ASSESSMENT OF THE PROGNOSIS OF PRESERVATION OR EXTRACTION OF PERIODONTOPATHIC TEETH FOR IMPLANT DECISIONS

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1 Parodontology ASSESSMENT OF THE PROGNOSIS OF PRESERVATION OR EXTRACTION OF PERIODONTOPATHIC TEETH FOR IMPLANT DECISIONS Atamna Hussein Magde 1, Mâr]u Silvia 2 1. PhD Student, Gr.T.Popa U.M.Ph Iasi, Romania, Implantology, Tel Aviv, Israel 2. Prof.PhD., Dept. Periodontolog,. Gr.T.Popa U.M.Ph Iasi, Romania Contact author: Mâr]u Silvia, parodontologie1@yahoo.com Abstract The aim of the study was to discuss and evaluate the prognostic of natural teeth vs. dental implants in decision-making, as well as the treatment strategies applicable to periodontally-compromised patients. Materials and method: 25 patients affected by aggressive periodontitis, with reserved prognostic for some teeth, were followed over a long period of time, the benefits and risks involved by treating periodontally-compromised dentures in association or not with implant s insertion being carefully analyzed. The benefits and risks related by the cost-efficiency ratio of using implants for improving the prognosis for either the natural mobile tooth or the pillar tooth from partially-fixed prostheses are also discussed. Results and discussion: The present study suggests that the longitudinal loss of bone mass around the implants is correlated with previous experiments on periodontal bone loss, and also that the patients susceptible to periodontopathy are more exposed than those not in danger of developing peri-implantitis. Consequently, the natural teeth of the patient should be carefully considered when planning and performing a complex periodontal treatment, and also when the decision of keeping or extracting a tooth prior to implanting is taken. Conclusions: An important aspect put into evidence in the study is the necessity of considering a strategical postponing of the implant (the optimum time for implant insertion) in a periodontally-susceptible patient, for a full utilization of the natural tooth and for extending and optimizing the longevity of dentition. Keywords: periodontally compromised teeth, tooth preservation, implant prognosis INTRODUCTION The dentures severely affected by periodontal diseases frequently cause problems not only to the patient, but also to the dentist, for whom a correct selection of the therapy to be followed may be especially difficult. The therapeutical options nowadays available complicate to a considerable extent the selection of the best strategy for an individualized treatment.(1, 2) The advanced periodontal disease will require extensive treatments, that should consider its cause and assure a healthy periodontal condition for the subsequent morpho-functional recovery through prosthesizing (1). As generally known, one s naturally-treated teeth, with a healthy periodontium, yet significantly reduced as support are capable of supporting conjunct extensive prostheses for quite a long time, at survival ratios of about 90%, on condition that the periodontal disease should be stabilized, and that any new loss should be prevented. The minute scientific researches developed in recent decades have provided a solid basis for implanting therapy as a reliable treatment alternative for the substitution of the teeth lost from periodontal reasons. (2, 3) Some clinicians consider that the prognosis, always complex in itself and usually time-consuming, as well as the practical application of such a periodontal therapy do not attain the high, successful levels of the treatment with implants (4). Consequently, more and more teeth are extracted and replaced by implants in patients affected by advanced, moderate or aggravated periodontal diseases. Such an opinion is based on hypotheses favourizing better performances on implants than on periodontally-compromised teeth, and on the idea that their longevity does not depend on one s individual susceptibility to periodontopathy. That is why, the teeth that might be saved and used as a support for partial conjunct prostheses, are extracted and replaced by implants, sometimes following unreliable indications. However, other specialists show excessive confidence in implantary therapy, along with the application of expensive International Journal of Medical Dentistry 287

