following abbreviated reports will illustrate this danger. A 13 year-old female was referred for orthodontic treatment. A s part of the treatment all four second premolars were extracted. Roentgenographs obtained at age 14, the time orthodontic treatment was initiated, yielded normal periodontal findings (Figures 1A and 1B). Roentgenographs obtained after completion of ortho dontic therapy, when the patient was 19 years of age, revealed areas of severe alveolar bone loss in the region of the molar-bicuspid, and the incisors (Figure 1C). Subsequently, the patient was referred for periodontal treatment and the case was stabilized (Figure 1D). The prognosis, however, remains slightly guarded for some of the teeth. In this case it is presumed that the onset of the periodontal disease occurred coincidental with, or shortly subsequent to, the initiation of the ortho dontic treatment and was not caused by the orthodontic therapy. One might assume that the prognosis might have been more favorable had the periodontal problem been diagnosed and treated earlier.
Periodontosis: A Problem in Orthodontics* by
P A U L N . B A E R , D.D.s.t F R A N K G . E V E R E T T , M . S . , D . M . D . , M.D.‡ S I N C E ITS FIRST suggestion as a clinical entity by Gottlieb, periodontosis has been an enigma to the dental profession. The term itself is a controversial one, and there have been some who have doubted its existence as a clinical entity. Even among those who agree that the disease does exist, there is considerable variation in opinion as to its frequency and as to how it should be defined. We prefer to define periodontosis as a disease of the periodontium occurring in an otherwise healthy adolescent that is characterized by a rapid loss of alveolar bone around more than one tooth of the permanent dentition. There are two basic forms. In one, only the first molars and incisors are affected. In the other more generalized form most of the dentition is affected. The amount of destruction manifested is not commensurate with the amount of local irritants present. ' ' ' 1
2
3
4
5
Malocclusion may also be present in patients as a result of periodontosis, because one of the signs of advanced periodontosis is pathologic migration of the teeth. Malocclusion in patients with periodontosis may also be present and unrelated to the periodontal condi tion. In either case, orthodontic treatment may be a useful part of the total therapeutic regimen (Figures 2A-2D).
6
7
The onset of periodontosis generally coincides with the onset of pubescence. Since malocclusions are quite common during this same age period, it is reasonable to expect some adolescents with malocclusions who seek orthodontic therapy either to have periodontosis or to develop this condition during active treatment. Ortho dontists, therefore should be aware of this disease and should routinely examine all their patients with the aid of a periodontal probe and adequate roentgenograms before initiating therapy and at yearly intervals during active orthodontic treatment. It must be kept in mind that the gingiva in the earlier stages of this disease looks quite normal and that mere clinical inspection does not betray the presence of pockets and alveolar destruction. The
SUMMARY A N D CONCLUSIONS
1. Periodontosis occurs in the same age group in which orthodontic therapy is most often done. It is a periodontal disease which in the early stages may show little or no gingival inflammation and is easily over looked unless one is aware of the existence of this condition and looks for it. 2. Since malocclusions are common in adolescents, it is reasonable to expect that some adolescents with malocclusions will also develop periodontosis. 3. Periodontosis may have its onset during active orthodontic treatment. 4. Orthodontists, should routinely examine all of their patients, using adequate roentgenograms and a periodon tal probe before initiating therapy and at periodic (yearly) intervals during active treatment. 5. Where malocclusions are present in patients who already have periodontosis, orthodontic treatment may be a necessary and beneficial part of the total treatment
* Presented at the Orthodontic Periodontic Continuing Education Conference sponsored by the American Association of Orthodontists and the American Academy of Periodontology in St. Louis, Mo., March 24-26, 1974. † State University of New York at Stony Brook School of Dental Medicine. ‡% U n i v e r s i t y of Oregon Dental School.
