By: Victor M. Sternberg, D.M.D. 

June 17, 2024 

The issues presented by this young patient posed a challenge on several levels. 

Her advanced periodontal disease threatened the survival of her dentition. The position of her teeth presented an enormous aesthetic challenge, and for this young lady, an emotional one as well. 

The mission of dentistry is to preserve the natural dentition in a state of health. This particular case challenges all of the paradigms of the treatment of periodontal disease and the benefits of altering tooth position. 

The 30-year-old individual was presented for a third opinion. The first two opinions strongly urged her to have her remaining teeth removed and implants placed to restore her dentition, aesthetically and functionally. 

Given her youth and the severity of periodontal disease, one had to be concerned about the long-term management of even implant survival. 

The patient chose to pursue the journey, if possible, of preserving her teeth and improving her aesthetics.

Step number one was to ascertain the pathogenic bacteria that were causing her periodontitis. Below are the results of a culture taken of the deep pockets in her mouth, as well as the charting of the pocket depth she presented with.

Her family had a history of tooth loss so genetics were not in her favor. However, she was highly motivated and intelligent enough to understand that her role in prevention was the key to the survival of her natural teeth as well as the success of orthodontics. 

The first step in clinical treatment was the non-surgical debridement of all of the teeth, save for the third molars which were removed early on. Systemic antibiotics, as recommended by the culture, were administered at the onset of scaling. 

The patient was meticulous in her oral hygiene. Following initial debridement she began orthodontic therapy.

Orthodontics was done for two purposes. Number one was to realign the teeth in an aesthetic fashion. A second goal would be to allow implants and/or restorations to be placed in ideal positions. 

During the three-year period, from the beginning of periodontal treatment to the completion of orthodontic treatment, the patient underwent frequent visits of continuous scaling, with local anesthesia as needed, as well as, and most importantly, scaling with the perioscope to remove any residual calculus during orthodontic therapy. Even though she had gone through numerous bouts of initial scaling, calculus was still found at the time of perioscopic evaluation. 

Antibiotics were only administered at the onset of therapy and in the absence of recurrent bleeding and inflammation they were not prescribed again. 

The decision to avoid surgical treatment was made because of her response to non-surgical care, as well as the concern about surgical procedures resulting in the loss of soft tissue which would compromise the ultimate aesthetic result. 

The result of non-surgical outcome of therapy is now demonstrated. 

Because of a non-surgical approach recession was minimalized. In many of these teeth, the tissue seemed to migrate coronally as tooth movement done slowly over a period of time in the presence of health resulted in what appeared to be a gain in attachment. Pocket depth was markedly reduced with localized 5- millimeter pockets noted around lower molars which began with furcation involvements. There was no bleeding upon probing. The patient demonstrated meticulous oral hygiene as demonstrated by the final photographs. 

There is no question she has a long epithelial attachment on many of these teeth which she can be only maintained with meticulous oral hygiene and frequent maintenance. 

To say the patient was thrilled is to put it mildly. 

Although this is an extreme example, it reminds us that our role in dentistry is to preserve the natural dentition in a state of health. 

As I and many of my fellow practitioners are spending more and more time treating peri-implantitis, which is challenging and unpredictable at best, the preservation of the natural dentition remains the sine qua non of our profession. 

As always, your comments are appreciated. 

Yours truly, 

Dr. Victor M. Sternberg 

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Kudos to our dental hygienists Anni Perkowski who provided all the educational, motivational and non surgical care. 

Kudos to the incredibly outstanding orthodontic care provided by Dr. Ilan Shamus.

By Westchester Center for Periodontal & Implant Excellence

December 25, 2023