Having the patient in a rigorous home plaque control regimen as well as regular three‐month periodontal maintenance are strongly recommended [19] and may considerably reduce the risk of recurrence. In a study of 38 individuals, 18 months after surgical therapy, the recurrence rate of gingival overgrowth in patients taking cyclosporine or nifedipine was 34%. Age, gingival inflammation, and attendance at periodontal maintenance visits were all significantly related to recurrence, and they suggest that regular remotivation and professional care at frequent recall appointments are of great importance in patients with a history of drug‐induced gingival overgrowth [20]. To prevent postsurgical recurrence, a chlorhexidine rinse twice daily is recommended [21].
Several medications have been shown to ameliorate gingival enlargement, such as systemic or topical folic acid [22] or a short course of metronidazole or azithromycin. The latter drugs work particularly well for significant resolution of cyclosporine‐induced gingival overgrowth [23]. The mechanism of action for these antibiotics is not clear, but it is suggested they may contribute to inhibition of collagen fiber proliferation in addition to their antimicrobial action.
Case 1.5 Aggressive Periodontitis
CASE STORY
A 23‐year‐old African American female patient presented with a chief complaint of “Bleeding gums on brushing and swollen gums in specific areas of the mouth.” The patient’s dentist observed 7–10 mm probing depths in several teeth in all four quadrants of the mouth and referred her to a periodontist for a periodontal consultation.
LEARNING GOALS AND OBJECTIVES
To be able to understand the definition and diagnostic criteria of molar/incisor pattern periodontitis
To understand the various treatment options available for this condition
To understand the prognosis of periodontal and implant treatment in these patients
Medical History
There were no findings on medical history and the patient did not report any allergies to food or to drugs. The patient was not taking any medications.
Review of Systems
Vital signsBlood pressure: 120/80 mmHgPulse rate: 73 beats/minute (regular)Respiratory rate: 15 breaths/minute
Social History
The patient was a nonsmoker and reported that she did not consume alcohol.
Extraoral Examination
There were no significant findings. The patient had no masses or swelling and the temporomandibular joint was within normal limits.
Intraoral Examination
There were no abnormal findings with respect to the tongue, floor of the mouth, palate, and buccal mucosa.
A gingival examination revealed mild marginal erythema with areas of rolled margins and swollen papillae in the areas of all first molars and mandibular incisors (Figures 1.5.1–1.5.5).
A periodontal charting was completed (Figure 1.5.6). Teeth #3, #14, #19 and #30 exhibited probing depths of more than 7 mm especially in the interproximal areas. The mandibular incisors also exhibited probing depths in the range of 6–7 mm (Figure 1.5.7).Figure 1.5.1 Preoperative frontal view.Figure 1.5.2 Preoperative maxillary dentition.Figure 1.5.3 Preoperative mandibular dentition.Figure 1.5.4 Preoperative left occlusal view.Figure 1.5.5 Preoperative right occlusal.
Grade 3 mobility was observed in mandibular lateral incisors.
The teeth other than incisors and molars exhibited probing depths in the range of 2–4 mm.
Grade II furcation involvements were recorded for all the affected molars.
The patient’s oral hygiene was good.
Occlusion
There were no occlusal discrepancies or interferences.
Radiographic Examination
A full‐mouth set of radiographs was ordered. The periapical radiographs of the affected molars are shown in Figure 1.5.8. The radiographs show vertical bone defects around all first molars. The bone defects are confined to interproximal areas of the maxillary molars (involving the proximal furcations) and are circumferential in the mandibular molars involving the buccal or lingual furcation areas. Radiographs also revealed severe vertical bone loss in the maxillary and mandibular incisors (radiographs not shown).
Figure 1.5.6 Probing pocket depth measurements during phase 1 reevaluation. B, buccal; P, palatal; L, lingual.
Figure 1.5.7 Intraoral clinical photographs depicting deeper probing depth associated with maxillary and mandibular molars.
Figure 1.5.8 Periapical radiographs demonstrating the intrabony defects surrounding all four molars and the relatively normal premolars and second molars.
Diagnosis and Prognosis
The patient’s age, ethnicity, history, and clinical and radiographic exams led to the diagnosis of molar/incisor pattern stage III grade C periodontitis. The molars were not mobile and the defects surrounding them were intrabony, which are highly amenable to regeneration by guided tissue regeneration or enamel matrix protein. Moreover, the patient also had very good oral hygiene and was highly compliant. Therefore these molars will have a fair prognosis. However, the long‐term prognosis of mandibular incisors is questionable as the sites exhibited severe destruction of the periodontium with bone loss almost to the apex of the teeth.