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J Clin Periodontol 2012; 39: 7379 doi: 10.1111/j.1600-051X.2011.01811.


Nils Ravald and Carin

Division of Cardiovascular Medicine,
Department of Medical and Health
Linkoping University, Center for Oral
Rehabilitation, County Council of
stergo tland, Linkoping, Sweden

Tooth loss in
treated patients. A long-
study of periodontal
disease and
root caries

Ravald N, Starkhammar Johansson C. Tooth loss in periodontally treated patients.

A long-term study of periodontal disease and root caries. J Clin Periodontol 2012;

Aim: To study periodontal conditions, root caries, number of lost

teeth and
causes for tooth loss during 1114 years after active periodontal

Material and Methods: Sixty-four patients participated in

the follow-up study.
Reasons for tooth loss were identified through previous case book and
radiographs. To identify factors contributing to tooth loss, a logistic
multilevel regression analysis was used.

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
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.

Conclusion: Previously treated patients at a specialist clinic for

continued to lose teeth in spite of maintenance treatments at general
and dental hygienists. The main reason for tooth loss was periodontal
Tooth loss was significantly more prevalent among smokers than non-
Tooth-related risk factors were smoking, low numbers of teeth and
prevalence of
periodontal pockets, 46 mm.

Epidemiological studies have shown that periodontal disease and

caries are the main reasons for tooth loss in different populations.
Although the prevalence of periodontal disease seems to decrease in the
Swedish population, still approximately 40% of the population have been
found subjected to moderately advanced periodontal disease.
Approximately 10% of the population show severe periodontal disease
(Hugoson et al. 2005, 2008). The prevalence of caries, especially root
caries is an increasing problem in the older patients. Root caries has been
found to be one of the main reasons for tooth loss in the ageing
population (Fure & Zickert 1997, Fure 2003).
In a recent study from Finland, it has been shown that severe
periodontal disease and dental caries tend to accumulate in the same
patients (Mattila et al. 2010). Previous studies in periodontally treated
patients have shown the cause of root caries to be of multifactorial
character (Ravald et al. 1986, Fadel et al. 2011). At the middle of the past
century, the main cause of periodontal disease was considered to be the
amount of dental plaque and time of exposure(Lo vdal et al. 1958, Schei
et al.

During the 1970s and 1980s, it was shown that specific

microorganisms such as Aggregatibacter actinomycetemcomitans and
Porphyromonas gingivalis are of specific importance in the pathogenesis
of periodontal disease (Socransky & Haffajee 1992, Slots & Ting 1999).
Today, it is widely accepted that microbial dental biofilms are the principal
aetiological factor of periodontitis. In an earlier study in periodontally
diseased patients, we found root caries to be more prevalent among
smokers than non-smokers (Ravald et al. 1986). During a 2 years
experimental study with intensive prophylactic treatments, 34 times a
year, we found that approximately 50% of the population developed new
root caries lesions. The periodontal conditions were almost unchanged.
Only a few teeth were lost during the experimental period. However, in
the long run, loss of teeth is evident even in well-maintained populations
(Hirschfeld & Wasserman 1978, Nabers et al. 1987, Faggion et al. 2007,
Carnevale et al. 2007a). Our working hypothesis is that tooth loss exists in
the long run in previously treated periodontal patients in spite of regular
visits at dental hygienists and general dental practitioners.
Material and Methods:
Of a sample of initially 147 patients referred for treatment of
periodontal disease (Ravald & Birkhed 1991), 117 individuals got indicated
to periodontal restorative and reconstructive treatments during a time
period of 624 months. Thereafter, 99 patients were involved in a
maintenance programme consisting of periodontal and root caries
prophylactic regimes during 24 months (Ravald & Birkhed 1992).At the
end of the experimental period, the patients were referred back to their
general practitioners and dental hygienists for maintenance on an
individual basis. After 1114 years, (Mean: 12.5 years) 64 individuals, 30
men and 34 women aged 4991 years (Mean age: 64 years, standard
deviation, SD: 8.3), were re-examined. It was not possible to examine 35
individuals due to death (n = 18), illness (n = 5), leaving the area (n = 4)
or not interested to participate (n = 8). The study protocol was approved
by the Ethics Committee of the University of Linko ping, Sweden, and the
patients gave their informed consent to participate in the study.
Clinical examinations:
Before the final clinical examination, the patients were called to a
specially trained dental assistant for standardized dental colour
photographs and a full mouth radiographic dental examination.

Samples were collected for determination of salivary secretion rate

(Heinze et al. 1983). Data were collected about general health,
medications, dental habits, use of fluorides and tobacco use. The severity
of periodontal disease was classified into five categories in accordance
with Hugoson & Jordan (1982):
Group 1: Healthy or almost healthy gingival units (<12 bleeding units in
the molarpremolar regions) and normal alveolar bone height;
Group 2: Gingivitis (12 bleeding gingival units in the molarpremolar
regions) and normal alveolar bone height;
Group 3: Alveolar bone loss at the majority of the teeth not exceeding
1/3 of the length of the roots;
Group 4: Alveolarm bone loss at the majority of the teeth ranging
between 1/3 and 2/3 of the length of the roots;
Group 5: Alveolar bone loss at the majority of the teeth exceeding 2/3 of
the length of the roots, presence of angular bony defects and/or furcation
defects. All exposed root surfaces were identified, and the distance from
the gingival margin to the cemento-enamel junction or existing filling
restoration was measured.
Subject characteristics:

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.

Table 1. Prevalence of general diseases and smoking habits at the final

Variable Number of
Percentage of the
individuals studied

Cardiovascular disease 8 13
High blood pressure 14 22
Asthmatic/allergic problems 16
Rheumatic disease 4 6
Diabetes (type 1 and 2) (1 + 5)
Gastro-intestinal disease 10
Other medical problems 12
Smoking 19 cig/day 7
Smoking >10 cig/day 11 17

Table 2. The dental histories at the final examination

Variable Number of
Percentage of the
individuals studied subjects
Bleeding gums 13 20
Sensitive teeth 14 22
Mouth dryness 17 27
Tooth brushing _2/day 62 97
Inter-dental cleaning _1/day 56 88
Use of extra fluorides 11 17
Visits at dentists 12 times/year 58 91
Visits at dental hygienists 14 times/year 45 71

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.

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.