Parameters Affecting Tooth Loss during Periodontal Maintenance in a Greek Population Alexandra Tsami, Eudoxie Pepelassi, George Kodovazenitis

and Mado Komboli J Am Dent Assoc 2009;140;1100-1107 The following resources related to this article are available online at jada.ada.org ( this information is current as of August 7, 2011):
Updated information and services including high-resolution figures, can be found in the online version of this article at:
http://jada.ada.org/content/140/9/1100

This article cites 28 articles, 1 of which can be accessed free: http://jada.ada.org/content/140/9/1100/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx

Downloaded from jada.ada.org on August 7, 2011

2011 American Dental Association. The sponsor and its products are not endorsed by the ADA.

C L I N I C A L

P R A C T I C E

Parameters affecting tooth loss during periodontal maintenance in a Greek population

Alexandra Tsami, DDS, PhD; Eudoxie Pepelassi, DDS, MSc, PhD; George Kodovazenitis, DDS, MSc, MPH, PhD; Mado Komboli, DDS, PhD

he rate of tooth loss is relatively high for people with periodontitis who have not received periodontal treatment.1-5 Periodontal treatment and maintenance care can reduce tooth loss significantly.2,3,6-12 Lovdal and colleagues13 reported that undergoing scaling and root planing at regular intervals reduced tooth mortality at five years not only for patients with plaque-free dentitions, but also for patients with inadequate plaque control. Ramfjord and colleagues14-16 followed 104 patients with moderate-to-advanced periodontitis for seven years after they completed periodontal therapy and found that only 1.15 percent of teeth were lost owing to progression of periodontitis. Lindhe and Nyman17,18 studied 61 patients with severe periodontitis who underwent periodontal surgery and were able to maintain excellent oral hygiene for 14 years. At five years, none of the patients 1,330 teeth were lost. At 14 years, 30 teeth were lost; one-half were extracted owing to caries, endodontic defects or both. The tooth loss rate at 14 years was 2.3 percent. Investigators in other studies

Downloaded from jada.ada.org on August 7, 2011

ABSTRACT
Background. Investigators have evaluated predictive parameters of tooth loss during the maintenance phase (MP). The authors conducted a retrospective study to evaluate the rate of tooth loss and to explore the parameters that affect tooth loss during MP in a Greek population. Methods. A periodontist administered periodontal treatment and maintenance care to 280 participants with severe periodontitis for a mean period standard deviation of 10.84 2.13 years. The periodontist recorded the following parameters for each participant: oral hygiene index level, simplified gingival index level, clinical attachment level, probing depth measurements, initial tooth prognosis, smoking status, tooth loss during active periodontal treatment and MP, and compliance with suggested maintenance visits. Results. The authors found that total tooth loss during active treatment (n = 1,427) was greater than during MP (n = 918) and was associated with the initial tooth prognosis, tooth type group, participants compliance with suggested maintenance visits, smoking status and acceptability of the quality of tooth restorations. Most of the teeth extracted during maintenance had an initial guarded prognosis (n = 612). Participants whose compliance was erratic had a greater risk of undergoing tooth extraction than did participants whose compliance was complete. Conclusions. Participants initial tooth prognosis, tooth type, compliance with suggested maintenance visits and smoking status affected tooth loss during MP. Initial guarded prognosis and erratic compliance increased the risk of undergoing tooth extraction during maintenance. Clinical Implications. Determining predictive parameters for disease progression and tooth loss provides critical information to clinicians so that they can develop and implement rational treatment planning. Key Words. Tooth loss; periodontal maintenance; tooth prognosis; patient compliance; smoking; tooth type. JADA 2009;140(9):1100-1107.

Dr. Tsami is an associate professor, Department of Periodontics, School of Dentistry, University of Athens, Greece. Address reprint requests to Dr. Tsami at 45 Michalacopoulou St., Athens, 115 28 GR, Greece, e-mail atsami@dent.uoa.gr. Dr. Pepelassi is an assistant professor, Department of Periodontics, School of Dentistry, University of Athens, Greece. Dr. Kodovazenitis is a periodontist, Department of Periodontics, School of Dentistry, University of Athens, Greece. Dr. Komboli is an associate professor, Department of Periodontics, School of Dentistry, University of Athens, Greece.

