Predicting Tooth Longevity

Abstract

Data gathered during periodontal assessment also helps to answer questions about prognosis that are highly relevant to patients and practitioners: what is the likelihood of tooth loss without treatment? How likely will treatment prevent tooth loss? Will treatment work? Is it worth the effort to treat? Which teeth will most likely be lost? Is the patient better off without certain teeth? Which teeth should be removed? How difficult will it be to remove teeth?

This chapter will describe thought processes that can help answer these questions and provide guidance for treatment planning and extractions.

Learning Objectives

  • Judge how likely a patient will lose teeth.

  • Judge how likely periodontal treatment will succeed.

  • Determine which teeth should be removed.

  • Weigh benefits and risks of tooth removal, tooth replacement, and tooth retention.

Case

A 47-year old female African American patient presents to you to get “periodontal work and anything else needed done.” She states that she could not take care of her teeth for a while, and would like to keep them as long as possible now that she has dental insurance. She also would like to “improve her smile.” She used to be seen by a corporate dental chain office until about 15 years ago when she lost her job. She reports that her gums bleed when she flosses and that floss catches between her teeth. She also tells you that she clenches her teeth, especially when driving. She brushes her teeth twice a day with a soft brush and fluoridated toothpaste, flosses twice daily, and rinses with an antiseptic mouthwash.

She checks “high blood pressure” on the medical history form and lists “Amlodipine” as the only medication she is taking. She does not report any allergies, but records “gall bladder removal” under the surgery item on the form. When questioned, she reports that she had her gall bladder removed 2 years ago after experiencing severe pain, and her blood pressure presented a problem for the surgery. Since then, she is taking amlodipine once a day, but does not experience any side effects. She used to smoke cigarettes about a pack every day for 20 years, before she quit 2 years ago after the surgery. She denies taking any recreational drugs, but says she treats herself and drinks a few glasses of wine once a week with friends.

Vital signs: 5′ 11?, 230 lb, blood pressure 138/93 mm Hg, pulse 79 beats per minute.

The intraoral exam reveals significant periodontal disease as evidenced through bleeding on probing, pocketing, attachment loss, recession, and tooth mobility. The majority of posterior maxillary teeth are missing, and mandibular molars have begun to migrate into this space. Fremitus was noted on maxillary incisors nos. 8 and 9. See Fig. 4.1, for clinical appearance and Fig. 4.2, for radiographs.

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Fig. 4.1 Facial view.

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Fig. 4.2 Radiographic series.

Maxilla facial

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

PD

543

536

535

536

635

444

424

635

536

BOP

1

1

1

1

1

1

1

1

1

CAL

3

4

2

8

GR

112

22

MGJ

454

555

666

999

999

999

999

989

667

Furc

PLQ

2

2

2

2

1

1

2

2

2

Maxilla lingual

PD

535

536

645

535

657

756

535

535

545

BOP

1

1

1

1

1

1

1

1

1

CAL

8

8

10

8

6

GR

Furc

Mobil

1

1

2

2

PLQ

1

1

1

1

2

2

1

1

Mandible Lingual

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

PD

655

645

658

646

745

646

645

524

535

435

435

545

535

435

537

557

BOP

111

111

111

111

11

111

11

1

1

1

1

11

111

111

111

111

CAL

5

8

7

5

6

6

6

7

7

5

5

5

5

5

8

4

GR

222

212

1

111

MGJ

999

999

999

999

999

999

999

999

999

999

999

999

999

999

999

999

Furc

1

1

PLQ

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

Mandible facial

PD

568

945

656

645

635

434

635

535

524

526

645

536

535

637

549

447

BOP

111

111

111

111

111

111

111

111

111

111

111

111

111

111

111

111

CAL

7

8

9

GR

MGJ

666

999

766

878

768

989

989

989

979

879

979

999

899

989

998

866

Furc

Mobil

1

1

2

2

1

PLQ

3

3

2

2

2

1

1

2

2

1

1

2

2

2

3

3

Abbreviations: BOP, bleeding on probing (1); CAL, clinical attachment level; Furc, furcation involvement (Glickman class); GR, gingival recession; MGJ, position of mucogingival junction from margin; Mobil, tooth mobility (Miller grade); PD, probing depths; PLQ, plaque level (O = none, 5 = heavy).

What can be learned from this case?

