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Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 545552

A clinical follow-up study of the periodontal conditions of


RPD abutment and non-abutment teeth
. G . R O N C A L L I ,
B . A . D O A M A R A L * , A . O . B A R R E T O * , E . G O M E S S E A B R A , A
A . D A F O N T E P O R T O C A R R E I R O & E . O . D E A L M E I D A *Federal University of Rio Grande do Norte,
Natal, RN, Department of Dentistry, Federal University of Rio Grande do Norte, Natal, RN, Aracatuba School of Dentistry, UNESP Univ.
Estadual Paulista, Brazil

The purpose of this study was to evaluate


the periodontal conditions of removable partial
denture (RPD) wearers, comparing direct and indirect abutment teeth, and the teeth not involved in
the denture design before denture placement and
1 year later. Fifty patients (32 women and 18 men),
average age 45, were assessed by the same examiner
at the moment of denture insertion and 3, 6, 9 and
12 months later. The following items were verified
in each assessment: probing depth (PD), plaque
index (PI) and gingival index (GI). PD and PI data
were evaluated by ANOVA test for linear trend
followed by TukeyKramer post-test, while GI data
were analysed by Friedmans test. Results showed
that the teeth not involved in the denture design
SUMMARY

Introduction
Removable partial dentures (RPD) are an alternative
treatment for the restoration of edentulous areas; these
dentures are conservative treatments and provide a
rapid solution and accessible cost. However, longitudinal studies have shown that they have been associated
with increased gingivitis, periodontitis and abutment
teeth mobility (1, 2).
Clinical studies (3, 4) have emphasized RPD-related
periodontal tissue reactions, such as inflammation,
increase in probing depth, in dental mobility and in
marginal bone loss. Drake & Beck (4) stated that RPDs
have an unfavourable effect on patients periodontal
conditions. In addition, it appears that abutment teeth
suffer even more damaging effects, besides receiving
2010 Blackwell Publishing Ltd

were the least affected for all variables studied. It


was also verified that PD and GI mean values
increased from the initial assessment to 1 year of
RPD wearing in every group, but that only PI
showed a significant increase. This study indicated
that direct and indirect retainer elements tend to
undergo more damaging periodontal effects associated with RPD wearing when compared with
non-abutment elements. Plaque index values were
significantly higher after 1 year of denture use.
KEYWORDS: dental plaque, oral hygiene, periodontal
diseases, removable partial denture
Accepted for publication 30 January 2010

clasps and being subject to additional loads, which


could cause mobility. That is, abutment teeth are more
susceptible to caries and periodontal problems than
other teeth, as the clasps surrounding abutment teeth
facilitate dental biofilm accumulation.
The adverse effects of RPD wearing on the teeth and
periodontium could be minimized by dental biofilm
control programmes and with satisfactory denture
design requirements (1, 5). However, Drake & Beck
(4) reported that RPD wearing can alter the oral
environment and cause some harm, especially to
abutment teeth, which receive clasps. In contrast,
authors such as Bergman et al. (6) have reported that
RPD alone causes no additional oral pathology. For
this, appropriate oral hygiene instructions, regular
maintenance and control intervals for coronal-root
doi: 10.1111/j.1365-2842.2010.02069.x

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Table 1. Type of teeth (incisor, canine, pre-molar and molar) presented in the study
Maxilla

Direct
Indirect
Control
Total

Mandible

Incisor

Canine

Pre-molar

Molar

Incisor

Canine

Pre-molar

Molar

Total

16
3
39

42
3
2

27
7
9

48
22
19

10
31
44
441

15
6
20

34
2
14

23
1
4

215
75
151

scaling and planning, as well as denture adjustments


are necessary. Nonetheless, these results are inconclusive and sometimes contradictory (1).
In view of this controversy, and considering the fact
that numerous RPD wearers present periodontal alterations (7), the purpose of this study was to clinically
evaluate for 1 year, the periodontal conditions of RPD
wearers, associated with professional dental biofilm
control, comparing direct and indirect retainer and
non-abutment teeth.

