Adjacent Tooth Has Advanced Periodontal Disease: Keep It or Place Second Implant?

The first molar has probably a better prognosys than any implant you could ever place. Keep it. The prognostic elements required to evaluate the longevity of the molar are fourcation involvement, pocket depth, presence or not of inflammation, the kind of periodontal disease (aggressive or chronic), the overall periodontal condition of the patient (that does not look extremely bad) and, last but not least, the quality of hygienic maintenance. Some of these prognostic factors have to be evaluated through time and can be modified by treatments and improving oral hygiene. So take your time, maintain the patient periodontically, and probably that tooth will be still there in 10 years. Implants replace missing teeth. The first molar is not missing, but just sick. And even implants have problems, especially in patients that are periodontically compromised (aggressive perio patients and implants are like cats and dogs).

I donno wats wrong wit the Radiographs u uploaded... but #3 in IOPA Appears to be in better condition wen compare to Panoramic view. Acording to IOPA keep the #3 Always its better...Before placing implant Treat the Tooth adjacent to it and later Hygeine maintenence is imp too.

For such cases i Recommend CT will help to evaluate properly.

The first image is from a CBCT. Quote "How can I convince patient to take out the tooth which has no pain, no mobility, and is in good function now?" That's why you should leave #3 alone and treat the patient's Perio first.

Dr. Chan is right, The first image is a pseudo-panoramic view obtained from a ct scan. Dr. Habeeb I think that the two radiological images are very coherent with each other. They are not in contradiction, but just the outcomes of two different technologies. The first is a thin slice that cuts throught the molar buccaly, showing the two periodontal defects (mesial to the mesial root and distal to the distal root), that are buccally localized. The second is a periapical x-ray, where the defects are still visible (especially the mesial one) but partially hidden by the overlap of the palatal bone, which is maintained. A good way to make a periodontal diagnosis is a periapical x-ray and a periodontal probe. I would leave the cbct alone. Regards.

I agree with Paolo Rossetti. This looks like an ideal case for a Lanap procedure on #3 and possibly other teeth as well. Get the perio issue under control before going forward with sinus grafting and implant placement.

What were the pocket depths on #3, you stated it has a poor periodontal prognosis. Has the patient been evaluated by a periodontist? The hard part is the patient's perio vs allowing continuing to allow bone loss to occur, it is very hard to gain it back. Was the extraction site grafted? It may be prudent to have backup with a specialist exam you can trust.

The bacterial pathology associated with 3 will affect implant healing at site 4 and could cause it to fail. if she wants to keep it then treat the perio and get 3 healthy before any implant is placed at 4 or failure will be the result then the liability is on you.

How about anyone taking a periodontal probe and finding out how deep the lesion really is. Radiographic analysis is one thing but there is no information about clinical exam. First of all, the pocket cannot be left as is. Therefore, before placing the implant or at the same time, definitive periodontal therapy is needed at #3. The problem is furcation involvement so how successful are we going to be at treating such a defect. Post-pone the extraction and potentially have negative effects on the implant not a good idea. Old school would tell us if regeneration is not possible to do a root amputation. This would require root canal and and crown on #3. What is the clinical success of RCT with root amputation versus an implant. I'd favor the implant any day. However, if the area can be successfully treated by regeneration, that would be the way to go. Leave this to a specialist who does this over and over again instead of second guessing your treatment decision.

I strongly agree with the above posters who say that the proper sequence in this case is to first treat the periodontal issues (this includes any others around other teeth in the mouth) and then address replacement of missing teeth. As for your question about how to "convince" this patient to do anything, I think we should NEVER have to convince our patients to do anything. There are certainly enough factual, evidence-based studies out there for you to educate the patient about the major risks of placing an implant adjacent to a tooth that has active periodontal disease. Lastly, if you do not want to own the consequences of such treatment, perhaps you should advise this patient to seek treatment elsewhere. DrT

While one should consider salvaging #3, the overall picture is conveying a negative prognosis. Look at all the chronic, untreated problems in that mouth. How did things get that way? do you really think the patient will find religion just because you put in one implant? Also, something smells of bad protoplasm, i.e., borderline diabetic or liver problems or some bone maintenance shortcoming? Check out that Mesial pocket - 'goes right down to the sins wall. How much viable medullary bone there? My long term experience in placing an implant so close to a chronic perio infection has been that the infection will migrate over to your implant site. It's unlikely that the patient will immediately become good cleaner, a good eater, or a compliant person. What you see is what you get. As such, I'd paint a black picture about that perio getting into the implant site at some point and make certain the patient knows that you will not be responsible for the problems caused by the perio with which she walked in to your office. I'd advise removing the first molar and eliminating perio before implant placement. John

