Journal OA 5

Bull Tokyo Dent Coll (2019) 60(2): 131–138
Case Report doi: 10.2209/tdcpublication.2018-0048
Periodontal Regenerative Therapy with Enamel Matrix

Derivative in Patient with Chronic Periodontitis: A 3.5-year
Follow-up Report
Takahiro Bizenjima1), Yutaka Osuka2), Sachiyo Tomita3) and Atsushi Saito3)

1)
Tokyo Dental College Chiba Dental Center,
1-2-2 Masago, Mihama-ku, Chiba 261-8502, Japan
2)
Osuka Dental Clinic,
311 Konawatecho, Toyohashi-shi, Aichi 440-0873, Japan
3)
Department of Periodontology, Tokyo Dental College,
2-9-18 Kanda-Misakicho, Chiyoda-ku, Tokyo 101-0061, Japan
Received 16 August, 2018/Accepted for Publication 22 August, 2018

Published Online in J-STAGE 15 March, 2019
Abstract
Here, we report periodontal treatment including regenerative therapy in a patient
with generalized chronic periodontitis. The patient was a 53-year-old woman who pre-
sented with the chief complaint of gingival swelling and tooth mobility in the right maxil-
lary molar region. An initial examination revealed 36% of sites with a probing depth of
≥4 mm and 16.7% with bleeding on probing. Radiographic examination revealed verti-
cal bone resorption in #15, 24, 27, 34, 37, 45, and 47. Horizontal resorption was noted in
other regions. The clinical diagnosis was moderate chronic periodontitis. Initial peri-
odontal therapy consisted of plaque control, scaling, and root planing together with
treatment for caries. Occlusal adjustment of premature contact sites was performed after
suppression of inflammation. Periodontal regenerative therapy using enamel matrix
derivative was performed on #15, 24, 34, 45, and 47. Other sites with residual periodontal
pockets were treated by open flap debridement. Tooth #27 was extracted due to a bone
defect exceeding the root apex; #37 was extracted due to frequent acute symptoms fol-
lowing periodontal surgery. Following re-evaluation, the patient was placed on supportive
periodontal therapy. Periodontal regenerative therapy improved vertical bone resorp-
tion. This improvement has been adequately maintained over a 3 years 6 months period.
Additional care is necessary, however, to further improve the patient’s oral health-related
quality of life during supportive periodontal therapy.
Key words: Chronic periodontitis — Intrabony defects —
Periodontal regenerative therapy — Enamel matrix derivative —
Supportive periodontal therapy
131
132 Bizenjima T et al.
Introduction health of the patient was good.

She had first become aware of periodontal
The purpose of periodontal treatment is to disease approximately 10 years earlier. She
remove the cause of periodontal disease, had a history of caries treatment, and had
regenerate periodontal tissue, recover occlu- received regular check-ups every 3 months at
sal function, and create an environment in a local dental office. Her dentist referred her
which management of oral hygiene is easy. to our clinic for the treatment of periodonti-
Periodontitis destroys gingival fibrils and peri- tis. Figure 1 shows an oral view obtained at her
odontal ligament fibers, which results in first visit. Gingival inflammation and subgin-
absorption of alveolar bone. This weakens gival calculus were mostly evident in the molar
support for the dentition that is normally pro- region. Lingual inclination was observed in
vided by periodontal tissue. Bone defects due #31. Premature contact was observed in #15
to absorption of alveolar bone are classified and 45.
either as horizontal, or as angular or intrabony. The results of the periodontal examination
Intrabony defects are often associated with are shown in Fig. 2. They revealed that 36% of
occlusal trauma5). Such defects can also occur sites had a probing depth (PD) of ≥4 mm,
where occlusal force is normal, however, due and 10.1% a PD of ≥7 mm. Bleeding on prob-
to abnormalities in the cementum, such as ing (BOP) was observed at 16.7% of sites. The
exfoliation21). The distance between adjacent level of plaque control as assessed by the
teeth, a depression in the root surface, and O’Leary plaque control record (PCR)14) was
anatomical factors may also result in intrabony 23%. Radiographic examination (Fig. 3)
defects. Currently, various regenerative thera- revealed angular bone defects in #15, 24, 27,
pies are available for the treatment of 34, 37, 45, and 47; and widening of the peri-
intrabony defects due to periodontitits. One odontal ligament space in #15. The diagnosis
example is the use of enamel matrix deriva- of furcation involvement was Degree I for
tive (EMD), which is derived from porcine #37. As a measure of patient reported out-
tooth buds and is currently available in a com- come, oral health-related quality of life (QoL)
mercial formulation (Emdogain® Gel, Biora was assessed using an oral health-related QoL
AB, Malmö, Sweden)7). Enamel matrix deriva- instrument (OHRQL)16). The total OHRQL
tive has been applied in various types of peri- score was 23.
odontitis-induced defect, and the results have
demonstrated its ability to encourage peri- 2. Diagnosis
odontal regeneration. Here, we report suc- The clinical diagnosis was moderate
cessful periodontal regenerative therapy with chronic periodontitis1). A treatment plan was
EMD for intrabony defects due to chronic presented to the patient and her consent to
periodontitis. the proposed plan obtained.
Case Presentation Clinical Procedures and Outcomes
Written informed consent was obtained 1. Treatment plan

