663
Retained "Hopeless" Teeth: Lack of Effect Periodontally-Treated Teeth Have on the Proximal Periodontium of Adjacent Teeth 8-Years Later Michael S.
Wojcik, * Cheryl H. DeVore,* F.
Michael Beck,* and John E. Horton*
the lack of effect periodontally-treated teeth prognosed and retained for 3.4±1.5 years have on the proximal periodontium of ad"hopeless" We teeth. now our findings for the same group of subjects following report jacent 8.4 ±0.7 years of "hopeless" tooth retention. Of the 17 "hopeless" and adjacent teeth originally measured in 17 subjects, 14 of the subjects were still available for re-evaluation. Measures used to assess the periodontium of proximal surfaces of adjacent teeth included pocket depths (PD), radiographie alveolar bone level (R-BL), and periodontal ligament space width (W-PL). Treatment for the subjects consisted of surgical therapy (N 15) and scaling and root planing (N 2). Of the 14 subjects re-examined, 2 were eliminated due to loss of adjacent tooth reference points and 2 due to extraction of the "hopeless" tooth (N 10). Differences in measurements (i.e., nonadjacent to "hopeless" tooth value minus adjacent to "hopeless" tooth value) were analyzed using a repeated measures ANOVA. There were no significant differences for PD (P 0.20), R-BL (P 0.29), or W-PL (P 0.16). These data confirm our original findings that retained periodontally "hopeless" teeth do not significantly affect the proximal periodontium of adjacent teeth following therapy. / Periodontol 1992; 63:663-666. We
previously reported
=
=
=
=
=
=
Key Words: Periodontal diseases/etiology; periodontal diseases/therapy; periodontium/ anatomy and histology.
The decision to extract a periodontally "hopeless" tooth is often based on the empirical assumption that its retention accelerates the destruction of the adjacent proximal periodontium. "Strategic extractions" have been advocated in the past to prevent this phenomena.1"3 However, Becker et al.4 have also questioned the over-zealous removal of such teeth. They suggested that the effects these teeth have on the remaining dentition be further examined.5 Machtei et al.6 have reported that in the absence of periodontal treatment the retention of a "hopeless" tooth has a destructive effect on the periodontium of adjacent teeth. If therapy is not feasible they recommended extraction of the "hopeless" tooth. However, they also suggested that the effect periodontal therapy has on bone loss associated with retained "hopeless" teeth needs further assessment. In a previous study we reported on the retention of teeth diagnosed as periodontally "hopeless" but included in treatment rather than extracted at the expressed desire of
Department of Periodontology, The Ohio State University College Dentistry, Columbus, OH. + Division of Dental Hygiene. * Department of Diagnostic Services. *
of
the patient.7 This initial study evaluated the influence such treated teeth had on the proximal periodontium of adjacent teeth 3.4 years following periodontal therapy. No significant change was found in probing depths, radiographie alveolar bone level, and width of the periodontal ligament between interproximal tooth surfaces adjacent to and nonadjacent to the treated "hopeless" tooth. We have now extended our study to report findings for the same group of "hopeless" teeth retained 8.4 ± 0.7 years following periodontal therapy.
MATERIALS AND METHODS The original study consisted of 17 adult subjects (9 males, 8 females; mean age 55.1 ± 1.42 years) each presenting with one "hopeless" and one mesially adjacent non-"hopeless" tooth which were treated for periodontal disease. Retention and treatment of the prognosed "hopeless" tooth was at the expressed desire of the patient. The pretherapy prognosis of a "hopeless" tooth was confirmed by possession of a minimum of at least 2 of the established criteria
(Table 14>5). Of the original subjects
14
were
available for re-exami-
664
J Periodontol August 1992
RETAINED "HOPELESS" TEETH: EFFECTS ON PERIODONTIUM OF ADJACENT TEETH
Table 1. Criteria Used to Determine a "Hopeless" Prognosis With the Percentage and Number Corresponding With Each
Criteria4 Loss of
>
75% of the
supporting bone
8 mm Class III furcation involvement Class III mobility with tooth movement in mesial, distal, and vertical directions Poor crown-root ratios Root proximity with minimal interproximal bone and evidence of horizontal bone loss History of repeated periodontal abscess
Probing depths greater than
Number
(%)
2 7 1 6
(20) (70) (10) (60)
4 0
(40)
0
0
Table 2. Number of "Hopeless" and
Adjacent Teeth by Tooth Type Anterior
Bicuspid
Molar
Hopeless
Mandibular
Maxillary Adjacent
Mandibular
Maxillary
0
Table 3. Mean Pocket Depth (mm ± S.E.) for Adjacent and NonSurfaces of the Proximal Tooth