From the panorex image produced from the scan, what is being described as a first molar, in my opinion is a second molar...which is extruded, as well as having severe periodontal breakdown on the distal aspect of the root....this is not a healthy tooth....and all the fine scaling is not going to regenerate the absence of bone around the roots. The fact that this tooth is being maintained means that there is some bone surrounding all the roots, and if it is extracted and a "backfill" bone graft is done, there is a possibility of avoiding doing a sinus lift ....and should a sinus lift be necessary, then it is a simple procedure. I suggest the dentist place the bicuspid implant, and extract the molar at the same appointment....followed by a bone graft several weeks later for the molar, to allow any pathogens or granulomatous tissue to be cleared out of the socket. It is generally not a good idea to place implants next to periodontally compromised teeth.

Very good comments mentioned above. As previously stated, more information is needed. What is the patient's age, health status, periodontal status (locally around 16, and full mouth)? What is the cause of the vertical bone loss around 16 (e.g. is the tooth vital, fractured, or does it have predisposing local anatomy, such as an enamel projection?). Regarding prognosis - a hopeless prognosis tooth can be maintained in function for years. I have yet to see that done for an implant.

Hi folks; The best X-ray to judge the periodontal defect is bitewing X-ray, so u need one. Second u need to evaluate the16 prognosis wither good, questionable or hopeless. If defect more than 6 mm which I'm sure then u have to do OFD( open flap debridement) and local antibiotic application. Keep pt on 3 months recall. U should see result in 9 months where u need to reevaluate and assess wither to keep or extract it. We all know periodontitis is a site specific disease which mean it might stay with 16 and does not affect the 15 area in future if treated proberly. Give 16 try for 9 months and then u will be able to make agood decision and convince the pt. What I'm pretty sure of is not to leave 16 with no comprehensive treatment. Good luck

What are the probing depths on the mesial and distal? Is there furcation involvement, and if so, how deep? If there is significant bone loss, especially with the mesial bifurcation, extraction and later implant placement would be more likely to produce a trouble free result than attempting to salvage the tooth.

Before we talk about implants ,periodontal status must be evaluated and when you say that #3 has advanced perio,why would you keep a tooth under those condition next to a possible implant/sinus lift surgery that just increase the posiblity of failure. Sometime we have to learn how to say no, you mention the fact that the patient will like to keep the tooth. when you go to court the patient wishes are second to the fact that you decide to keep a tooth that was possible responsible for the failure of a nothing but good intention treatment plan. Perio first

The panoramic is useless, in this scenario. Some ct scanners fabricate these images just so they can advertise the panoramic feature. I agree that correcting the Perio disease before proceeding with implants, makes sense. A bite wing is helpful, but a ct scan Is the equivalent of 1000 bite wings, plus. Bv

Hi, I wanne tell if there is advanced periodental disease and the researchesand pathogens in bocket we will find it after 40 to 50 days around implant. and the othere thing is so-called ground back which means you plane for what you will get before you do. from x- ray i see the deep pocket around mesiobuccal root and there is enlargement of sinus and i think it will increase in future, so i am with extract for 3 and put 2 implants with sinus lefting .

Informed consent, my friend. Tell the patient the situation and the positives and negatives of keeping #3 or removing and replacing #3 with #4. The truth is, why do you need to do a sinus lift twice unless you are thinking of the osteotome technique? Just make a stupid lateral window and get it over with especially if you are considering keeping #3 for a longer period of time. In my opinion, I would assume that #3 has a mesial lingual furcation involvement that could be a class II or class III furcation. I can also see calculus in the radiograph which is contributing to its bone loss. I know that flap surgery will help treat #3, but will not help predictibly in removing any calculus if it is a class II or III furcation involvement. In my opinion, do something definitive and predictable..or at least encourage that. Otherwise, if the patient wants to save #3 for whatever reason, INFORMED CONSENT INFORMED CONSENT INFORMED CONSENT.