from the patient for inclusion in this report. 1) Initial periodontal therapy
This comprised oral hygiene instruction,
1. Baseline examination quadrant scaling and root planing (SRP), car-
In August 2011, a 53-year-old woman visited ies treatment of #16, 17, 26, 27, 36, 37, 46, 47,
the Clinic of Conservative Dentistry at Tokyo and occlusal adjustment for #15 and 45.
Dental College Chiba Hospital with the chief 2) Reevaluation
complaint of gingival swelling and tooth 3) Periodontal surgery
mobility in the molar region. The general Periodontal surgery for sites with a PD of
【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り
【図】●図番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイトル折り返し：番号の後（続
く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
【表】●番号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
罫の太さ　1.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　字下げなし　
Regenerative
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシはTherapy with EMD
-（ハイフン）に F50：tohaba の文字スタイルをかけて作成 133

Fig.　1　Oral view at first visit
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成

く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　 Fig.　2　Periodontal examination at first visit
Fig.　3　Radiographic view at first visit

134 Bizenjima
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは T et al. F50：tohaba の文字スタイルをかけて作成
-（ハイフン）に
Table　1　Treatment process
August 2011 Initial periodontal therapy

· Plaque control
· Quadrant SRP
· Occlusal adjustment (#15, 45)
· Caries Treatment (#16, 17, 26, 27, 36, 37, 46, 47)
August 2012 (Reevaluation)

Surgical periodontal therapy
· Open flap debridement (#14, 16, 17, 25, 26, 35, 36, 37, 44, 46)
· Regenerative therapy with Emdogain® Gel (#15, 24, 34, 45, 47)
· Extraction (#27 and 37)
June 2014 to present (Reevaluation)

Supportive periodontal therapy
· Oral hygiene instruction
· Professional tooth cleaning
SRP: scaling and root planing
≥4 mm. Periodontal regenerative therapy 3) Periodontal surgery

