Chronic severe periodontitis: treatment plan?

Well, this is a very bad situation... I think that short-term treatment would be imediate extraction 18,16,15,12, 22, 26, 28, 32, 31, 41. I presume that patient has severe pain, so this woud be first aid. Try to go with agressive therapy with toothpastes and mouthwashes with chlorhexidine, also include some antibiotics therapy. It is necessary to make very carefull and detailed cleaning of this remaining teeth first with Sonicflex or Cavitron, then with some polishing paste. I recommend also scraping remaining teeth (their deep pockets) with Gracey curette for subgingival cleaning. It is very important to teach patient how to properly use toothbrush and interdental brushes to maintain high level of oral hygiene. If remaining teeth will react to your treatment, they will be reinforced, but not drastically (time table: 2-6 months). Then, and only then if they reinforce and there is a periodontal regression, then I would go with implants. If you see that there is no improvements of any kind in 2 months, I would go to total extraction-but this is really drastic. Then, when the wounds heal, you sould assess how many bone has left and then decide about implants (maybe mini implants?). Temporary solution in meanwhile could be complete dentures. Hope this helps...

I would not say this patient is in excellent health with this dentition. I would remove everything and fabricate a denture. Could have a couple of locators in the mandible but I doubt the patient would maintain it.

CRS spot on! It might be advisable to recommend a physical work up. Something is not functioning properly. The condition of his bone is bound to be really compromised so implants will be pretty much out of the question for a period of time, perhaps very long. A blessing to get those nasty teeth out though.

I applaud Laetitia's comment that interdental brushes be utilized in the treatment of this patient's periodontal condition. Ultimately, should anything other than a removable full denture attached to locator attachments be used to prosthetically replace the dentition, the patient must be well versed in the use of interdental brushes (with Teflon covering over the center wire stem to which the bristles are attached) to maintain the health of any implants. Interdental brushes are the very best interproximal cleansing apparatus and are underutilized in our profession. Let the patient demonstrate their capability, dexterity and proficiency in the use of these brushes on their remaining anterior teeth. Implant placement should be contingent upon whether this patient can master this oral hygiene regimen. I would recommend the Curaprox interdental brush system as it has at least 15 different sizes and firmness gradations for patients to use (and doctors to prescribe) and they all fit into an indestructible metal handle that allows an unchanged angle for insertion between the teeth or implants. Plastic handles flex and make use of interdental brushes more difficult. Good luck to you and this patient!

Extract and immediate denture/make a new denture in 6 months explain that pt will hate dentures but that's all that's left. Explain pt maybe a candidate for implants later but certainly not now. Implants do require some level of work to maintain. Don't waste your time and his money.

A discussion of maintenance procedures for this patient is a moot point. I don't see any teeth that would serve as abutments for anything fixed, removable, or in combination with implants. If any teeth were retained, as soon as they are put under a load in function they would go downhill rather quickly and you would be faced with re-making your prosthesis. This is an immediate denture case. The patient can't possibly be eating much of anything in their present state so sometimes well made dentures are an improvement functionally and esthetically.

My suggested TP based on opinion that none of the teeth should be saved. 1. Clean up the mouth to get reasonable soft tissue health. 2. Fabricate mandibular posterior bite rim to obtain acceptable vertical and CR. 3. Block out all undercuts and make good impressions using custom trays. 4. Mount models using face bow and centric registration. 5. Send to lab with instructions to use existing teeth as guide for setting lower posteriors and then cut off all teeth on the upper and lower models, fabricate base plates, wax set up all teeth and return for doctor to OK. An incisal edge guide could be used if existing teeth locations are acceptable to patient. 6. Remove all teeth and deliver immediate U/L dentures. 7. Follow conventional immediate denture post-op protocol including relines and new denture if indicated. 8. After approximately one year discuss additional treatment options, which are many, based on patient's desires and finances.

In the current situation the patient is not an implant candidate. Laetitia makes a good point. We know the teeth are pretty much done for but why not clean up everything first and put the patient on an intensive home-care program with teepee, OHI etc and see if they can actually keep the teeth clean. If yes then maybe look at an implant option (either locators or a bar OD) but make sure they can clean teeth before placing any fixtures.

I presume you have done all the basic cleaning on these teeth .know how to maintain the correct occlusion and cone beam vision. Full lower clearance and immediate 6 to 6 fixed denture on five or six implants is possible ,.looks simple to do and has a very good history of success. Immediate loading in the lower arch is a very successful technique.The lower denture can be well clear of the mucosa for easy cleaning .Gingival height aesthetics are never a concern in the mandible .. This will restore the function so vital to maintain this good health he currently has .Full occlusion will assist the peroidontium of the remaining upper teeth as well . This allows you to gradually assess the upper arch and replace as time goes by with less disruption to the comfort and chewing cycle of the patient . Start soon! .

