A 51-year-old woman presented with chief complaints of bleeding gums and chewing disability. Her medical history revealed that she had received renal transplantation surgery in 1999 and had remained in a stable condition without graft-versus-host disease ever since. She suffered from hypertension and gout, both of which were being well controlled and followed by treating physicians. Her medications at the time of initial examination including the immunosuppressive regimen (cyclosporine, prednisolone, and mycophenolate mofetil) are listed in Table . The patient was a nonsmoker who did not consume alcohol. She stated that she seldom brushed her teeth and had not flossed for a long time because of serious gum bleeding upon brushing or flossing.\nA facial examination revealed normal appearance without lymph node enlargement or local heat. No temporomandibular joint related symptoms were reported. Normal hard and soft tissue were observed in the patient’s oropharynx, hard and soft palates, floor of the mouth and tongue. An intraoral examination revealed highly inflamed periodontal tissue with heavy plaque and calculus deposition. Fibrotic changes over interdental papillae, facial and also lingual gingivae were noted, especially in the anterior segment (Fig. ). The patient’s upper left and lower left molars were missing. Her anterior teeth were flaring and highly mobile with a diastema of approximately 2.5 mm between the maxillary central incisors. Upon examination, we noted full mouth deep probing pocket depth (up to 15 mm) and profound bleeding. A fistula with suppuration was observed over buccal gingiva of tooth 46 (lower right first molar). Periapical films revealed generalized horizontal bone loss with the supporting bone of less than one half or one third of the root length. Periradicular radiolucency with an angular bony defect extending beyond the apex was observed over the mesial root of tooth 46 (Fig. ).\nThe clinical diagnosis was severe periodontitis and gingival disease modified by medication []. A hopeless prognosis was assigned to tooth 46. After consultation with treating physicians and discussion with the patient, a tentative treatment plan was formed involving cause-related periodontal treatment and extraction of tooth 46. In addition, the immunosuppressive regiment was not altered.\nThe patient was treated in the Department of Periodontics in Taipei Chang Gung Memorial Hospital between July 2014 and January 2015. Dental appointments were coordinated with physician appointments to obtain blood test results before each dental visit. Data were mostly within the normal range except for the occurrence of mild thrombocytopenia (listed in Table ). Prophylactic antibiotics (amoxicillin, 2 g) were prescribed before each appointment []. The treatments included scaling, root planing, oral hygiene instruction, and extraction. Although tooth mobility decreased after multiple visits, we discovered occlusal interference during the patient’s lateral excursion and anterior jaw movement; therefore, occlusal adjustment was incorporated into the treatment plan. Six months after the patient’s initial visit, a marked improvement of her periodontal condition as well as more effective plaque control were observed. The gingivae were considerably less edematous and glazed and without any residual fibrotic appearance (Fig. ). The periodontal probing result revealed some residual but largely decreased periodontal pockets and grade I tooth mobility over the upper and lower anterior teeth and lower right second molar []. In addition, the diastema between the upper incisors closed “spontaneously” after treatment.\nPocket elimination periodontal surgery was initially planned to treat the upper right and lower right second molars; however, nonsurgical treatment was eventually selected as the final treatment plan after the patient rejected surgery and the residual periodontal pocket depth were mostly less than 6 mm with horizontal bone loss pattern (Fig. ) []. After 3 months of follow-up, the patient was referred to our prosthodontic department for oral rehabilitation with removable partial dentures. The dentures were designed with palatal strap, lingual bar, and wrought-wire clasps (Fig. ). The periodontal supportive treatment recall interval was monthly in the first year and every 3 months subsequently []. A clinical examination and periodontal probing after 2 years of follow-up revealed excellent oral hygiene, continuous pocket reduction, and tooth mobility within normal limit for all remaining teeth (Figs. and ). The difference of attachment level gain, probing depth reduction, and change of the distance from cementoenamel junction to gingival margin (CEJ-GM) between anterior (canine to canine) and posterior teeth were shown in Fig. . No recurrence of gingival enlargement was recorded throughout the follow-up period. The diastema between the upper incisors remained closed without centric or lateral occlusal interference (Fig. ). Full mouth periapical and bite-wing radiographs revealed that the alveolar bone level had been maintained from its initial condition (Fig. ). The treating prosthodontist also recalled the patient regularly. The patient reported good chewing function, considerable ease in conducting oral hygiene practices, and overall high satisfaction with the treatment outcomes.
A 27-year-old female patient reported with the chief complaint of increasing spacing between her upper front teeth since the last nine months. There was no history of previous dental treatment. Her family and medical history were noncontributory. The patient provided a history that there was no spacing between the maxillary central incisors two years back. A gradual increase in spacing was noticed between the maxillary central incisors over the last nine months. On intraoral examination, other than a poor oral hygiene status, a 9 mm deep periodontal pocket was noticed between the maxillary central incisors. Both the teeth were showing Miller's Grade I mobility. There was high labial frenum attachment and a 2 mm diastema was present between the two central incisors []. Functional occlusal evaluation was done, which revealed an increased overbite that could be traumatic to the opposing maxillary teeth. An intraoral periapical radiograph revealed horizontal bone loss in between #11 and #21 [].\nAfter the completion of Phase-1 therapy, the patient was re-evaluated, during which the pocket depth was reduced to 7 mm. There was no gingival recession around the involved teeth. Occlusal equilibration was done to relieve the occlusal interference in the maxillary and mandibular anterior teeth. Periodontal flap surgery, along with excision of the high frenum attachment was planned, explained to the patient, and informed consent was obtained from the patient. Under local anesthesia, frenectomy was performed and a full-thickness mucoperiosteal (papilla preservation) flap was reflected []. Thorough degranulation was followed by root planing and saline irrigation. Black silk was used for suturing and simple interrupted sutures were placed []. Periodontal dressing was also done. The patient was discharged after giving postoperative instructions and prescribing antibiotics and analgesics/anti-inflammatory drugs. After one week, the periodontal dressing and sutures were removed and the area was thoroughly irrigated with saline. Three months postoperatively, there was complete closure of the diastema [] and both the teeth showed no signs of clinical mobility. Intraoral periapical radiographs showed bone gain between the two maxillary central incisors []. At three months, the periodontal probing depth was 3 mm and a gingival recession of 2 mm was noticed around both the maxillary central incisors. The patient was explained the importance of maintenance therapy and also the chances of a relapse of pathological migration in case of recurrence of periodontal disease. The patient was provided the option of a retainer to maintain the tooth in position, which the patient declined. The patient is being followed with no signs of recurrence of pathological migration.