with EMD for #15, 24, 27, 34, 37, 45, and 47. The need and options for periodontal sur-
4) Reevaluation gery based on these findings were explained
5) Supportive periodontal therapy (SPT) or to the patient. After consultation, she chose
maintenance to receive regenerative therapy with EMD
(Emdogain® Gel, Straumann Japan, Tokyo).
2. Treatment process Subsequently, regenerative therapy was per-
An outline of the treatment process is formed on #15, 24, 34, 45, and 47 to treat
shown in Table 1. deep intrabony defects (Fig. 4).
1) Initial periodontal therapy Open flap debridement was implemented
After obtaining informed consent for the for #14, 16, 17, 25, 26, 35, 36, 37, 44, and 46 to
proposed treatment plan, instruction was reduce periodontal pockets. Intraoperatively,
given on maintaining oral hygiene and quad- #27 had to be extracted due to a bone defect
rant SRP performed. Caries treatment was exceeding the root apex. Tooth #37 was
performed for #16, 17, 26, 27, 36, 37, 46, 47. extracted due to frequent acute symptoms fol-
Occlusal adjustment was implemented for lowing periodontal surgery.
#15 and 45. 4) Reevaluation
2) Reevaluation On reevaluation, an improvement was
Subsequent reevaluation revealed a reduc- observed in gingival inflammation and PD.
tion in the PCR score to 13%, and a decrease The patient’s level of plaque control was good
to 16.7 and 3% for sites with a PD of ≥4 and (PCR <20%). Various levels of improvement
7 mm, respectively. The OHRQL total score were observed radiographically at those sites
was 13. Closed pockets22) were observed in selected for regenerative therapy. Resolution
70.3% of the teeth, and BOP in 24.1%. These of tooth mobility was observed in #15. The
results were judged to be “insufficient” periodontal conditions were judged to be
according to the criteria for the success of stable, and the patient was placed in a recall
non-surgical periodontal therapy10). system for SPT. The total OHRQL score was 9,
indicating an improvement in QoL from at
Regenerative
Fig.　4　Periodontal regenerative therapy with enamel matrix derivative (EMD) (#34)

a: after debridement, b: filling of defects with EMD, c: closed flap with polytetrafluoroethylene non-re-
sorbable sutures, d: First visit radiographic view, e: Post-initial periodontal therapy, f: 6 m supportive perio-
dontal therapy (SPT), g: 3y6m SPT
first visit. resolution of inflammation by SRP. Periodon-

5) Supportive periodontal therapy titis can progress rapidly when occlusal
During 3 years 6 months of SPT, pockets trauma is present. When bone resorption
with a PD of 4 mm were found in #15, 16 and extends to the apex of the root, conserving
45 (Fig. 6), but the periodontal conditions the teeth becomes extremely difficult. An
remained stable in most of the teeth (Figs. 5 increase in bone resorption and attachment
and 7). A 3-mm gain in average clinical attach- loss were observed in #17 on reevaluation,
ment was observed in the teeth treated with necessitating extraction. Patient consent for
EMD (Fig. 8). Occlusion was frequently exam- this had not yet been obtained at this point,
ined to control occlusal trauma during SPT. however, so first initial periodontal therapy
was performed prior to judging whether #17
could be conserved during further surgical
Discussion treatment.
It has been reported that applying EMD
Deposition of plaque and calculus and sec- greatly improves clinical parameters and
ondary occlusal trauma were thought to have bone loss compared with flap surgery17,19). No
played a major role in the progression of significant difference was observed between
destruction of periodontal tissue observed in combined use of EMD and autologous bone
the present case. Traumatic occlusion due to compared with EMD alone in the treatment
bruxism or early contact promotes destruc- of intrabony defects6). The results of the pres-
tion of periodontal tissue13). In such cases, ent case appear to support this earlier finding,
therefore, it is necessary to control occlusal in that relatively beneficial effects were
force, which includes removing both local fac- obtained by treatment of both one- and two-
tors (occlusion abnormalities such as early wall defects with EMD alone. The type of osse-
contact) and general factors (mental stress)15). ous defect has been shown to be an important
In the present case, premature contact of the determinant in EMD treatment, however3).
premolars was recognized. Therefore, occlu- Recent studies have reported that combina-
sal adjustment was performed following the tions of different regenerative therapies, such
136 Bizenjima
斜体は New Baskerville ITC Std Italic（タグは <l>）　半角ダーシは T et al. F50：tohaba の文字スタイルをかけて作成
-（ハイフン）に

く説明の先頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　 Fig.　5　Oral view at 3y6m of SPT
Fig.　6　Periodontal examination at 3y6m of SPT
as application of EMD and bone grafting ment in PD at 3 years 6 months compared

materials, are effective20). In addition, guide- with at baseline (Fig. 8).
lines issued by the Japanese Society of Peri- One study found a mean reduction in PD
odontology recommend using both EMD and of 4.4 mm and a gain in CAL of 3.2 mm at 2
a bone graft when the osseous defect exceeds years following EMD therapy4). The results at
4 mm in depth and 2 mm in width on dental 3 years 6 months in the present case are also
X-ray images9). Transplantation of autologous in agreement with other long-term data18).
bone together with application of a bone sub- Caution should to be exercised when compar-
stitute such as EMD might further enhance ing these results, however, as the defect types
regeneration of periodontal tissue in such and initial PD and attachment levels were
cases. In the present case, application of EMD different.
in a total of 5 teeth resulted in an improve- In the present case, an increase in radiopac-
Regenerative
396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

