Periodontal Conditions and Mucogingival Surgical Treatment of A

OLGU RAPORU (Case Report)
Hacettepe Diş Hekimliği Fakültesi Dergisi
Cilt: 33, Sayı: 1, Sayfa: 41-46, 2009
Periodontal Conditions and Mucogingival
Surgical Treatment of A Patient with
Scleroderma
Skleroderma Hastasında Periodontal Durum ve
Mukogingival Cerrahi İle Tedavisi
*Özlem Özer Yücel DDS, PhD, **Esra Ercan, DDS
*Private Practice
**Hacettepe University Faculty of Dentistry Department of Periodontlogy
ABSTRACT
ÖZET
Scleroderma, which usually begins as a dermatologic
Dermatolojik bir bozukluk olarak başlayan sklero-
disorder, is also known as a systemic collagen dise-
derma, sistemik kollajen doku hastalığı olarak bilinir.
ase. There are limited reports of dental treatment
Skleroderma hastalannın dental tedavileri ve peri-
and periodontal surgical procedures for patients with
odontal cerrahi tedavileri hakkında çok az çalışma
scleroderma. This case report presents oral and peri-
vardır. Bu vaka raporunda 33 yaşında bayan sklero-
odontal changes, surgical and non-surgical periodon-
derma hastasındaki oral ve periodontal değişimler,
tal therapy and 18-months follow-up of a 33 year-old
cerrahi ve cerrahi olmayan periodontal tedavisi ve kli-
female patient with scleroderma. The healing was
nik takibi verilmiştir. Cerrahi tedaviden sonra iyileşme
uneventful after surgical therapy and stable during
sorunsuz olmuştur ve 1,5 yıllık takibi sonunda stabil
1,5-year follow-up. Mucogingival surgery procedures
olduğu görülmüştür. Skleroderma hastalarının oral
may result successfully in patients with scleroderma,
dokulardaki sertlik, damarsal değişiklikler ve sınırlı
despite limited mouth opening, vascular changes and
ağız açıklıklaına rağmen mukogingival cerrahi prose-
stiffness of the oral tissues.
dürlerin başarı ile uygulanabileceği gösterilmiştir.
KEYWORDS
Skleroderma, mucogingival surgery
ANAHTAR KELİMELER
Skleroderma, mukogingival cerrahi
42
INTRODUCTION
Scleroderma, is a chronic disease of unknown etiology, is characterized by diffuse sclerosis of the connective tissues of skin and visceral organs, vasculopathy, and autoantibodies.
The disease is uncommon, onset usually begins
in middle age and occasionally familial, although
there is no definite pattern of inheritance. Three
to four times as many females are affected as
males. The disease presents in a wide spectrum
both systemic and localized forms1,
Approximately 80 % of the patients have
manifestations in the head and neck region, with
dysphagia and reflux esophagitis being in common 2. Scleroderma also affects oral and perioral
tissues. Oral manifestations reported in these patients include fibrosis and rigidity of tongue and
oral tissues, limited mouth opening, telengiectasis, xerostamia, increased frequency of caries and
periodontal disease and increased periodontal ligament width1. Structural changes of the jawbone
as well as widening of the periodontal ligament
space have been revealed on radiographs3.
FIGURE 1
The telengiectasia of face and mouth rigidity
CASE REPORT
A 33-year-old female was referred to our clinic
for evaluation of gingival recession in November
2005. She reported diagnosis of scleroderma in
2001. Furthermore, the patient was prescriped
drugs for osteoporosis. She also prescriped deflazacort, azathioprine, acetylsalicylic acid, nifedipine, famotidine and pentoxifylin. She never smoked
and was brushing her teeth once two days.
She was found to have a poor dentition with
caries and periodontal disease affecting all remaining teeth. A marked xerostomia was also
noted. We detected telengiectasia of face and
mouse rigidity by physical examination (Fig.
