Clinical Advances in Periodontics Vol. 7, No. 4, November 2017 : Page-182

CASE REPORT Treatment of Localized Aggressive Periodontitis With Guided Tissue Regeneration Technique and Enamel Matrix Derivative Fatemeh Momen-Heravi* and Philip Kang* Introduction: Aggressive periodontitis (AgP) is a form of periodontitis characterized by rapid attachment loss in other-wise healthy individuals. Although different treatment options have been explored for management of the disease, control of disease progression and subsequent regeneration of the attachment apparatus are considered the ideal treatment objec-tives. Limited evidence is available with respect to the efficacy of different regenerative materials in the treatment of AgP. Case Presentation: The present case report describes periodontal regeneration techniques and 6-month outcomes in bilateral intrabony non-contained defects around mandibular first molars in a 21-year-old patient diagnosed with localized AgP (LAgP). Periodontal lesions were treated with regenerative therapy with enamel matrix derivative (EMD) and allograft on the right side and allograft with bioabsorbable collagen membrane without EMD on the left side. Treatment yielded favorable clinical outcomes in terms of probing depth reduction, clinical attachment level gain, minimal gingival inflammation, and ra-diographic bone fill. Radiographic bone fill was observed after 6 months, suggesting possible periodontal regeneration. Conclusion: Both regeneration techniques used in this clinical report (guided tissue regeneration involving allograft and bioabsorbable membrane versus EMD combined with allograft without a barrier membrane) resulted in favorable out-comes in the treatment of deep ( ‡ 7 mm) non-contained intrabony defects in LAgP. Clin Adv Periodontics 2017;7:182-189. Key Words : Aggressive periodontitis; bone resorption; guided tissue regeneration; periodontitis; reconstructive surgical procedures; regeneration. Background Localized aggressive periodontitis (LAgP) is an aggressive form of periodontal disease characterized by early onset and familial aggregation, presenting rapid destruction of the periodontal attachment around incisors and first molars in otherwise healthy individuals. 1 Phagocyte ab-normalities and a hyper-responsive macrophage pheno-type have been reported as secondary features of LAgP. 1 If untreated, LAgP may lead to premature tooth loss. Thus, early diagnosis and effective periodontal treatment are of great importance. The combination therapy of scaling and root planing (SRP) with adjunctive antibiotics has been suggested as * Division of Periodontics, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine, Columbia University, New York, NY. Submitted February 2, 2017; accepted for publication May 7, 2017 doi: 10.1902/cap.2017.170007 the first line of treatment for AgP, in an attempt to reduce pathogenic bacteria and their byproducts, especially Aggre-gatibacter actinomycetemcomitans , which has been strongly associated with LAgP pathogenesis. 1,2 Surgical treatment might follow non-surgical periodontal treatment in cases of persistence of pathologic periodontal pockets and can in-clude both flap surgeries and regenerative procedures. Ide-ally, regeneration of the periodontal attachment apparatus should be the goal of periodontal treatment for severe cases. This involves not only eliminating the microbiologic etiol-ogy and thereby arresting the progression of destruction of disease but also regenerating the lost periodontal appara-tus, which restores the function and esthetics of the dentition and maximizes patient comfort and satisfaction. 3 Regenerative periodontal therapy can be achieved by conventional guided tissue regeneration (GTR), which in-cludes using tissue barriers for selection of cell popula-tions, 4 or application of growth factors such as enamel matrix derivative (EMD), for promoting regeneration. 5 The combination of EMD with different bone graft 182 Clinical Advances in Periodontics, Vol. 7, No. 4, November 2017

Treatment Of Localized Aggressive Periodontitis With Guided Tissue Regeneration Technique And Enamel Matrix Derivative

Fatemeh Momen-Heravi, and Philip Kang

Introduction: Aggressive periodontitis (AgP) is a form of periodontitis characterized by rapid attachment loss in otherwise healthy individuals. Although different treatment options have been explored for management of the disease, control of disease progression and subsequent regeneration of the attachment apparatus are considered the ideal treatment objectives. Limited evidence is available with respect to the efficacy of different regenerative materials in the treatment of AgP.