Adjacent nation (2 died, 1 moved away). Of the 14, 2 were eliminated due to extraction of the "hopeless" tooth and 2 due to loss of adjacent tooth reference points (i.e., a restoration was placed to obscure the cemento-enamel junction of the tooth). Of the remaining 10 subjects there were 6 males and 4 females with a mean age of 57.3 ± 13.7 years. Since the last study 60% of the patients received supportive periodontal therapy (SPT) > 2 times a year; 20% received yearly maintenance; and 20% received < 1 year maintenance. All clinical measurements were made on the mesial and distal surfaces of each adjacent tooth from both the buccal and lingual surfaces. The mesial measurements of each adjacent tooth represent the control to the corresponding distal measurements of adjacent surfaces for each "hopeless" tooth. Probing depths (PD) were measured to the nearest millimeter from the gingival margin to the bottom of the sulcus of each tooth using a William's periodontal probe with Michigan "O" markings. Probing measurements were taken as close to the contact area as possible and parallel to the long axis of each tooth. The radiographie alveolar bone level (R-BL) for each tooth measured was determined from radiographs taken at initial presentation and compared with those taken at the first and second post-therapy examinations. The initial radiograph was taken using a long-cone parallel technique8 with a Rinn positioning device at 70 kVP while both posttherapy radiographs consisted of long cone paralleling vertical bite-wing radiographs9 exposed at 70 kVP using an Up-Rad positioning device. Measurements from the radiographs were made using the Duckworth et al. modification10 of the Schei Ruler technique.11-12 Analysis of the width of the periodontal ligament space (W-PL) was made with a radiographie projection system modified13 from that origi-
nally reported by Bjorn et al.14 For the adjacent proximal periodontium and non-adjacent proximal periodontium, measured differences between the pretherapy and first and second post-therapy scores for all variables (PD, R-BL, and W-PL) were analyzed using a repeated measures ANOVA for location, time, and location by time. Differences in pretherapy scores and first and second post-therapy scores (i.e., non-adjacent interproximal periodontium minus adjacent to proximal periodontium) were analyzed using a repeated measures ANOVA.
Pre-
Post-
Post-
Therapy
Therapy T,
Therapy T2
4.10±0.233 3.90±0.245 4.00 ±0.207
3.10 ±0.277 3.45 ±0.203 3.28 ±0.169
3.55 + 0.203 3.25 ±0.239 3.40 ±0.140
(B*)
(B*)
Tooth
Adjacent Non-Adjacent Main effect for time
(A*)
Location: F 0.05, df 1/9, Time: F 4.51, df 2/18, Location time: F 1.80, df * Means with the same letter are =
=
=
=
=
0.8340. 0.0259.
= = =
2/18,
not
=
0.2033.
statistically significant (P
>
0.05).
Table 4. Mean ( ± S.E.) Radiographie Bone Loss for Adjacent and Non-Adjacent Periodontium of Proximal Tooth Post-
PreLocation
Therapy
Adjacent Non-Adjacent
Post-
Therapy T, Therapy T2
75.0: : 14.10 80.1 ±6.67 68.0 ±7.86 65.0: : 13.90 58.0±11.80 55.0±8.06
Location: F 6.41, df 1/9, Time: F 0.50, df 2/18, time: F Location 1.33, df =
=
=
=
=
Main Effect for Location 74.5 ±8.27 59.3±9.91
0.0322. 0.5808.
= =
=
2/18,
=
0.2898.
Initial and first post-therapy measurements were made by CD. Following reproducibility of the original measurements, the second post-therapy analysis was made by MW. RESULTS Table 2 indicates the representative tooth types for both the "hopeless" and adjacent tooth types, respectively. Forty percent of the "hopeless" teeth were multirooted, with 75% of these being maxillary teeth. Fifty percent of the adjacent teeth were premolare while the remaining 50% were anterior teeth. Mean values (± S.E.) for PD, R-BL, and W-PL for adjacent and non-adjacent areas across the 3 time periods are shown in Tables 3, 4, and 5. Significant effects across time were shown for P-D (P 0.0259) and across location for R-BL (P 0.0322). No other significant effects were observed. Table 6 illustrates the mean change (non-adjacent minus adjacent) values (± S.E.) for PD, R-BL, and W-PL across the 3 time periods. No significant differences were observed. The power of the F-test (alpha 0.05) to detect PD differences of ± 1 mm was 92.5%; to detect R-BL =
=
=
Volume 63 Number 8
WOJCIK, DEVORE, BECK, HORTON
Table 5. Mean ( ± S.E.) Width of the Periodontal Periodontium of Proximal Tooth
Tooth
Adjacent Non-adjacent Total
Pre-Therapy
Post-Therapy T,
Post-Therapy T2
Total
0.300 ±0.0382 0.338 ± 0.0325 0.319 ±0.0286
0.338 ±0.0529 0.250 ±0.0373 0.294 ±0.0385
0.296 ±0.0157 0.296 ±0.0219
=
=
=
Ligament for Adjacent and Non-Adjacent
0.250 ± 0.0323 0.300 ± 0.0382 0.275 ±0.0267
Location: F 0.00, df 1/9, Time: F 0.46, df 2/18, Location time: F 2.04, df =
=
1.00. 0.6381.