8
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559
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J. Periodontol. September, 1975
F I G U R E 1A and IB. Roentgenographs taken in 1964 before orthodontic treatment revealing normal level of alveolar bone. (Age 14 years). C , Gridded roentgenographs taken five years later (1969) some months after discontinuation of orthodontic therapy. All four second premolars had been extracted. Note severe loss of bone in premolar areas. (Age 19 years.) D, Roentgeno graphs, same patient, another 5 years later (1974). The condition has essentially been stabilized, and improved in the lower pre molars. (Age 24 years.)
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2. A, Photograph of patient with periodontosis. Marked tooth mobilities and diastemas are present in anterior region. B, Note diastemas and design of appliance to reposition the teeth. C, Appliance in place. D, Diastemas have been closed by simple tooth movement and teeth stabilized by wire ligation.
FIGURE
REFERENCES 1. Gottlieb, B.: Die diffuse Atrophie des Alveolarknochens, Z Stomal 2 1 : 195, 1923. 2. Haupl, K., and Lang, F. J.: Marginale Paradentitis, (Entgegnung auf die Randbemerkungen Orban's). Z Stomal 25: 1100-1123, 1927 (page 1121) 3. Baer, P. N.: The case for periodontosis as a clinical entity, J Peridontol 42: 516, 1971. 4. Baer, P. N., and Benjamin, S. D.: Periodontal disease in children and adolescents: Philadelphia, J. B. Lippincott Com
pany, 1974. 5. Grant, D. A., Stern, I. B., and Everett, F. G.: Orban's Periodontics. 4th ed., St. Louis, C. V. Mosby, 1972. 6. Gottlieb, B., and Orban, B.: Zahnfleishchentziindung and Zahnlockerung, page 246 and following pages, Berlin, Berlinische Verlagsanstalt, 1933. 7. Marks, M. H., and Corn, H.: The role of tooth movement in periodontal therapy, Dent Clin North Am 13: 229, 1969. 8. Everett, F. G., and Fixott, H. C : Use of an incorporated grid in the diagnosis of oral roentgenograms. Oral Surg 16: 1061, 1963.
Abstracts PENICILLIN CONTROL OF SWELLING AND PAIN AFTER PERIODONTAL OSSEOUS SURGERY Kidd, E. A . M. and Wade, A . B. J. Clin Periodont 1: 52, N o . 1, 1974. Seventeen patients, 4 men and 13 women, ages ranging from 24 to 56 years, were included in the trial which was comprised of comparable flap procedures with curettage and osseous recontouring, performed on either side of the jaw at least one month apart. Each patient received phenoxymethyl penicillin (250 mgm) to use for five days at four-hour intervals, and a placebo, identical in all respects except that no antibiotic was included, for the other. Patients were also given 20 aspirin tablets (300 mgm) and were asked to take two tablets every four hours as needed for pain. Patients were seen at 48 hours and 1 week for assessment of postoperative pain and facial swelling. Total number of aspirin consumed after the use of penicillin and placebo, respectively, was further noted as an indication of pain experience. Healing was more rapid and postoperative discomfort and facial swelling tended to be less when there was antibiotic coverage after periodontal surgery involving bone although the difference was not significant statistically. Department of Periodontology, Royal Dental Hospital, Leicester Square, London, W.C. 2, England
MOUTH LESIONS IN IRON-DEFICIENT ANEMIA: RELATIONSHIP TO Candida Albicans IN SALIVA AND TO IMPAIRMENT OF LYMPHOCYTE TRANSFORMATION Fletcher, J., Mather, J., Lewis, M . J., and Whiting, G. J Infect Dis 131: 44, January, 1975. Sixteen of 29 patients selected because of chronic iron-deficient anemia had angular chelosis or atrophic glossitis. The flow of saliva was stimulated by chewing on parafin and samples were collected in iron-free sterile bottles. Peripheral blood lymphocytes from 23 patients (12 with mouth lesions) were separated by the use of Plasmagel. Candida albicans was isolated from the saliva of all 16 patients with angular chelosis or atrophic glossitis. There was a significantly greater difference in the initial count from the patients with mouth lesions than from either of the patients without mouth lesions or the controls. The growth of Candida as a result of impaired lymphocyte function was studied. In iron-deficient subjects, transformation of lymphocytes was depressed, as well as the lymphocyte count in the peripheral blood. It was suggested that a local factor, such as the effect of lack of iron on the indigenous bacterial flora, may be of importance. Department of Clinical Haematology and the Public Health Laboratory, City Hospi tal, Nottingham, England
