​Desafios clínicos do tratamento da periodontite estágio III associada a​ ​obesidade e outras comorbidades:​ ​relato de caso

Abstract

​This​ ​case​ ​report​ ​describes​ ​a​ ​48-year-old​ ​male,​ ​non-smoker,​ ​with​ ​class​ ​III​ ​obesity​ ​(BMI​ ​52.6​ ​kg/m2)​ ​and​ ​multiple​ ​comorbidities​ ​(type​ ​2​ ​diabetes​ ​mellitus,​ ​systemic​ ​arterial​​hypertension,​​and​​glaucoma),​​who​​sought​​care​​due​​to​​tooth​​mobility.​​The​​aim​ ​was​ ​to​ ​present​ ​the​ ​main​ ​challenges​ ​of​ ​basic​ ​periodontal​ ​therapy​ ​in​ ​a​ ​complex​ ​systemic​ ​scenario​ ​and​ ​to​ ​discuss​ ​the​ ​limited​ ​clinical​ ​response​ ​even​ ​when​ ​a​ ​1%​ ​melatonin​ ​gel​ ​was​ ​used​ ​as​ ​an​ ​adjunct​ ​in​ ​selected​ ​sites.​ ​Based​​on​​medical​​history,​ ​full-mouth​ ​periodontal​ ​charting,​​radiographic​​assessment,​​and​​laboratory​​evaluation,​ ​the​ ​patient​ ​was​ ​diagnosed​ ​with​ ​generalized​ ​stage​ ​III,​ ​grade​ ​C​ ​periodontitis,​ ​with​ ​indirect​ ​evidence​ ​of​ ​rapid​ ​progression​ ​potentiated​ ​by​ ​poor​ ​metabolic​ ​control.​ ​The​ ​treatment​​protocol​​included​​intensive​​oral​​hygiene​​instruction​​and​​motivation,​​scaling​ ​and​ ​root​ ​planing​ ​over​ ​multiple​ ​sessions,​ ​extraction​ ​of​ ​tooth​ ​27,​ ​and—within​ ​a​ ​split-mouth​ ​design—single​ ​subgingival​ ​application​ ​of​ ​1%​​melatonin​​gel​​(test)​​versus​ ​placebo​ ​(control)​ ​in​ ​selected​ ​deep​ ​periodontal​ ​pockets,​ ​followed​ ​by​ ​periodontal​ ​dressing​ ​and​ ​monthly​ ​supportive​ ​care.​ ​At​ ​the​ ​3-month​ ​re-evaluation,​ ​a​ ​marked​ ​improvement​​in​​visible​​plaque​​index​​was​​observed​​(39.4%​​to​​7%);​​however,​​bleeding​ ​on​ ​probing​ ​did​ ​not​ ​improve​ ​(51.5%​ ​to​ ​53%),​ ​probing​ ​depth​ ​and​ ​clinical​ ​attachment​ ​showed​ ​only​ ​slight​ ​reductions,​ ​and​ ​the​ ​number​ ​of​ ​teeth​ ​with​ ​suppuration​ ​increased​ ​(from​​4​​to​​9),​​indicating​​persistent​​infection​​and​​a​​limited​​therapeutic​​response.​​Given​ ​ongoing​ ​symptoms​ ​and​ ​lack​ ​of​ ​periodontal​ ​stability,​ ​a​ ​non-conservative​ ​plan​ ​was​ ​established,​ ​including​ ​multiple​ ​extractions​ ​and​ ​prosthetic​ ​rehabilitation​ ​(maxillary​ ​complete​ ​denture​ ​and​ ​mandibular​ ​removable​ ​partial​ ​denture,​ ​maintaining​ ​teeth​ ​31​ ​and​ ​46).​ ​Overall,​ ​this​ ​report​ ​underscores​ ​that​ ​periodontal​ ​stability​ ​in​ ​patients​ ​with​ ​morbid​ ​obesity​ ​and​​uncontrolled​​diabetes​​requires​​an​​interdisciplinary​​approach​​and​ ​strict systemic control in addition to conventional mechanical periodontal therapy.​