= = =
2/18,
=
0.1586.
Table 6. Mean (± of Proximal Tooth
S.E.) Change Values (non-adjacent-adjacent) Over Time for PD, R-BL, and W-PL
Measurement
Pre-therapy
PD R-BL W-PL
665
Post-therapy T,
0.200 ± 0.238 10.0±5.77 -0.050± 0.0464
0.350 ±0.343 22.0±7.72 0.0375 ± 0.0419
-
Post-therapy T2
F
df
P*
0.300 ±0.405 13.0±8.44 0.0875 ± 0.0495
1.80 1.33 2.04
2/18 2/18 2/18
0.2033 0.2898 0.1586
-
The power of the F test (alpha 0.05) to detect PD differences of ± 1 mm was 92.5%; to detect R-BL differences of ± 18% was 84.1%; and to detect W-PL differences of ± .15 mm was 70.5%. *
differences of differences of
=
± ±
18% was 84.1%; and to detect W-PL 0.15 mm was 70.5%.
DISCUSSION
Historically, "hopeless" teeth have been recommended for
extraction since their retention was believed to accelerate the destruction of the adjacent tooth's proximal periodontium. The results of this study indicate that at least 8.4 years following therapy retained periodontally "hopeless" teeth do not affect the adjacent proximal periodontium. The periodontal therapy in all subjects consisted of preparatory treatment (i.e., scaling and root planing, oral hygiene instructions, and occlusal adjustment as needed) and surgical treatment in all but one case. The non-surgically treated anterior tooth received only scaling and root planing which has been shown to be an effective treatment modality for single-rooted teeth.15 At the pretherapy evaluation, there were no significant differences in PD or W-PL for the tooth surfaces adjacent to the "hopeless" tooth and the interproximal surfaces nonadjacent to the "hopeless" tooth. There was, however, a significant difference in R-BL between the adjacent and non-adjacent proximal surfaces. At the first post-therapy examination there were significant reductions in the mean PD for the adjacent and nonadjacent interproximal periodontium. This reduction was maintained at the second post-therapy evaluation. Examination of mean differences indicated there was not a significant difference between adjacent and non-adjacent proximal surfaces over time. The reduction in PD found is consistent with other studies documenting treatment of presurgical and surgical therapies.1619 When R-BL was examined at both post-therapy examinations, a significant difference remained between the adjacent and nonadjacent proximal periodontiums. However, the mean differences (i.e., non-adjacent minus adjacent) did
change significantly over time. This suggests that peritherapy may inhibit further loss of bone at the adjacent proximal periodontium. Although there are variations in the percent bone loss within each group, they are not significant and may reflect reproducibility of the measurements. Duckworth states the reproducibility of the radiographic analysis is ± 0.5 mm in measuring crestal bone levels.10 The average crown height for the adjacent and non-adjacent proximal periodontium over the 3 examination periods was calculated by using the vertical reference lines not
odontal
the slide scale and found to be 6.8 mm for both the mesial and distal periodontium of the adjacent tooth. This is well within the expected crown heights of the teeth used in this study when compared to average measurements taken on permanent teeth.20 Therefore our reproducibility error is approximately 7% of the crown height. The W-PL was examined to determine whether a relationship existed with changes in the height of the alveolar crest. All measurements were within the average range of 0.25 mm ± 50%.21 No significant differences were found between adjacent and non-adjacent proximal periodontium over any of the examination periods. It is interesting to note that a change in the W-PL pre-therapy did not correlate to the significant differences in R-BL pre-therapy between the adjacent and nonadjacent periodontiums. The power of the study was analyzed to assess its ability to detect PD differences of ± 1 mm, R-BL differences of ± 18% (1.2 mm), and ± .15 mm for W-PL. These were considered clinically significant values. All power values were over 70%. Factors which may influence the adjacent proximal periodontium if a "hopeless" tooth is retained following therapy should be examined. These include frequency of supportive periodontal therapy (SPT), interradicular distance between the "hopeless" and adjacent tooth, stability of the occlusion, anatomy of the "hopeless" tooth, and on
666
RETAINED "HOPELESS" TEETH: EFFECTS ON PERIODONTIUM OF ADJACENT TEETH
resistance of "hopeless" tooth to treatment
(i.e., refractory
Periodontitis). The majority of the patients followed received SPT > 2 times per year. This falls within the expected range for compliance.22 The importance of SPT following periodontal therapy has been well documented and indicates that a recurrence of the disease follows treatment when supportive periodontal therapy and plaque control are irregular.5'12-23'24 There are situations in which the retention of a "hopeless" tooth may be considered. The practitioner may encounter patients who have a psychological aversion to the
