Aggressive Periodontitis Treatment Plan: Flap surgery, Emdogain, and Grafting?

Hey...great questions. I am a periodontist and have been in practice for over 25 years. I will tell you straight out, although you do have a form of early onset periodontitis, your case is very treatable. I have seen much worse! As for emdogain, yes, it can be expensive. The material cost is high and there is no guarantee that regeneration will occur. I have had success with this material but truth be told, it works best in 3 walled "more" defects. Most of your bone loss is flat and mainly horizontal in nature. Maybe I am a tad old school, but most of your issues can be resolved with "osseous" or pocket reduction surgery. With good pocket reduction and then strict recalls, I really think you will have great results. Now don't get me wrong, I do all of the latest and greatest...and if a site is amenable for grafting, I will certainly consider...but there is no question that in some cases (and yours may be one) a more definitive and predictable answer may just be pocket reduction surgery (read Kaldahl et al. J Perio, 1992) a great longitudinal study that supports this) . So don't despair! Your case is very treatable and seriously NOT THAT BAD! No need to feel like emdogain, GEM-21 or any biologic is the only way to go. You can also ask about using PRF. A great way to introduce growth factors that are harvested from your blood...much less expensive! But again, only in areas that are truly amenable for grafting....and most of your bone loss is not. Neil Zachs Periodontist, Scottsdale AZ

I think Dr. Zachs comments are correct and it is certainly very appropriate for treatment to be rendered by a periodontist. My only suggestion as an oral surgeon would be to consider taking out the remaining 4 wisdom teeth. There is always controversy when asymptomatic (non painful) malposed or impacted wisdom teeth are present. However pain is a poor predictor for chronic issues . The bone loss and pocketing of the upper wisdom teeth are an example of that. Being difficult to maintain do to being so far back might also be contributing to the bone loss of the second molars. The lower wisdom teeth are horizontal full boney impactions and serve no useful purpose and being in that position more than likely have caused the loss of bone on the distal of the second molars. At the time of their removal I would graft these sites to try to generate some bone fill. The removal of these teeth by a qualified OMFS should not be that difficult that nerve injury would be an issue. Although I am not a proponent of coronoplasty that is an option determined by the surgeon.

That is an excellent response Neil. The only thing that I would add to this is that the treatment of periodontal disease is a lifetime effort. You should expect to be seeing your periodontist or dentist every three months to stay on top of your oral hygiene, In addition, your homecare needs to be exceptional (and it may be already). As for the biologics, every practitioner has procedures that work well in their hands with their clinical experience and they may have had excellent results with this material in the past in conjunction with surgical intervention.

Excellent suggestions above..... we have not been shown photographs of your mouth, we do not see the inflammation in the teeth that are affected...I agree all the wisdom teeth should be extracted, and if you are interested, choose either the left or right side upper molars and allow your periodontist to use the Emdogain on the side you have chosen..... and compare it to the untreated side three years down the road....then you will see if this procedure has worked for you....in the meantime, vigorous oral hygiene must be done several times a day, see t the periodontist every three months and....please keep us posted and let us know how it worked out in 2022.

I would recommend DNA culture, then thorough closed SRP with an antibiotic if indicated by DNA culture. I would re-evaluate in a couple of months and only then would I consider flap surgery. I would also do complete occlusal analysis as part of initial closed scaling therapy

This is a perfect case for LANAP, the patient will get a predictable, positive response, without the traditional flap surgery or requested the use of emdogain, thereby making it a less expensive procedure and therefore he will be more apt to have the treatment done to control his periodontal disease.

I am a prosthodontist (teeth) – so I am a different type of specialist to a periodontist (gums). I explain this only so you understand that I am coming from a different perspective to the other writers. My objective is to have all my patients keep their teeth for a lifetime. Obviously whether this can be done is influenced by the age of the patient when they first present and the condition of their teeth and gums (ie how bad is the initial situation and how long can my restorations last). Having explained this, I can say that from my point of view, I agree with all the above comments. • Yours is not a ridiculously bad situation although as mentioned more detail is required. Your problem should be treatable • The wisdom teeth need to be extracted as there is considerable bone loss being caused by them • Grafting in the respective extraction sites would be sensible to consider Therefore the issue is who should perform the treatment and what treatment should be done. Grafting might be an option if you have specific pockets that could benefit from such treatment – but it is not likely grafting would be needed around all teeth (more detail required). It is important for you to realise that your best treatment is meticulous cleaning (by you) everyday. If you do not commit to this then you will continue to have problems. There are also different treatment options – and the truth is you will not get dentists to agree about this issue because they all have their own ideas and preferences. This probably does not matter as long as the respective treatments end up successful. This is not a recommendation but you could check “periolase” on Google and investigate it. It is a conservative treatment and reports are that it gets good results (remember I am not a gum specialist). In the end, you will have to trust your periodontist and if you are in doubt then get a second opinion (however remember my comment above – dentists often prefer different treatment methods). Please also realise that this forum is for dentists to discuss professional problems and ideas. We usually do not get all the clinical information required for an exact diagnosis or treatment decision. We are essentially just a discussion group. So it would be unwise to take our comments as accurate since we have not examined you personally and do not have relevant information that could be important to form final opinions. You treating dentist has to be your final “go to” person.

