Periodontal, Microbiological and Immunological Clinical Conditions in a 9-Year-Old Child with Localized Advanced Periodontitis: Case Report in a 18-Month Follow-Up
Bruna Lara Franca1, Amanda Almeida Costa2, Luís Otavio Miranda Cota3, Fernando Oliveira Costa3
Copyright : © 2018 Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The objective of this study is to report a clinical case of a 9 year old child diagnosed with localized advanced and high risk periodontitis through periodontal clinical parameters and radiographic, microbiological and immunological exams. In the clinical examination was observed probing depth alteration of the four first molars, although there was no plaque compatible with the periodontal condition. Radiographic examination revealed angular bone loss in the mesial sites of elements 26, 36 and expressively of 16. Microbiological and immunological tests were performed from the collection of crevicular gingival fluid and saliva. Thus, total bacterial load count and specific bacterial levels of Aggregatibacter actinomycete- mcomitans; Tannerella forsythia, Porphyromonas gingivalis; Treponema denticola; Prevotella intermedia and Actinomyces naeslundii were performed by qPCR (Polymerase Chain Reaction - real time), while levels of the biomarkers Interleukin 10 (IL-10), Interleukin 6 (IL-6), Interleukin beta (IL-β), Metaloproteinase of matrix-8 (MMP-8) and tumor necrosis factor alpha (TNF-α) by ELISA. The proposed treatment included non-surgical and surgical periodontal therapy and antimicrobial use. During the 18 month follow-up of the patient, the mechanical and chemical periodontal treatment promoted a significant improvement in all clinical and radiographic periodontal parameters and positively influenced the patient's bacterial and immunological profile.
Periodontitis, Localized aggressive periodontitis, Bone graft, Antibiotic therapy
Aggressive periodontitis (AgP); Interleukin 10 (IL-10); Interleukin 6 (IL-6); Interleukin beta (IL-β); Metaloproteinase of matrix-8 (MMP-8); tumor necrosis factor alpha (TNF-α); plaque index (PI); probing depth (PD); bleeding on probing (BOP); clinical attachment level (CAL); (T1) previous to periodontal therapy; (T2) 4 months after treatment; (T3) 18 months after the start of periodontal treatment.
1. Introduction
2. Materials & Methods
3. Results And Discussion
A complete periodontal examination was also performed on the mother and on the 6-year-old patient’s sister, but no site with altered PD (≥4 mm) was found.
In addition, radiographs of all dental elements were performed (Figure 1). In the periapical radiographs of elements 16, 26 and 36, severe angular bone losses were observed on mesial surfaces.
At first consult, it was explained to mother and child the importance of following the instructions of oral hygiene correctly (brushing techniques and use of dental floss). It was also performed coronary polishing and supra and subgingival scaling of elements 16, 26, 36 and 46 under local anesthesia. In addition, use of Amoxicillin (500mg) + Metronidazole (400mg) was prescribed for 15 days [10].
After 15 days, second session was performed with new evidence of plaque, reinforcement on instructions for oral hygiene and coronary polishing. During the first reassessment, 30 days after starting treatment, PI was 22% and mean BOP reduced to 4.2% of the sites. It was observed decrease of PD in all sites, however, with persistence of altered PD in elements 16, 26 and 36. Elements 26 (mesial PD = 5mm with BOP) and 36 (mesial PD = 4mm with BOP) received scaling and root planning under local anesthesia again. However, in mesial of 16, PD, which had the value of 12mm, was now 10mm, still very high (Table 1). Thus, it was decided to perform periodontal surgery involving Kirkland flap procedure and bone graft to fill the bone defect and try to maximize the periodontal repair.
The surgery was performed under local anesthesia with 2% lidocaine with 1: 100,000 epinephrine. During the procedure, a 10 mm intraosseous defect was found in the mesial site of element 16, with preservation of buccal and palatal bone. Scaling and root planning were performed and the bone defect was filled with a mixture of autogenous bone (collected by osteoplasty in the buccal region) associated with the bovine bone graft (Gen Mix, Baumer, SP, Brazil). The suture was made with silk thread (Ethicon, 4.0 Jonhson & Jonhson, SP, Brazil).
After 45 days of performing these procedures, a significant improvement was observed in the mesial site of element 16 (initial PD = 12 mm for PD = 5 mm) and element 26 (PD = 4 mm with BOP) (Table 1). Thus, despite the significant improvement, as a mild inflammatory condition still persisted, it was decided to reinforce the specific hygiene of these sites, mainly in relation to the use of dental floss and the inclusion of interdental brush, besides keeping the patient in a rigorous program of periodontal maintenance therapy (PMT), performed approximately every 3 months throughout the 18-month follow-up of this case. It should be noted that during PMT at 9 months and 18 months (T3) the PD in the mesial of element 16 and 26 passed to 4 mm without BOP (Table 1). Figures 2, 3, 4, 5, 6 and 7 illustrate the treatment and evolution of this clinical case.
In addition, 12 months after the beginning of therapy, orthodontic therapy was started for correction of left posterior crossbite with anterior crowding.
In relation to laboratory exams, there were significant reductions from T1 to T3 in levels of total and specific bacterial load associated with periodontitis: T. forsythia, P. gingivalis, T. denticola, P. intermedia, A. actinomycetem-comitans (T1 > T2> T3) and also a beneficial increase of A. naeslundii, representative of the blue complex (T1 < T2 < T3).
