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Tooth loss in
periodontally
treated patients. A long-
term
study of periodontal
disease and
root caries
Results: The number of lost teeth was 211. The main reason was
periodontal disease
(n = 153). Due to root caries and endodontic complications, 28 and 17
teeth,
respectively, were lost. Thirteen teeth were lost for other reasons. The
number of
teeth (p = 0.05) smoking (p = 0.01) and the number of visits at dental
hygienists significantly contributed to explain the variation in tooth loss.
The mean age of the examined patients, 30 men and 34 women, was
52 years (range: 3078, standard deviation, SD: 10.6) at the baseline
examination and 64 years (range: 49 91, SD: 8.3) at the final
examination. The prevalence of medical problems and smoking habits
reported by the patients at the final examination are summarized in Table
1. Eighteen patients (28%) reported daily smoking, of which 11 (17%)
smoked more than 10 cigarettes per day. In addition, 36 individuals
reported intakes of one or more prescribed medications. Seventeen
individuals reported intakes of blood attenuating medication, and 17
reported intake of medications for cardiovascular diseases. Eighteen
individuals took drugs due to gastrointestinal problems. Finally, 15
reported intake of some other prescribed drug. The dental histories at the
final examinations are summarized in Table 2. Fifty-six patients (88%)
performed some kind of daily inter-dental cleaning, and 45 individuals
(71%) reported that they visited dental hygienists 14 times a year.
Cardiovascular disease 8 13
High blood pressure 14 22
Asthmatic/allergic problems 16
25
Rheumatic disease 4 6
Diabetes (type 1 and 2) (1 + 5)
9
Gastro-intestinal disease 10
16
Other medical problems 12
19
Smoking 19 cig/day 7
11
Smoking >10 cig/day 11 17
Discussion:
The main findings from this longitudinal study in periodontally
treated patients were that the patients, to a considerable extent,
continued to lose teeth after active periodontal therapy during the
maintenance phase at general practitioners and their dental hygienists. In
the studied population, 64 teeth (22 molars, 13 with furcation
involvements grade II and III) were extracted during the active periodontal
and restorative treatment (Ravald & Birkhed 1991, 1992). Loss of teeth in
connection with periodontal therapy is in accordance with other studies
(Nyman & Lindhe 1979, Nabers et al. 1987, Carnevale et al. 2007b,
Eickholz et al. 2008). During the of the observation period of 2 years with
intensive maintenance at the specialist clinic, no teeth were extracted due
to periodontal disease. Root caries development was arrested, however,
not completely in spite of the intensive prophylactic treatments (Ravald &
Birkhed 1992). Totally, 211 teeth were lost during the observation period
of 11 14 years in the 64 patients remaining in the study. A majority (73%)
were lost due to periodontal disease.
At the final examination, 91% of the patients reported regular
visits to dentists (once or twice a year), and 71% reported 14 visits a
year at dental hygienists. Obviously, the recommended numbers of visits
were fulfilled. Surprisingly, the numbers of visits at hygienists were
positively correlated with the number of lost teeth. It seems reasonable to
assume that the patients with the most advanced periodontal disease and
caries problems were the most frequently called patients for maintenance
treatments. However, the quality of the supportive treatments might be
questioned. It is also reasonable to speculate that the daily plaque control
by the patients themselves have been insufficient over time. The studied
group showed at the final examination, a mean plaque index of 39%. This
was higher than reported in earlier studies. In the present study, the
reason for tooth loss was predominantly periodontal disease. This is in
accordance with other long-term studies in patients treated for
periodontal disease (Hirschfeld & Wasserman 1978, Checchi et al. 2002,
Fardal et al. 2004). However, other reasons for tooth loss have been
reported (Nyman & Lindhe 1979, Axelsson et al. 2004, Carnevale et al.
2007b). Root fractures have been reported to be the most prevalent
reason for tooth extractions (Nyman & Lindhe 1979, Axelsson et al. 2004,
Carnevale et al. 2007b). In geriatric populations, root caries seems to be
the main reason for tooth loss (Fure & Zickert 1997, Slade et al. 1997,
Luan et al. 2000). Problems with root caries in periodontal patients have
been shown in previous studies (Ravald et al. 1986, Reiker et al. 1999).
Recently, Fadel et al. (2011) presented in a study of a risk model for root
caries that about one-fifth of the patients referred for periodontal
treatment showed an increased risk which is in accordance with our
findings. In the present study, population the problem with root caries
exists, but seems not to be the main reason for tooth loss. However, in
elderly and disabled individuals with periodontal problems, root caries
must be considered as a risk factor for tooth loss (Takano et al.
2003,Avlund et al. 2004).
In our study, we found the patient related parameter smoking to be
significantly correlated with tooth loss. Obviously, tooth loss is more
prevalent among smokers than non-smokers(OR: 8). Smoking must be
considered as an important risk factor for tooth loss in this patient
category. This is in accordance with findings from earlier studies in
periodontally diseased populations (Haber et al. 1993, Bergstrom &
Preber 1994, Fardal et al. 2004, Dannewitz et al. 2006). In contrast to
earlier studies, (Axelsson & Lindhe 1981, Fardal et al. 2004, Eickholz et al.
2008) we found a positive correlation between the number of self-reported
visits at dental hygienists and loss of teeth. The results from the present
study have shown, in a group of previously treated patients with advanced
periodontal disease, in spite of repeated regular maintenance performed
by general practitioners and dental hygienists that future tooth loss is not
prevented. The main reason for tooth loss is periodontal disease. A
lifelong maintenance programme, individually adapted to each patient,
should be designed by the specialist and when possible be performed by a
hygienist in close connection with the periodontist.
Conclusions:
Periodontally treated patients are in a longer perspective at risk of
further tooth loss. Maintenance performed at general practitioners and
dental hygienists seems not to be sufficiently effective for prevention of
tooth loss. Smokers with low numbers of remaining teeth and deepened
periodontal pockets are at higher risk for future tooth loss.