extraction of their teeth. Rather than submit to an extraction, they request treatment even though the prognosis would be "hopeless." A patient may have to defer reconstructive treatment due to financial considerations. In such cases, the "hopeless" tooth could be included with treatment and retained until more definitive therapy can be performed. Such retention could assist to maintain the height and width of existing alveolar bone rather than result in the rapid bone loss which takes place following extraction.25'26 In summary, we previously reported the lack of effect treated teeth prognosed "hopeless" and retained 3.4 ± 1.5 years had on the proximal periodontium of adjacent teeth. This present study was able to analyze 10 of the 17 original teeth available from the same patients 8.4 ± 0.7 years post-therapy. No significant differences were found for pocket depth, radiographie bone level, or width of the periodontal ligament. These results confirm our original findings that following treatment retained periodontally "hopeless" teeth do not affect the proximal periodontium of adjacent teeth. REFERENCES 1. Arlin MI. Strategic extraction: Periodontal and restorative considerations. Oral Health 1983; 73:15-18. 2. Yulzari JC. Strategic extraction in periodontal prosthesis. Int J Periodontics Restorative Dent 1982; 2(2):51-65. 3. Ibbot CG. The role of extraction in periodontal therapy. Can Dent AssocJ 1986; 62; 144. 4. Becker W, Berg L, Becker B. The long term evaluation of periodontal treatment and maintenance in 95 patients. Int J Periodontics Restorative Dent 1984; 4(2):55-71. 5. Becker W, Becker B, Berg L. Periodontal treatment without maintenance. / Periodontol 1984; 55:505-509. 6. Machtet EE, Zubrey Y, Yehuda AB, Soskolne WA. Proximal bone loss adjacent to periodontally "hopeless" teeth with and without extraction. J Periodontol 1989; 60:512-515. 7. DeVore CH, Beck FM, Horton JE. Retained "hopeless" teeth; effects
J Periodontol August 1992
the proximal periodontium of adjacent teeth. / Periodontol 1988; 59:647-651. Updegrave WJ. The paralleling extension cone technique in intra-oral dental radiography. Oral Surg 1951; 4:1250-1261. Duckworth J, Judy P, Goodson M, Socransky S. A method for the geometric and densitometric standardization of intraoral radiographs. J Periodontol 1983; 54:435^40. Duckworth J, Mecler A, Siegal R, McCauley L, Goju G. Evaluation of two methods for clinical analysis of serial intraoral radiographs. / Dent Res 1985; 64(Spec. Issue):205)(Abstr. 272). Schei O, Waerhaug J, Lovdal A, Arno A. Alveolar bone loss as related to oral hygiene and age. / Periodontol 1959; 30:7-16. DeVore CH, Duckworth JE, Beck, FM, Hicks MJ, Brumfield FW, Horton JE. Bone loss following periodontal therapy in subjects without frequent periodontal maintenance. / Periodontol 1986; 57:354359. Brumfield FW, Hicks MJ, Beck FM, DeVore CH, Duckworth JE, Horton JE. Relationship of radiographie appearance of periodontal ligament to clinical mobility. / Dent Res 1985; 64(Spec. Ison
8. 9.
10.
11. 12.
13.
14.
sue):262(Abstr. 784). Björn H, Hailing A, Thyberg H. Radiographie assessment of marginal
bone loss. Odontol Rev 1969; 20:165-179. 15. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy. II. Severely advanced Periodontitis. / Clin Periodontol 1984; 11:63-76. 16. Morrison EC, Ramfjord SP, Hill RW. Short term effects of initial, nonsurgical periodontal treatment (hygienic phase). / Clin Periodontol 1980; 7:199-211. 17. Hughes TP, Caffesse RG. Gingival changes following scaling, root planing, and oral hygiene. / Periodontol 1978; 49:245-252. 18. Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. / Clin Periodontol 1975; 2:67-79. 19. Westfeit E, Nyman S, Socransky S, Lindhe J. Significance of frequency of professional tooth cleaning for healing following periodontal surgery. J Clin Periodontol 1983; 10:148-155. 20. Ash MM. Wheeler's Dental Anatomy, Physiology, and Occlusion, 6th ed. Philadelphia: W Saunders; 1984:13. 21. Lindhe J. Textbook of Clinical Periodontology, 2nd ed. Copenhagen: Munksgaard; 1989:47. 22. Wilson TG Jr. Compliance. A review of the literature with possible applications to periodontics. / Periodontol 1987; 58:706-714. 23. McFall WT Jr. Tooth loss in 100 treated patients with periodontal disease. J Periodontol 1982; 53:539-549. 24. Hirshfeld I, Wasserman B. A long term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978; 49:225-237. 25. Atwood DA. Bone loss of edentulous alveolar ridges. J Periodontol 1979; 50:11-21. 26. Atwood DA. Some clinical factors related to rate of résorption of residual ridges. J Pros Dent 1962; 12:441-450. Send reprint requests to: Dr. John E. Horton, Department of Periodontology, The Ohio State University College of Dentistry, 305 West 12th Ave., Columbus, OH 43210. Accepted for publication February 7, 1992.