It has become more of a standard today to start with the most invasive treatment and observe what happens. Since there is a good likelihood in your case (age being the factor) that you suffer from some genetic disorder, a conservative approach would be a good start. There are no tests to determine if your condition is for sure because related to genetic or perhaps some neglect. I would like to see some reference point to refer to over a period of time. Record the condition as it is now in every possible way and consider it a starting point. Observe changes and make conclusions. For starters a thorough sub gingival curettage of all teeth should be undertaken and the future treatment plan determined in the future. Nothing drastic will happen in a span of 6 months to a year, guaranteed. The records should reflect radiographs, accurate probings and a 3D scan.

Hello, 30 yr periodontist here. I like the idea of conservative. There is so much we don't know about your case. Photos would definitely be helpful. Are the teeth loose. What's the occlusion ( bite). Are you grinding? I would not be so quick to extract those lower 3rd molars. Big defect left behind. Plenty of time to extract those once your periodontist has a handle on the disease process. Maybe antibiotic with scaling and root planning. No reason not to culture first to get an idea of which antibiotic to use. I don't think you need a DNA test. No way to know how successful treatment will be with this info. If teeth are loose and you cannot get a handle on bite and disease process, treatment may not work. If you respond to conservative treatment, then you an look at Emdogain or Gem 21, flap surgery etc. Bone grafts without biologics are not really that successful. You have to pick your sites. Trust your periodontist. Start slow, see the response, add to it, see the response. No surgery yet IMO, no extractions yet. Gotta be certain of the real goal & benefits of surgery, since you will lose bone just by opening the case and you are already pretty advanced. Agreed that this case has possibilities. We've all had them. Most do well, others tank over time. Slow and steady. I have a few very advanced cases that are only maintained by cleaning every 3 months and antibiotics every year and a half/2yr. These were so advanced, I wouldn't open or cases that did not respond to full mouth surgery.

Definitely get a Lanap consult !!!

All comments really valid, representing the diversity of periodontal treatment planning from around the world. May I suggest to possible consider laser assisted initial periodontal therapy, with use of Er,Ch:YSGG (2780nm) and diode lasers (dual wave)..or even consider LLLT (photobiomodulation) in combination with antimicrobial photodynamic therapy (PDT). The aim would be to control the initial symptoms (with emphasis on home care oral hygiene), reassess and then possible consider other options, including long term supportive maintenance, should majority of the sites respond well to the non-surgical therapy. All the best..

I have been a dentist for 40 years and I get more question about perio diagnosis and treatment than anything else. Patients, as you, get on these sites for quick easy answers. I don't like that. Your dentist is a professional and knows you much better than I know you. I am a big advocate of trusting one's professional. When my accountant or lawyer or medical doctor tells me something, I have many years of building confidence with them. I don't know what they know. You should do the same. Now I am not saying this is an absolute trust... with my wallet that is. Periodontists are exceptional at what they do. If you had presented this treatment plan from a GP, I might get a second opinion. This google stuff makes everyone an 'expert' and I don't like it...yes, I know, my wife says I am an old man

In response to the last comment, I do not see how TRUST can be an issue if this individual has just begun with the periodontist. In addition, since as you say, there is a great deal of variety in treatment options in periodontal therapy, I think it is quite wise for this individual to seek other opinions. So to the patient, I strongly support your seeking other opinions regarding your treatment

Dr.T, Please listen to your wife. You are an old man. You live in a world that left some time ago.

Sorry, my message should have been directed to Mark. With regard to the number of years one had been in practice, the only response I know of is: so what. Each one of us needs to realize that the world revolves and if one refuses or has some other excuse to slow down the revolutions, things move on and the individual ends up in slow lane. Years in practice does not equal superior knowledge or a better understanding of the subject.

As a general dentist I would add my comment on obtaining excellent oral hygiene first before you start any treatment .Then you may find your situation improving .