2 Atamna Hussein Magde, Mâr]u Silvia treatments, with uncertain prognosis, even if other solutions, capable of saving a higher number of natural teeth were compatible for longer time periods (5-7). Such situations prevent a correct evaluation of the annual periimplantary bone loss over longer periods of time. In studies devoted to total mandibulary bridges on implants, developed over 20 years, Ekelund et al. (8) and Attard & Zarb (9) reported that, annually, the bone loss was very low, on the average, yet extremely variable. This situation explains the absence of longterm data on the implantary success or failure in patients affected by advanced or rapidly progressive periodontopathy. Nevertheless, the peri-implantary lesions (with radiographic image of the loss of marginal bone mass of at least 2 mm) in one or more implants occurred in ratios of 16-28% in patients with implants, after 5-10 years (10-12), prevailing in patients with multiple implants (11). All these studies suggest that the longitudinal loss of bone mass around the implants is correlated with previous periodontal bone loss, and also that the patients susceptible to periodontopathy are more exposed to periimplantitis than the non-susceptible ones (13-15). Such observations evidence the necessity of a careful analysis for a most suitable selection of the therapy. Consequently, the natural teeth of a patient should be seriously considered when planning and performing a complex periodontal treatment. TEETH SURVIVAL VS. IMPLANTS The prevalence of severe periodontopathies has been traced in 10-15% of the populations of the industrial world (14, 15). In spite of this, most of the teeth may still survive. Another important cause of teeth loss, seldomly recognized, is dental extraction, preferred for various and quite personal reasons. Substitution of the lost teeth with implants assumes the introduction of an artificial structure in the oral cavity, apparenly highly successful on medium term, but with a hardly acknowledged success on long term, at both populational and world level. Recent reports indicate that the implants may follow the survival curve in the same way as the natural teeth, which means that they have a variable distribution at populational level. In this way, the risk of bone support loss in time seems to be approximately the same, for an implant, as the loss of the periodontal support for a natural tooth. In other words, a natural tooth in a patient suffering from periodontopathy may have a prognostic comparable to that of an implant, whereas the risk for an implant to loose its bone support seems, on the average, higher than for a tooth, in both periodontally-susceptible or not patients. Consequently, a tooth will have a prognostic at least equally good if not better than that of an implant with normal length, on condition of simplifying the evaluations to a problem of distances. In the case of periodontites or periimplantites, the bone mass loss may advance more rapidly and uncontrollably. However, it is generally known that even a severe periodontopathy may be successfully treated, and also that pathological bone destruction may be prevented (16). If periodontal destruction is stopped by the success of the periodontal treatment, there is obviously no need to replace a tooth (be it carious or not) by an implant, even in situations with significant bone loss. Obviously, some differences do exist between a natural teeth with a significantly reduced periodontal support and a bone implant with significantly reduced support. The teeth (when individual) may become hypermobile, yet, if sufficiently well-distribuited, they may act as successful supports for the extended bridges. Even if an inferior limit of the periodontal support exists, it seems that less than 25-30% of the remaining periodontal support will be sufficient, even on long term (17). Hopefully, the cases discussed in the present study will illustrate this postulate. The natural tooth should not be considered as an obstacle, but as a possibility, if the treatment includes implants or not. If the implantary treatment is the variant preferred in periodontopathies, it should be preceded by elimination of the causes 288 volume 1 issue 3 July / September 2011 pp

3 ASSESSMENT OF THE PROGNOSIS OF PRESERVATION OR EXTRACTION OF PERIODONTOPATHIC TEETH FOR IMPLANT DECISIONS of the periodontal diseas, through maintenance and supporting anti-infectious treatments. A continuous control for combating the infection should be also performed in implanted patients, for preventing the development of periand implantites and of any peri-implantary bone loss, independently on the existence of natural teeth, because the dental implants activate microorganisms, which threaten their longevity. The decision of maintaining or extracting a periodontally-affected tooth for saving the bone is essentially depending both on the radiographic evaluation and correct interpretation of the clinical signs, in their dynamics, and on the evaluation of the dental prognostic. In this respect, 2 aspects should be considered: the global prognostic and the individual prognostic on the tooth. THE AIM OF THE STUDY The aim of the present study is to discuss the manner in which the clinical decisions are taken, along with the establishment of the treatment strategies in the management of periodontallycompromised patients vs implanting. plaque and his compliance risk factors for technical and biological defects, and complexity and costs of the treatments. The case discussed below will exemplify the capacity of both natural teeth and implants of serving as long-term functional units. Stress will be laid on the possible treatment alternatives, frequently eliminated or even left aside, even