I think first thing to do is to maintain the optimum oral hygine before starting surgery.Then begining with the upper jaw do total extraction and augment the rigde by using bone grafts membranes flap mobilization also resect the sharp bony partsclose the wound wait for the wound to heal do the same operation for the lower jaw.After healing is c0mpleated Make total dentures when thebone healing is confirmed radiologically you can start your implant therapy. good luck

I treat many cases of this type. I am a periodontist with decades of experience..My approach is two-fold. 1. I want a complete blood and urine workup and want to see if all chemistries are normal, I want to know about the patient's endocrine function, particularly thyroid, and pancreas-whether they are diabetic or pre-diabetic. Therefore I request a 5 hour glucose tolerance test, an HbA1c, a fasting glucose as part of the 5 hour, so that I can see the curve of sugar absorption and insulin output. I do this now so that IF the patient does need medical help prior to implants, they can get started on it now with their physician, and be ready for later implant surgery.. 2. I want to know if there is a family history as tendency for periodontal disease can be genetically passed on. Same with diabetes. 3. Assuming patient is medically ok, I would immediately advance to full extractions and immediate dentures after the antibiotic protocol below. . I am assuming you all know how to do immediate dentures.. 4. Prior to extraction, I usually place the patient on clindamycin, 300 mg, T.I.D.., and Peridex rinsed B.I.D, You can also use Amoxycillin 500 mg,28 caps, BID for 7 days. You can also use Augmentin. They are on this regimen for 1 week to destroy a lot of the bacteria surrounding the teeth, They are also rinsing with Peridex BID. Physically cleaning the remaining teeth in a mouth like this, in my opinion, is a waste of time, and patient money. 5. Simultaneously, the general dentist I work with will do the necessary steps to make an immediate denture at the lab. Whenever possible, we ask the patient to wait 10 days in an edentulous state, to get better healing prior to taking impressions and making the immediate denture. Where not possible for self image reasons, it will be made, and ready for insertion with soft reline at the time of surgery. 6.This denture often will require several relines or a new one, prior to final patient satisfaction with the denture stage. 7. At the 6 month mark, assuming the patient wants implants, I would have catscans done of the upper and lower arches. 8. I would determine by height and width where I could put implants, including both conventional diameter implants, and/or short wide implants (eg Megagen). 9. In this patient, the posterior maxillary crests below the sinus are totally resorbed and do not permit any implant approach without sinus lifts. I would prefer a lateral approach because I can be more sure of having adequate bone both in height and up against the medial wall of the sinus. I would need a lot of bone because I would want to use 16 mm implants. Why? Because the replacement teeth would need to be quite long to establish a normal vertical so I want long implants, and as wide as I can use. 10. In the anterior maxilla, even in severely atrophic cases, it is usually possible to get implants in the cuspid area, and I would need to see the scan to see about the other anterior positions, as well as the possibility of ridge bone grafting. 11. Obviously, the patient would have to be given several treatment alternatives, since the more implants, bone grafting. and sinus elevations, the higher the cost of treatment. 12 In our offices, we present what I described above as the most ideal if the patient can afford it. If not, we discuss either a bar supported implant hybrid case, or a ball supported case, or just leave the upper as a full denture. 13. In this situation, given the patient's age, I do not like to see them with a full denture now, as a long term prosthetic solution, because I am concerned about ultimately breaking through the sinus floor over time, with an oral-antral fistulation. Then you really have a dental cripple. So I would explain to the patient those long term dangers and try to get implant cooperation. 14. I feel that surgically, unless the dentist has had many, many courses in implant surgery, including advanced courses, these type of cases should be referred to a specialist. 15.On the lower arch. there is quite a bit of bone left for implants. On the right side, there is enough to go back to the first molar, and on the left, enough to go back to the second molar. The lower anterior, because of no mandibular nerve, can also get long implants even though a lot of height has been lost. 18. For financial reasons, again all 3 types of cases would be presented. ie, fully fixed, bar over-denture (locators), or ball attachments. 19. Because of the potential cost of this case, we always present either CareCredit, bank financing, and/or explain to the patient that if they do all the work in one year, they can get a significant offset on their income tax after deduction of the normal minimum requirements from their gross income. This often can save the patient as much as 35-40% of their total cost on larger cases if they have a decent income. 20. We often do a staged approach on these type of cases. We might do bone regeneration first, implants second, and then rebuild one arch first, and later the other. That way the patient can spread the costs over 2 insurance years, which may help somewhat. 21. We explain to the patient that they can also lose implants from bacterial infection if they do not keep their implants clean. On fixed cases, I strongly recommend the patient use the PerioProtect system long term to help prevent peri-implantitis. 22. The patient is also advised that they must be in to have their teeth and implants checked two or three times a year, to make sure nothing is starting to break down. That's about it. Hope the above was helpful. For those of you interested in patient education, I have just revised an earlier version of my book, Gum Disease: Care and Treatment, 2015. It is on Amazon's Kindle, and was written for patients. It is a short book, very easily read. In addition, for my colleagues who wish to have a periodontist in their office, or who are taking courses in Periodontics or Implants so they can do some of these procedures, I have just completed a 140 page digital book on "Getting Started with an In-Office Periodontal and Implant Practice" . The book has a tremendous amount of letters, medical info, pre-and post op instructions, and a huge amount of scripting for the dentist on case presentation, the office manager, or front desk person on phone communication skills, handling undecided patients, and for the hygienist on preparing the patient for their visit with the Dr., and everything else I have found I needed in 40 years of my own practice and developing 5 practices for general dentists. I am giving a series of one day, and two day courses later in the year in Long Beach, LI, NY, with another dentist with tremendous experience who has a Catscan company and teaches catscan interpretation and other aspects of using catscans, surgical templates, etc. Preparation for these courses was what inspired my writing the two books (the one for the public and the digital "Getting Started book for the dentist). If anyone is interested in the dental digital book, please write to me and based on the requests, I will see about publishing the Dentist book or selling it online.Reach me at http://www.drhowardmarshall.com/