Extracting the molar to improve the prognosis of the implant is called "sacrifice", which means giving up something in order to get a higher advantage. It is a therapeutical option, but I do not like it. I think that today's implant therapy should help the patients keep their own teeth, and not to speed up the loss of teeth (no doubt that the molar would have to be maintained, if no implant therapy had been planned). To put it simple, if the nature of the periodontal disease is such that the molar is easy to periodontically stabilize, then why not to keep the molar? Differently, If the periodontal disease is so aggressive that it is difficult or impossible to get a full stabilization, than do you think that the patient is a good candidate for implant placement (especially if a graft is needed)? In both cases the replacement of the molar with an implant would be far from the ideal treatment. So, Why not considering unconventional treatment options, like crowning the molar and cantilivering the premolar? Easy, quick, cost effective treatment with no surgery, and a treatment that would meet the patient's request to keep the molar. Please do not answer that the extraction of the molar would prevent further bone loss...

Obviously, maintenance of the molar will prevent bone loss. Yes, the " implant thing " is getting out of hand. Nothing replaces a tooth better than a tooth. Implants should be the last option in the restorative dentist and periodontist list of ways to treat. I sent a patient of mine to a young restorative dentist this week that bought another's practice, to get an Essex temp. made. I was placing her 4th implant. At the end of that visit he almost had her convinced to go to another surgeon to have 12 healthy teeth removed so that an all on four could be placed, at the maxilla. She did not walk out of his office, she ran...... Bv. Vinci Oral and Facial Surgery. Baton Rouge, la.

Again the area not raised is occlusion or parafunctions and the effects on the supporting tissues. Placing and Implant concurrently with the usual OH improvement and root planning with grafting may be the best way forward. Of course a careful analysis of the occlusal forces is Vital and then at loading an improved balance will be of benefit. Peter

All the questions about the patient are correct ( pain,probing, bliding,mobility,compliance ecc.), and also all arround extraction or not the 1.6. But, lookin only to the xray immediatly I've immagined a perio-prosthetic solution. Rootcanal of palatal and distobuccal roots; professional hygien and resective osseo surgery (rizectomy of the mesio buccal root. Control of mobility and occlusion with four provvisionals in acrylic from 1.7-1.6-x-1.4. Revalutation after six months, to define the final restoration. No thing may live in a mouth like a tooth. Good luck

Dear Dario, It is true that we like maintaining teeth and avoiding implant therapy, but the therapeutic option you have mentioned (4 unit bridge involving n° 3, after rizectomy) seems to me a bit invasive to the natural teeth. Also, trimming down healthy teeth and putting them under acrylic for months, before having defined the final prog

Dear Dario, It is true that we like maintaining teeth and avoiding/postponing implant therapy, but the therapeutic option you have mentioned (4 unit bridge involving n° 3, after rizectomy) seems to me a bit invasive to the natural teeth. Also, trimming down healthy teeth and putting them under acrylic for months, before defining the final rehabilitation...and what if you change your mind at last? Finally, I consider removing a root on an upper molar just when the other two are in good condition...watch the distal one! Un saluto Paolo

Plaintiffs lawyer " Doctor why did you only treat part of the patients disease" ? Doctor, " Because that is what the patient told me to do."

Dear all my colleagues, First of all, thank you very much for your all advices. I'm a beginner in implantology, so I need to study from all of you. Some my questions seem stupid, but I've received a lots of useful comments from you. I respect this very much. About my case, may I try to open the flap, root planning for tooth 16, maybe lateral sinus augmentation and implant placement for tooth 15 at the same time (in 01 appointment)or I should do the root planning first then 02 months later I start the next step sinus lift and implant placement.

If you are new in implantology then I strongly suggest that you do one procedure at a time. Also, as many of the above posters have suggested, I think it most advisable to first treat the periodontal problems on the molars and allow for several months of healing before you proceed with any implant or sinus treatment. DrT

I agree with Dr. T's comments. Treat and stabilize the perio first. There is no rush to get the implant and sinus lift done - the most significant amount of bone loss around 15 site has already happened (within 3 months of tooth exo). Ensure that all possible etiological factors for 16 are addressed first (and in the rest of the mouth as well). Once 16 is stable, you have one less problem to deal with. As Dennis Tarnow says - "One miracle at a time."

I think that it is not good to treat a patient only from a Rx informations. In this case if the molar do not have mobility, pain or gingival inflamation, you do not have any reason to get it out!!!Today you have a wide range of implant types and dimensions so you can place an implant for 15.Do not complicate simple things!!!Be cause if there some things go wrong it will be dificult to explain why you choose the complicated way.And there is one thing:how old is your patient? good luck!!!

