quadrant, modified Widman flap sur-gery was performed from tooth 14 to tooth 16concomitantly with the amputation of the distobuc-cal root of 16 and the separation of the other 2roots of 16. In the third quadrant, tooth 37 washemisected during access flap surgery. The distalroots of teeth 37 and 38 were subsequently ex-

tracted. The mesial root yielded more remainingdentin and an angulation of the coronal part inparallel with tooth 35. A pulpal extirpation wasperformed on the mesial root of 37. The impactedtooth 48 was surgically extracted and the distal as-pect of tooth 47 was re-instrumented. During thesurgical healing periods the patient was rinsingwith a 0.1% Chlorhexidine solution (Hibitane®).

Reconstructive InterventionsAn endodontic re-treatment was performed for thepalatal and the mesiobuccal roots of tooth 16.Also, the mesial root of tooth 37 was endodonti-cally treated. Composite build-ups (Tetric®,Vivadent, Schaan/Liechtenstein) were performedwithout the use of any posts on the mesiobuccalroot of tooth 16 and on the mesial root of tooth37. The amalgam filling on tooth 35 was replacedby a composite filling. A post (CM Dental,Cendres & Metaux SA) and core build-up (Tetric®,Vivadent, Schaan/Liechtenstein) was performedon the palatal root of tooth 16 (Figs. 11a–f). Noendodontic re-treatment was performed on teeth15 and 25, since these teeth were asymptomaticand no periapical lesions were present. The exist-ing posts were maintained and the cores were re-built with composites. The abutment teeth were pre-pared (bevel preparation) and provisional crownsand bridges inserted (Fig. 12). The inter-maxillaryrelationship was registered (Figs. 14a, b) after thefinal preparations (Figs. 13a–e) and impression-taking (Impregum® Espe, Seefeld, Austria). At thesubsequent appointments the fit and retention of theframework was checked. The 2 roots of tooth 16were splinted with the framework in a manner fa-cilitating easy cleansing (Figs. 15a–d). The colorof the prosthetic reconstruction was adjusted to fitthe remaining teeth, also in the occlusal part of thefixed partial dentures. The distal cantilever of tooth25 had only a centric stop with tooth 37 and nocontacts in the lateral movements. After checkingthe occlusion, articulation and the aesthetic as-pects, the fixed partial dentures were cementedwith Ketak-Cem® (Espe, Seefeld, Austria) (Figs. 16a, b). A new composite filling was placed on tooth13. A splint made of heat cured acrylic and with aflat occlusal surface with canine guidance (Michigansplint) was given to the patient for use at night.Six months after surgery and three weeks after thefinal insertion of the fixed partial dentures, a re-evaluation of the periodontal status was undertak-

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Quality assessment after hygiene phaseDescription of the tissues: A/B

• 5 residual pockets of 5 mm• Bleeding on probing 29% (> 25%)• Plaque Control Record 13% (< = 30%)

Patient compliance: A

Table 6 Quality Assessment after hygiene phase

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Figs. 11a–c First quadrant.Fig. 11a Palatal view of teeth 15 and 16 before treat-ment.

Fig. 11b Palatal view of teeth 15 and 16 after hy-giene phase.

Fig. 11c Palatal view after the root amputation and theextraction of the distobuccal root of 16.

Figs. 11d–f Third quadrant.Fig. 11d Lingual view of teeth 37 and 38 before treat-ment.

Fig. 12 Provisional crowns and fixedpartial dentures were inserted an all fourquadrants.

Fig. 11e Lingual view of teeth 37 and 38 after hy-giene phase.

Fig 11f Lingual view after the hemisection of tooth 37and the extraction of the distal root of 37 and of tooth 38.

a b

c d

e f

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Fig. 13a–d A beveled preparation was performed.

Fig. 13e The preparation distally on the root 37 wasslightly subgingival.

Figs. 14a, b Lateral views. The mesial root of tooth 37was parallel to tooth 35.

a b

c d

a b

e

en (Figs. 17a, b). Three residual pockets of 5 mmwere still present at teeth 14, 15 and 47. BOPwas 17% and the Plaque Control Record was20%. According to the quality assessment of theSwiss Society of Odontology (SSO 2000) (Table5) the quality standard corresponded to an A. Thepatient compliance corresponded to a standard ofB owing to the increased plaque scores (Table 7).

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Figs. 15a–d A single crown on tooth 15 and splinted crowns on the mesiobuccal and palatal roots of tooth 16 werecemented. The patient was able to clean between the crowns with interdental brushes.