In addition, the biomarkers Interleukin 10 (IL-10), Interleukin 6 (IL-6), Interleukin beta (IL-β), matrix metalloproteinase-8 (MMP-8) and alpha tumor necrosis factor (TNF-α) were evaluated. It was observed that there was a significant and progressive reduction (T1> T2> T3) in the amount of all pro-inflammatory biomarkers evaluated (Table 2).
During the 1-year and 6-month follow-up, mechanical and chemical periodontal treatment promoted restoration of patient's periodontal health, with a significant improvement of radiographic and clinical aspects. It also positively influenced the patient’s bacterial and immunological profile.
Recently, a new classification proposed at a Workshop of the American Academy of Periodontics and European Federation of Periodontics (FEP) in 2017 brought together the previously named Chronic Periodontitis and Aggressive Periodontitis (AgP) into a single group (Periodontitis) based on the prematurity of the scientific evidence of pathophysiological differences between these two "forms" of periodontitis. According to the new classification of 2017, the diagnosis of the case reported is localized advanced (stage IV) and high-risk (degree C) periodontitis [3].
Once an early and advanced form of periodontitis is installed, several factors may eventually interfere on the progression of inflammation, aggravating it. The lesion’s extent and severity are related to host’s resistance level to microbial factors, since bacteria and their products are able to initiate local responses of the host by generation of inflammatory mediators like cytokines, besides the recruitment of inflammatory cells and activation of osteoclasts, which are the basis of periodontal destruction [6,7,11]. It is noteworthy that the patient in this clinical case presented high levels of proinflammatory cytokines in T1 and, with the success of treatment, there was a significant reduction of all researched biomarkers.
In addition, periodontal diseases are polymicrobial and biofilm-related infections vary widely in microbial composition and diversity between sites and individuals with similar clinical manifestations [12]. They result not only from the presence of specific microorganisms, but from the imbalance between those there are pathogenic and those there are beneficial. To date, studies on the microbiological profile of "AgP" are diversified in their methodology and results [13]. However, according to Faveri et al. [14], bacteria of the species A. actinomycete-mcomitans appear to be associated with the appearance of "AgP" and other bacterial species such as P. gingivalis, T forsythia, Treponema denticola, Campylobacter gracilis, Eubacterium Nodatum, A. naeslundii and P. intermedia, play an important role in progression of the disease. Generally, the amount of A. actinomycetem-comitans found after establishment of the disease is inferior to other species, such as P. gingivalis, which can be explained by the fact that deepening of pockets results in an anaerobic environment, favoring the growth of other pathogens, such as strict anaerobes. In addition, A. actinomycete-mcomitans bacteria are highly virulent and, therefore, even low levels of this species can trigger periodontal destruction, even in non-mature oral biofilm of young individuals. These timely issues have been corroborated by our results that shows a significant reduction of bacteria associated with periodontitis.
It is a consensus that mechanical removal of supra and subgingival dental biofilm by scaling and root planing is the gold standard of periodontal therapy, since it promotes bacterial reduction and often provides resolution for many cases of periodontitis [15, -18]. However, unlike gingivitis and CP, only mechanical therapy does not always provide the expected results when treating "AgP" [15]. In these cases, antimicrobials can be used as adjuvants on treatment to eliminate or reduce the number of specific microorganisms and improve clinical parameters [15,19,20].
Despite controversial results about use and timing of use of antibiotic therapy in treatment of "AgP", in this reported case the antimicrobial treatment was indicated at the beginning of causal therapy. This choice was due to the severity of periodontal destruction in relation to age and was also justified by the literature, which points that immediate application of systemic antibiotics seems to be more advantageous in treatment of "AgP" because it promotes a more rapid and robust reduction of PD [10].
Patients with "AgP" usually have residual vertical bone defects as a result of periodontal disease and regenerative procedures may be one of the possible treatment options. One way of attempting to improve periodontal regeneration is by using bone replacement grafts, as reported in the clinical case of the present study. We believe that filling the bone defect with a mixture of autogenous bone (collected by osteoplasty on the buccal region) associated with bovine bone graft (GenMix, Baumer, SP, Brazil) may have favored periodontal repair and the expressive reduction of PD in element 16 (PD T1=12Mm, T2=10mm e T3= 4mm). GenMix is a composite biomaterial of bovine origin, obtained from inorganic medullary portion, organic cortical portion and a natural binder composed of denatured bone collagen. Currently, this biomaterial is considered a good bone replacement, with reasonable cost and good osteoconductive properties that favor a predictable and efficient bone repair [21].
Given the early onset and rapid progression characteristic of "AgP", early intervention is important. If it is not treated, additional resorption of alveolar bone and tooth loss or extraction will occur sequentially [22], and extensive prosthetic procedures will be required [23]. Furthermore, the treatment should also be directed towards elimination of infection caused by microorganisms. This disease leads to an increase in serum concentration of various inflammatory process indicators, such as chemical mediators and proinflammatory cytokines, as well as presents response of antibodies to different bacteria associated with periodontitis. Therefore, there is an upward concern with the interrelationship between periodontal disease and systemic health, subject of investigations and wide discussion in the dental literature [24].
Currently, the patient is undergoing orthodontic treatment at Dentistry School of UFMG and continues under periodontal maintenance therapy. For movement of teeth, a healthy periodontium is necessary. Thus, in patients with "AgP", orthodontic treatment is only possible when the disease is controlled by careful monitoring before, during and after active therapy and it may be a beneficial adjuvant for providing a good occlusion [25].
4. Conclusion
References