Retained "Hopeless" Teeth: Lack of Effect Periodontally-Treated Teeth Have on the Proximal Periodontium of Adjacent Teeth 8-Years Later Michael S.
Wojcik, * Cheryl H. DeVore,* F.
Michael Beck,* and John E. Horton*
the lack of effect periodontally-treated teeth prognosed and retained for 3.4±1.5 years have on the proximal periodontium of ad"hopeless" We teeth. now our findings for the same group of subjects following report jacent 8.4 ±0.7 years of "hopeless" tooth retention. Of the 17 "hopeless" and adjacent teeth originally measured in 17 subjects, 14 of the subjects were still available for re-evaluation. Measures used to assess the periodontium of proximal surfaces of adjacent teeth included pocket depths (PD), radiographie alveolar bone level (R-BL), and periodontal ligament space width (W-PL). Treatment for the subjects consisted of surgical therapy (N 15) and scaling and root planing (N 2). Of the 14 subjects re-examined, 2 were eliminated due to loss of adjacent tooth reference points and 2 due to extraction of the "hopeless" tooth (N 10). Differences in measurements (i.e., nonadjacent to "hopeless" tooth value minus adjacent to "hopeless" tooth value) were analyzed using a repeated measures ANOVA. There were no significant differences for PD (P 0.20), R-BL (P 0.29), or W-PL (P 0.16). These data confirm our original findings that retained periodontally "hopeless" teeth do not significantly affect the proximal periodontium of adjacent teeth following therapy. / Periodontol 1992; 63:663-666. We
previously reported
=
=
=
=
=
=
Key Words: Periodontal diseases/etiology; periodontal diseases/therapy; periodontium/ anatomy and histology.
The decision to extract a periodontally "hopeless" tooth is often based on the empirical assumption that its retention accelerates the destruction of the adjacent proximal periodontium. "Strategic extractions" have been advocated in the past to prevent this phenomena.1"3 However, Becker et al.4 have also questioned the over-zealous removal of such teeth. They suggested that the effects these teeth have on the remaining dentition be further examined.5 Machtei et al.6 have reported that in the absence of periodontal treatment the retention of a "hopeless" tooth has a destructive effect on the periodontium of adjacent teeth. If therapy is not feasible they recommended extraction of the "hopeless" tooth. However, they also suggested that the effect periodontal therapy has on bone loss associated with retained "hopeless" teeth needs further assessment. In a previous study we reported on the retention of teeth diagnosed as periodontally "hopeless" but included in treatment rather than extracted at the expressed desire of
Department of Periodontology, The Ohio State University College Dentistry, Columbus, OH. + Division of Dental Hygiene. * Department of Diagnostic Services. *
of
the patient.7 This initial study evaluated the influence such treated teeth had on the proximal periodontium of adjacent teeth 3.4 years following periodontal therapy. No significant change was found in probing depths, radiographie alveolar bone level, and width of the periodontal ligament between interproximal tooth surfaces adjacent to and nonadjacent to the treated "hopeless" tooth. We have now extended our study to report findings for the same group of "hopeless" teeth retained 8.4 ± 0.7 years following periodontal therapy.
MATERIALS AND METHODS The original study consisted of 17 adult subjects (9 males, 8 females; mean age 55.1 ± 1.42 years) each presenting with one "hopeless" and one mesially adjacent non-"hopeless" tooth which were treated for periodontal disease. Retention and treatment of the prognosed "hopeless" tooth was at the expressed desire of the patient. The pretherapy prognosis of a "hopeless" tooth was confirmed by possession of a minimum of at least 2 of the established criteria
(Table 14>5). Of the original subjects
14
were
available for re-exami-
664
J Periodontol August 1992
RETAINED "HOPELESS" TEETH: EFFECTS ON PERIODONTIUM OF ADJACENT TEETH
Table 1. Criteria Used to Determine a "Hopeless" Prognosis With the Percentage and Number Corresponding With Each
Criteria4 Loss of
>
75% of the
supporting bone
8 mm Class III furcation involvement Class III mobility with tooth movement in mesial, distal, and vertical directions Poor crown-root ratios Root proximity with minimal interproximal bone and evidence of horizontal bone loss History of repeated periodontal abscess
Probing depths greater than
Number
(%)
2 7 1 6
(20) (70) (10) (60)
4 0
(40)
0
0
Table 2. Number of "Hopeless" and
Adjacent Teeth by Tooth Type Anterior
Bicuspid
Molar
Hopeless
Mandibular
Maxillary Adjacent
Mandibular
Maxillary
0
Table 3. Mean Pocket Depth (mm ± S.E.) for Adjacent and NonSurfaces of the Proximal Tooth