1100

JADA, Vol. 140

http://jada.ada.org

September 2009

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

also documented a low rate of tooth loss after the patients underwent periodontal therapy and maintenance. Ross and colleagues19 and Ross and Thompson20 evaluated 180 patients after periodontal treatment for a mean period of 8.6 years and found that most of the periodontally involved teeth were retained at the final evaluation. Hirschfeld and Wasserman21 assessed 600 patients with periodontitis with a total of 15,666 teeth for a mean of 22 years. Most of the patients (76.5 percent) had severe periodontitis at the initial evaluation, and 2,141 teeth had a questionable prognosis (one in which the teeth had furcation involvement, a deep pocket, extensive alveolar bone loss or marked mobility [greater than two degrees on a scale of three] in conjunction with increased probing depth). The mean tooth loss rate per patient was 2.2 teeth. The mean tooth loss rate per patient per year was 0.1 teeth. Thirty-one percent of the teeth with an initial questionable prognosis were lost by the end of follow-up. Goldman and colleagues22 evaluated patients who underwent periodontal therapy for a mean of 22.2 years and found that the mean tooth loss rate per year was 0.16 teeth. They placed each patient into one of three groups according to the number of teeth lost per 10 years: patients whose teeth were well maintained who had a mean tooth loss rate of 0.45 teeth per 10 years, patients whose teeth were poorly maintained who had a mean tooth loss rate of 2.6 teeth per 10 years and patients whose teeth were extremely poorly maintained who had a mean tooth loss rate of 6.4 teeth per 10 years. Of the patients evaluated, 62 percent were classified as having well maintained teeth, 28 percent were classified as having poorly maintained teeth, and 10 percent were classified as having extremely poorly maintained teeth. To our knowledge, no retrospective study designed to evaluate the rate of tooth loss and to explore the parameters that affect tooth loss during maintenance has been conducted yet in a Greek population, which has a low rate of compliance with maintenance therapy. Therefore, we conducted a retrospective study to do this. We also studied the possible associations between the rate of tooth loss and parameters concerning participants and their teeth.
PARTICIPANTS, MATERIALS AND METHODS

BOX

Prognosis classification.
GOOD Control of etiologic factors and adequate periodontal support as measured clinically and radiographically to ensure the tooth would be relatively easy to maintain properly. MODERATE Less than 50 percent attachment loss as measured clinically and radiographically, Class I or II furcation involvement, or both. The location of the furcation would allow proper maintenance with good patient compliance. GUARDED More than 50 percent attachment loss resulting in a poor crown-to-root ratio. Poor root form; Class II furcations, not easily accessible to maintenance care, or Class III furcations; two mobility or more. HOPELESS Inadequate attachment to maintain the tooth in health, comfort and function.

Downloaded from jada.ada.org on August 7, 2011

private periodontal practice in Athens, Greece. The selection criteria at the initial evaluation were that the participant have generalized severe chronic periodontitis,23 have at least 20 teeth of all tooth types, be willing to participate in the maintenance program for at least eight years, have no systemic diseases affecting the progression of periodontitis, have not undergone periodontal therapy for the six months previously and not be taking systemic medication. Before undergoing treatment, each participant signed a consent form after being advised of the nature of the study. The University of Athens, Greece, review and ethics committee approved the study protocol. We included in our study only participants who met the inclusion criteria. We evaluated 280 participants (154 women and 126 men). Their ages ranged from 43 to 62 years, with a mean standard deviation (SD) of 51.64 6.34 years. A periodontist (A.T.) whose technique had been calibrated took all clinical measurements and provided APT and maintenance treatment. All participants underwent thorough clinical and radiographic examinations in which the periodontist recorded their oral hygiene index levels,3 simplified gingival index levels,3 clinical attachment levels and probing depth measurements and obtained full-mouth periapical radiographs. She also recorded the number and type of existing teeth before APT and after its completion and assessed the prognosis of each tooth on the basis of clinical and radiographic data (Box).