if they may provide several advantages, related to both prognosis and efforts undertaken. Patient I only one periodontally-compromised tooth, from an uninterrupted arch in the anterior maxillary zone; 50 year-old female patient, 12 years of dispensarisation, good health condition. The patient suffered from gingiva bleeding, tooth mobility and vestibularization of teeth from the frontal zone of the upper maxillary, especially the trema between 12 and 13. The clinical and radiological condition during the initial exam are illustrated in Fig. 1. A, B. Tooth 12 had a 9 mm distal periodontal pocket and an intrabone defect evaluated both clinically and radiographically. MATERIALS AND METHOD A number of 25 patients, suffering from aggressive periodontites with reserved prognostic for some teeth, were followed over a long period of time. The benefits and risks of treating periodonally-compromised teeth/dentures, either associated or not with the implant s position, have been analyzed. Examples have been provided by case studies on patients with one or more teeth affected by a severe, advanced periodontal disease, or in the cases in which the dental implants are usually seen as an alternative. To obtain the best possible long-term prognostic, the clinical decision for selecting the optimum treatment strategy in periodontally-susceptible patients should be based on evaluations of: gravity and progress of the periodontal disease, functional and aestehtic requirements, patient s capacity of having control upon the A B Fig. 1. Patient I. Initial clinical (A) and radiographic aspect (B) Clinical decision. Tooth 12 was considered as a key tooth with doubtful prognosis. If extracted, its substution with a gnato-protetic de- International Journal of Medical Dentistry 289

4 Atamna Hussein Magde, Mâr]u Silvia vice or an implant might cause some other decisional problems (extended device?, one single implant as a suitable alternative to the available bone volume and aesthetic requirements?). Otherwise, the alternative in such a case remains a bridge or an implant. Is there a sufficient bone mass for an implant? Would this be an aesthetically satisfactory solution? In such a case, the response to both questions is probably yes. However, such an alternative is equally expensive and time-consuming. Treatment: Periodontal surgery of 1.2, to confirm the local anatomical diagnosis and to grant an optimum debridement and healing of the periodontal defect. Causal periodontal therapy was initiated, including information for the patient, instructions of oral hygiene, and supra- and sub-gingival scaling of the teeth. Mucoperiostal vestibular and lingual flaps from teeth 11 to 13 were created (fig. 2). Fig. 2. Intra-surgical clinical aspect in case I The granulation tissue was eliminated, and the root surface was carefully scaled and planned. The periodontal bone defect was classified as a defect of one entrance surface and three surfaces in the deeper part. No bone surgery had been performed. The flaps were repositioned and suturated for copletely covering the defect. The patient was instructed to rinse the mouth with a 0.2% chlorhexidine solution, twice a day, for 15 days. Evaluation of the treatment. The patient responded well to the treatment, no pockets larger than 4 mm and no bleeding being noticed during the control examinations. Tooth 1.2 was spontaneoulsy repositioned to its initial position, a satisfactory aesthetics thus resulting (radiographic evaluation after 5 years). (fig 3) A Fig. 3. Radiographic aspect (A-prior to treatment, B-after 5 years) DISCUSSION The visits to the dentist, scheduled prior to the current treatment, showed that the patient was especially interested in having a healthy denture. She mentioned that, progressively, her frontal maxillary teeth migrated, got leaned, a trema thus resulting between 1.2 and 1.3, with unpleasant aesthetic consequences. Nevertheless, the patient did not fully realize the severity of the partial periodontal destruction. Many stomatologists would have suggested extraction of tooth 1.2, if considering the deep bone defect, the obvious mobility and exaggerated vestibular tilt. The etiological and surgical treatments led to a good periodontal and bone healing, as well as a satisfactory aesthetic aspect. Another observation was that, after the treatment, the trema between was spontaneously closed, so that tooth 1.2 came back to its initial position on the arch simply by retrocession of the inflammatory phenomena and bone restructuring. The applied treatment was relatively cheap, comparatively with either implanting or conjunct prosthesizing. However, how predictable remains periodontal healing by this bone recovery? Several factors may be involved in the healing reaction, such as: morphological defects (a three-wall bone defect will be healed with bone filling more than a two- or an one-wall one, the result of the treatment being easily controllable), tooth mobility, the graft for defect covering and, obviously, the patient s compliance level. An- B 290 volume 1 issue 3 July / September 2011 pp

