Cases reported "Periodontal Diseases"

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1/83. guided tissue regeneration in the management of severe periodontal-endodontic lesions.

    diagnosis of combined periodontal-endodontic lesions can prove difficult and frustrating. They are often characterised by extensive loss of periodontal attachment and alveolar bone, and their successful management depends on careful clinical evaluation, accurate diagnosis, and a structured approach to treatment planning for both the periodontic and endodontic components. Recent advances in regenerative periodontics have led to improved management of periodontal-endodontic lesions. This paper reviews the management of such lesions in light of these recent advances and illustrates this through reports of two patients who had severe periodontal involvement.
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2/83. Effective periodontal treatment in a patient with type IIA von Willebrand's disease: report of a case.

    von Willebrand's disease (vWD) is one of the most common hereditary hemorrhagic disorders. A mild to moderate deficiency of factor viii and von willebrand factor (vWf) often is associated with gingival bleeding. In this case report, the periodontal treatment of a patient with vWD is described. A 45-year-old woman with type IIA vWD was referred for periodontal therapy because of an episode of gingival hemorrhage and percussion pain of teeth #18 and #47. The periodontal findings included probing depths ranging from 2 to 6 mm, horizontal bone loss, and Class II furcation involvement of tooth #46. After consultation with a hematologist, apically positioned flap surgery and hemisection were performed on tooth #46 following completion of oral hygiene instruction, scaling and root planing, and endodontic therapy. The patient was given 500 units of factor viii including vWf multimer 30 minutes before surgery. After healing of the periodontal tissue, prosthodontic treatment was undertaken on the posterior mandibular sextants. At follow-up, the probing depths ranged from 2 to 3 mm, and gingival bleeding on probing was minimal. The patient's children all had vWD. They had mild to moderate periodontitis with probing depths ranging from 2 to 5 mm and gingival bleeding on probing. With the combined efforts of the periodontist and hematologist, effective periodontal treatment can be provided to patients with von Willebrand's disease.
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3/83. Enamel matrix derivative for periodontal reconstructive surgery: technique and clinical and histologic case report.

    This paper describes a step-by-step technique for the application of Emdogain, a new enamel matrix derivative (EMD) graft material, for periodontal reconstructive surgery. A case report is presented with a 1-year follow-up. The rationale for use and advantages and disadvantages of EMD are discussed. An additional human histologic case report demonstrates that the formation of new bone, cementum, and periodontal ligament is possible following the use of EMD.
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4/83. Functional and esthetic outcome enhancement of periodontal surgery by application of plastic surgery principles.

    The closure of surgical wounds in a layer-by-layer fashion, a common principle of plastic surgery, is applied in this article to the field of periodontal surgery with the introduction of a new flap design. The suggested technique is indicated with all periodontal procedures that aim for hard and soft tissue augmentation (guided bone regeneration, mucogingival surgery, or plastic periodontal surgery) where passive, tension-free wound closure is fundamental for wound healing and a successful functional and esthetic outcome. By means of a series of incisions, buccal and lingual flaps are split several times; this results in a double-partial thickness flap and a coronally positioned palatal sliding flap, respectively. Thus, several tissue layers are obtained and the passive advancement of flaps becomes possible for the coverage of augmented areas. Wound closure with microsurgical suture material is accomplished in a multilayer approach, which ensures adaptation and closure of the outer tissue layers without any tension. Two case reports demonstrate the new plastic periodontal approach.
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5/83. Periodontosis: a phenotypic and genetic analysis.

    Two families who provide additional data concerning the metabolic, radiographic, and clinical parameters of periodontosis are presented. These findings include decreased serum alkaline phosphatase levels with absent liver isozyme fractions, decreased tubular bone over-all width and medullary space with relatively increased cortical area, and at least one case of primary dentition alveoloclasia with no permanent dentition alveoloclasia. In addition, a segregation analysis was performed on these two families and all completely reported families found in the literature. The results indicate that periodontosis is most probably inherited as an X-linked, dominant trait with decreased penetrance but relatively consistent gene expressivity. The female: male ratio of affected persons is approximately 2:1, and there is an over-all deficiency of males in these affected families.
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6/83. The periodontal management of a patient with a profound immunodeficiency disorder.

    A case of severe, uncontrolled periodontal disease in a patient with a profound immunodeficiency disorder is reported. The periodontal disease was noted before the age of 10 years and is generalized, with marked associated alveolar bone loss, even threatening a mandibular fracture. Severely involved teeth were allowed to exfoliate, and extractions were avoided. At the age of 17 years, the patient now has only nine remaining teeth. The management adopted and alternative approaches are critically reviewed. The implications of the dental findings for current concepts of the pathogenesis of periodontal disease and dental caries are discussed.
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7/83. Subgingival plaque and loss of attachment in periodontosis as observed in autopsy material.

    Histologic sections from six autopsy cases which from a clinical point of view fitted into the criteria of periodontosis were examined with the aim at evaluating the role of subgingival plaque in the etiology of the loss of attachment in this condition. The following pertinent observations were made: 1. The subgingival plaque in most instances was not calcified to form calculus. 2. The thickness of the subgingival plaque varied between 20 and 200 mu (0.02-0.2 mm). 3. Where loss of attachment had taken place, the distance from the most apical part of the subgingival plaque to the most apical point of the epithelial cuff varied between 0.2 and 1.1 mm; this distance was never found to be more than 1.1 mm. This would indicate a cause and effect relationship, the plaque being the obvious cause. 4. There was very severe chronic inflammation in the soft tissue bordering upon the plaque with resulting collagenolysis. 5. The cellular infiltration and the collagenolysis may be limited to a zone of 1 to 2 mm in the immediate vicinity of the plaque. Between the inflamed area and the surface of the gingivae buccally and lingually there may be a fairly wide zone of healthy tissue which hides the symptoms of inflammation from being observed on a clinical examination. In turn this could leave the clinician with the impression that attachment has been lost and bone resorbed because of degenerative changes. The following conclusions can be made: In these six cases of "alveolar bone loss vastly out of proportion to what one would expect from the local etiologic factors in the patient at that age" there was no morphologic evidence that degenerative changes were responsible for the loss of attachment. On the contrary inflammatory changes induced by the subgingval plaque dominated the histopathologic picture.
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8/83. Congenital neutropenia. Report of a case and a biorationale for dental management.