Material and methods


Fifty patients (32 women and 18 men) participated in
the study, after placement of RPD at the Dentistry
Department of the Federal University of Rio Grande do
Norte (RN, Brazil). Patients were between 26 and
66 years (average age, 45 years). Every patient received
previous oral treatment and their mouths were specifically prepared for each case and planned using a dental
surveyor. Assessment was conducted in accordance
with the norms and guideline studies involving humans
(resolution number 196, approved on 10 October 1996,
by the National Health Council) and approved by the
Federal University of Rio Grande do Norte Research
Ethics Committee. All patients provided written informed consent authorizing their participation in the
study, making their data available for evaluation and
publication.
The patients were divided into three groups: direct
retainers (teeth close to the denture space that receive
denture elements), indirect retainers (teeth further
away from the denture space, but which also support
denture elements) and control teeth (teeth with no
denture elements). The kind of tooth (incisor, canine,
pre-molar and molar), clasp design and missing area
were presented in Tables 1, 2 and 3.
At the moment of RPD insertion, an anamnesis was
carried out, using clinical records to assess patients
overall health condition, oral health, oral hygiene,

reasons for seeking RPD treatment, as well as previous


experiences with other dentures. The intra-oral physical assessment, performed by a trained examiner,
identified the dentures general characteristics: tooth
function (direct and indirect retainers, and non-abutment) and periodontium conditions (probing depth,
and plaque and gingival indexes).
Probing depth (PD) was verified using a Williams
periodontal probe* in the following locations: vestibular, disto-vestibular, mesio-vestibular, lingual, mesiolingual and disto-lingual.
Gingival index (GI) was assessed by means of sulcular
bleeding; that is, the bleeding that occurs after probing.
Plaque index (PI) was verified using a disclosing
solution Eviplac. For both indexes, each tooth on the
record was also represented by a square and each dental
surface by a triangle (vestibular, palatine lingual,
mesial, and distal). Bleeding surfaces dyed by the
disclosing solution were marked on the corresponding
triangle. Subsequently, similarly to the gingival index,
plaque indexes were obtained by means of the number
of surfaces with plaque and bleeding, respectively, for
each tooth, ranging from zero to four.
PI and GI values (percentage) per patient were
calculated using the modified OLeary Index, according
to the formula: number of surfaces with plaque
100 number of teeth 4.
The initial assessment was performed at the moment
of RPD insertion. In addition to the assessment, patients
received oral hygiene instructions, as well as a brief
explanation about dental biofilm pathogenicity and the
importance of plaque control, coronal-root scaling and
planing (CRSP) and prophylaxis using a micromotor,
rubber cup or Robinson bristle brush with prophylactic
paste. The entire assessment described previously, as
well as CRSP, when necessary, was performed every
3 months for 1 year, totalling five assessments, four of
*Trinity periodontics, Jaragua, SP, Brazil.

Biodinamica Qum. Farm. Ltda, Ibi pora, PR, Brazil.


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PERIODONTIUM OF ABUTMENT AND NON-ABUTMENT TEETH


Table 2. Clasp design (C-clasp or T-bar clasp) presented in the study
Maxilla
Clasp design

Mandible

Incisor

Canine

Pre-molar

Molar

Incisor

Canine

Pre-molar

Molar

Total

7
8

22
10

27
7

67
2

1
4
219

3
11

17
13

20
0

164
55

C-Clasp
T-bar clasp
Total

Maxilla

Mandible

Total

(direct and indirect retainers and control). However,


Friedmans test was performed for the GI variable in the
control group, because the data did not present a
normal distribution.

198
37

97
103

295
140
385

Results

Table 3. Classification of arch and RPD support type presented in


the study
Classification
Tooth support
Tooth-mucosa-supported
Total

which were for professional dental biofilm control


(before RPD insertion and after 3, 6, 9 and 12 months).
The data were compiled on a database, using Microsoft Office Excel 2003. SPSS 13.0 was used for descriptive
statistics and confidence interval analysis, and Graph
Pad InStat 3.05 for analysis of variance. ANOVA test for
linear trend followed by TukeyKramer post-test was
performed to evaluate quantitative (PD, GI, PI) dependent variable behaviours over time for each group

Variable behaviours were separately evaluated within


1 year (Tables 35, Figs 13). In general, there were no
statistically significant differences in the periodontal
conditions across the three groups; however, the plaque
indexes showed significant difference.

Probing depth (PD)


Every group had increased PD values during the
study. However, there were no statistically significant
differences between the initial assessment and at

Table 4. Sample size (n), mean, standard deviation, median, minimum, maximum, inferior limit and superior limit (95% confidence
interval) for probing depth (PD) in the studied groups

Time Point
Direct Retainer
Base line
3 months
6 months
9 months
12 months
Indirect Retainer
Base line
3 months
6 months
9 months
12 months
Control
Base line
3 months
6 months
9 months
12 months