5 ASSESSMENT OF THE PROGNOSIS OF PRESERVATION OR EXTRACTION OF PERIODONTOPATHIC TEETH FOR IMPLANT DECISIONS other alternative of conventional, prosthetic or implanting therapy of only one tooth could hardly produce a more favourable aesthetic effect. What can be learnt? First, one should learn that it is possible to successfully and rationally treat and preserve periodonthopated teeth with advanced periodontal destruction. Secondly, the lost periodontium may be recovered, even if only partially. Thirdly, a successful treatment with limited costs is possible and last but not least the attitude and compliance of the patient are decisive for attaining good results on long term. More than that, other options, apart from implantary therapy, should be always seriously considered. Patient II A 68 year-old woman, in good health condition, was sent to the specialzed clinics for mandibulary periodontal problems, no edentation, only tooth 3.3 having some periodontal problems. The patient was following a maintenance therapy program for 5 years. Along the last 6 months, an increased mobility of the left inferior canine could be observed (3.3) A B Fig. 4. Patient II (Initial clinical aspect (A) and radiographic image (B ) The clinical situation observed on initial examination is illustrated in Fig. 4.A. On probing, tooth 3.3 showed deep periodontal pockets: 6 mm mezially, 4 mm buccally, 9 mm lingually, and 12 mm distally. No other periodontal problems were discovered, with the exception of a slight papillary inflammation in sextant 4. The radiography shows a deep infra-bone defect at tooth 3.3 (Fig. 4.B). The tooth was not in traumatic occlusion and was vital (sensible to electrical testing), so that the lesion was diagnosed as simply of periodontal nature. Clinical decision Tooth 3.3 may be viewed as a key-tooth. Application of a fixed prosthesis for its replacement is difficult, involving sacrifice of the neighbouring teeth, and problems of morpho-functional recovery, which means an expensive treatment, so that the implant may be selected as an alternative. The large bone defect that might result after extraction will require bone augmenting, for obtaining an adequate bone volume capable of assuring a correct implant positioning. In such a case, an additional healing period of at least 6 months is necessary. Immediate implant positioning, without bone addition, should be still investigated to this site, as the implant might be too apically localized to permit an adequate oral hygiene. Treatment. After the initial therapy and some instructions of oral hygiene, the periodontal surgery was performed. Fig. 5. (A, B). Worth mentioning is the depth of the bone defect in tooth 3.3., observed intra-surgically. Evaluation of the treatment. The patient continued the maintenance therapy, which involved visits to the dental hygienist and/or implantologist once a year, for a corresponding maintenance plan. Fig. 6 presents the radiographic results 5 years after the therapy. The general periodontal condition was good (low plaque index and low bleeding index). On probing, no bleeding pockets were found around tooth 3.3. The radiographies (fig. 6) taken after healing show a cancelled bone defect comparatively with the initial condition. (fig. 4.B.) International Journal of Medical Dentistry 291

6 Atamna Hussein Magde, Mâr]u Silvia A B Fig. 5. Intra-surgical aspect: vestibular (A) and lingual viewa (B) Discussion. The proposed solution of treatment, quite simple, gave a good functional result on long term. Similarly with the case of patient I, post-surgical healing led to significant bone consolidations, even if a pronounced vestibular gingival recession could be also observed. Nevertheless, the exposed root was not a concern for the patient, as no hyperestesia phenomena occurred and no influences affected the aesthetic aspect, once the zone was not visible. What can one learn from here? Similarly with the case of patient I, patient II had a periodontal lesion localized on a key-tooth. This tooth could not be substituted by an implant in the absence of some extraordinary measures taken for an acceptable attaining of the bone level. Alternative prosthetic treatments should have been quite extended in the left mandibulary zone. Both alternatives would have been more time-consuming and more expensive than the applied periodontal therapy. GENERAL REMARKS Fig. 6. Patient II. Clinical and radiographic aspect at the age of 5 As generally acknowledged, any serious dental treatment aims at obtaining the best possible prognostic of the therapy, that is attaining the proposed objective with minimum complications, over the longest possible period of time. In spite of all these, the benefits and risks of the selected therapy should also consider the time and financial resources of the patient, in a similar way in which narrower or larger safety limits for both dentist and patient are prepared for the realization of the selected therapy. Such problems may be highly variable, not only among different stomatologists, but also from one patient to another. Considerable performances will be attained if the variability of the tretament strategies will be backed up by the competence, experience and dental attitude of both dentist and pacient. The limited access to different specialists might constitute a decisive moment, influencing the selected therapy. The most comprehensive, high-impact factors are, undoubtedly, the attitudes and resources provided by the society. Consequently, the selection, planning and performance of the treat- 292 volume 1 issue 3 July / September 2011 pp

