1. Calcium sulfate as a bone replacement graft in the management of localized aggressive periodontitis:
A 1 year follow up report
Leela Subhashini Choudary Alluri BDS, Abhiram Maddi DDS, PhD, Amarpreet Sabharwal DDS, MS, Nabeeh Alqahtani BDS, MS.
Case Management and Clinical Outcomes
The periodontal management was performed in three phases:
Initial Phase : Patient education and non-surgical therapy with adjunctive
systemic antibiotic that comprised of amoxicillin and metronidazole 500 mg
each, t.i.d for 10 days.
Surgical Phase : Treatment involved surgical therapy with guided tissue
regeneration using absorbable collagen membrane (OraMem, Salvin Dental
Specialities, Charlotte, NC) coupled with calcium sulfate hemihydrate as
bone graft substitute (GenMatrix, Innovative Implant Technology, Aventura,
FL) at #3, #8, #14, #19 and #25 (Figure 2).
Abstract
We report a case of localized aggressive periodontitis (LAP), which precipitated during fixed orthodontic treatment in a 16 years old female African-American patient. Oral hygiene instruction, removal of orthodontic bands and non-surgical periodontal therapy was followed by surgical treatment of multiple sites, using calcium sulfate as a synthetic bone graft material and collagen membrane as a barrier, to achieve guided tissue regeneration. One year follow up of the case demonstrates that use of calcium sulfate as a synthetic bone substitute may provide favorable outcome in LAP patients. Furthermore, LAP patients undergoing orthodontic treatment can be successfully managed without tooth morbidity.
Introduction
Localized aggressive periodontitis (LAP) is characterized by an aggressive pattern of destruction of periodontal tissue and alveolar bone.
Microbial agent Aggregatibacter actinomycetemcomitans has been implicated as key factor.
LAP often occurs around puberty and also shows a racial predilection towards the African-American population.
Clinically, LAP is characterized by periodontal destruction localized to the first molars and incisors.
Figure 3: Periapical radiographs at baseline (B) and 1 year (1Y) post-treatment in quadrants 1 & 2.
Clinical Presentation
A 16 years old African-American female patient came with the chief complaint of “my gums bleed occasionally and are painful”.
Dental history: The patient was undergoing orthodontic treatment that was later suspended due to bleeding and pain around the affected teeth.
No significant medical history.
Periodontal examination
30% O’Leary’s plaque index .
The bleeding index 7.4%.
Radiographic Analysis
Figure 2: Guided tissue regeneration at #3 mesial using calcium sulfate as bone graft and collagen membrane as barrier. In clockwise arrangement: (A) elevation of full-thickness mucoperiosteal flap, (B) placement of calcium sulfate in the periodontal and furcation defects, (C) adaptation of collagen membrane barrier and (D) primary closure of flap.
Postoperative drug therapy included amoxicillin 500 mg t.i.d for 1 week, and Ibuprofen 400 mg every 4-6 hourly.
At 6 months after surgery, the PD reduced at all treated sites to a range of 2-4 mm except for #14 where a 6 mm pocket persisted at the mesiopalatal site. At this point, this site was retreated with demineralized freeze dried bone allograft (DFDBA) mixed with doxycycline in a 1:1 ratio.
Maintenance Phase: Oral hygiene recall at every 3 months was planned following surgical therapy for a period of 1 year. At 1 year following the initial surgical therapy all the sites including the retreated defect at #14 were found to be stable and maintainable with PD of 5 mm or less (Figure 3 and Figure 4).
Figure 4: Periapical radiographs at baseline (B) and 1 year (1Y) post-treatment in quadrants 3 & 4.
Conclusions
LAP was successfully treated by non-surgical and surgical therapies to achieve a stable periodontal health in our patient.
We also demonstrate that calcium sulfate can be used successfully as a bone substitute for achieving periodontal regeneration in LAP patients.
Long term and controlled clinical trials are needed to further validate this finding.
Although there are no long term studies, the few case reports of LAP available in the literature indicate that orthodontic treatment is suitable for patients with a history of LAP if the patient can achieve periodontal stability by periodic maintenance.
However, adequate time needs to be allowed for healing and stabilization of periodontal tissues before proceeding with orthodontic treatment.
Figure 1: The panoramic radiograph demonstrates sharply defined vertical
bone loss restricted to the first molars and incisors in all four quadrants
indicating the diagnosis of LAP.