Case Presentation: The present case report describes periodontal regeneration techniques and 6-month outcomes in bilateral intrabony non-contained defects around mandibular first molars in a 21-year-old patient diagnosed with localized AgP (LAgP). Periodontal lesions were treated with regenerative therapy with enamel matrix derivative (EMD) and allograft on the right side and allograft with bioabsorbable collagen membrane without EMD on the left side. Treatment yielded favorable clinical outcomes in terms of probing depth reduction, clinical attachment level gain, minimal gingival inflammation, and radiographic bone fill. Radiographic bone fill was observed after 6 months, suggesting possible periodontal regeneration.

Conclusion: Both regeneration techniques used in this clinical report (guided tissue regeneration involving allograft and bioabsorbable membrane versus EMD combined with allograft without a barrier membrane) resulted in favorable outcomes in the treatment of deep (‡7 mm) non-contained intrabony defects in LAgP. Clin Adv Periodontics 2017;7:182-189.

Key Words: Aggressive periodontitis; bone resorption; guided tissue regeneration; periodontitis; reconstructive surgical procedures; regeneration.

Background

Localized aggressive periodontitis (LAgP) is an aggressive form of periodontal disease characterized by early onset and familial aggregation, presenting rapid destruction of the periodontal attachment around incisors and first molars in otherwise healthy individuals.1 Phagocyte abnormalities and a hyper-responsive macrophage phenotype have been reported as secondary features of LAgP.1 If untreated, LAgP may lead to premature tooth loss. Thus, early diagnosis and effective periodontal treatment are of great importance.

The combination therapy of scaling and root planing (SRP) with adjunctive antibiotics has been suggested as the first line of treatment for AgP, in an attempt to reduce pathogenic bacteria and their byproducts, especially Aggregatibacter actinomycetemcomitans,which has been strongly associated with LAgP pathogenesis.1,2 Surgical treatment might follow non-surgical periodontal treatment in cases of persistence of pathologic periodontal pockets and can include both flap surgeries and regenerative procedures. Ideally, regeneration of the periodontal attachment apparatus should be the goal of periodontal treatment for severe cases. This involves not only eliminating the microbiologic etiology and thereby arresting the progression of destruction of disease but also regenerating the lost periodontal apparatus, which restores the function and esthetics of the dentition and maximizes patient comfort and satisfaction.3

Regenerative periodontal therapy can be achieved by conventional guided tissue regeneration (GTR), which includes using tissue barriers for selection of cell populations, 4 or application of growth factors such as enamel matrix derivative (EMD), for promoting regeneration.5 The combination of EMD with different bone graft materials, EMD alone, and GTR have been evaluated in studies on treatment of intrabony defects associated with chronic periodontitis (CP), and significant improvement in clinical parameters has been documented.6 However, only a small number of trials have reported results on periodontal regeneration involving GTR with or without application of EMD in patients with AgP, and those results have been somewhat inconsistent.7,8 Although multiple lines of evidence showed favorable outcomes of regenerative periodontal surgery compared with open flap debridement (OFD), the benefit of GTR over conventional OFD was not evident in clinical outcomes of patients with AgP.8

This report describes a successful clinical outcome in the reconstruction of bilateral 1- and 2-wallbony defects in a patient with LAgP, comparing a conventional GTR technique using an allograft and bioabsorbable collagen membrane with the use of EMD and allograft in a split-mouth fashion.

Clinical Presentation

A 21-year-old African-American male without any significant health history was referred for a comprehensive periodontal evaluation at the Postgraduate Periodontics Clinic, College of Dental Medicine, Columbia University, New York, New York, in April 2016. He denied any history of smoking. Family history revealed premature edentulism in his mother. His dental history included regular dental visits since childhood. He had no dental caries and his oral hygiene was good (Fig. 1). He had received a dental prophylaxis every 6 months until 2 years prior to being referred to the clinic. Bilateral bone loss localized to the mandibular first molars was noticed, and his general dentist advised that he should be seen by a periodontist. Upon clinical examination, oral hygiene was very good, and the full-mouth plaque score (FMPS) at the initial visit was 5 mm), a vertical defect, and severe attachment loss (AL) were observed between teeth #29 and #30 as well as #19 and #20 (Fig. 2, Table 1). Bleeding on probing (BOP) was observed in the interproximal sites of teeth #19 and #20 as well as #29 and #30. No other area in the dentition presented AL or BOP except for the aforementioned sites. Based on his medical history, age, and periodontal examination, a diagnosis of LAgP was made. Written informed consent for treatment was obtained from the patient.