Hello everyone and thank you so much for your responses. I am really heartened by the level of care and interest in this online community. I am grateful for your considerate responses and would like to address some of them by providing some more context. I was not and am not expecting that someone would 'diagnose' me online, I am just after some more informed opinion and advice. I am reasonably well educated and I like to make educated and informed decisions about my body, as much as I can. Hence my questions to this forum, which btw is a great resource! And, I like my periodontist...he tells long stories about gum disease and provides ample information, and i generally agree with his diagnosis and believe in his advice. So I am not after a 'google' diagnosis:) Also, to make it clear, I know fighting periodontitis is a lifetime thing for me, I have to maintain very good dental hygiene for the rest of my days and even then I might not be in the clear with bone loss and periodontitis, but at least I have a good chance of postponing teeth loss. Like my periodontist says, its like having diabetes....you can't just stop treating it. I am sorry but I don't have photos of my mouth. But as far as I can tell there has been no mobility in my molars, although quite a bit of gum receding in some places, so that on my right upper side i do have a rather big gap between two teeth. BUT my teeth are not wobbly. Unfortunately my situation is such that exploring some options mentioned above is beyond me. I think that my periodontist, whom I have seen twice now, does not do LANAP - he never mentioned it. Either way, I don't have the time to explore that option...I am based in South Africa, but in two weeks i will be in the UK for a year teaching....so will come back to SA only during semester breaks. I dont't have time to explore some of the other options, including LANAP, as I just don't have time in the next year to start with another periodontist, go back and forth with 2-3 meetings, etc. I can't even try and do it in the UK as the cost might be too much. And most importantly, I would like to get my pockets cleaned and hopefully stop the disease within the next year, so postponing it for too long is also not a good option. So my circumstances make it a somewhat most likely option to go with the flap surgery and cleaning and then regular 3 monthly follow up cleanings. Ideally, I would like to look into LANAP, or even more conservative approaches, but that would take time I dont have. It is a situation of doing what is best possible over what is ideal. Anyway, your responses have made me think about this wisdom teeth issue. My very basic follow up question is: could someone explain please my which mechanism, or how, do wisdom teeth contribute to my bone loss? I am asking this because I am thinking of discussing that issue with my periodontist and eventually get the wisdom teeth extracted. Thanks again for all your advice

I posted earlier too. 30 year perio here. your wisdom teeth came in sideways. Bone never grows where enamel is on the tooth and your enamel butts up against the back of your second molars. You may have never had much bone there. Would have been great to remove them when younger. You're still pretty young but getting those defects to fill in is much more of a gamble. Emdogain is great, Love the stuff, but it does not work everywhere all the time. My personal opinion is work on the highest priority first. Wisdom teeth are not your highest priority. Get healthy, confirm your bite is good and your teeth are not loose. You cannot tell this as well as your periodontist can. Ask him. Watch for clenching and grinding because it is so destructive. Get root planning and scaling and home care instructions ( most important thing) and see how you response. Surgery after that. Not an Lanap fan. I agree with Dr. Sachs, go with tried and true

Dear Periodontal Patient: Without examining you clinically and just looking at OPG I will suggest you that first of all get extracted the upper last molars (tooth number 18, 28), because they will continue to extrude and will be the cause of pushing food so much so that these teeth may also disturb the area behind your teeh numbers 37 & 47. It appears that flap surgery can be postponed and periodontal condition can be kept under observation teaching and giving you instructions on meticulous oral hygiene. In case flap surgery is opted in near future it may be papilla preservation rather than the pocket reduction. Pocket reduction doesn't appear a good idea in your case right now and one may watch and observe the success of papilla preservation with good oral hygiene with the aim to control the reaccumulation plaque taking the help of disclosing solution / tablets. The lower wisdom teeth (numbers 38 & 48) must also be kept under observation and their extraction can be postponed for at least two or more years.

I can help you. Listen very carefully. Im kind of genius not a dr. So i dont take any responsbility and so and so . If you with me still take deep breath im smart most of the dr and dont have intrest so Everyone full of shit. What you gonnaß to do .is no no to surgery. Prob. Your teeth fall in the process cause you have civir bone lost. The treatment protocol. Is to clean deep clean every mounth long time of year and half. Brush with water like power clean special tool and lil' brush between the teeth. Then wash all with chlorxidine. Then Take a scan again and thanks me later.