1). Clinical evaluation revealed severe gingival
recession depth of 10 mm. and 9 mm. with a
3-mm probing depth on the mid-buccal of the
mandibular right first premolar teeth and left
first premolar teeth respectively. Radiographic
changes included uniform widening of the periodontal ligament space with an associated loss of
radicular lamina dura (Fig.2 and 3). The patient
FIGURE 2
The panaromic radiograph of the patient
FIGURE 3
Periapical radiographs exhibiting extreme widening of the
periodontal ligament space
43
complained about xerostomia. As xerostomia
rampant caries were widely observed especially
in the anterior teeth (Fig.4.), we prescribed Biotene® oral care set. After motivating for oral hygiene, the patient was referred to Department of
Conservative Dentistry for fillings.
After consultation with the patient’s doctor,
the patient was prescribed Amoxiciline 1 gr.
tablet before surgical treatments for bacteriamia
risk. Initial therapy consisted of oral hygene
instructions, scaling and root planing by quadrants, and re-evalution. The periodontal pockets
responded well to scaling and root planing and
improved oral hygiene required no further treatment. The areas of gingival recession exhibited
root surface sensitivity, and narrow zones of attached gingiva. A decision to treat the areas of
recession with mucogingival surgery was made
after careful consideration (Figs. 5 and 6).
Local anesthesia was obtained with 2% lidocaine 1:100,000 epinephrine. Teeth #34 and
#45 were treated with free gingival grafts obtained from palate using the modified technique
described by Langer and Langer (Figs.7 and 8.).
The grafts were sutured with 5.0 silk sutures. Surgical dressing were placed at the recipient sites.
The sutures were removed 10 days after surgery.
The patient was prescribed 0.12% clorhexidine
mouthwash two times a day for 2 weeks. The patient was prescriped systemic analgesic (naproxen sodium) 1 tablet every 6 hours if needed for
pain and an antibiotic (amoxicilin) for 7 days. The
postoperative course was uneventful. Follow-up
controls were made at 6 months, 1 year and 18
months postoperatively. Six months postoperative healing is demonstrated in Figures 9 and 10.
After the periodontal treatment was completed,
the patient was referred to Department of Prosthodontics for removable partial dentures.
Clinical measurements, including plaque index, gingival index, recession depth, probing
depth, clinical attachment level and bleeding on
probing were recorded before surgery and at 6
months, 1 year, 18 months postoperatively. Measurements of recession depth, probing depth,
and clinical attachment level were made at the
mid-labial aspect of the teeth
FIGURE 4
The rampant caries because of xerostomia
FIGURE 5
Before surgery (lower left first premolar teeth)
FIGURE 6
Before surgery (lower right first premolar teeth)
44
FIGURE 7
FIGURE 10
During surgery (lower left first premolar teeth)
6 months after surgery for lower right first premolar teeth
(Table 1 and 2). The probing depth was
reduced 3 mm. to 1 mm. for both teeth from
baseline to 6 months. Also gingival index and
plaque index values reduced at 12 months and
18 months according to baseline. Furthermore,
the patient could provide brushing in these regions more effectively.
DISCUSSION
FIGURE 8
During surgery (lower right first premolar teeth)
FIGURE 9
6 months after surgery for lower left first premolar teeth
The most common problem with dental treatment of scleroderma patients is the physical one
caused by the narrowing of the oral opening and
the rigidity of the tongue4. Patients with scleroderma often show up with caries and moderateto-advanced periodontal disease due to poor oral
hygiene and patient susceptibility 5. Oral hygiene
measures and dental treatment become more difficult as the severity of the soft tissue involvement
increases 1,6,7.