The participants in our retrospective study received active periodontal treatment (APT) at a

ABBREVIATION KEY. APT: Active periodontal treatment. MP: Maintenance phase.

JADA, Vol. 140 http://jada.ada.org September 2009 1101

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

Each participant underwent phase I therapy, which consisted of oral hygiene instruction, removal of the supragingival deposits, scaling and root planing and removal of the teeth that received a hopeless prognosis. After six weeks, the periodontist re-evaluated the participants periodontia to determine if further treatment was needed. She based the decision to intervene surgically on whether the participant had residual probing depths of 6 millimeters or greater, bleeding on probing, Class II or III furcation defects or endosseous defects. She performed periodontal surgery in 158 participants and enrolled all of the participants in the maintenance program. She planned the frequency (every three or four months) and nature (reinforcement of oral hygiene instructions, supragingival removal of deposits with or without scaling and root planing) of supportive treatment according to the participants risk for disease progression.5 Participants who developed further periodontal disease during the maintenance phase (MP) did not receive any therapy other than the prescribed maintenance regimen. In addition to the parameters the periodontist recorded at the initial examination, she recorded the following parameters for each participant during MP: the number of extracted teeth, the time between APT completion and each extraction, the etiology of the extraction (classified as periodontitis progression or other reasons), the degree of compliance with the suggested maintenance visits, and the acceptability of the quality of the tooth restorations. The periodontist considered restorations with overhanging margins, restorations with margins extending more than 0.5 mm apically to the gingival margin or restorations that did not leave adequate interproximal space for plaque removal unacceptable. We placed the participants into categories as follows: dSmoking habit, four groups: nonsmokers (never smokers), light smokers (< 10 cigarettes per day), moderate smokers (10-20 cigarettes per day) and heavy smokers (> 20 cigarettes per day).24 dDegree of compliance with the suggested maintenance visits, two groups: participants whose compliance was complete (kept at least 75 percent of the scheduled maintenance appointments) and participants whose compliance was erratic (kept more than 40 percent but less than 75 percent of the scheduled maintenance appointments).6 None of the participants kept less than 40 percent of
1102 JADA, Vol. 140 http://jada.ada.org September 2009

scheduled maintenance appointments. We placed the existing teeth into four groups according to type: dmaxillary anterior teeth (incisors and canines); dmandibular anterior teeth (incisors and canines); dmaxillary posterior teeth (premolars and molars); dmandibular posterior teeth (premolars and molars). We excluded third molars from the study material. We used one-way analysis of variance to assess the possible associations among the rate of tooth loss during MP, extraction time and tooth type. We used 2 tests to assess the differences in data distribution among the various groups in relation to the classification of the parameters tested. We used logistic regression analysis to assess the degree of association between tooth loss during maintenance and various parameters (smoking, initial tooth prognosis, tooth type, participants compliance with suggested maintenance visits, age and sex). We set the level of statistical significance at .05 for all analyses.
RESULTS

Downloaded from jada.ada.org on August 7, 2011

We initially assessed 6,673 teeth with severe periodontitis: 1,315 maxillary anterior teeth, 1,386 mandibular anterior teeth, 1,944 maxillary posterior teeth and 2,028 mandibular posterior teeth. Table 1 summarizes the number and percentage of existing teeth and teeth extracted in relation to treatment phase and tooth type group. A total of 1,427 teeth received a hopeless prognosis, and the periodontist extracted these teeth during APT. Of the remaining teeth, 872 received a guarded prognosis, 2,503 received a moderate prognosis, and 1,871 received a good prognosis. The periodontist extracted 246 teeth in the maxillary anterior group, and 1,069 teeth were initially maintained (not extracted at APT). The periodontist extracted 415 teeth in the mandibular anterior group, and 971 were initially maintained. The periodontist extracted 355 teeth in the maxillary posterior group, and 1,589 teeth were initially maintained. The periodontist extracted 411 teeth in the mandibular posterior group, and 1,617 teeth were initially maintained. At APT completion, there were 5,246 teeth. Follow-up ranged from eight to 16 years (during the period of 1992-2008), with a mean SD period of 10.84 2.13 years. The mean incidence of tooth loss per