Adjacent nation (2 died, 1 moved away). Of the 14, 2 were eliminated due to extraction of the "hopeless" tooth and 2 due to loss of adjacent tooth reference points (i.e., a restoration was placed to obscure the cemento-enamel junction of the tooth). Of the remaining 10 subjects there were 6 males and 4 females with a mean age of 57.3 ± 13.7 years. Since the last study 60% of the patients received supportive periodontal therapy (SPT) > 2 times a year; 20% received yearly maintenance; and 20% received < 1 year maintenance. All clinical measurements were made on the mesial and distal surfaces of each adjacent tooth from both the buccal and lingual surfaces. The mesial measurements of each adjacent tooth represent the control to the corresponding distal measurements of adjacent surfaces for each "hopeless" tooth. Probing depths (PD) were measured to the nearest millimeter from the gingival margin to the bottom of the sulcus of each tooth using a William's periodontal probe with Michigan "O" markings. Probing measurements were taken as close to the contact area as possible and parallel to the long axis of each tooth. The radiographie alveolar bone level (R-BL) for each tooth measured was determined from radiographs taken at initial presentation and compared with those taken at the first and second post-therapy examinations. The initial radiograph was taken using a long-cone parallel technique8 with a Rinn positioning device at 70 kVP while both posttherapy radiographs consisted of long cone paralleling vertical bite-wing radiographs9 exposed at 70 kVP using an Up-Rad positioning device. Measurements from the radiographs were made using the Duckworth et al. modification10 of the Schei Ruler technique.11-12 Analysis of the width of the periodontal ligament space (W-PL) was made with a radiographie projection system modified13 from that origi-
nally reported by Bjorn et al.14 For the adjacent proximal periodontium and non-adjacent proximal periodontium, measured differences between the pretherapy and first and second post-therapy scores for all variables (PD, R-BL, and W-PL) were analyzed using a repeated measures ANOVA for location, time, and location by time. Differences in pretherapy scores and first and second post-therapy scores (i.e., non-adjacent interproximal periodontium minus adjacent to proximal periodontium) were analyzed using a repeated measures ANOVA.
Pre-
Post-
Post-
Therapy
Therapy T,
Therapy T2
4.10±0.233 3.90±0.245 4.00 ±0.207
3.10 ±0.277 3.45 ±0.203 3.28 ±0.169
3.55 + 0.203 3.25 ±0.239 3.40 ±0.140
(B*)
(B*)
Tooth
Adjacent Non-Adjacent Main effect for time
(A*)
Location: F 0.05, df 1/9, Time: F 4.51, df 2/18, Location time: F 1.80, df * Means with the same letter are =
=
=
=
=
0.8340. 0.0259.
= = =
2/18,
not
=
0.2033.
statistically significant (P
>
0.05).
Table 4. Mean ( ± S.E.) Radiographie Bone Loss for Adjacent and Non-Adjacent Periodontium of Proximal Tooth Post-
PreLocation
Therapy
Adjacent Non-Adjacent
Post-
Therapy T, Therapy T2
75.0: : 14.10 80.1 ±6.67 68.0 ±7.86 65.0: : 13.90 58.0±11.80 55.0±8.06
Location: F 6.41, df 1/9, Time: F 0.50, df 2/18, time: F Location 1.33, df =
=
=
=
=
Main Effect for Location 74.5 ±8.27 59.3±9.91
0.0322. 0.5808.
= =
=
2/18,
=
0.2898.
Initial and first post-therapy measurements were made by CD. Following reproducibility of the original measurements, the second post-therapy analysis was made by MW. RESULTS Table 2 indicates the representative tooth types for both the "hopeless" and adjacent tooth types, respectively. Forty percent of the "hopeless" teeth were multirooted, with 75% of these being maxillary teeth. Fifty percent of the adjacent teeth were premolare while the remaining 50% were anterior teeth. Mean values (± S.E.) for PD, R-BL, and W-PL for adjacent and non-adjacent areas across the 3 time periods are shown in Tables 3, 4, and 5. Significant effects across time were shown for P-D (P 0.0259) and across location for R-BL (P 0.0322). No other significant effects were observed. Table 6 illustrates the mean change (non-adjacent minus adjacent) values (± S.E.) for PD, R-BL, and W-PL across the 3 time periods. No significant differences were observed. The power of the F-test (alpha 0.05) to detect PD differences of ± 1 mm was 92.5%; to detect R-BL =
=
=
Volume 63 Number 8
WOJCIK, DEVORE, BECK, HORTON
Table 5. Mean ( ± S.E.) Width of the Periodontal Periodontium of Proximal Tooth
Tooth
Adjacent Non-adjacent Total
Pre-Therapy
Post-Therapy T,
Post-Therapy T2
Total
0.300 ±0.0382 0.338 ± 0.0325 0.319 ±0.0286
0.338 ±0.0529 0.250 ±0.0373 0.294 ±0.0385
0.296 ±0.0157 0.296 ±0.0219
=
=
=
Ligament for Adjacent and Non-Adjacent
0.250 ± 0.0323 0.300 ± 0.0382 0.275 ±0.0267
Location: F 0.00, df 1/9, Time: F 0.46, df 2/18, Location time: F 2.04, df =
=
1.00. 0.6381.
