Implants with Aggressive Periodontitis: suggested treatment plan?

I saw this patient (47 years old) for extraction of her maxillary left canine and lateral incisor and placement of a graft, 3 months prior.  I recommended extraction of all remaining maxillary teeth and replacement with implants.  She has a generalized, aggressive form of periodontitis and many of her teeth are mobile and with a poor long term prognosis.  She has declined the treatment plan.  What do you recommend as a predictable treatment plan?

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26 thoughts on “Implants with Aggressive Periodontitis: suggested treatment plan?

  1. This is more a patient management case than anything else. Extensive periodontal disease. She is going to lose most of her teeth. With all due respect, you have to make sure that the patient understands the situation pre-operatively. We are doctors, not miracle workers (for the most part). You opened a Pandora’s box. You’ve got to make the patient understand and find a way to close that box.

    1. Complex question with enormous open ended answers. The treatment plan I recommend is caution and compassion. This patient has advanced problems, and they need to own that. If they are open to that, I’d recommend identifying what got them to this stage without engaging in accusations of poor choices. Once the patient accepts their own problem and the causitive factors are addressed, it is then a matter of what the patient wants and what limitations (usually financial) they might face. Their treatment will ultimately depend on that factor. Once they commit to improving their dental health, then move on to a definitive treatment plan. Right now I believe judgements need to be made regarding acute elimination of pathology first, followed by repair of damaged teeth and soft tissues that will be needed in definitive treatments. I always want to “rush in” and ” save the patient”, but I have learned things turn out better if I completely, compassionately engage the patient before ever touching any non-emergent problem. Best of all to you and your patient.

    2. I’ll go ahead and offer a treatment plan based solely on my interpretation of the radiographic evidence as I can see it on this forum, with the assumption of a motivated patient who understands their role:
      1) CBCT. The data I glean is invaluable in educating the patient and knowing the true condition of each tooth and bone support. Along with a thorough periodontal exam.

      2) Extraction of maxillary teeth, removal of fixation screws, ridge grafting with L-PRF/particulate grafts and membranes, all impregnated with metronidazole, and delivery of a maxillary immediate trial denture.

      3) Laser microsurgery for the treatment of the mandibular arch on conjunction with L-PRF, including the implant. Again, this is offered making certain assumptions about existing perio conditions.
      This would be preceded by restorations where needed, stabilization of any teeth exhibiting pathologic mobility and careful occlusal adjustment to achieve lingualized contact and canine disclusion if possible.

      4) Supervised evaluation of healing, patient home care, and tolerance of mx denture.

      5) Secondary prosthetic/implant treatment as indicated/desired.

      So there is an option out there. Not easy, and an understanding, informed, and motivated patient is the foundation.

  2. She really has some issues going on….the Mandibular arch is out of control. Is she a Diabetic? And, Blood Sugar over 200? Some other Immune Deficiency? Long-time smoker? It appears her situation is beyond poor, as you said. I would want to know what was going on, metabolically, before placing any more Implants. However, all teeth need some Sunshine. Good luck!

  3. If she refuses the treatment plan that you recommend then do nothing. You have informed her of her problem and it’s up to her to follow your treatment plan. If she refuses then the consequences are hers. Make sure you tell her the long term prognosis (hopeless) and that you will do nothing more than a temporary partial denture to replace the anteriors until she commits to treatment. That could be as simple as a maxillary denture (in which case your bone graft was not needed) or as complex as maxillary implants. However, the entire dentition needs addressing before extensive, expensive treatment is contemplated. Many patients refuse treatment and that’s OK, doing nothing is also a treatment option so no need to feel guilty. I call this treatment option “supervised neglect”. We are watching a dentition fail, knowing full well the ultimate plan is removing the teeth but the patient isn’t quite ready to face that reality. Therefore, keep them in your practice and tell them when something hurts to give you a call. Sooner or later they’ll be ready to move forward with appropriate care.

    1. You have not gotten the patient to accept anything in tx. That’s the first step. And nowadays, not everything is implants. A tx plan she might go for is to remove hopeless teeth, place partials, and have her accept good ongoing perio tx. Tell her she might get 5-10 years if she maintains a good environment. Sometimes dentistry is about small steps rather than big ones. Patients are reluctant to lose teeth, even when they are hopeless

  4. Looks to me that she is facing a full denture on top. You might possibly retain teeth #’s 20,21,29,31 as abutments to support a removable partial denture for the lower to keep her out of a full denture there for as long as possible. I advise patients like this that ultimately they will lose their teeth. Offer them the best. If they do not accept this I agree that palliative care with a flipper is acceptable until they are ready to proceed. I also try to make these patients understand that you need bone to support and retain a denture or implant and the more the better. If they hang on to these teeth until the bitter end there will be no bone left to work with. Sometimes it is better to cut to the chase and be pro-active now to preserve as much bone as possible for whatever treatment plan you two agree on.