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

participant per year in our TABLE 1 study was 0.3 teeth. At the Number and percentage of existing teeth and teeth final evaluation, there were 4,328 teeth. When we extracted in relation to treatment phase and tooth classified the teeth type group. extracted during MP TOOTH EXISTING TEETH (NO. [%]) EXTRACTED TEETH (NO. [%]) according to their type, we TYPE At Initial At At Final During During GROUP found that 151 maxillary Evaluation* Periodontal Evaluation Active Maintenance Treatment Periodontal Phase anterior teeth, 140 manCompletion * Treatment dibular anterior teeth, 293 Maxillary 1,315 (19.71) 1,069 (16.02) 918 (13.76) 246 (3.69) 151 (2.26) maxillary posterior teeth Anterior and 334 mandibular posMandibular 1,386 (20.77) 971 (14.55) 831 (12.45) 415 (6.22) 140 (2.10) terior teeth had been Anterior extracted (Table 1). Maxillary 1,944 (29.13) 1,589 (23.81) 1,296 (19.42) 355 (5.32) 293 (4.40) The number of teeth Posterior extracted during APT Mandibular 2,028 (30.39) 1,617 (24.23) 1,283 (19.23) 411 (6.16) 334 (5.01) Posterior (n = 1,427) was significantly greater than the TOTAL 6,673 (100.00) 5,246 (78.62) 4,328 (64.86) 1,427 (21.38) 918 (13.76) number extracted during * = 9.715, P < .05. MP (n = 918). The number = 65.54, P < .001. of teeth extracted during TABLE 2 APT was greatest for mandibular anterior teeth Correlation of tooth loss during maintenance phase (n = 415) and lowest for to various parameters. maxillary anterior teeth (n = 246). The number of PARAMETER CORRELATION DETERMINING P VALUE COEFFICIENT (r ) FACTOR (r 2) teeth extracted during MP Participants Compliance 0.253 0.064 < .01 was greatest for mandibWith Scheduled Maintenance ular posterior teeth Visits (n = 334) and lowest for Age 0.097 0.0094 Not significant (NS) mandibular anterior teeth Sex 0.072 0.0051 NS (n = 140). The distribution Smoking Status 0.195 0.038 < .01 of the teeth extracted was Initial Prognosis 0.345 0.119 < .001 significantly different Tooth Type Group 0.318 0.1011 < .001 between the evaluation at Acceptability of the Quality 0.147 0.021 < .05 APT completion and the of the Restorations final evaluation (P < .001) (Table 1). For each tooth type group, most of the teeth Classification of the participants according to were retained for more than 10 years after APT. their degree of compliance with the suggested Statistical analysis of the data revealed that maintenance visits indicated that 148 particithere was a significant difference in the rate of pants compliance was complete and 132 particitooth loss among the various tooth type groups. pants compliance was erratic. The former group Table 2 summarizes the associations between lost significantly fewer teeth (n = 364) than did tooth loss during MP and the various parameters the latter group (n = 554), irrespective of tooth studied. The parameters associated with tooth type group (P < .001). loss during maintenance were, in descending Ninety-five participants were nonsmokers, 87 order, the initial tooth prognosis (r = 0.345, were light smokers, 66 were moderate smokers, P < .001), the tooth type group (r = 0.318, P < .001), and 32 were heavy smokers. Nonsmokers had sigparticipants compliance with scheduled maintenificantly fewer teeth extracted (n = 176) than did nance visits (r = 0.253, P < .01), smoking status smokers (n = 742). Light smokers had 279 teeth (r = 0.195, P < .01) and the acceptability of the extracted, moderate smokers had 256 teeth quality of the restorations (r = 0.147, P < .05). extracted, and heavy smokers had 207 teeth
2 3 2 3

