Residual pockets, a furcation, and a request for an implant
A 44-year-old woman returns for re-evaluation 6 weeks after full-mouth scaling and root planing. She smokes 12 cigarettes per day and has type 2 diabetes managed with metformin alone; her most recent HbA1c is 8.4%. Probing depths are 3–4 mm in the anterior sextants, but 6–7 mm on the molars, with bleeding on probing at 65% of sites. There is a class II buccal furcation on #30 and roughly 30% horizontal bone loss throughout. Tooth #19 is missing. Plaque scores are low and her home care is good. She asks whether she needs "another deep cleaning" or surgery, and whether she can have an implant for #19 now.
1. Assign a stage and grade, and justify each with the data given. What additional information would raise the grade?
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Stage III: interdental clinical attachment loss ≥5 mm, bone loss extending into the middle third of the roots, a class II furcation, and fewer than four teeth lost to periodontitis. The 6–7 mm pockets on molars with 65% bleeding fit Stage III rather than Stage II.
Grade C (rapid progression risk): two grade modifiers are present and either alone is sufficient - smoking ≥10 cigarettes/day and a diabetes diagnosis with HbA1c >7.0%. Grade is a risk estimate, not a severity measure, and drives the recall interval and how aggressively you treat.
Data that would raise the grade further: radiographic bone loss exceeding the expectation from age (bone loss % / age > 1.0), documented attachment loss of ≥2 mm over 5 years, or a history of teeth extracted for periodontitis that has not yet been disclosed.
Practical consequence: a Grade C smoker with an HbA1c of 8.4% should be placed on a short recall (3 months) and the risk factors addressed before any surgical decision, because surgery in an uncontrolled patient predictably underperforms.
2. Choose among repeat subgingival instrumentation, access flap surgery, extraction of #30, and continued maintenance. Defend your choice and state your decision point.
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Do not operate yet. Six weeks is the earliest reasonable re-evaluation, but with 65% bleeding and 6–7 mm residual pockets the disease is still active; surgery on an inflamed, incompletely debrided site simply lays a flap over untreated deposits.
Preferred sequence:
- Re-instrument the residual pockets ≥5–6 mm with bleeding, with attention to the molar furcations, under local anesthesia.
- Reinforce interproximal cleaning and address the two modifiable risk factors (see below).
- Re-evaluate at 8–12 weeks. Decision point: pockets ≥6 mm with bleeding that persist despite good hygiene and completed debridement → site-specific access flap or regenerative surgery at those sites only.
#30: a class II buccal furcation with a 7 mm pocket is maintainable if the patient can clean it and bleeding resolves; it becomes an extraction candidate if the furcation cannot be kept plaque-free, if it becomes symptomatic, or if it develops a through-and-through defect. Do not extract on the day of re-evaluation purely because the numbers look bad.
Anterior sextants: 3–4 mm with low bleeding need maintenance, not surgery.
3. How do smoking and the HbA1c of 8.4% change what you tell her about the implant at #19?
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Both are dose-dependent risk multipliers for implant failure and peri-implantitis, and neither is an absolute contraindication.
What I would say:
- Implant survival in treated, stable periodontitis patients is acceptable, but a history of periodontitis raises the risk of peri-implantitis, so she must be enrolled in a maintenance program before, not after, the implant.
- Smoking 12/day measurably increases failure and marginal bone loss; cessation (even reduction) before surgery improves outcomes, and I would offer referral rather than a lecture.
- An HbA1c of 8.4% is above the range generally associated with uncomplicated healing; coordinate with her physician and aim to defer the implant until control improves.
Sequencing: risk-factor counseling and residual-pocket retreatment first → confirm stability at 3 months → then place the implant. This is also the honest answer to "can I have it now": not now, but probably soon, and she should know exactly which milestones unlock it.
Consent point: document the discussion and the alternatives (fixed partial denture, no replacement, removable partial denture) so the decision is hers and informed.