Case Management

The patient underwent phase I periodontal therapy that included patient education, oral hygiene instructions, adult prophylaxis, and localized SRP of affected regions in conjunction with 250 mg metronidazole and 500 mg amoxicillin (AMOX) three times daily for 7 days. Six weeks later, periodontal reevaluation was performed, and periodontal indices were re-recorded. Reevaluation revealed that initial therapy yielded an improvement in clinical parameters, reflected by a 1- to 2-mm decrease in the probing depth (PD) in both defects and absence of previously observed BOP on the distal aspect of tooth #20. The plaque index was reduced to <10%.

Periodontal regeneration was planned for treatment of the intrabony defects at both sites. Regenerative therapy with EMD† and allograft‡ was performed to treat tooth
30 (Fig. 3). The intrasulcular incision was made from

the mesial aspect of tooth #29 to the mesial aspect of tooth
31 at both buccal and lingual aspects. Full-thickness flaps

were reflected. Soft tissue debridement followed by thorough SRP was conducted to smooth the exposed root surface. A deep 2-wall defect (depth of 7 mm, width of 9 mm) was observed. The root surface was treated with 24% EDTA for 2 minutes, followed by copious saline rinsing. Allograft particles were soaked in EMD and placed to fill the defect. The flap was secured by simple interrupted sutures, using 5-0 bioabsorbable polyglactin 910.x

On tooth #19, the intrabony defect was treated with GTR with allograft‖ and a bioabsorbable non-cross-linked collagen membrane{ (Fig. 4). An intrasulcular incision was made fromthemesial aspect of tooth #20 to themesial aspect of tooth #18 at both lingual and buccal aspects. Full-thickness flaps were reflected. Soft tissue debridement followed by thorough SRP was conducted to smooth the exposed root surface. A deep combination defect (depth of 9 mm, width of 10 mm) consisting of a 1-wall defect at the coronal aspect and a 2-wall defect at the apical aspect was observed. The bony defect was filled with allograft and the bioabsorbable collagen membrane was placed after trimming to cover the site. Primary flap closure was achieved after periosteal release and simple interrupted sutures, using 5-0 bioabsorbable polyglactin 910.

After each surgery, the patient received meticulous postoperative instructions for plaque control. The patient received an oral antibiotic of 500 mg AMOX three times daily for 7 days and a non-steroidal anti-inflammatory drug, ibuprofen (600 mg), for 5 days. One 600-mg ibuprofen tablet was given immediately after each surgery and one after 8 hours; further doses of ibuprofen were taken when needed. The patient was advised to use amouthrinse of 0.12%chlorhexidine (CHX) for 1 minute twice daily for 4 weeks. Instruction was given to the patient to gently swab the surgical site with a cotton swab soaked in 0.12% CHX solution. Sutures were removed 2 weeks after surgery. The patient was placed on a meticulous maintenance program involving weekly monitoring for the first month and monthly monitoring for the next 6 months. In the follow-up sessions, oral hygiene was reinforced, and supragingival plaque removal was done. Clinical attachment level (CAL) and PD were recorded at baseline, reevaluation, and 6 months after surgery. Periapical radiographs were taken at the initial examination and at 6 months.

Clinical Outcomes

Patient compliance and plaque control were very satisfactory. Six month post-surgery periodontal indices (PD, CAL, BOP) provided evidence of substantial clinical improvements. At the mandibular right side treated with EMD and allograft, the PD at 6 months after surgery was 2 to 3 mm without any recession, indicating a 6-mm improvement in PD at the mesio-buccal aspect of tooth #30 (Table 1).At the mandibular left side treated with GTR, the PD at 6 months after surgery was 2 to 3 mm, indicating a 7-mm improvement in PD at the mesio-buccal aspect of tooth #19. A 2-mm recession was notable at the mesio-lingual aspect of tooth #19 (Table 1). The attached gingiva maintained a healthy appearance throughout subsequent visits, with no signs of edema or BOP. The postoperative radiographs taken at 6-month post-surgical treatment revealed radiographic evidence of bone fill by both techniques. The radiographs were standardized by the placement of acrylic resin on posterior bite blocks and recorded at the maximum intercuspal position to ensure the reproducibility of the radiographic technique in the occlusal plane. Quantification of bone fill using image processing software# showed 50% area bone fill and 2.9-mm vertical bone fill at the mesial aspect of tooth
19 treated with GTR and allograft and 53% area bone fill and 3.1-mm vertical bone fill at the mesial aspect of tooth
30 (Figs. 5 and 6).