Periodontosis: A Problem in Orthodontics* by
P A U L N . B A E R , D.D.s.t F R A N K G . E V E R E T T , M . S . , D . M . D . , M.D.‡ S I N C E ITS FIRST suggestion as a clinical entity by Gottlieb, periodontosis has been an enigma to the dental profession. The term itself is a controversial one, and there have been some who have doubted its existence as a clinical entity. Even among those who agree that the disease does exist, there is considerable variation in opinion as to its frequency and as to how it should be defined. We prefer to define periodontosis as a disease of the periodontium occurring in an otherwise healthy adolescent that is characterized by a rapid loss of alveolar bone around more than one tooth of the permanent dentition. There are two basic forms. In one, only the first molars and incisors are affected. In the other more generalized form most of the dentition is affected. The amount of destruction manifested is not commensurate with the amount of local irritants present. ' ' ' 1
2
3
4
5
Malocclusion may also be present in patients as a result of periodontosis, because one of the signs of advanced periodontosis is pathologic migration of the teeth. Malocclusion in patients with periodontosis may also be present and unrelated to the periodontal condi tion. In either case, orthodontic treatment may be a useful part of the total therapeutic regimen (Figures 2A-2D).
6
7
The onset of periodontosis generally coincides with the onset of pubescence. Since malocclusions are quite common during this same age period, it is reasonable to expect some adolescents with malocclusions who seek orthodontic therapy either to have periodontosis or to develop this condition during active treatment. Ortho dontists, therefore should be aware of this disease and should routinely examine all their patients with the aid of a periodontal probe and adequate roentgenograms before initiating therapy and at yearly intervals during active orthodontic treatment. It must be kept in mind that the gingiva in the earlier stages of this disease looks quite normal and that mere clinical inspection does not betray the presence of pockets and alveolar destruction. The
SUMMARY A N D CONCLUSIONS
1. Periodontosis occurs in the same age group in which orthodontic therapy is most often done. It is a periodontal disease which in the early stages may show little or no gingival inflammation and is easily over looked unless one is aware of the existence of this condition and looks for it. 2. Since malocclusions are common in adolescents, it is reasonable to expect that some adolescents with malocclusions will also develop periodontosis. 3. Periodontosis may have its onset during active orthodontic treatment. 4. Orthodontists, should routinely examine all of their patients, using adequate roentgenograms and a periodon tal probe before initiating therapy and at periodic (yearly) intervals during active treatment. 5. Where malocclusions are present in patients who already have periodontosis, orthodontic treatment may be a necessary and beneficial part of the total treatment
* Presented at the Orthodontic Periodontic Continuing Education Conference sponsored by the American Association of Orthodontists and the American Academy of Periodontology in St. Louis, Mo., March 24-26, 1974. † State University of New York at Stony Brook School of Dental Medicine. ‡% U n i v e r s i t y of Oregon Dental School.
8
plan.
559
560
Baer, Everett
J. Periodontol. September, 1975
F I G U R E 1A and IB. Roentgenographs taken in 1964 before orthodontic treatment revealing normal level of alveolar bone. (Age 14 years). C , Gridded roentgenographs taken five years later (1969) some months after discontinuation of orthodontic therapy. All four second premolars had been extracted. Note severe loss of bone in premolar areas. (Age 19 years.) D, Roentgeno graphs, same patient, another 5 years later (1974). The condition has essentially been stabilized, and improved in the lower pre molars. (Age 24 years.)