Dear my lovely colleagues, Thank you very much for your comments. I discuss with my patient and he agrees to try to keep the tooth 16. I'll plan to do root planning next week. However, patient told me that he had root planning 01 time 03 years ago at another clinic. So do I need to try again 01 more time? Now, still bleeding when using probe. Best regards,

Dear doctor; What type of root planing pt. had? U need to do OFD( open flap debridentem ) where u can Have access and good visibility to assess and treat. Do u have previous reading of probing depth to be able to assess wither the first RP worked or not? Did the pt. gain new attachment level? Is it stable, progressing or regressesing? If its stable or gained attachment level then it's fine, just keep him on a 3 months recall.if not then u need to be more aggressive in RP this time with using local antibiotic also. Reduction in bleeding is a good assissts in making an idea wither the treatment is working or not but it's not and absolute indication. U always have to rely on attachment level. If second RP with antibiotic didn't work then it's hopeless tooth and u need to extract it to stop the bone resorption. If pt. insist on what he want then either send him to a periodontist for consultation or state that in Informed consent. Good luck MY OPENION IS RIGHT BUT MIGHT BY WRONG, WHILE OTHERS OPENION IS WRONG BUT MIGHT BE RIGHT

I agree regarding the previous root planing. It is important to try to determine why the root planing that was done a few years was ineffective in arresting the periodontal disease. I would also caution you about indiscriminately using antibiotics in conjunction with more root planing. What is your rationale for using antibiotics? Thank you. DrT

Dr Nguyen, you seem like a caring doctor! I suggest to try to get the perio and and occlusal issues under control. The patients inability to maintain proper OH, may preclude any implant treatment. Think about plan B.

The problem with the "Panoramic" image is that it's a small slice from a CT. You can generally get a very good pano from a CT, one just needs to thicken the slcie. As it is, only the outer most buccal aspect of the molar (not even the apex of the mesial roots) is included in the slice. Also, bleeding on probing is not an indication for extraction. There is a perio issue with the molar, but from the information you have provided we can't get a good idea of the extent. Address the perio issues first. You need to open a flap to access the areas, then you can confidently remove any calculus while evaluating the types of defects present. By the way, the scan may provide some valuable information concerning the periodontal defects.

If you are going to properly treat the periodontal disease on the molar(s) you will need to do more than an open flap and some root planing. You should be prepared to do GTR or else, please refer this to a periodontist. DrT

Why does everybody speak about gtr as a predictable thing? Can we consider the gtr like an everyday job (especially in a case like this)? Is a papilla preservation flap so easy to do on the distal root?

GTR is certainly not a totally predictable procedure. However, the literature supports the fact that it is much more effective than open flap curettage. As for making a papillary preservation flap, based on the x-rays, there is a large IBD on the mesial aspect of the second molar,and it would be quite easy to make a papillary preservation incision in this area. DrT

Does LANAP periodontal treatment really work? What is the mechanism of bone regeneration? Please would more experieneced surgeons shed some light on this subject, as I am seemingly living in London in the dark ages!

Drk Lanap is the full mouth use of the millennium mvp7 laser on the peiodontium. So far there is more and mor research with biology showing results comparable to traditional treatment. The idea behind its use in perio treatment is the minimally invasive and effective approach to treatment. The science behind its use is from old classic perio research. This specific laser only removes the junctional epithelium and GRANULOMATOUS tissue while keeping the GRANULATION tissue intact. I think you know the difference between the two. At the same time, this specific laser allows its energy to penetrate an additional 9 to 14 mm through the soft tissue and bone without vaporizing it. This specific laser has shown to be effective in killing pigmented bacteria for a long time. After calulus removal the laser is placed under another setting to create wet hemostasis. And then lots of occlusal adjustment and or splinting of mobile anterior teeth are needed. For the most part you have almost sterilized an infected pocket and kept healthy granulation tissue intact. This creates a natural environment for regeneration. This is what was done pre bone grafting but with lots of antibiotics instead of a laser. Finally, not all lasers do the same thing. More research backs the millennium laser. FYI, I'm not a salesman or the company nor do I receive any royalties from them. I just speak from current experience

Dear all my colleagues, Thank you very much for your all comments. I'll see my patient in next week. I'll report the result as soon as possible. Best regards, Dr. Tri Dung.