CI (95%)
Lower

Upper

3830
4500
4330
9000
4500

2028
2176
2164
2386
2239

2195
2361
2339
2864
2424

1170
1330
1330
1330
1330

4330
4000
5170
9000
3830

1759
1946
1995
2001
2014

2052
2198
2334
2729
2330

1000
1170
1000
1000
1170

4000
4330
4000
4830
4830

1759
1908
1872
1894
1907

1935
2084
2067
2103
2106

Mean*

Standard deviation

Median

Minimum

Maximum

141
141
141
141
141

211a
226a
225a
262b
233a

05062
05613
05300
1450
05600

2000
2170
2170
2330
2170

1170
1000
1330
1330
1500

58
58
58
58
58

190a
207a.c
216a.c
236b.c
217a.c

05573
04788
06446
1383
06006

1830
2000
2085
2000
2000

99
99
99
99
99

184a
199a
196a
199a
200a

04406
04428
04861
05221
04987

1830
2000
2000
2000
2000

*TukeyKramer test: same letters indicate statistically equal values.


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Table 5. Sample size (n), mean, standard deviation, median, minimum, maximum, lower and upper limits (95% confidence interval) for
gingival index (GI) in the studied groups

Time Point
Direct Retainer
Base line
3 months
6 months
9 months
12 months
Indirect Retainer
Baseline
3 months
6 months
9 months
12 months
**Control
Time point
Baseline
3 months
6 months
9 months
12 months

Mean*

Standard deviation

Median

Minimum

Maximum

CI (95%)
Lower

Upper

141
141
141
141
141

27199a.c
34021b
24695c
30518a
32000a

12253
18373
13314
17510
18742

25000
29000
25000
33000
28000

3000
7000
0000
6000
9000

62000
69000
57000
75000
96000

25176
30989
22497
27628
28906

29221
37054
26893
33408
35094

58
58
58
58
58

28293a
36379b
27621a
30397a.b
33138a.b

13679
16538
14503
13470
15539

29000
33000
23500
28000
29000

3000
7000
5000
6000
9000

62000
68000
57000
65000
59000

24695
32029
23806
26854
29051

31891
40729
31435
33939
37225

Ranks

Sum of ranks

Median

Minimum

Maximum

25000
28000
17000
33000
33000

3000
7000
5000
8000
9000

59000
69000
54000
75000
96000

104
104
104
104
104

31950a
34250a
22200b
31600a
36000a

*TukeyKramer test: same letters indicate statistically equal values.


**Friedmans test.

12 months. There was a statistically significant difference across groups in terms of time-points: the direct
retainer group had greater PD values at 9 months when
compared with the other time-points; in the indirect
retainer group, PD values increased significantly from
initial assessment to 9 months. The direct retainer
group presented greater probing depth averages than
the other groups at all times, whereas the control group
had the lowest values. Every group demonstrated a
linear trend; that is, values increased over time, as
verified by the ANOVA test for linear trend (P < 0001)
(Table 4, Fig. 1).

28

26

Probing depth

548

24

22

20

18
Baseline

3 months

6 months

9 months

12 months

Time

Gingival index (GI)


GI values increased from initial assessment to
12 months, with no statistically significant difference
between groups. At 3 months, there was a significant
increase in GI in the direct and indirect retainer groups.
At 6 months, the direct and indirect retainer groups
presented a significant reduction when compared with
values at 3 months, and the control group presented a
significant reduction at 6 months when compared with

Direct retainer

Indirect retainer

Control

Fig. 1. Groups behaviour (function) in relation to mean values


for probing depth during the study.

the rest of the period. At 9 months, these values


increased again, resulting in higher values at 12 months
than at initial assessment; however this difference was
not statistically significant. Regarding the linear trend,
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PERIODONTIUM OF ABUTMENT AND NON-ABUTMENT TEETH


the direct retainer group and, most of the times, they
were also lower than in the indirect retainer group. This
was not observed, however, at 3 months, when the
control groups value was slightly higher than that of
the indirect retainer group (Table 6, Fig. 3).

400

Gingival index

350

300

Baseline comparison (BL)


250

200
Baseline

3 months

6 months

9 months

12 months

Time

Direct retainer

Indirect retainer

Control

Fig. 2. Groups behaviour (function) in relation to mean values


for gingival index during the study.

800
750

Plaque index

700
650
600

Comparison between baseline and quantitative results


demonstrated that considering the probing depth (PD),
the direct retainer group exhibited statistically significant higher values than the control group. The three
groups presented no statistically significant difference
for the gingival index (GI) and plaque index (PI). So,
there was no difference in GI and PI across groups at
baseline Table 7.
The KruskalWallis test was used to analyse the timepoint data, as irregular distribution and no association
between the variables were noted Table 8. There was
no statistically significant difference between 12-month
follow-up and baseline for all groups considering the
following variables: probing depth (PD) and plaque
index (PI). Considering the gingival index (GI), there
was statistically significant difference across groups
with lower results for the control group in comparison
with the direct and indirect retainer groups.