Discussion

GTR and EMD-based regeneration are two treatment modalities to support periodontal regeneration relying on two distinct biologic pathways. In spite of differences in concept, comparable results were achieved in the present case report for treatment of LAgP after 6 months of followup at both sides. GTR and EMD plus allograft application without presence of occlusive membrane led to bone fill of 50% and 53%, respectively, in deep (‡7 mm) intrabony non-contained defects. PD reduction and CAL gain of ‡6 mm was achieved in both treatment modalities. The follow-up radiographs obtained by a standardized approach showed increased density immediately after surgery through 6 months after surgery, suggesting bone fill and possible periodontal regeneration.

Although many studies have investigated the clinical outcomes of GTR versus EMD,6 a number of limitations and inconsistencies are present in the literature. Only some studies examined the efficacy of regenerative procedures using GTR or EMD application in patients with AgP, mostly without use of simultaneous bone graft with EMD application.7,10,11 In most parallel studies published on regeneration techniques in intrabony defects,12 patient characteristics and disease diagnosis (AgP versus CP) were not taken into account, and studies reported collective results with regard to bony defects rather than disease diagnosis and characteristics. In a recent comparative study conducted by Artzi et al.,13 the authors retrospectively evaluated and compared the two regenerative periodontal procedures of GTR with deproteinized bone xenograft and bioabsorbable collagen membrane versus combination therapy of EMD plus deproteinized bone xenograft in young individuals with AgP. They reported similar clinical results in terms of PD reduction and CAL over 1 year of study.13

Studies comparing GTR and EMD did not find significant differences in the clinical outcomes of two treatment modalities.6,14 However, most studies did not take into account the different intrabony configurations as a variable factor in the interpretation of outcomes. Effect of bone defect morphology is well documented in studies considering short- and long-term regenerative outcomes.6 In a study conducted by Siciliano et al.,15 superior clinical outcomes were observed in terms of PD reduction and CAL gain for treating 1-wall defects in the GTR group compared with the EMD group. In a systematic review conducted by Esposito et al.,14 no evidence of significant difference in clinical outcomes was found between GTR and EMD in the treatment of intrabony defects.However, use of bone substitute material was associated with less soft tissue recession compared with the application of EMD alone.14 Considering these reports, the non-contained 1-wall defect present at the left side was treated by GTR as opposed to EMD. Allograft was added to the EMD to provide mechanical support for the soft tissue during the healing phase.13 Stability of regenerative outcomes is expected after 1-year follow-up, as a similar study reported stability of CAL and PD and comparable results between 6 months and 1 year of regenerative treatment in patients with AgP.8 Specifically, Rakmanee et al.8 reported 1.6- and 1.7-mm gain in CAL at 6 and 12 months, respectively, after GTR treatment in patients with AgP.

Further studies would be beneficial in determining a possible correlation between the configuration of the intrabony defect and the type of regenerative application and treatment outcome in long-term follow-up.

In addition to flap design, choice of biomaterial, surgical technique, and meticulous execution of the surgery, patient compliance and strict maintenance and home care regimen appear to be key factors in treatment outcomes, regardless of the surgical mode of operation. Although this aspect is under-investigated in regenerative outcomes in patients with AgP, it has been shown that elements of plaque can trigger inflammation and counteract wound healing in periodontal regeneration.6 FMPS or full-mouth bleeding score of <25%has been suggested as acceptable oral hygiene status before regenerative surgery.16 In the present case report, the patient was placed on a stringent maintenance program, and plaque control was meticulous. Meticulous oral care was reported to result in long-term predictable outcomes in patients with AgP and slowing of the disease progression.17

Use of regenerative treatment modalities, as well as meticulous maintenance and acceptable oral hygiene, may lead to satisfactory clinical outcomes in regenerative treatment of intrabony defects in LAgP. In the present case, use of EMD in and a bone graft without barrier membrane led to excellent clinical outcomes in the treatment of deep 2-wall intrabony defects. Well-designed studies are needed to investigate the role of patient-related factors, surgical techniques, and biomaterials in regenerative outcomes of patients with AgP.

Summary

Why is this case new information?

■ EMD can be used with bone graft without occlusive membrane for regeneration of deep intrabony (>7 mm) defects in treatment of LAgP.