Downloaded from jada.ada.org on August 7, 2011

JADA, Vol. 140

http://jada.ada.org

September 2009

1103

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

TABLE 3

Number and percentage of teeth extracted during maintenance phase in relation to tooth type group and smoking status.
TOOTH TYPE GROUP NONSMOKERS (NO. [%]) Fewer Than 10 Cigarettes per Day Maxillary Anterior Mandibular Anterior Maxillary Posterior Mandibular Posterior TOTAL * 29 = 17.139, P < .05. 29 (3.16) 37 (4.03) 49 (5.33) 61 (6.65) 176 (19.17) 35 (3.81) 42 (4.57) 98 (10.68) 104 (11.33) 279 (30.39) SMOKERS (N [%])* 10-20 Cigarettes per Day 42 (4.57) 31 (3.38) 78 (8.50) 105 (11.44) 256 (27.89) More Than 20 Cigarettes per Day 45 (4.91) 30 (3.27) 68 (7.41) 64 (6.96) 207 (22.55) TOTAL 151 (16.45) 140 (15.25) 293 (31.92) 334 (36.38) 918 (100.00)

Downloaded from jada.ada.org on August 7, 2011

TABLE 4

groups of different initial prognoses continued to Number and percentage of teeth extracted during exist when the teeth were maintenance phase in relation to tooth type group subclassified in relation to and initial prognosis. the tooth type group (P < .001) (Table 4). TOOTH TYPE GOOD MODERATE GUARDED TOTAL PROGNOSIS PROGNOSIS PROGNOSIS GROUP Among teeth with an (NO. [%]) (NO. [%])* (NO. [%])* initial guarded prognosis, Maxillary 25 (2.72) 47 (5.12) 79 (8.61) 151 (16.45) 612 were extracted during Anterior MP; 298 were extracted Mandibular 19 (2.07) 35 (3.81) 86 (9.37) 140 (15.25) because of periodontitis Anterior progression, and the other Maxillary 32 (3.49) 45 (4.90) 216 (23.53) 293 (31.92) Posterior 314 were extracted for other reasons (mainly Mandibular 39 (4.25) 64 (6.97) 231 (25.16) 334 (36.38) Posterior caries). Most extractions of TOTAL 115 (12.53) 191 (20.81) 612 (66.67) 918 (100.00) the teeth with an initial good or moderate prognosis * = 24.138, P < .001. were for reasons other extracted. Maxillary anterior tooth loss was than periodontitis. Twenty-seven teeth with an initial good prognosis and 53 teeth with an initial greatest for the heavy smokers (n = 45), whereas moderate prognosis were extracted because of mandibular anterior tooth loss was greatest for periodontitis progression; 88 teeth with an initial light smokers (n = 42). Maxillary posterior tooth good prognosis and 138 teeth with an initial modloss was twice as great for light smokers (n = 98) erate prognosis were extracted for reasons other as for nonsmokers (n = 49). Mandibular posterior than periodontitis. The reasons for tooth extractooth loss was the least for nonsmokers (n = 61) tion among teeth with different initial prognoses and was almost double that for moderate were statistically significantly different (P < .001). (n = 105) and light (n = 104) smokers (Table 3). We studied the loss rates of the teeth extracted The number of teeth extracted was signifiduring MP owing to periodontitis progression in cantly different among teeth that received difrelation to the tooth type group and the time they ferent initial prognoses. The number was signifiwere maintained in the oral cavity, and we found cantly greater for teeth that received an initial that the loss rates were significantly different guarded prognosis (n = 612) than it was for teeth among the various tooth type groups (P < .05). with an initial good prognosis (n = 115) and for The anterior teeth were maintained longer than teeth with an initial moderate prognosis (n = 191). were the posterior teeth. However, the longest The differences in tooth loss percentage among
2 6

