A Plethora of Dental Problems Causing a Periodontal Abscess

Update below.

I have recently had an email exchange with a German colleague in which I had tried to correct certain misconceptions about Scandinavian Dentistry and its self-proclaimed superiority as compared to that of the “American”, “British” or “German” profession. Dental textbooks with “The Scandinavian Way” as a subtitle have fortunately vanished in the meantime. Maybe Scandinavians have understood (or were told) that “Am deutschen Wesen …” was a really bad example and did imply in fact frank racism.

A whole generation of, in particular, German periodontists has long been influenced by Scandinavian teachers and scientists such as Sigurd Ramfjord and Jan Lindhe, who had frequently visited the country, made friends with many colleagues and had an enormous impact on the development of modern Periodontology in Germany. I take pride of being a member of this generation and I have always tried to convey the messages by these and other Scandinavian giants in my discipline to contemporary students of Dentistry.

I remember vivid dicussions in the early 1980s in self-proclaimed dental elites like the Neue Gruppe, which was eager to invite both outstanding Scandinavian and American colleagues as speakers for their annual meetings, about whether the “Scandinavian approach”, which was allegedly “determined biologic”, should be favored when compared to the “determined mechanistic” treatment practiced by German dentists and, in particular “gnathologists”, who considered themselves a bit like “dental engineers”. “Biologic” more or less meant cause-related, and was mainly based on emerging scientific revelations from oral microbiology and immunology, oral physiology and biochemistry. The “mechanistic approach” on the other hand was mainly based on occlusion and a strive for improving “fit, form and function” of restorations which comprised nearly 100% of dental work in dental practice.

The truth lies somewhere in between, as usual. I am grateful for a profound education in occlusal concepts during both undergraduate and postgraduate education. Since, as a specialist, I used to treat patients who could usually not be treated by other colleagues, I was from the very beginning prepared to expand knowledge and skills to definitely restore periodontally mutilated dentitions with the necessary precision. Although being a specialist in Perio, comprehensive dental care has always been at the center of my treatment, the main reason why I had recently joined two dental schools which apparently favored respective concepts in dental education. I had not expected what I would encounter on a daily basis: bad dentistry.

The following case (and I want to warn the unprepared reader, graphic imagery may be disturbing) is in no way special and how it was treated before I was involved (and probably afterwards) is typical.

Upper left: Periapical radiograph in August 2010. Presumed furcation involvement of (tilted) tooth #37. Upper right: Periapical radiograph in November 2011. A periodontal abscess has developed at tooth #37. Lower left: Clinical situation on the working side. Note the occlusal contact between the mesiopalatal cusp of tooth #27 and the distobuccal cusp of tooth #37. Lower right: Situation one week after removal of the working side contact and restoration overhangs in particular in the furcation area of tooth #37, and subgingival scaling and root planing.

Upper left: Periapical radiograph in August 2010. Presumed furcation involvement of (tilted) tooth #37. Upper right: Periapical radiograph in November 2011. A periodontal abscess has developed at tooth #37. Lower left: Clinical situation on the working side. Note the occlusal contact between the mesiopalatal cusp of tooth #27 and the distobuccal cusp of tooth #37. Lower right: Situation one week after removal of the working side contact and restoration overhangs in particular in the furcation area of tooth #37, and subgingival scaling and root planing.

A 55-year-old male was first seen at the university dental clinic (UTK) in August 2010 when clinical and radiographic examinations were done. The furcation involvement at tooth #37 was not recorded, and the completely insufficient quality of amalgam restorations not further addressed. What specific treatment had been offered could not be found out from the file.

Next, the patient showed again at UTK in autumn 2011 because he had lost parts of the restoration at tooth #35. The treatment plan revealed that it was decided that this problem had to be addressed first although a new periapical radiograph had shown a deep infrabony lesion on the mesial aspect which almost extented to the root apex. A few days later, the patient developed a periodontal abscess at tooth #37. At the mesial aspect, a 9 mm deep pocket was measured. Pus emanated while probing the pocket. I was then asked for specialist consultation.

Medical history revealed that the patient has been prescribed a calcium channel blocker for hypertension for one year. He was in pain. The tooth was hypermobile with a mobility of degree 3. A quick occlusal analysis revealed a working side contact between  the mesiopalatal cusp of tooth # 27 (or #28) and the distobuccal cusp of tooth #37. The overall low quality amalgam restoration of tooth #37 included an overhang which extended into the buccal furcation of the tooth. A degree 1 or 2 furcation involvement was present.  The patient expressed his strong wish to keep the tooth.

The patient got a mandibular block and while waiting for the desired effect, the working side contact was removed with a flame-shaped diamond bur in a high-speed handpiece. Also, all overhangs were removed in particular in the buccal furcation area of tooth #37. Thorough subgingival scaling of the deep infrabony lesion at the mesial aspect as well as in the furcation area (furcation involvement turned out to be rather degree 1) was followed by instillation of 1% chlorhexidin gel. The entire emergency treatment was completed within 45 minutes including on-site teaching. Healing was uneventful and was documented by the student with a clinical picture after one week and a periodontal reevaluation in January 2012 when at the mesial aspect of tooth 37 a periodontal probing depth of just 4 mm was measured. Patient, student and I were equally satisfied. It remains to be checked what has later happened to the bony lesion and whether the patient received new restorations.

I usually dedicate lecture time to students who report their interesting cases. So, we discussed extensively possible reasons for the periodontal abscess and why healing response was so impressive. Mechanics is important in Dentistry, and working side contacts on second molars may in fact be deleterious. They should be diagnosed and removed. A frequently made observation is very poor quality of amalgam restorations in our patients. In any case, overhangs have to be removed in a very early phase of the treatment since they usually interfere with proper oral hygiene. In general, operative dentists in Scandinavia (called cariologists) tend not to polish old amalgams due to mercury exposure and the opening of margins with a potential activation of secondary caries. Respective arguments are very weak and not based on strong evidence. Old amalgams should be polished properly in an early phase of the treatment or, if insufficient, replaced. A question remains: by any chance, could the (new) medication of a calcium channel blocker have contributed to active periodontitis and the development of a periodontal abscess? We know that calcium channel blockers might lead to gingival enlargement which sometimes requires surgical intervention. The clinical pictures do not indicate that gingival enlargement had occurred. The impact of the medication on the development may be regarded low.

I have, in a previous post, questioned the approach of a German group by placing a composit resin restoration in one session while obviously violation the biological width. However, one should not make any mistake here. The described restorative procedures there must be regarded high-end restorative dentistry by all means. That surgical crown lengthening had not been done but rather electrosurgery in order to remove gingiva close to the alveolar bone has incited quite a lot of criticism here and elsewhere. But the quality of the restoration is of course outstanding.  I do not know whether bad dentistry can be found in patients visiting University dental schools in Germany on a daily basis. I actually doubt. My overall impression after a couple of years in Tromø is that dentistry in Germany has long outperformed Scandinavian standards while Dentistry found in Scandinavian countries is on decline.

Update 5 January 2015

A routine check at the University Dental Clinic today revealed that the above patient had been seen in October 2013 by a former student when I had not been in Tromsø. A periapical exposure had been taken indicating considerable bone gain.

bos-patient-10-10-2013

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