What are the keys to successful management of this case?

■ Stability of the graft, strict plaque control, and use of regenerative biomaterial and bone substitute materials are required.

What are the primary limitations to success in this case?

■ Patient compliance affects treatment outcomes.

Acknowledgment

The authors report no conflicts of interest related to this case report.

CORRESPONDENCE:

Dr. Philip Kang, Division of Periodontics, Section of Oral, Diagnostic, and Rehabilitation Sciences Columbia College of Dental Medicine, Columbia University, #PH7E-124, 630 W. 168 St., New York, NY 10032. E-mail: pyk2104@cumc.columbia.edu.

References

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2.Gunsolley JC, Ranney RR, Zambon JJ, Burmeister JA, Schenkein HA. Actinobacillus actinomycetemcomitans in families afflicted with periodontitis. J Periodontol 1990;61:643-648.

3.Miliauskaite A, Selimovic D, Hannig M. Successful management of aggressive periodontitis by regenerative therapy: A 3-year follow-up case report. J Periodontol 2007;78:2043-2050.

4.Gottlow J. Guided tissue regeneration using bioresorbable and nonresorbable devices: Initial healing and long-term results. J Periodontol 1993;64(Suppl. 11):1157-1165.

5.Yilmaz S, Cakar G, Yildirim B, Sculean A. Healing of two and three wall intrabony periodontal defects following treatment with an enamel matrix derivative combined with autogenous bone. J Clin Periodontol 2010;37:544-550.

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7.Zucchelli G, Brini C, De Sanctis M. GTR treatment of intrabony defects in patients with early-onset and chronic adult periodontitis. Int J Periodontics Restorative Dent 2002;22:323-333.

8.Rakmanee T, Griffiths GS, Auplish G, et al. Treatment of intrabony defects with guided tissue regeneration in aggressive periodontitis: Clinical outcomes at 6 and 12 months. Clin Oral Investig 2016;20: 1217-1225.

9.O’Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38.

10.Buchmann R, Nunn ME, Van Dyke TE, Lange DE. Aggressive periodontitis: 5-Year follow-up of treatment. J Periodontol 2002;73:675-683.

11.Roshna T, Nandakumar K. Generalized aggressive periodontitis and its treatment options: Case reports and review of the literature. Case Rep Med 2012;2012:535321.

12.Corbella S, Weinstein R, Francetti L, Taschieri S, Del Fabbro M. Periodontal regeneration in aggressive periodontitis patients: A systematic review of the literature [published online ahead of print October 25, 2016]. J Investig Clin Dent. doi:10.1111/jicd.12245.

13.Artzi Z, Tal H, Platner O, et al. Deproteinized bovine bone in association with guided tissue regeneration or enamel matrix derivatives procedures in aggressive periodontitis patients: A 1-year retrospective study. J Clin Periodontol 2015;42:547-556.

14.Esposito M, Grusovin MG, Papanikolaou N, Coulthard P,Worthington HV. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. A Cochrane systematic review. Eur J Oral Implantol 2009;2:247-266.

15.Siciliano VI, Andreuccetti G, Siciliano AI, Blasi A, Sculean A, Salvi GE. Clinical outcomes after treatment of non-contained intrabony defects with enamel matrix derivative or guided tissue regeneration: A 12-month randomized controlled clinical trial. J Periodontol 2011; 82:62-71.

16.Cortellini P, Nieri M, Prato GP, Tonetti MS. Single minimally invasive surgical technique with an enamel matrix derivative to treat multiple adjacent intra-bony defects: Clinical outcomes and patient morbidity. J Clin Periodontol 2008;35:605-613.

17.Nibali L, Farias BC, Vajgel A, Tu YK, Donos N. Tooth loss in aggressive periodontitis: A systematic review. J Dent Res 2013;92: 868-875.

indicates key references.


Division of Periodontics, Section of Oral, Diagnostic, and Rehabilitation Sciences, College of Dental Medicine, Columbia University, New York, NY.

Submitted February 2, 2017; accepted for publication May 7, 2017

doi: 10.1902/cap.2017.170007

Read the full article at http://onlinedigeditions.com/article/Treatment+Of+Localized+Aggressive+Periodontitis+With+Guided+Tissue+Regeneration+Technique+And+Enamel+Matrix+Derivative/2908843/445120/article.html.

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