= = =
2/18,
=
0.1586.
Table 6. Mean (± of Proximal Tooth
S.E.) Change Values (non-adjacent-adjacent) Over Time for PD, R-BL, and W-PL
Measurement
Pre-therapy
PD R-BL W-PL
665
Post-therapy T,
0.200 ± 0.238 10.0±5.77 -0.050± 0.0464
0.350 ±0.343 22.0±7.72 0.0375 ± 0.0419
-
Post-therapy T2
F
df
P*
0.300 ±0.405 13.0±8.44 0.0875 ± 0.0495
1.80 1.33 2.04
2/18 2/18 2/18
0.2033 0.2898 0.1586
-
The power of the F test (alpha 0.05) to detect PD differences of ± 1 mm was 92.5%; to detect R-BL differences of ± 18% was 84.1%; and to detect W-PL differences of ± .15 mm was 70.5%. *
differences of differences of
=
± ±
18% was 84.1%; and to detect W-PL 0.15 mm was 70.5%.
DISCUSSION
Historically, "hopeless" teeth have been recommended for
extraction since their retention was believed to accelerate the destruction of the adjacent tooth's proximal periodontium. The results of this study indicate that at least 8.4 years following therapy retained periodontally "hopeless" teeth do not affect the adjacent proximal periodontium. The periodontal therapy in all subjects consisted of preparatory treatment (i.e., scaling and root planing, oral hygiene instructions, and occlusal adjustment as needed) and surgical treatment in all but one case. The non-surgically treated anterior tooth received only scaling and root planing which has been shown to be an effective treatment modality for single-rooted teeth.15 At the pretherapy evaluation, there were no significant differences in PD or W-PL for the tooth surfaces adjacent to the "hopeless" tooth and the interproximal surfaces nonadjacent to the "hopeless" tooth. There was, however, a significant difference in R-BL between the adjacent and non-adjacent proximal surfaces. At the first post-therapy examination there were significant reductions in the mean PD for the adjacent and nonadjacent interproximal periodontium. This reduction was maintained at the second post-therapy evaluation. Examination of mean differences indicated there was not a significant difference between adjacent and non-adjacent proximal surfaces over time. The reduction in PD found is consistent with other studies documenting treatment of presurgical and surgical therapies.1619 When R-BL was examined at both post-therapy examinations, a significant difference remained between the adjacent and nonadjacent proximal periodontiums. However, the mean differences (i.e., non-adjacent minus adjacent) did
change significantly over time. This suggests that peritherapy may inhibit further loss of bone at the adjacent proximal periodontium. Although there are variations in the percent bone loss within each group, they are not significant and may reflect reproducibility of the measurements. Duckworth states the reproducibility of the radiographic analysis is ± 0.5 mm in measuring crestal bone levels.10 The average crown height for the adjacent and non-adjacent proximal periodontium over the 3 examination periods was calculated by using the vertical reference lines not
odontal
the slide scale and found to be 6.8 mm for both the mesial and distal periodontium of the adjacent tooth. This is well within the expected crown heights of the teeth used in this study when compared to average measurements taken on permanent teeth.20 Therefore our reproducibility error is approximately 7% of the crown height. The W-PL was examined to determine whether a relationship existed with changes in the height of the alveolar crest. All measurements were within the average range of 0.25 mm ± 50%.21 No significant differences were found between adjacent and non-adjacent proximal periodontium over any of the examination periods. It is interesting to note that a change in the W-PL pre-therapy did not correlate to the significant differences in R-BL pre-therapy between the adjacent and nonadjacent periodontiums. The power of the study was analyzed to assess its ability to detect PD differences of ± 1 mm, R-BL differences of ± 18% (1.2 mm), and ± .15 mm for W-PL. These were considered clinically significant values. All power values were over 70%. Factors which may influence the adjacent proximal periodontium if a "hopeless" tooth is retained following therapy should be examined. These include frequency of supportive periodontal therapy (SPT), interradicular distance between the "hopeless" and adjacent tooth, stability of the occlusion, anatomy of the "hopeless" tooth, and on
666
RETAINED "HOPELESS" TEETH: EFFECTS ON PERIODONTIUM OF ADJACENT TEETH
resistance of "hopeless" tooth to treatment
(i.e., refractory
Periodontitis). The majority of the patients followed received SPT > 2 times per year. This falls within the expected range for compliance.22 The importance of SPT following periodontal therapy has been well documented and indicates that a recurrence of the disease follows treatment when supportive periodontal therapy and plaque control are irregular.5'12-23'24 There are situations in which the retention of a "hopeless" tooth may be considered. The practitioner may encounter patients who have a psychological aversion to the