Radiographic changes have been classically
described as a uniform widening of the periodontal ligament space with an associated loss of
radicular lamina dura 3,8. White et al. found 37%
of the patients heve abnormally thickened periodontal ligament spaces 9. In a controlled study,
Wood et al. reported 29% of the patients with
systemic sclerosis had resorptive lesions (erosions) of the mandible involving the mandibular
angle, the digastric region, the condylar head,
and the coronoid process 10. In our patient, no
resorptive lesions of the condyl and coronoid
45
TABLE I
Clinical Measurements of #34 (mid labial surface)
Preoperative
6 Months
12 Months
18 Months
GI
2
1
1
1
BOP
(+)
(-)
(-)
(-)
CAL (mm)
10
9
9
9
PD (mm)
3
2
1
1
Keratinized Gingiva
2
6
5
5
PI
2
1
1
1
GI=gingival index; BOP=bleeding on probing; CAL=clinical attachment level; KT;=width of keratinized tissue, the distance
between mucogingival junction and free gingival edge; PI=plaque index
TABLE II
Clinical Measurements of #45 (mid labial surface)
Preoperative
6 Months
12 Months
GI
2
1
1
18 Months
1
BOP
(+)
(-)
(-)
(-)
CAL (mm)
9
9
8
8
PD (mm)
3
2
2
2
Keratinized Gingiva
2
7
6
5
PI
2
1
1
1
GI=gingival index; BOP=bleeding on probing;C AL= clinical attachment level; KT= width of keratinized tissue, the distance
between mucogingival junction and free gingival edge; PI=plaque index
process were detected in transpharangeal radiography ( Fig 11).
Good mouth care is essential for patients
with scleroderma, helping to keep the mouth
free of dental caries and gingivitis and lessening the discomfort associated with xerostomia or
mouth stiffness 4. Xerostomia was found more
frequently in the patients with systemic sclerosis.
In the present case we found that plaque index
and gingival index values reduced at 18 months
compared to baseline. Eighteen months after the
patient had begun to use oral care mouth set, we
couldn’t detect any new caries. Wood and Lee
found the occurence of xerostomia and strong
association with the occurence of dental caries
10
. Performing professional dental profilaxies for
every 6 months and oral hygiene motivation together with the use of agents lessening xerostomia may be useful in such patients.
On the other hand, limited access to the oral
cavity makes definitive treatment difficult. Atrophy of the oral mucous membranes may be followed by “hardening” and fixation to underlying
FIGURE 11
Transpharengeal radiograph
soft and hard tissue structures 11, The orofacial
presentation of severe cases include featureless
perioral skin, microstomia, and pseudotrismus 1.
Performing dental treatment including periodontal surgery for such patients is hindered by the
reduced oral aperture.
There are limited reports in the literature
regarding dental treatment for these patients
46
and only one report of periodontal surgical procedures 1. That paper presents a case report of
periodontal surgical treatment in a 38-year-old
female patient with systemic scleroderma. Stanford et al. treated the teeth with localized gingival recession with subepithelial connective tissue
grafts and free gingival grafts from palatal donor
site using a modification of the technique first
described by Björn. They reported that healing
was uneventful demonstrating two years followup in accordance with the present case 1. The
only limitation of the report is the lack of pre-op
and post-op periodontal measurements.
Creeping attachment, which was described
by Goldman and Cohen, is known as the postoperative migration of the gingival margin tissue in
a coronal direction over portions of a previously
denuded root 12. This phenomen can be detected
1 to 12 months after graft surgery with an average coverage of ~1 mm 13. In the present case,
the creeping attacment occured after 6 months
and and probing depth reduced 3 to 1 mm. after
12 months. The creeping attachment became
stable 12 months after the surgery.
The oral circumference may be reduced by
up to 30%, making even the insertion of dentures difficult. Correction of microstomia has
been attempted using exercises and appliances
but with significant relapse 14. Another solution
to the problem of denture wearing is the use of
osseointegrated dental implants. In the present
case bilateral sinus lifting procedure was required
for dental implant treatment, which was so difficult to perform due to microstomia. The prevention of tooth loss in such patients with regular
periodontal treatment, including mucogingival
surgery is of great importance because of the
diffuculties in wearing dentures.
The periodontal surgical procedure including free gingival grafts, achieved in this patient
Geliş Tarihi : 10.02.2009
Kabul Tarihi: 15.05.2009
with scleroderma and the treatment outcomes
were stable for 1,5-year follow-up despite some
limitations. These limitations are xerostomia,
microstomia, and atrophy of the oral mucous
membranes, which make definitive periodontal
surgical treatment difficult.
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Received Date : 10 February 2009
Accepted Date : 15 May 2009
CORRESPONDING ADRESS
Esra Ercan DDS
Hacettepe University Faculty of Dentistry Department of Periodontology, Ankara, Turkey
Phone: +903123052219 (business) Fax: +903123104440 e-mail: esraercan82@gmail.com