Figs. 16a, b Lateral views of the final restorations.

a

b

c d

a b

Quality assessment 6 months after surgeryDescription of the tissues: A

• 3 residual pockets of 5 mm• Bleeding on probing 17% (< 25%)• Plaque Control Record 20% (< = 30%)

Patient compliance: B

Table 7 Quality Assessment after surgical phase

Maintenance Phase and Periodontal RiskAssessment (PRA)

Based on a Periodontal Risk Assessment (PRA) mod-el (Lang and Tonetti, 2003) (Table 8), the patientwas placed into a maintenance care program witha recall frequency every 4 months after the com-pletion of the surgical phase. BOP was assessedand the probing pocket depths were measured atevery recall visit. Supragingival deposits were re-moved, all bleeding sites were re-instrumented andfluorides applied to the tooth surfaces. The PlaqueControl Record of the patient varied from time totime and often scores of 30% to 40% were ob-served. The patient was periodically re-instructedand re-motivated. The night splint was periodicallychecked. The PRA after both the hygiene and sur-gical phases is presented in Figs. 18a, b.

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Fig. 17a Periochart after surgical treat-ment, only 3 pockets of 5 mm remain.

Table 8 Periodontal risk assessment (PRA) for patientsin supportive periodontal therapy

The PRA is a functional diagram based on the evalua-tion of 6 parameters:1. Percentage of bleeding on probing2. Prevalence of residual pockets greater than 4 mm

(≥5 mm)3. Loss of teeth from a total of 28 teeth4. Radiographic alveolar bone loss in relation to pa-

tient’s age5. Systemic (e.g. diabetes) and genetic conditions, if

tested or known6. Environmental factors, such as cigarette smoking.The area of the diagram represents the subject risk forprogression of periodontal disease and is used to as-sess the frequency of the recall interval (see Lang andTonetti, 2003).

Evaluation 2 years after the FinalReconstruction

Two years after the last examination, a new peri-odontal chart and a full radiographic examinationwas carried out (Figs. 19a–c). At the 2 year re-evaluation a thorough standard of oral hygienewas re-established (plaque scores of 11%) eventhough the patient had cleaned less well at the lastrecall visits (plaque scores of 30% to 35%). BOPwas 20%. There was, however, a slight worseningof the periodontal situation in localized areas (Fig.20a). Probing pocket depths of 5 mm and 6 mmwere scored between teeth 15 and 14, and at thefurcation area of 14. Probing pocket depths of 5mm were also present at teeth 16 (distal root), 47,

43, 32 and 37. Nonetheless, the radiographs(Fig. 20b) revealed stable periodontal conditionsaround almost all teeth. The lamina dura of thealveolar bone was clearly recognizable with theexception of the interdental spaces between theteeth 15 and 16, 32 and 33. All non-endodonti-cally treated teeth were vital and no caries was de-tected. All the fixed partial dentures were function-al, and the patient was satisfied. The patient stillsmoked heavily (1 to 2 packs a day). TheMichigan splint was worn almost every night. Twoyears after therapy, because of the presence of 10 sites with probing depths of more than 4 mmand because of the compliance of the patient, thequality standard corresponded to a B standard(Table 9, see next page).

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Fig. 17b Radiographic examination after final reconstruction. Tooth 48 has been extracted. New endodontic treatmentswere performed on teeth 16 (mesiobuccal and palatal roots) and 37 (mesial root).

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Fig. 18a Periodontal risk assessment (PRA) after hygienephaseAfter hygiene phase, BOP was 29%, there were 5 resid-ual pockets of 5mm or more, 6 teeth had been lost, theradiographic bone loss score was 0.77 (40% boneloss/age 52 years = 0.77), systemically healthy patient,and the patient was a heavy smoker. The recall intervalwas set at 3 months. (IL-1 polymorphism was not tested)

Fig. 18b Periodontal risk assessment (PRA) after surgicalphaseBOP was 17%, there were 3 residual pockets of 5mm ormore, 7 teeth had been lost, the radiographic bone lossscore was 0.75 (40% bone loss/ age 53 years = 0.75),systemically healthy patient and the patient was still aheavy smoker. The area of the diagram decreased as a result of the ad-ditional therapy. The recall interval was set at 4 months.