550
500

Discussion

450

The present study shows that teeth involved in RPDs


(direct and indirect retainers) are more affected by
gingival diseases than non-involved teeth. This result is
in accordance with Akaltan & Kaynak (8), who also
affirmed that gingival recession is more common on
denture-support teeth. However, in the present study,
abutment teeth were already damaged before RPD
insertion because of the surrounding dental loss, which
causes bone reabsorption, or to previous use of inadequate dentures.
The increase in probing depth noted in the present
study suggest that this occurs because of the gingival
oedema caused by dental biofilm accumulation and
consequent gingival inflammation, given that 1 year is
not sufficient to affirm that there was insertion loss.
With regard to plaque index (PI), mean values
increased significantly in the three groups. It was also
observed that the control group presented lower values
than the direct and indirect retainer groups for both GI
and PI. In line with these results, several authors (4, 8,

400
Baseline

3 months

6 months

9 months

12 months

Time
Direct retainer

Indirect retainer

Control

Fig. 3. Groups behaviour (function) in relation to mean values


for plaque index during the study.

the direct and indirect retainer groups presented no


significant correlation (P > 005). For the control group,
ANOVA test for linear trend could not be performed as
the data did not present normal distribution (Table 5,
Fig. 2). For this reason, Friedmans test was employed.

Plaque index (PI)


PI increased from initial assessment to 12 months, with
statistically significant differences in the three groups.
The control group PI values were always lower than in
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Table 6. Sample size (n), mean, standard deviation, median, minimum, maximum, inferior and superior limits (95% confidence interval)
for plaque index (PI) in the studied groups

Time Point
Direct Retainer
Base line
3 months
6 months
9 months
12 months
Indirect Retainer
Baseline
3 months
6 months
9 months
12 months
Control
Baseline
3 months
6 months
9 months
12 months

CI (95%)
Lower

Upper

10000
95000
99000
99000
99000

44665
56336
59336
60152
68754

51317
60811
65535
66506
73344

0000
17000
21000
9000
40000

10000
95000
99000
99000
99000

44882
48744
58669
52844
63177

57270
58673
69281
64979
70671

0000
20000
12000
9000
40000

99000
86000
99000
99000
99000

40444
53238
53637
53177
65899

47815
57959
61586
60662
71558

Mean*

Standard deviation

Median

Minimum

Maximum

225
225
225
225
225

47991a
58573b
62436b
63329b
71049c

25457
17126
23718
24313
17562

46000
58000
62000
59000
69000

0000
17000
12000
9000
40000

51076a
53709a.c
63975b.c.d
58911a.c.d
66924d

27608
22129
23651
27046
16703

45000
56000
69000
55000
66000

44130a
55599b
57611b
56920b
68728c

23935
15328
25809
24303
18375

43000
56000
55000
52000
68000

79
79
79
79
79
162
162
162
162
162

*TukeyKramer test: same letters indicate statistically equal values.

Table 7. Descriptive statistical analysis of probing depth (PD), gingival index (GI) and plaque index (PI) at baseline. P-values obtained
from analysis of variance. LL, lower limit; UL, upper limit
Group
Probing depth
Direct retainer
Indirect retainer
Control
Total
Gingival index
Direct retainer
Indirect retainer
Control
Total
Plaque index
Direct retainer
Indirect retainer
Control
Total

Mean

Standard deviation

Minimum

Maximum

LL (95%)

218
79
152
449

21047
19536
18794
20019

050559
057854
045114
051122

117
117
100
100

383
433
400
433

20372
18240
18071
19544

218
79
152
449

104
109
093
101

0976
0936
0896
0942

0
0
0
0

4
4
3
4

091
088
079
093

117
130
108
110

0414

218
79
152
449

190
192
163
182

1224
1196
1280
1243

0
0
0
0

4
4
4
4

174
166
143
170

207
219
184
193

0081

9) agree with the idea that RPDs lead to an increase in


dental biofilm accumulation, especially on the surface
of teeth in direct contact with the denture. Other
studies (1012) have reported the occurrence of
increased dental biofilm accumulation in the region
surrounding abutment teeth, as well as gingival inflammation in regions covered by the RPD (13, 14). This
increased bleeding on probing associated with deeper

UL (95%)

21722
20832
19517
20493

0000

probing depth in abutment teeth is closely related to


quantitative alterations in the dental biofilm, thus
increasing the risk of developing gingival inflammation
and periodontitis. This finding is important, as retainers
receive denture elements and are more susceptible to
accumulate greater amounts of dental biofilm, besides
impairing the self-cleansing action performed by saliva,
tongue and cheeks. Hence, if patients are not aware and
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PERIODONTIUM OF ABUTMENT AND NON-ABUTMENT TEETH