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2. A, Photograph of patient with periodontosis. Marked tooth mobilities and diastemas are present in anterior region. B, Note diastemas and design of appliance to reposition the teeth. C, Appliance in place. D, Diastemas have been closed by simple tooth movement and teeth stabilized by wire ligation.
FIGURE
REFERENCES 1. Gottlieb, B.: Die diffuse Atrophie des Alveolarknochens, Z Stomal 2 1 : 195, 1923. 2. Haupl, K., and Lang, F. J.: Marginale Paradentitis, (Entgegnung auf die Randbemerkungen Orban's). Z Stomal 25: 1100-1123, 1927 (page 1121) 3. Baer, P. N.: The case for periodontosis as a clinical entity, J Peridontol 42: 516, 1971. 4. Baer, P. N., and Benjamin, S. D.: Periodontal disease in children and adolescents: Philadelphia, J. B. Lippincott Com
pany, 1974. 5. Grant, D. A., Stern, I. B., and Everett, F. G.: Orban's Periodontics. 4th ed., St. Louis, C. V. Mosby, 1972. 6. Gottlieb, B., and Orban, B.: Zahnfleishchentziindung and Zahnlockerung, page 246 and following pages, Berlin, Berlinische Verlagsanstalt, 1933. 7. Marks, M. H., and Corn, H.: The role of tooth movement in periodontal therapy, Dent Clin North Am 13: 229, 1969. 8. Everett, F. G., and Fixott, H. C : Use of an incorporated grid in the diagnosis of oral roentgenograms. Oral Surg 16: 1061, 1963.
Abstracts PENICILLIN CONTROL OF SWELLING AND PAIN AFTER PERIODONTAL OSSEOUS SURGERY Kidd, E. A . M. and Wade, A . B. J. Clin Periodont 1: 52, N o . 1, 1974. Seventeen patients, 4 men and 13 women, ages ranging from 24 to 56 years, were included in the trial which was comprised of comparable flap procedures with curettage and osseous recontouring, performed on either side of the jaw at least one month apart. Each patient received phenoxymethyl penicillin (250 mgm) to use for five days at four-hour intervals, and a placebo, identical in all respects except that no antibiotic was included, for the other. Patients were also given 20 aspirin tablets (300 mgm) and were asked to take two tablets every four hours as needed for pain. Patients were seen at 48 hours and 1 week for assessment of postoperative pain and facial swelling. Total number of aspirin consumed after the use of penicillin and placebo, respectively, was further noted as an indication of pain experience. Healing was more rapid and postoperative discomfort and facial swelling tended to be less when there was antibiotic coverage after periodontal surgery involving bone although the difference was not significant statistically. Department of Periodontology, Royal Dental Hospital, Leicester Square, London, W.C. 2, England
MOUTH LESIONS IN IRON-DEFICIENT ANEMIA: RELATIONSHIP TO Candida Albicans IN SALIVA AND TO IMPAIRMENT OF LYMPHOCYTE TRANSFORMATION Fletcher, J., Mather, J., Lewis, M . J., and Whiting, G. J Infect Dis 131: 44, January, 1975. Sixteen of 29 patients selected because of chronic iron-deficient anemia had angular chelosis or atrophic glossitis. The flow of saliva was stimulated by chewing on parafin and samples were collected in iron-free sterile bottles. Peripheral blood lymphocytes from 23 patients (12 with mouth lesions) were separated by the use of Plasmagel. Candida albicans was isolated from the saliva of all 16 patients with angular chelosis or atrophic glossitis. There was a significantly greater difference in the initial count from the patients with mouth lesions than from either of the patients without mouth lesions or the controls. The growth of Candida as a result of impaired lymphocyte function was studied. In iron-deficient subjects, transformation of lymphocytes was depressed, as well as the lymphocyte count in the peripheral blood. It was suggested that a local factor, such as the effect of lack of iron on the indigenous bacterial flora, may be of importance. Department of Clinical Haematology and the Public Health Laboratory, City Hospi tal, Nottingham, England