Figs. 19a–c Two years after completion of treatment,all the reconstructions were functioning.

a b

c

Quality assessment after 2 yearsDescription of the tissues: B

• 10 residual pockets of ≥ 5 mm• Bleeding on probing 20% (< 25%)• Plaque Control Record 11% (< = 30%)

Patient compliance: B

Table 9 Quality Assessment 2 years after the final re-construction

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Fig. 20a The periochart at the 2 year re-evalua-tion documents an increase in localized areaswith probing depths ≥ 5mm.

Fig. 20b Radiographic examination 2 years after final reconstruction. No technical or biologi-cal complications were observed at the 2 year re-examination.

b

Based on the most recent examinations it was de-cided to monitor the oral hygiene condition of thepatient to assure low plaque scores. At the follow-ing recall appointment the Plaque Control Recordwas 8% and BOP was 7% (Fig. 21). There werelocalized sites which exhibited BOP and probingpocket depths ≥ 5 mm. Therefore, after reinstru-mentation, a decision was taken to retreat these lo-calized areas with a sustained-release biodegrad-able Doxycyclin polymer AtridoxTM® (Heico Dent).

Recall PrognosisBased on the previous PRA (Fig. 22), the patientwas recalled every 3 months. A good prognosisfor the entire dentition could now be attributed tothe patient.

DISCUSSION

Three years after the start of the treatment, the pa-tient’s periodontal and functional situations had im-proved markedly (Figs. 23a, b). The patient’s com-

pliance during the treatment was good. Eventhough there had been periods with less adequateplaque control, the patient could return to an ap-propriate oral hygiene level after re-motivation andre-instruction. The patient was still a heavy smoker(1 to 2 packs/day). Even though the adverse ef-fects of smoking on the outcome of scaling androot planing (Preber et al, 1986 a, b; Kaldahl etal, 1996) and flap surgery (Preber et al, 1990;Kahldahl et al, 1996) are well known, the patientresponded well to the treatment. At the initial ex-amination, BOP was 64% and the Plaque ControlRecord was 61%. These values dropped to 29%and 13%, respectively after the hygiene phase andto 17% and 20%, respectively after the surgicalphase. After completion of active therapy, the pa-tient was placed on a 3 to 4-month recall. Duringsupportive periodontal therapy the BOP droppedfurther to 7% and the plaque scores to 8%. The lo-calized sites which showed deepening of probingpocket depth and BOP at the 2 year re-evaluationwere treated with a sustained-release biodegrad-able polymer AtridoxTM® (Heico Dent). Several

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Fig. 21 Bleeding onProbing and Plaque ControlRecord. The patient againperformed very good oralhygiene. The localized ar-eas with probing depths ≥5mm and bleeding on prob-ing were treated withAtridoxTM® (Heico Dent).

Fig. 22 Periodontal risk assessment (PRA) two years af-ter final reconstructionBOP was 20%, there were 10 residual pockets of 5 mmor more, 7 teeth had been lost, the radiographic boneloss score was 0.73 (40% bone loss/ age 55 years =0.73), systemically healthy patient and the patient wasstill a heavy smoker. An increase in the area of the dia-gram can be noticed. The recall interval was set at 3months.

studies have shown an increase in probing depthreduction and clinical attachment gain after appli-cation of doxycycline-sustained devices in combi-nation with debridement (Wennström et al, 2001)or alone (Garrett et al, 1999, 2000) in the treat-ment of chronic periodontitis. Also, in terms ofprobing pocket depth reduction and clinical at-tachment gain, current smokers seem to respond asfavorably as former smokers or non-smokers to theapplication of controlled-release doxycycline alone(Ryder et al, 1999).Because the patient was a heavy smoker, recon-struction of the occlusion without the use of oral im-plants was preferred for the rehabilitation. Manyauthors report high early-implant and post-loadingfailures in smokers as compared to non-smokers(Bain et al, 1993; De Bruyn et al, 1994; Wallaceet al, 2000). A test to identify the IL-1 gene com-plex polymorphisms of the patient was not per-formed, since the patient decided to have a tooth-supported reconstruction. A positive outcome of thetest in heavy cigarette smokers has been associat-ed with an increased risk for peri-implant bone lossfollowing prosthetic reconstruction in spite of sup-portive periodontal care being rendered (Feloutziset al, 2002). Smokers appear to exhibit higherperi-implant probing depth, bleeding indices(Haas et al, 1996) and bone loss irrespective ofthe IL-1 genotype (Lindquist et al, 1997; Haas etal, 1996).Moreover, in patients with a past history of peri-odontitis, the long-term implant prognosis ap-peared lower and the incidence of peri-implantitishigher than for patients without a history of peri-odontitis (Karoussis et al, 2003). Because of thepatient’s desire for a fixed prosthodontic recon-