1104

JADA, Vol. 140

http://jada.ada.org

September 2009

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

times greater than that of teeth with an initial moderate prognosis. Fardal and colleagues26 examined the association between initial prognosis and tooth loss and found that most of the teeth that were lost because of periodontitis received an uncertain, poor or hopeless initial prognosis. Checchi and colleagues12 also found that the initial tooth prognosis affected tooth morDISCUSSION tality during maintenance. Initial tooth prognosis In our study, we assessed the tooth loss rate was associated more with tooth loss during MP in during MP and explored its possible association our study than in another study,21 which could be with various parameters concerning the particidue to the use of more precisely defined criteria in pants and their teeth. A total of 280 participants the assignment of a prognosis. Hirschfeld and with severe periodontitis underwent APT and MP Wasserman21 distinguished between favorable for a mean SD of 10.84 2.13 years. Of the and questionable prognosis with criteria that 6,673 teeth we examined initially, 1,427 were were not defined precisely. extracted during APT and 918 were extracted The participants compliance with the sugduring MP. The percentage of teeth extracted gested maintenance visits correlated to tooth loss during APT was significantly higher than that during MP. Participants whose compliance was extracted during MP, which is in erratic had a risk of undergoing agreement with findings in other tooth extraction that was 1.52 times studies.12,25 Teeth extracted during greater than that for participants The percentage of MP were mainly posterior teeth. whose compliance was complete. In teeth extracted during Findings in other studies also participants whose compliance was active periodontal demonstrated a higher frequency erratic, the risk of undergoing tooth therapy was of molar extraction during extraction was more than two times maintenance.12,21,22,25 greater than that for the anterior significantly higher A periodontist performed most of teeth, 1.5 times greater than that than that extracted the extractions a long time after the for maxillary posterior teeth and during the 1.15 times greater than that for participants underwent APT. In maintenance phase. mandibular posterior teeth in pareach tooth type group, more than ticipants whose compliance was one-half of the teeth were not complete. The results of Fardal and extracted until a decade after the colleagues26 study showed that complying with participant underwent APT. Most of the tooth extractions did not occur in a small portion of the maintenance visits was associated with low levels population, as reported in other studies,12,21,22,25 of tooth loss. but involved most of the population, which makes Checchi and colleagues12 found that patients the results of our study more significant than whose compliance was erratic had a risk of underthose of the other studies. The long survival time going tooth extraction that was 5.6 times greater demonstrated in our study is similar to that than that of patients whose compliance was comobserved in Chace and Lows10 study. In their plete. This difference in tooth loss between study, Chace and Low observed 455 teeth with an patients whose compliance was erratic and those initial guarded prognosis across 40 years. They whose compliance was complete, compared with found that the average survival rate of the the findings in our study, could be attributed to extracted teeth was 8.8 years and that no teeth the different definition of compliance between the were extracted the first two years after APT. two studies. Checchi and colleagues12 considered In our study, the initial tooth prognosis had the the compliance of only the patients who kept all strongest association with tooth loss during MP. of the suggested maintenance visits to be comMost of the extracted teeth had an initial guarded plete. All patients who failed to meet this criteprognosis, and teeth with an initial guarded progrion were considered to have erratic compliance. nosis had a risk of being extracted during mainteIn our study, a participants compliance was nance that was five times greater than that of determined according to the percentage of recall teeth with an initial good prognosis and three appointments that he or she kept. Participants
JADA, Vol. 140 http://jada.ada.org September 2009 1105

time that teeth extracted during MP were retained in the oral cavity was 14 years for the anterior teeth and 12 years for the posterior teeth. For the maxillary and mandibular posterior teeth, the percentage of the teeth extracted eight years after treatment was double that at four years.

