Two Case Reports on Refractory Periodontitis: Systemic Implications and a Potential New Therapeutic Strategy

Abstract

Two cases of Refractory Periodontitis (RP) were studied over an 8-month time period. Both received a novel regimen of “combination” Host-Modulation Therapy (HMT) (subantimicrobial-dose doxycycline plus low-dose flurbiprofen adjunctive to traditional non-surgical periodontal therapy. Prior to beginning “combination” HMT, Case #1 was characterized by progressive periodontal deterioration; dramatically elevated levels of inflammatory mediators (IL-1β) and tissue-destructive enzymes (collagenase activity) in periodontal pockets (GCF); and evidence of systemic inflammation (high serum levels of hs-C-reactive protein), and mildly elevated LDL and total levels of cholesterol, indicating an increased risk for cardiovascular disease (CVD). In contrast, Case #2 exhibited undetectable levels of local biomarkers of inflammation and tissue destruction in their periodontal pockets (GCF), and much lower levels of both serum hs-CRP and cholesterol indicating lower risk for CVD. Both cases, however, demonstrated the characteristics of RP including progressive loss of bone and attachment despite repeated periodontal therapy. During the 12-month regimen of, Case #1, who exhibited much higher levels of local and systemic biomarkers, responded much more dramatically to the “combination” therapy than Case #2. We suggest that this novel “combination” therapy may be particularly useful in a sub-set of RP patients who exhibit evidence of systemic inflammation in their serum (or plasma) samples indicating increased risk for CVD; in these patients “combination” therapy may dramatically reduce both periodontal disease activity and CVD risk. In order to test this hypothesis, which proposes the development of more individualized therapeutic strategies, it clearly must be validated in future randomized clinical trials.