  5. The skill of preoperative assessment is the most important before a decision to insert implants .don’t think all the patient the same !!
    Also short courses will not qualify for doing any case.
    Good luck

  6. I wouldn’t have touched this patient for grafting or implants, which is clearly contraindicated as it is. Only 4 teeth in the lower jaw and none in the upper might be periodontally managable.
    Implant survival in patient with advanced periodontitis in my experience is very limited.
    IMHO either upper full , lower partial denture treatment indicated as definitive treatment or as pre-treatment for implants. In case of patient’s persistence for implant treatment, it can be full clearance with 6-8 implant for the top and 4-6 for the lower after full recovery and socket preservation and grafting.
    NOW
    I would ask patient if he/she agrees to have all the implant treatments done with limited survival chance and better if is ready to loose his money in worse case scenario or happy to undergo all the treatment with high risk of failure and let him sign and video it.
    If you ignore the above advice and carry o doing implant work for this patient you might be in for a fat law suit and sanctions.

  7. very common situation in my clinic. The patient must be explained the hopeless prognosis of the teeth and the importance of the remaining bone for the future. When I have full patient compliance, full mouth clearance, immediate placement and immediate load with full arch restoration. I do not punish patients for the status of their mouth because we -dentist are all responsible for this supervised neglect. Perio bugs will die the minute periodontal ligaments are gone. the regular maintenance and super hygienic bridge design ( again our responsability) and there is the recipe for predictable, long term restoration with significant improvement in patient’s quality of life.

    1. immediate placement, immediate load. there is enough evidence in literature to support this. my clinical experience and the follow ups of hundreds of cases are in line with above.

  8. actually, we dentists are not responsible for supervised neglect. If the patients refuse to go forward with treatment and they understand the consequences then it is there responsibility, not ours. We as dentists should not be responsible for the fact many patients don’t want to go forward with treatment or don’t care about treatment. For some, oral health is second to taking a vacation or buying a car. We can’t force them to do anything.

  9. REFER to periodontist/ max fax surgeon and prosthodontist and you have managed her well. When the specialists advise her of her conditions and the treament options, she will be more compliant otherwise it will be a serious medico legal matter if you treat her and then managing any failures and complications which will most likely be in defensible and you may end up in a lot of trouble
    I wish you the best and these observations are just personal opinions and I totally respect any steps you take but 27 years in the game has taught me a lot and referral is often the very best defense and peace of mind is price less

  10. Hi.I would suggest the same treatment that you have suggested the patient anyway. But use of laser for perio disease after extraction is advised.Wait for 3 to 4 months after use of laser,then place implants.maybe an all on 4

  11. First excuse me for my english. Well, we don’t have a lot of data ( from clinical to occlusal registrations), but it seems the extreme damage of a serious periodontal desease. So I think the first goal it will be to solve the perio “problems” ( initial hygiene preparation, extractions, mantain at least 4/5 teeth per arch, and have temporary fixed acrylic bridges) and take time for a further revaluation. When better compliance of the patient, better conditions of soft and hard tissues are achieved, we can start in positioning some implants. Mantaining previous temporary till the evidence of the osteointegration. In that moment we can extract the remaining teeth and have a new implant supported prostesis. And this all takes two year of therapy, I fear.

  12. Do we not provide a more susceptible implant sulcus with direct bone access for the bugs when they return? Do they ever really leave?

    1. The question of implants in a patient with periodontitis depends on the patient’s acceptance of the increased possibility of peri-implantitis and their commitment to personal care and regular recare/hygiene follow up. To deny a patient increased function through dental implants merely due to a periodontal condition is almost cruel. No, periodontal disease does not “go away”; ther is no cure, and more advanced case types, possibly complicated by health considerations, are more difficult to deal with. We see more frequent recurrences and greater tissue losses which may complicate implant treatment. The decision must be made, patient-by-patient, about the risks of placing implants in their mouth vs. the benefits they are likely to receive. Until an absolute “cure” for periodontal disease is achieved (currently extraction of all existing teeth is the only sure method), do we deny comfort and function to an otherwise educated and committed patient? The term “complex” is a recurring theme, and it seems as if this clinical situation is the very definition of the word.

      1. Well said. As long as the patient is fully informed
        However some patients ( and clinicians) manage dentures without implants others not.
        Perhaps implant augmentation might be revisited afterward?
        Certainly if there are salvageable teeth remaining their use even if transitional
        has been warranted.
        Or is implant support alone now the preferable treatment of choice?
        Agreed a case by case decision but what say you?

        1. I believe all of the options proposed in your reply to be in the “decision tree”, again depending on the actual patient condition. I think you offer some thoughtful treatments. I don’t believe there is always only one correct treatment plan; only a correct direction of treatment. Dentures, implants, etc. are the tools we employ to restore whatever portion of function lost to dental disease. None are a perfect means to an end, hence the need for we, as clinicians, to deepen and broaden our knowledge and skill in order to know which tools to use in a given case. The old adage “If you only have a hammer, everything looks like a nail” is apropos. Not all patients with dentures need implants, and not all patients needing implant need a full arch supported prosthesis – or can afford one. We do the best we can given the needs and resources of each patient.

  13. why implants?simple solution is, remove the hopeless teeth followed by partial denture, do a good flap surgery and keep her under observation, check if her other medical problems are under control,smoking must be controlled, convince the pt if all fine we will think of implants in future

  14. If she’s losing teeth to Periodontitis, she’ll lose the implants too. She’s not taking care of the teeth, so she won’t take care of the implants.

    Make sure she understands that she still has to brush and floss even with implants. If she doesn’t want to do that, then Complete Dentures or edentulism are the only options.

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