extraction of their teeth. Rather than submit to an extraction, they request treatment even though the prognosis would be "hopeless." A patient may have to defer reconstructive treatment due to financial considerations. In such cases, the "hopeless" tooth could be included with treatment and retained until more definitive therapy can be performed. Such retention could assist to maintain the height and width of existing alveolar bone rather than result in the rapid bone loss which takes place following extraction.25'26 In summary, we previously reported the lack of effect treated teeth prognosed "hopeless" and retained 3.4 ± 1.5 years had on the proximal periodontium of adjacent teeth. This present study was able to analyze 10 of the 17 original teeth available from the same patients 8.4 ± 0.7 years post-therapy. No significant differences were found for pocket depth, radiographie bone level, or width of the periodontal ligament. These results confirm our original findings that following treatment retained periodontally "hopeless" teeth do not affect the proximal periodontium of adjacent teeth. REFERENCES 1. Arlin MI. Strategic extraction: Periodontal and restorative considerations. Oral Health 1983; 73:15-18. 2. Yulzari JC. Strategic extraction in periodontal prosthesis. Int J Periodontics Restorative Dent 1982; 2(2):51-65. 3. Ibbot CG. The role of extraction in periodontal therapy. Can Dent AssocJ 1986; 62; 144. 4. Becker W, Berg L, Becker B. The long term evaluation of periodontal treatment and maintenance in 95 patients. Int J Periodontics Restorative Dent 1984; 4(2):55-71. 5. Becker W, Becker B, Berg L. Periodontal treatment without maintenance. / Periodontol 1984; 55:505-509. 6. Machtet EE, Zubrey Y, Yehuda AB, Soskolne WA. Proximal bone loss adjacent to periodontally "hopeless" teeth with and without extraction. J Periodontol 1989; 60:512-515. 7. DeVore CH, Beck FM, Horton JE. Retained "hopeless" teeth; effects
J Periodontol August 1992
the proximal periodontium of adjacent teeth. / Periodontol 1988; 59:647-651. Updegrave WJ. The paralleling extension cone technique in intra-oral dental radiography. Oral Surg 1951; 4:1250-1261. Duckworth J, Judy P, Goodson M, Socransky S. A method for the geometric and densitometric standardization of intraoral radiographs. J Periodontol 1983; 54:435^40. Duckworth J, Mecler A, Siegal R, McCauley L, Goju G. Evaluation of two methods for clinical analysis of serial intraoral radiographs. / Dent Res 1985; 64(Spec. Issue):205)(Abstr. 272). Schei O, Waerhaug J, Lovdal A, Arno A. Alveolar bone loss as related to oral hygiene and age. / Periodontol 1959; 30:7-16. DeVore CH, Duckworth JE, Beck, FM, Hicks MJ, Brumfield FW, Horton JE. Bone loss following periodontal therapy in subjects without frequent periodontal maintenance. / Periodontol 1986; 57:354359. Brumfield FW, Hicks MJ, Beck FM, DeVore CH, Duckworth JE, Horton JE. Relationship of radiographie appearance of periodontal ligament to clinical mobility. / Dent Res 1985; 64(Spec. Ison
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bone loss. Odontol Rev 1969; 20:165-179. 15. Badersten A, Nilveus R, Egelberg J. Effect of nonsurgical periodontal therapy. II. Severely advanced Periodontitis. / Clin Periodontol 1984; 11:63-76. 16. Morrison EC, Ramfjord SP, Hill RW. Short term effects of initial, nonsurgical periodontal treatment (hygienic phase). / Clin Periodontol 1980; 7:199-211. 17. Hughes TP, Caffesse RG. Gingival changes following scaling, root planing, and oral hygiene. / Periodontol 1978; 49:245-252. 18. Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. / Clin Periodontol 1975; 2:67-79. 19. Westfeit E, Nyman S, Socransky S, Lindhe J. Significance of frequency of professional tooth cleaning for healing following periodontal surgery. J Clin Periodontol 1983; 10:148-155. 20. Ash MM. Wheeler's Dental Anatomy, Physiology, and Occlusion, 6th ed. Philadelphia: W Saunders; 1984:13. 21. Lindhe J. Textbook of Clinical Periodontology, 2nd ed. Copenhagen: Munksgaard; 1989:47. 22. Wilson TG Jr. Compliance. A review of the literature with possible applications to periodontics. / Periodontol 1987; 58:706-714. 23. McFall WT Jr. Tooth loss in 100 treated patients with periodontal disease. J Periodontol 1982; 53:539-549. 24. Hirshfeld I, Wasserman B. A long term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978; 49:225-237. 25. Atwood DA. Bone loss of edentulous alveolar ridges. J Periodontol 1979; 50:11-21. 26. Atwood DA. Some clinical factors related to rate of résorption of residual ridges. J Pros Dent 1962; 12:441-450. Send reprint requests to: Dr. John E. Horton, Department of Periodontology, The Ohio State University College of Dentistry, 305 West 12th Ave., Columbus, OH 43210. Accepted for publication February 7, 1992.