This case presents more severe periodontal disease than the cases presented earlier in this book, and the patient already is missing some teeth. If the patient wants to “improve her smile,” then part of addressing this chief complaint will be the need to replace missing teeth and prevent more teeth from getting lost, which of course involves “periodontal work.” So, what will be the “periodontal work?”

For this, we need to look at this case methodically, identifying the periodontal disease and its contributing factors, and developing a treatment plan as presented in Chapters 2 and 3. Starting with the periodontal diagnosis, we evaluate the six dimensions of this patient’s periodontal disease (Table 4.2).

The clinical findings are typical for periodontitis, such as bleeding on probing, pocketing, attachment loss, bone loss, tooth mobility, and gingival recession. The amount of attachment or bone loss is more severe than the average attachment loss seen at this age, and a possible explanation for this is her past history of heavy tobacco use. Given the current disease trajectory of this patient with above-average attachment loss, the risk of future attachment loss seems higher than average.

The systemic and local contributing factors in this case are shown in Table 4.3.

Using the tables from Chapter 3, the etiologies listed here translate into the following treatment (Table 4.4).

Table 4.2 Information to consider for periodontal diagnosis

Severity of inflammation

Erythema

Gingival bleeding—has BOP for at least one site every tooth

Depth of inflammation

Involving alveolar bone crest (bone loss/attachment loss)

Extent of inflammation

Generalized—all teeth are involved to a similar degree regarding bleeding on probing and bone loss

Microbial factors

Plaque—plaque scores 1–2 per tooth; visible at margin; likely has typical microflora associated with periodontitis

Systemic factors

Former tobacco user (20 pack years, quit 2 years ago)

Hypertension—mild

Calcium channel blocker use—but don’t see gingival enlargement

Local factors

Listed by tooth:

No. 4: tooth mobility; possible interference contact no. 30, root concavity

No. 5: tooth mobility; radiographic calculus (D), root concavity

No. 7: radiographic calculus

No. 8: tooth mobility, radiographic calculus, short conical root

No. 9: tooth mobility, radiographic calculus short conical root

No. 11: small caries into dentin (M), radiographic calculus

No. 12: radiographic calculus, root concavity; may have interference contact with no. 19

No. 17: partially erupted, radiographic calculus

No. 18: supraerupted, radiographic calculus, furcation involvement

No. 19: radiographic calculus

No. 20: radiographic calculus

No. 21: radiographic calculus

No. 23: radiographic calculus, tooth mobility

No. 24: radiographic calculus, short root, tooth mobility, anterior position, possible interference contact

No. 25: radiographic calculus, short root, tooth mobility, anterior position, possible interference contact

No. 26: radiographic calculus, tooth mobility

No. 28: radiographic calculus

No. 29: radiographic calculus

No. 30: radiographic calculus, furcation involvement

No. 31: radiographic calculus, supraeruption

No. 32: radiographic calculus, possible caries (O+M), rotated tooth

Table 4.3 Contributing factors

Systemic

Microbial

Local restorative

Local periodontal

Local anatomical

Local trauma

None currently;

Previous tobacco use

Plaque

Calculus

Caries

Deep pocketing,

Inflammation

Furcation

Tooth mobility

Recession

Rotated teeth

Tipped teeth

Margin discrepancy

infra/supra-erupted

Root concavities

Cemental tears

Occlusal trauma

Note that this list does not include past tobacco use as this is no longer something that need to be addressed, and that it does not list hypertension or calcium channel blockers as these are not problems that need to be addressed for periodontal treatment in this case (Hypertension does not cause periodontal disease. This patient does not show signs of drug-induced gingival overgrowth).

It also does not mention short conical roots as these do not contribute to periodontal disease development, but allow attachment loss to produce loose teeth much quicker than for teeth with longer roots.

Table 4.4 Etiology-based treatment plan

Factor

Treatment

Timing

Plaque

Oral hygiene instruction

0

Calculus

Scaling and root planing

3

Occlusal trauma

Occlusal analysis

Occlusal adjustment (limited or complete—depending on extent of tooth surface modifications needed)

6

Tooth mobility

Extra/intracoronal splinting where appropriate (see Chapter 9)

7

Periodontal re-evaluation

8

Deep pocketing

furcation involvement

Pocket reduction surgery (see Chapters 6, 7), if nonsurgical therapy did not eliminate these

10

Root concavities

+Odontoplasty

10

Recession

Corrective soft tissue surgery (Chapter 8)

11

Periodontal re-evaluation

Rotated teeth

Tipped teeth

infra/supraerupted

Orthodontic therapy (if feasible)

20

Indirect restorations (if needed)

21

Implant therapy to replace missing teeth (if needed/desired)

22

Periodontal maintenance

30

The initial part of the treatment plan is specific and clear, but becomes tentative toward the end. This is common with treatment planning complex cases as the later definite restorative treatment plan depends on the outcome of initial disease control, which may me be worse or better than anticipated.