7 ASSESSMENT OF THE PROGNOSIS OF PRESERVATION OR EXTRACTION OF PERIODONTOPATHIC TEETH FOR IMPLANT DECISIONS ments will considerably vary from one medical team to another, which also explains the large range of available treatments inevitably more or less simply to understand and apply. Teeth extraction and their substitution with implants become more and more frequently applied techniques for the management of the periodontallycompromised patients. Such an approach is based on hypotheses according to which the implants have better performances than the periodontally-compromised teeth, their longevity being independent on the individual susceptibility to periodontopathy. In spite of all these considerations, recent studies suggest that the periodontally-susceptible patients are more exposed to peri-implantites. CONCLUSIONS A decisive component of a long-term prognostic in the management of patients suffering from periodontopathies is the efficient control of the bacterial plaque, capable of maintaing the periodontal tissues in good health. Also, a central element of the implanting therapy should be the control of the possible infections around the implants, for maintaining a healthy condition of the peri-implantary tissues. The decision of preserving or extracting the teeth from the periodontopathed area depends on numerous factors, related to both patient or/and applicable conditions. Some treatment strategies and the performances may be, nevertheless, inadequate, from either lack of knowledge or/and other unexcusable causes on dental attitudes. References 1. Lundgren D., Rylander H.,Laurell L.: To save or to extract, that is the question: natural teeth or dental implants in periodontitis susceptible patients: clinical decision-making and treatment strategies exemplified with patient case presentations. Periodontology 2000,2008:47: Nyman S, Lindhe J. A longitudinal study of combined periodontal and prosthetic treatment of patients with advanced periodontal disease. J Periodontol 1979: 50: Tan K, Pjetursson BE, Lang NP, Chan ESY.: A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least5 years. III. Conventional FPDs. Clin Oral Implants Res.,2004: 15: Wennstrom JL, Serino G, Lindhe J, Eneroth L, Tollskog G.: Periodontal conditions of adult regular dental care attendants. A 12-year longitudinal study. J Clin Periodontol 1993:20: Lang NP, Pjetursson BE, Tan K, Bragger U, Zwahlen M.: Asystematic review of the survival and complicati on rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. II. Combined tooth-implant supported FPDs. Clin Oral Implants Res 2004: 15: Schou S, Holmstrup P, Worthington HV, Esposito M. Outcome of implant therapy in patients with previous tooth loss due to periodontitis. Clin Oral Impl. Res 2006:17(Suppl. 2): Pjetursson BE, Tan K, Lang NP, Bragger U, Egger M, Zwahlen M. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. I. Implant-supported FPDs. Clin Oral Implants Res 2004: 15: Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res 2005: 16: Gunne J, Astrand P, Lindh T, Borg K, Olsson M. Tooth implant and implant supported fixed partial dentures: a10-year report. Int J Prosthodont 1999: 12: Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol 2002:29(Suppl. 3): Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res 2005: 16: Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine to fourteen-year follow-up of implant treatment. Part II:presence of peri-implant lesions. J Clin Periodontol 2006:33: Hardt CR, Grondahl K, Lekholm U, Wennstrom JL. Outcome of implant therapy in relation to experienced loss of periodontal bone support: a retrospective 5-year study.clin Oral Implants Res 2002: 13: Hugoson A, Laurell L, Lundgren D. Frequency distribution of individuals aged years according to severity of periodontal disease experience in 1973 and J ClinPeriodontol 1992: 19: International Journal of Medical Dentistry 293

8 Atamna Hussein Magde, Mâr]u Silvia 15. Papapanou PN, Wennstrom JL, Sellen A, Hirooka H,Grondahl K, Johnsson T. Periodontal treatment needs assessed by the use of clinical and radiographic criteria. Community Dent Oral Epidemiol 1990: 18: Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease. J Clin Periodontol 1984: 11: Nyman S, Ericsson I. The capacity of reduced periodontal tissues to support fixed bridgework. J Clin Periodontol, 1982: 9: volume 1 issue 3 July / September 2011 pp