    Congenital neutropenia is characterized by a marked decrease in or lack of circulating PMN's in children with no prior history of drug intake. The neutropenia is persistent and the clinical course is one of early onset of severe, recurrent, and eventually fatal infections. bone marrow studies show a maturation arrest of neutrophilic precursors. Because of their greatly increased susceptibility to infection, patients with congenital neutropenia present a difficult dental management problem. A case of congenital neutropenia has been presented, as well as a biorationale for dental treatment. On the basis of reports in the literature, the following recommendations for the management of patients with congenital neutropenia are made: 1. The prevention and control of infection and the interception of dental disease before surgical intervention becomes necessary should be the overriding considerations in the management of patients with congenital neutropenia. 2. The carious breakdown of teeth should be prevented by the daily application of a 0.4 per cent stannous fluoride gel in addition to oral hygiene and limitation of sucrose intake. 3. Periodontal therapy should be palliative only, since alveolar bone loss is progressive despite frequent oral hygiene instruction and prophylaxis. The goal of periodontal therapy for patients with congenital neutropenia should therefore be a decrease in gingival inflammation to make the patient's mouth more comfortable and to slow down alveolar bone loss. Periodontal surgery is contraindicated. 4. bacteremia and subsequent septicemia should be prevented since a minor infection can become life threatening in patients with congenital neutropenia. The patient should rinse for 30 seconds and the gingival sulci should be irrigated with a phenolated antiseptic mouthwash prior to all dental manipulations of the soft tissue. This will significantly reduce the incidence of bacteremia. 5. Surgery should be avoided if at all possible because of the high risk of post-operative infection. All surgery sholld be performed in the hospital, and the patient should be given antibiotics as determined by his physician. Primary closure should be done with fine polyglycolic acid sutures to reduce the chance of infection. If postoperative infection can be prevented, wound healing will progress normally despite the complete absence of PMN's.
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9/83. Implant site development using orthodontic extrusion: a case report.

    One of the most important factors in the successful placement of endosseous implants is the presence of adequate alveolar bone at the recipient site. alveolar bone loss associated with destructive periodontal disease frequently results in osseous defects that may complicate subsequent implant placement. Typically, such defects are treated prior to or at the time of implant surgery using the principles of guided bone regeneration. Under certain circumstances, however, such defects may be managed non-surgically by orthodontic extrusion. orthodontic extrusion can be used to increase the vertical bone height and volume and to establish a more favourable soft-tissue profile prior to implant placement. The addition, the increase in the vertical osseous dimension at interproximal sites may assist in the preservation of the interdental papillae and can further enhance gingival aesthetics. This report illustrates the treatment sequence for site development with orthodontic extrusion prior to immediate implant placement.
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10/83. The relationship between peripheral levels of leukocytes and neutrophils and periodontal disease status in a patient with congenital neutropenia.

    BACKGROUND: Congenital neutropenia is characterized by an almost total absence of neutrophils and increased susceptibility to infection. oral manifestations include ulcerations of mucous membranes, acute gingival inflammation with focal necrosis, and rapid loss of attachment. Treatment with recombinant human granulocyte colony-stimulating factor (rhG-CSF) increases neutrophil numbers and ameliorates the periodontal status. methods: We report the treatment of a 22-year-old male with congenital neutropenia (Kostman syndrome), referred to us due to periodontal disease, and the effect of treatment on peripheral neutropenia. diagnosis of neutropenia was made at year 1; at age 15, the patient started to receive injections of rhG-CSF, reducing the occurrence of infection and improving neutrophil count, although levels remained below normal. The patient underwent extraction of a molar at age 8; scaling, root planing, and modified Widman flaps at age 9; and oral hygiene maintenance every 2 to 3 months from age 18 to 21. At age 23, he initiated treatment at our periodontal clinic. The patient's gingiva was severely inflamed, and the dentition was covered with plaque and calculus. Attachment loss was advanced, all teeth were mobile, and bone loss was approximately 75% in most sites. Neutrophil counts were below normal, but other hematologic parameters were normal. Scaling and root planing were performed and the patient received antibiotics and chlorhexidine rinses twice each day for 2 weeks. Extracoronal splinting was performed, fluoride varnish was used to desensitize cervical areas, and tooth FDI #46 was restored. root planing and deplaquing were repeated, and the patient received subgingival chlorhexidine irrigation 13 times over one year. Assessments were made on presentation, after the initial treatment, and at 1 and 2 years post-treatment. RESULTS: Mean probing depth was reduced posttreatment with a further reduction during the maintenance period. This was correlated with an increase in attachment levels. Total white blood cells increased, due in part to an increase in neutrophils, reaching normal levels. CONCLUSIONS: This report demonstrates for the first time that periodontal therapy, resulting in decreased bacterial load, may result in restoration of normal levels of circulating neutrophils in individuals with congenital neutropenia under treatment with rhG-CSF. The results also suggest that periodontal pathogens may be associated with depressed neutrophil levels, even when patients receive treatment for neutropenia.
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