For prognosis, the following questions need to be asked:

  • What is the likelihood of tooth loss?

  • Will treatment reduce the chance of tooth loss?

  • Should teeth be removed?

Findings in the periodontal chart are as follows:

What is the Likelihood of Tooth Loss?

Given the disease trajectory, tooth loss is unlikely in the short term (5 years) in this case. In the long term, the maxillary premolars (teeth nos. 4, 5, and 12) and central incisors (teeth nos. 8 and 9) have the highest risk as they have the most severe attachment loss, largest amount of bone loss, preexisting tooth mobility, and worst crown-to-root ratio of all teeth along with simple, conical-shaped, relatively short tooth roots. The mandibular canines will be the least likely teeth to be lost given their good level of bone support, long root length, low amount of attachment loss, and absence of most periodontal disease-associated factors.

Will Treatment Reduce the Chance of Tooth Loss?

Systemic factors in this patient are likely not an impediment to periodontal treatment. The patient has hypertension, but not to a degree that poses a high risk for a myocardial infarct or stroke during dental treatment. The patient’s local contributing factors can be partially controlled. Plaque and calculus can most likely be treated with oral hygiene instruction and scaling and root planing, and pocket-reduction surgery can be effective. However, furcation treatment may be more difficult, and the patient has multiple occlusal conditions (Class III relationship, severe bone loss complicating orthodontic therapy) that may not be correctable. Therefore, periodontal treatment may produce some improvement in inflammation and pocketing, but the restoration of periodontal health is questionable.

Should Teeth Be Removed?

Removal of the supraerupted mandibular 2nd and 3rd molars would likely simplify periodontal treatment, as it will remove four teeth with significant pocketing, and allow better access to the distal surface of the first molar. Even though the incisors have short roots and a significant amount of bone loss, it may be best to maintain these teeth with conservative periodontal therapy. Removal of these teeth will result in a difficult implant therapy scenario involving significant vertical and horizontal tissue loss.

Judging How Likely a Patient Will Lose Teeth

For most patients, keeping their teeth is the primary motivation for dental care. The ability to accurately predict and then ensure tooth survival is key to maintaining the continued trust of patients.

Prognosis—What Does it Mean?

There are three basic types of questions that need to be asked:

  • How likely is tooth loss?

    • Without treatment, how quickly would the patient’s periodontal condition deteriorate?

    • Without treatment, how fast will the patient loose teeth?

    • What is the likelihood of tooth loss for each tooth?

  • How likely will periodontal treatment succeed?

    • How aggressive should the treatment be?

    • How likely will the proposed treatment succeed in eliminating periodontal disease?

    • How likely will the proposed treatment work in saving a given tooth?

    • Which teeth are most suitable for restoration in the long term?

  • Which teeth need to be removed?

    • Are there teeth that should be sacrificed for improved survival of key teeth?

    • Are there teeth that should be sacrificed to create a better dental implant site?

    • For teeth that should be removed, how likely is it that the site becomes suitable for dental implants?

    • For teeth that should be removed, could immediate implant therapy be an option?

    • For teeth that should be removed, what is the risk of surgical complications at a given site?

    • For sites where teeth need to be removed, how likely are long-term complications without tooth replacement?

The answer to these questions require extrapolation of the current periodontal condition into the future based on the patient’s evidence of past periodontal disease activity, and the prognosis can change depending on the success of dental treatment. Usually, periodontal prognosis is worse at the beginning of treatment and improves with treatment. For instance, a patient may present with severe periodontal disease, poor oral hygiene, and several slightly mobile teeth initially. At the onset of treatment, the risk of tooth loss seems high and the chance of treatment success low given the initial appearance. However, if this patient develops good oral hygiene and tissues respond favorably to treatment, pocketing, tooth mobility, and inflammation, it results in a better chance of tooth survival.

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Dec 4, 2021 | Posted by in Periodontics | Comments Off on Predicting Tooth Longevity

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