struction teeth 16 and 37, which initially had adoubtful prognosis, became strategically impor-tant. An extraction of tooth 16 would have resultedin extensive bone loss, and an implant placementin this area would have most probably required anelevation of the maxillary sinus floor. In a heavysmoker, however, such procedures and subsequentimplant therapy would have been risky. Severalstudies reported high failures rates for implantsplaced into grafted maxillary sinuses in smokers(Geurs et al, 2001; Kann et al, 1999). Becauseteeth 16 and 37 had Grade 3 furcation involve-ments (per Hamp et al, 1975 Classification), ad-ditional treatment in terms of endodontic treat-ments/revisions, and periodontal surgical proce-dures was necessary to use these teeth asabutments for fixed bridgework.Several studies reported survival rates of 89% orhigher after root resective therapy (Klavan et al,1975; Carnevale et al, 1998, 1991; Hamp etal, 1975; Bergenholz et al, 1972; Erpenstein etal, 1983; Svärdström et al, 2000). In their studyof patients on supportive periodontal therapy,Carnevale et al (1998) found that the survival rateof root-resected teeth after 10 years was 93%. Theresected roots (234 roots out of 175 furcation-in-volved teeth) were used as: terminal abutments forfixed bridge reconstruction (60%); intermediateabutments (24%); and also abutments for singlecrown restorations (16%). During 10 years of main-tenance, the recurrence of periodontitis leading toextractions was only 2%. The prosthetic survivalrate at 10 years was 97%.The rationale for extractions was most likely en-dodontic in nature; or caries and root fracturesmay also have contributed. Periodontal disease re-

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Figs. 23a, b Lateral views at 2 years. Absence of complications at the 2 year examination.

a b

currence, however, seemed to be the least com-mon reason for extraction (Carnevale et al, 1998,1991; Erpenstein et al, 1983; Bühler et al,1988). The failure rates reported vary from 0% af-ter 5 years (Hamp et al, 1975) to 38% after 10years (Langer et al, 1981). The palatal and themesiobuccal roots of tooth 16 were maintained inthe present patient after separation of all roots(Grade 3 furcation involvement). These roots had agreater amount of supporting bone than themesiobuccal root. Furthermore, they were not mo-bile after the separation, had a favorable positionin the dental arch, and had good periapical con-ditions. The endodontic re-treatment was per-formed without difficulty. For the restoration, com-posites for the mesiobuccal root and post and com-posites for the palatal root were performed. Thetwo roots were splinted with the framework to im-prove stability and to allow proper cleansing. Inthe lower arch, the mesial root of tooth 37 wasmaintained. The residual dentinal core permittedthe build-up with composites only. At the 2 yearexamination, the single crowns and the fixed par-tial denture in the third quadrant did not discloseany problems.Even though an increased risk of complications forfixed partial dentures with extensions has been re-ported (Randow et al, 1986 a, b; Landolt et al,1988), a fixed partial denture was placed in thesecond quadrant to avoid implant installation. Anincreased risk of root fractures (35%) has also beenreported (Landolt et al, 1988) for extensionbridges when compared to conventional recon-structions. However, Lindquist et al (1998) report-ed no difference in the survival rate (65%) of fixedpartial dentures with or without extensions after 20years. A heat cured acrylic Michigan night splint(Ash et al, 1994; Geering et al, 1978) was fab-ricated to reduce the risks of technical failures dueto nocturnal bruxism. Two years after completion of treatment the peri-odontal situation of this heavy smoking patient wasunder control, and no technical complications oc-curred. Extensive surgical and prosthetic fixedbridgework interventions were performed to satisfythe patient’s wish for a fixed reconstruction withoutthe installation of oral implants. The patient contin-ues to attend a three to four-month recall to furthermonitor and maintain the treatment results throughsupportive periodontal care.

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Reprint requests:Prof. Dr. Dr. h.c. Niklaus P. Lang, M.S. Department of Periodontology andFixed ProsthodonticsSchool of Dental MedicineUniversity of BerneFreiburgstrasse 7 CH-3010 Bern, SwitzerlandFax: +41 31 632 4915E-mail: [email protected]

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IAI PadoTest 4•5®

The IAI PadoTest 4•5® is a therapy-supportingtest with an informational value going beyondthe diagnosis of periodontal pathogens. Thetest results are compared with the data from abroad-based field study and provide informa-tion on whether and which antibiotics can beconsidered for therapy.

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