Table 8. KruskalWallis test for comparison across groups considering the difference between 12-month follow-up and baseline for
probing depth (PD), gingival index (GI) and plaque index (PI)
Group
Probing depth
Direct retainer
Indirect retainer
Control
Gingival index
Direct retainer
Indirect retainer
Control
Plaque index
Direct retainer
Indirect retainer
Control

Rank

Sum of ranks

Mean

141
58
99

21587
94845
13480

15310
16353
13616

01700
03300
01700

)1000
)1170
)05000

1500
2330
1170

01203

141
58
104

19535
89345
17587

13854
15404
16911

3000
6000
8000

)43000
)43000
)15000

71000
28000
71000

00255

225
79
162

53014
16129
39669

23562
20416
24487

25000
15000
25000

)37000
)37000
)31000

99000
63000
99000

00833

motivated about oral hygiene, they may be at high risk


for developing periodontal diseases and dental caries.
Finally, there is a correlation between gingival and
plaque indexes. In fact, in the present study, a positive,
statistically significant correlation between these variables was found (r = 06510 and P < 00001). That is, as
PI increases, GI also tends to increase. The increase in
GI, observed at 3 months, in the direct and indirect
retainer groups is suggestive of the increased PI effect,
as they were the first contact with the new denture, for
some patients, indicating an initial adaptation. On the
other hand, reductions in GI at 6 months may have
occurred because of the effect of the motivation
performed at baseline and at 3 months. Later, some
lack of care possibly occurred, as values increased again
at 9 months.
Thus, data indicate that alterations in the periodontium resulting from RPD wearing are more evident in
teeth involved in the denture design. Moreover, these
teeth are more prone to forming dental biofilm, as the
denture is a host for dental biofilm bacteria (1, 2). The
increased PD values in every group suggest that RPD
causes changes, and that these changes are not irreversible, as the difference was not significant during this
study. This indicates that the four professional dental
biofilm control treatments performed every 3 months
were able to minimize the effect of high plaque indexes,
which, in turn, significantly increased over time.
Therefore, it is extremely important that RPD wearers
be instructed about biofilm pathogenicity, and that
dental surgeons be concerned with professional dental
biofilm control. Moreover, it should be explained to the
patients that treatment does not end with denture
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Median

Minimum

Maximum

placement. There should be an equal concern with the


technical principles involved in planning and performing RPD clinical and laboratory execution.
Although the number and distribution of remaining
abutment teeth is similar when planning any removable partial denture, some particular characteristics of
each case may influence the design of the metallic
framework. The guide plane, retentive area, esthetics,
and mucosa and bone interferences are factors that
contribute to surveying and may individualize the
metallic framework design (1). In some situations, the
design of the retainers increases plaque accumulation,
probing depth and gingival index. However, if the
patient receives proper instruction and maintains satisfactory oral hygiene, the differences on planning will
not significantly influence the periodontal indexes.
The results of this study show that restorative
treatment by means of RPDs, when well planned and
executed, combined with dental biofilm control, is a
feasible alternative treatment, recommended to rehabilitate edentulous patients, although RPDs do not
eliminate the chance for new problems to appear. Thus,
prognosis mostly depends on appropriate biofilm
control. However, as the present study shows that
these changes were observed during a 12-month
period, it cannot be affirmed that RPD causes damage
to the periodontium, because many alterations were
not significant. It may be suggested, however, that
RPDs increase dental biofilm accumulation, which, if
not correctly removed, can cause some damage.
Therefore, further studies are needed, as well as the
continuation of the present study, to follow patients for
longer periods and verify whether this linear trend of

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increasing periodontium damage becomes significant or


continues to cause controlled inflammatory episodes,
without leading to insertion loss.

Conclusions
1 Direct and indirect retainer elements tend to undergo
more damaging periodontal effects associated with
RPD use when compared with non-abutment elements, with greater probing depth, gingival index
and plaque index values.
2 Following 1 year of denture use, plaque index values
were significantly higher than before its placement.

Acknowledgments
The authors thank the Coordinators of the Master of
Science in Dentistry Program from the Federal University of Rio Grande do Norte (UFRN) for the support in
the experimental part of this study.

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Correspondence: Erika Oliveira de Almeida, Departamento de
Materiais Odontologicos e Protese, Rua Jose Bonifacio, 1195, Vila
Mendonca, Aracatuba SP, Brazil. E-mail: erikaunesp@gmail.com

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