Dear all I would like to thank all of you who posted constructive comments on my initial question. I wanted to give you a brief update. On Tue I had my flap surgery and cleaning. It went by quickly for me given that I was under some anaesthesia but still awake. Anyway, my perio was happy with it, he said everything went well. I did ask him to not put Emdogain in at least one area so that we can compare the results in a few years, which he agreed to do. The plan was that the least worst affected area would be left Emdogain-free. But, although I still don’t recall correctly our conversation as I was quite woozy, I think he ended up telling me he did put it into all areas because he wanted to finish the vial, and I did have some really severe bone loss. Well, at least it ended up costing me half of what he quoted me for the Emdogain (around $600). He told me I had severe bone loss in the upper right hand corner tooth, and the bottom one as well. Not really a surprise, but perhaps he was a bit surprised given that it possibly looked worse than it did on my X-rays. Well, now I can only hope the cleaning did the trick and with vigorous self-disciplined regular cleaning, and 4 trips a year to the perio for cleans, I will keep my periodontitis at bay. As for the bone loss, maybe Emdogain will help with that (I don’t much think so), but no point in worrying about what has already happened. He did suggest the wisdom tooth on that side should come out in the next year, which was something I was asking him about given the advice I received here. So the next step is, if all else stays well with my gums, to get that right bottom wisdom tooth out. I do have some questions for you all, if you could oblige. My perio gave me an antibiotic to drink for 5 days (penicillin- Sandoz Co-amoxyclav 1000, 10 tablets), one pain killer to drink as needed (Gen-Payne codeine phosphate 10mg, ibuprofen 200mg, paracetamol 250mg, 30 tablets), and an antibacterial mouthwash to rinse with (as I am not supposed to brush) for 10 days (Corsodyl – Clorhexidine Gluconate 2mg/ml and ethanol 5.4% m/v). However, by Thur night (two days after the procedure) I started getting a really bad side effect, and I don’t know what it is from. Essentially, I started getting white ulcers inside my mouth. At first 2 and 3 on the left and right back sides of the throat, but by now 4 on the front outside bottom gum, and a few here and there inside the throat, and inside sides of my molar gums. It seems to be getting worse. It is pretty painful, in fact more painful than the sutured gums! I read all the clinical info that came with the drugs, and a bit online, and at first was sure the Corsodyl must be the cause. I asked my perio about it, he said he hadn’t had patients with those side-effects from the mouthwash, but that he had read about it. He suggested I try watering down the Corsodyl, or simply use lukewarm salty water. So I am on salty water now. But today I as doing a bit more research and I read that it is possible the penicillin could be the cause as of the mouth ulcers well. I excluded the penicillin and painkillers as a cause because I have had both of those in the past (not the exact same brands)….just in the last year I had a month worth of antibiotics for an unrelated thing, and painkillers for a coccyx operation. Never had any worse side effects than constipation. However, when I think about it, I am not sure if the antibiotics I have had in the past 2 years were penicillin-based. I am finishing the course of my penicillin tomorrow morning. My questions: Have you ever had any patients with similar side effects? Do you think it could be the mouthwash, or the penicillin? I would be very grateful for any experiences and insights you could share. Cheers

I would stop the chlorhexidine rinse...research shows that should NOT be used post perio surgery. I would suggest going to a health food store and finding a rinse with tea tree oil and use twice daily. I would also suggest taking garlic capsules or better yet whole garlic several times daily. Lastly, I would recommend Vit C up to 1,000 mg daily. Best of luck!!

It's pretty curious that no one has suggested the use of a simple antiseptic protocol of irrigating the pockets with povodine iodine for 5 minutes prior to debridement and the use of a dilute bleach mouthwash twice weekly. This is a protocol advocated by Prof Jorgen Slots. A review of the past 25 years of period research in Periodontology 2000 states that periodontal disease involves complex dynamic interactions among herpesviruses, specific bacterial pathogens and destructive immune responses. Orthodox therapy - mostly reliant on debridement with mechanical devices may not be enough in many cases. Add anti-infective agents to the treatment. I'm not saying the perio guys are wrong, I'm just saying that for many perio patients just cleaning is not enough.

By the way the crop of ulcers post surgery may indicate the presence of latent viruses in the tissues that have become activated by the trauma of surgery. I see this from time to time close to recent implant surgery sites. Those patients will say the implant site doesn't hurt but boy those ulcers do. A 'readable' set of articles about the tie up between herpesviruses and aggressive periodontitis can be found in the 2011 edition of the California Dental Association Journal from June of that year. You can view the journal online at no cost

What a fascinating discussion - (except for the genius of course)and that's what this forum is all about. A suggestion to ask your oral surgeon - when you eventually have your wisdom teeth out . There will be bone loss behind your second molars with the extraction of your wisdom teeth and as Joel suggested these areas will need grafting. Instead of using costly material to graft with there is a relatively new procedure of grinding up your extracted tooth and using those pieces as graft material. I have used this method whenever I need to and it really works well. Just something to keep in mind!!

Have you ever thought about [url=https://www.thommenmedical.com/en/dental-professionals/products/implantology/implant-system] Dental implant systems [/url]? This might be the key for a healthy bite.