A 58-year-old smoker with diabetes, a failing lower molar and a bleeding implant

Staging measures severity and the complexity of management, not the depth of one pocket.

• 46 has interdental clinical attachment loss of at least 5 mm and a probing depth of at least 6 mm, Class II furcation involvement and grade II mobility. Furcation involvement (Class II or III), probing depths of 6 mm or more and vertical bone loss of 3 mm or more are Stage III complexity factors.
• He has lost two teeth (16, 26) to periodontitis. Stage IV requires five or more teeth lost to periodontitis plus a need for complex rehabilitation (masticatory dysfunction, secondary occlusal trauma, ridge deficiency, bite collapse). Two teeth keeps him in Stage III.
• Record extent (generalised if more than 30% of teeth are affected) and distribution, and chart all sites, not just 46.

Grading reflects rate of progression and expected response. Smoking of 10 or more cigarettes a day and HbA1c of 7.0% or more in a person with diabetes both move him to Grade C regardless of the bone-loss/age ratio; compare the older radiographs to document actual progression. Grade C changes the prognosis you quote and the review interval.

The implant at 16 shows bleeding on probing with 4 mm pockets and no progressive bone loss: that is peri-implant mucositis, not peri-implantitis. It is common, reversible and treated by mechanical deplaquing (with or without an antiseptic), reinstruction and review at 8 to 12 weeks. What matters for the implant's long-term survival is enrolment in a structured supportive peri-implant care programme, which also modifies his risk for any new implant.

Why immediate placement at 46 is a poor choice here

1. The site is actively infected. A 9 mm mesial pocket with Class II furcation involvement means the interradicular septum and part of the buccal plate are already lost. Immediate placement into a periodontally infected socket carries higher infection and failure rates because the socket cannot be debrided to a clean, contained defect.
2. Primary stability. Immediate placement relies on an intact socket wall and 3 to 5 mm of apical bone for torque. A furcation defect removes the septum, so both are compromised, and a prosthetically driven position may not be achievable.
3. Gap and contour. If the buccal wall is deficient you cannot contain a graft, and you commit to a large grafting volume with a thin buccal plate and a recession risk in the aesthetic zone (less critical at 46, but the bone problem remains).
4. The patient is not stable. He has an untreated 5 mm pocket on 45, a smoking habit of 15 a day and HbA1c of 7.9%. Elective implant surgery in an untreated, hyperglycaemic smoker is predictable failure, and peri-implantitis risk is higher in patients with a history of periodontitis.

A defensible alternative: non-surgical debridement of all sites first; extract 46 atraumatically; consider ridge preservation if the buccal wall is lost; reassess the tissues at 3 to 4 months; then place the implant. Also ask whether 46 must be replaced at all: with 47 present this is partly a shortened-arch decision, and one molar in a patient with multiple risk factors may not justify the surgical risk. Offer the option of no replacement and review.

Sequence and timescale

• Weeks 0 to 6: full periodontal chart and radiographs, letter to his GP requesting a current HbA1c and asking for optimisation, brief smoking advice (advise, offer referral, record the refusal), oral hygiene instruction, non-surgical debridement of every site of 4 mm or more, and review of the implant at 16 for mucositis.
• Weeks 8 to 12 (reassessment): this is the decision point. Plaque control, bleeding on probing and residual pocket depths determine whether elective surgery is offered. A pragmatic threshold before surgery is bleeding on probing below about 10% to 15% of sites and no residual pockets of 5 mm or more, with documented improvement.
• 46: extraction and, if the buccal wall is lost, ridge preservation; implant placement at 3 to 4 months; restoration at 7 to 9 months. This does not fit the wedding.
• 45: a 5 mm distal pocket without furcation involvement or mobility is a treated site, not an extraction. Do not replace it.

What must be documented: the diagnosis and staging, the written statement that the ideal plan does not fit a five-month deadline, the offer of an interim replacement (conventional or resin-bonded) for the wedding, the statement that implant survival is reduced in smokers and in poorly controlled diabetes, his refusal of smoking cessation support, and the advice to return if pain or swelling develops.

Put the options in writing, with the risks and the cost of each. The clinical failure here would not be the implant; it would be promising a fixed tooth by a date that the biology does not allow.