Downloaded from jada.ada.org on August 7, 2011

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

who kept at least 75 percent of the scheduled recall appointments were considered to be completely compliant. Participants who kept less than 75 percent but more than 40 percent of the scheduled appointments were considered to be erratically compliant. The differences in patient population (92 versus 280 patients) and in the mean observation time (6.7 versus 10.84 years) also might have influenced the difference in findings between Checchi and colleagues12 study and ours, respectively. Miyamoto and colleagues27 evaluated the relationship between patients compliance and tooth loss. Compliance was defined in two ways: patients who missed less than 30 percent of all maintenance visits were classified as complete compliers, and patients who never went two years without a maintenance visit also were classified as complete compliers. Patients whose compliance was complete, according to both definitions, tended to have reductions in plaque index levels and bleeding on probing across time compared with the findings in patients whose compliance was erratic. However, change in periodontal pockets across time varied according to the definition of compliance that was used. Patients whose compliance was complete, according to the second definition, were less likely to experience a reduction in the percentage of periodontal pockets greater than 3 mm than were patients who compliance was erratic, whereas patients whose compliance was complete, according to the first definition, had about the same likelihood of demonstrating a reduction in periodontal pockets as did patients whose compliance was erratic. Under both definitions, patients whose compliance was complete were more likely to exhibit tooth loss than were patients whose compliance was erratic, with the greatest tooth loss exhibited by patients whose compliance was complete according to the first definition. Furthermore, Miyamoto and colleagues27 results seem to indicate that dentists decisions to extract teeth at maintenance visits may result in greater tooth loss. In our study, we found that smoking affected tooth mortality during MP, and smokers had a 4.22 times greater chance of undergoing tooth extraction than did nonsmokers. Smoking was correlated less with tooth loss than were other parameters, possibly because of the rate of tooth extraction at APT in smokers, which could have masked the effect of smoking on disease progression and tooth loss. Fardal and colleagues26
1106 JADA, Vol. 140 http://jada.ada.org September 2009

showed that tooth loss was significantly related to smoking (P = .019, odds ratio = 4.2), which was a predictor of tooth loss due to progressive periodontitis. Jansson and Lagervall28 found a significant correlation between smoking and increased long-term tooth loss. Matuliene and colleagues29 showed that heavy smoking was a risk factor for disease progression and future tooth loss. Tonetti and colleagues25 studied tooth mortality during APT and MP in 270 patients who were undergoing periodontal treatment. They found that the mean percentage of tooth loss was 4.78 percent during APT and 4.24 percent during MP. The differences in results between our study and those of Tonetti and colleagues25 study are the mean percentages of participants who lost teeth and the mean percentages of teeth lost during APT and MP. These differences could be attributed to differences in the study design between the two investigations with regard to the patient population (Tonetti and colleagues25 evaluated patients with varying periodontal conditions) and the observation time (ours was almost double that of Tonetti and colleagues25). The mean incidence of tooth loss per participant per year in our study (0.3 teeth) was similar to that found by Tonetti and colleagues (0.4 teeth).25 Our study results also agree with those of other studies12,25 in that more teeth were extracted during APT than during MP, and our findings agree with those of Tonetti and colleagues25 in that the reasons for tooth loss during maintenance varied according to the severity of initial periodontal involvement. The limitations of our study were that the number of participants could have been greater and the evaluation period could have been longer.
CONCLUSIONS

Downloaded from jada.ada.org on August 7, 2011

Determining predictive parameters for disease progression and tooth loss provides critical information to clinicians when they are developing and implementing rational treatment planning. Within the limitations of our study, initial tooth prognosis, tooth type, participants compliance with suggested maintenance visits and smoking affected tooth loss during MP. Participants whose compliance was erratic and whose teeth received an initial guarded prognosis were at an increased risk of undergoing tooth extraction during MP.
Disclosure. None of the authors reported any disclosures. 1. Becker W, Berg L, Becker BE. Untreated periodontal disease: a longitudinal study. J Periodontol 1979;50(5):234-244.

