Five years later:

During the intervening five years, the patient had visited a local dentist and had prophylaxes twice a year. His oral hygiene was good. He did not take any antibiotics during this five-year period.

Clinical photo 5-yrs post-op.	X-rays 5 years later.

Examination revealed little marginal inflammation. The gingival tissue tone was good and the patient was comfortable in all parts of his mouth. Caries was noted on tooth # 20. Portions of the A-splint were cracked and in need of repair. However, instead of presenting with a hopeless dentition, the teeth exhibited a favorable prognosis.

Fourteen year follow-up:

The patient was examined one other time, in 1991. At this visit, the gingival tissues were still healthy, no significant deterioration had occurred, but new restorations were in place. Since some of these restorations were unsatisfactory, arrangements were made to have them replaced. However, the patient has not returned to this office since.

Fourteen year follow-up

Discussion:

In 1977, the concept of rapidly progressive periodontitis did not exist. What was known was that this case did not follow any of the usual patterns of breakdown. It was difficult enough to devise a logical treatment plan for the patient, and it was made harder by being limited to only 10 weeks for treatment. What criteria could be used to formulate a treatment approach, given the paucity of similar examples at that time (and since)?

1. It was important to keep the integrity of the arches intact. This prevented the need for selective extraction and a commitment to a prosthetic restoration that the patient did not have the time to receive (in this country).
2. At the same time, it was decided not to keep any tooth that would jeopardize "sound" abutments. The reality was, however, that no posterior tooth would make a sound abutment to support a prosthesis(SIGMA)so try to keep all of them.
3. It was decided to immobilize the loose teeth. (These teeth had mobilities of two and three). Otherwise, the teeth were so loose it would have been too difficult to perform the surgery, plus healing and post-operative pain are worse on mobile teeth.
4. Local etiologic factors were identified and treated: plaque, calculus, suppuration, severe mobilities, poor oral hygiene, etc.
5. Since nearly all posterior teeth in both arches were deemed hopeless, there was little risk to treating them. A definitive treatment plan would have included wholesale extractions(SIGMA)and by todays standards, this would have been an implant case.

Adult periodontal disease has been described in all sorts of ways, from analyzing its bacterial components to implicating genetic predispositions to immunologic responses. The patterns of periodontal breakdown are classic. Yet when we see a variation to the "norm," are we witnessing a poor host response or a new disease? In this case, not only did the behavior of the disease entity defy conventional descriptions, but so did the shape and extent of the periodontal defects. As it turns out, so, too, did the healing.

So what was the key to treating this case? The bone grafts? Probably not. The A-splinting? That may have helped. Though it cant be proved, the most important aspect of care rendered here was placing the patient immediately on antibiotics. As luck would have it, he responded well to tetracycline. In essence, this was not a case of chronic periodontitis that rapidly advanced, it might better be described as an acute infection of the periodontium(SIGMA)like tonsillitis or appendicitis. Once the bugs were suppressed by the antibiotics, periodontal treatment gave the tissues a chance to heal.

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