号・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　図タイトルと説明のアキ　9Q　●タイ
Fig.　7　Radiographic viewトル折り返し：番号の後
at 3y6m of SPT （続
頭は字下げ不要）　●図説の幅　片段：片段固定　全段：図幅　　
・タイトル・説明：11.3Q　12.7H　New Baskerville ITC Std　タイトルと表のアキ　10.5Q　●罫線　表はじめのみ双罫　表中の
.411mm ●表中：11.3Q　12.7H　New Baskerville ITC Std　●脚注　11.3Q　12.7H　New Baskerville ITC Std　字下げなし　
Baskerville ITC Std Italic（タグは <l>）　半角ダーシは -（ハイフン）に F50：tohaba の文字スタイルをかけて作成
levels of subgingival microbiota over a pro-

longed period of time2). Based on these ear-
lier reports, the present patient was placed on
a 3-month recall schedule for SPT and the
level of oral hygiene checked each such visit.
Acknowledgements
The authors declare no conflict of interest

with regard to this case report. The authors
Fig.　8　Contribution of gingival recession and attach- would like to thank Professor Jeremy Williams
ment gain to reduction in probing depth of the Department of International Medical
Communications at Tokyo Medical University
for his editing of the English of this
manuscript.
ity was confirmed in the 5 sites treated with
EMD after 6 months of SPT, and further
improvement was also observed at 3 years and
6 months. One earlier study reported that References
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Bull Tokyo Dent Coll (2019) 60(2): 131–138

Case Report doi: 10.2209/tdcpublication.2018-0048

Periodontal Regenerative Therapy with Enamel Matrix

Takahiro Bizenjima1), Yutaka Osuka2), Sachiyo Tomita3) and Atsushi Saito3)

Received 16 August, 2018/Accepted for Publication 22 August, 2018

Introduction health of the patient was good.

Case Presentation Clinical Procedures and Outcomes

Written informed consent was obtained 1. Treatment plan

【版面】W：396 pt（片段 192 pt） H：588 pt 【本文】行数不明（手組み） 10pt 12pt 送り

【版面】W：396 pt（片段 192 pt） H：588 pt 【本文】行数不明（手組み） 10pt 12pt 送り

Fig. 3 Radiographic view at first visit

August 2011 Initial periodontal therapy

August 2012 (Reevaluation)

June 2014 to present (Reevaluation)

SRP: scaling and root planing

≥4 mm. Periodontal regenerative therapy 3) Periodontal surgery

Fig. 4 Periodontal regenerative therapy with enamel matrix derivative (EMD) (#34)

first visit. resolution of inflammation by SRP. Periodon-

【版面】W：396 pt（片段 192 pt） H：588 pt 【本文】行数不明（手組み） 10pt 12pt 送り

Fig. 6 Periodontal examination at 3y6m of SPT

as application of EMD and bone grafting ment in PD at 3 years 6 months compared

396 pt（片段 192 pt） H：588 pt 【本文】行数不明（手組み） 10pt 12pt 送り

levels of subgingival microbiota over a pro-

The authors declare no conflict of interest

Tokyo Dent Coll 52:​215–221. Fukaya C, Matsumoto S, Ueshima F, Hayakawa

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Case Report doi: 10.2209/tdcpublication.2018-0048

【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

Fig.　3　Radiographic view at first visit

Fig.　4　Periodontal regenerative therapy with enamel matrix derivative (EMD) (#34)

【版面】W：396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

Fig.　6　Periodontal examination at 3y6m of SPT

396 pt（片段　192 pt）　H：588 pt　【本文】行数不明（手組み）　10pt　12pt 送り

Tokyo Dent Coll 52:215–221. Fukaya C, Matsumoto S, Ueshima F, Hayakawa