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

C L I N I C A L

P R A C T I C E

2. Oliver RC. Tooth loss with and without periodontal therapy. Periodontal Abstr 1969;17(1):8-9. 3. Lindhe J, Karring T, Lang NP, eds. Clinical Periodontology and Implant Dentistry. Copenhagen: Munksgaard; 1981:327-352. 4. Glavind L, Le H. Errors in the clinical assessment of periodontal destruction. J Periodontal Res 1967;2(3):180-184. 5. Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing: an indicator of periodontal stability. J Clin Periodontol 1990; 17(10):714-721. 6. Wilson TG Jr. Compliance: a review of the literature with possible applications to periodontics. J Periodontol 1987;58(10):706-714. 7. Wilson TG Jr. Compliance and its role in periodontal therapy. Periodontol 2000 1996;12:16-23. 8. Nabers CL, Stalker WH, Esparza D, Naylor B, Canales S. Tooth loss in 1535 treated periodontal patients. J Periodontol 1988;59(5): 297-300. 9. Wood WR, Greco GW, McFall WT Jr. Tooth loss in patients with moderate periodontitis after treatment and long-term maintenance care. J Periodontol 1989;60(9):516-520. 10. Chace R Sr, Low SB. Survival characteristics of periodontallyinvolved teeth: a 40-year study. J Periodontol 1993;64(8):701-705. 11. McLeod DE, Lainson PA, Spivey ID. The effectiveness of periodontal treatment as measured by tooth loss. JADA 1997;128(3): 316-324. 12. Checchi L, Montevecchi M, Gatto MR, Trombelli L. Retrospective study of tooth loss in 92 treated periodontal patients. J Clin Periodontol 2002;29(7):651-656. 13. Lovdal A, Arno A, Schei O, Waerhaug J. Combined effect of subgingival scaling and controlled oral hygiene on the incidence of gingivitis. Acta Odontol Scand 1961;19:537-555. 14. Ramfjord SP, Nissle RR, Shick RA, Cooper H Jr. Subgingival curettage versus surgical elimination of periodontal pockets. J Periodontol 1968;39(3):167-175. 15. Ramfjord SP, Knowles JW, Nissle RR, Shick RA, Burgett FG. Longitudinal study of periodontal therapy. J Periodontol 1973;44(2): 66-77. 16. Ramfjord SP, Knowles JW, Nissle RR, Burgett FG, Shick RA. Results following three modalities of periodontal therapy. J Periodontol 1975;46(9):522-526. 17. 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. J Clin Periodontol 1975;2(2):67-79. 18. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol 1984;11(8):504514.

19. Ross IF, Thompson RH Jr, Galdi M. The results of treatment: a long term study of one hundred and eighty patients. Parodontologie 1971;25(4):125-134. 20. Ross IF, Thompson RH Jr. A long term study of root retention in the treatment of maxillary molars with furcation involvement. J Periodontol 1978;49(5):238-244. 21. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49(5):225-237. 22. Goldman MJ, Ross IF, Goteiner D. Effect of periodontal therapy on patients maintained for 15 years or longer: a retrospective study. J Periodontol 1986;57(6):347-353. 23. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4(1):1-6. 24. Martinez-Canut P, Lorca A, Mgan R. Smoking and periodontal disease severity. J Clin Periodontol 1995;22(10):743-749. 25. Tonetti MS, Steffen P, Muller-Campanile V, Suvan J, Lang NP. Initial extractions and tooth loss during supportive care in a periodontal population seeking comprehensive care. J Clin Periodontol 2000;27(11):824-831. 26. Fardal , Johannessen AC, Linden GJ. Tooth loss during maintenance following periodontal treatment in a periodontal practice in Norway. J Clin Periodontol 2004;31(7):550-555. 27. Miyamoto T, Kumagai T, Jones JA, Van Dyke TE, Nunn ME. Compliance as a prognostic indicator: retrospective study of 505 patients treated and maintained for 15 years. J Periodontol 2006; 77(2):223-232. 28. Jansson L, Lagervall M. Periodontitis progression in patients subjected to supportive maintenance care. Swed Dent J 2008;32(3): 105-114. 29. Matuliene G, Pjetursson BE, Salvi GE, et al. Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol 2008;35(8):685-695.

Downloaded from jada.ada.org on August 7, 2011

JADA, Vol. 140

http://jada.ada.org

September 2009

1107

Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.