Implants with Aggressive Periodontitis: suggested treatment plan?

Complex question with enormous open ended answers. The treatment plan I recommend is caution and compassion. This patient has advanced problems, and they need to own that. If they are open to that, I'd recommend identifying what got them to this stage without engaging in accusations of poor choices. Once the patient accepts their own problem and the causitive factors are addressed, it is then a matter of what the patient wants and what limitations (usually financial) they might face. Their treatment will ultimately depend on that factor. Once they commit to improving their dental health, then move on to a definitive treatment plan. Right now I believe judgements need to be made regarding acute elimination of pathology first, followed by repair of damaged teeth and soft tissues that will be needed in definitive treatments. I always want to "rush in" and " save the patient", but I have learned things turn out better if I completely, compassionately engage the patient before ever touching any non-emergent problem. Best of all to you and your patient.

Speaking of open ended answers!

I'll go ahead and offer a treatment plan based solely on my interpretation of the radiographic evidence as I can see it on this forum, with the assumption of a motivated patient who understands their role: 1) CBCT. The data I glean is invaluable in educating the patient and knowing the true condition of each tooth and bone support. Along with a thorough periodontal exam. 2) Extraction of maxillary teeth, removal of fixation screws, ridge grafting with L-PRF/particulate grafts and membranes, all impregnated with metronidazole, and delivery of a maxillary immediate trial denture. 3) Laser microsurgery for the treatment of the mandibular arch on conjunction with L-PRF, including the implant. Again, this is offered making certain assumptions about existing perio conditions. This would be preceded by restorations where needed, stabilization of any teeth exhibiting pathologic mobility and careful occlusal adjustment to achieve lingualized contact and canine disclusion if possible. 4) Supervised evaluation of healing, patient home care, and tolerance of mx denture. 5) Secondary prosthetic/implant treatment as indicated/desired. So there is an option out there. Not easy, and an understanding, informed, and motivated patient is the foundation.

You have not gotten the patient to accept anything in tx. That's the first step. And nowadays, not everything is implants. A tx plan she might go for is to remove hopeless teeth, place partials, and have her accept good ongoing perio tx. Tell her she might get 5-10 years if she maintains a good environment. Sometimes dentistry is about small steps rather than big ones. Patients are reluctant to lose teeth, even when they are hopeless

immediate placement, immediate load. there is enough evidence in literature to support this. my clinical experience and the follow ups of hundreds of cases are in line with above.

The question of implants in a patient with periodontitis depends on the patient's acceptance of the increased possibility of peri-implantitis and their commitment to personal care and regular recare/hygiene follow up. To deny a patient increased function through dental implants merely due to a periodontal condition is almost cruel. No, periodontal disease does not "go away"; ther is no cure, and more advanced case types, possibly complicated by health considerations, are more difficult to deal with. We see more frequent recurrences and greater tissue losses which may complicate implant treatment. The decision must be made, patient-by-patient, about the risks of placing implants in their mouth vs. the benefits they are likely to receive. Until an absolute "cure" for periodontal disease is achieved (currently extraction of all existing teeth is the only sure method), do we deny comfort and function to an otherwise educated and committed patient? The term "complex" is a recurring theme, and it seems as if this clinical situation is the very definition of the word.

Well said. As long as the patient is fully informed However some patients ( and clinicians) manage dentures without implants others not. Perhaps implant augmentation might be revisited afterward? Certainly if there are salvageable teeth remaining their use even if transitional has been warranted. Or is implant support alone now the preferable treatment of choice? Agreed a case by case decision but what say you?

I believe all of the options proposed in your reply to be in the "decision tree", again depending on the actual patient condition. I think you offer some thoughtful treatments. I don't believe there is always only one correct treatment plan; only a correct direction of treatment. Dentures, implants, etc. are the tools we employ to restore whatever portion of function lost to dental disease. None are a perfect means to an end, hence the need for we, as clinicians, to deepen and broaden our knowledge and skill in order to know which tools to use in a given case. The old adage "If you only have a hammer, everything looks like a nail" is apropos. Not all patients with dentures need implants, and not all patients needing implant need a full arch supported prosthesis - or can afford one. We do the best we can given the needs and resources of each patient.

Level of mobility? I would try to perform general periodontic threatment with temporary splint. If dynamics is posistive - next step is prosthetic treatment.