J Clin Periodontol 2012; 39: 73–79 doi: 10.1111/j.1600-051X.2011.01811.

Tooth loss in periodontally Nils Ravald and Carin Starkhammar

Johansson
Division of Cardiovascular Medicine,

treated patients. A long-term Department of Medical and Health Sciences,

Linköping University, Center for Oral
Rehabilitation, County Council of

study of periodontal disease and Östergötland, Linköping, Sweden

root caries
Ravald N, Starkhammar Johansson C. Tooth loss in periodontally treated patients.
A long-term study of periodontal disease and root caries. J Clin Periodontol 2012;
39: 73–79. doi: 10.1111/j.1600-051X.2011.01811.x.

Abstract
Aim: To study periodontal conditions, root caries, number of lost teeth and
causes for tooth loss during 11–14 years after active periodontal treatment.
Material and Methods: Sixty-four patients participated in the follow-up study.
Reasons for tooth loss were identified through previous case books, radiographs
and clinical photos. To identify factors contributing to tooth loss, a logistic multi-
level regression analysis was used.
Results: The number of lost teeth was 211. The main reason was periodontal dis-
ease (n = 153). Due to root caries and endodontic complications, 28 and 17 teeth,
respectively, were lost. Thirteen teeth were lost for other reasons. The number of
teeth (p = 0.05) and prevalence of probing pocket depths, 4–6 mm (p = 0.01) at
baseline, smoking (p = 0.01) and the number of visits at dental hygienists
(p = 0.03) during maintenance, significantly contributed to explain the variation
in tooth loss.
Conclusion: Previously treated patients at a specialist clinic for periodontology
continued to lose teeth in spite of maintenance treatments at general practitioners
and dental hygienists. The main reason for tooth loss was periodontal disease. Key words: extraction; periodontal disease;
Tooth loss was significantly more prevalent among smokers than non-smokers. root caries; smoking
Tooth-related risk factors were smoking, low numbers of teeth and prevalence of
periodontal pockets, 4–6 mm. Accepted for publication 23 September 2011

Epidemiological studies have shown
that periodontal disease and caries
are the main reasons for tooth loss
in different populations. Although
the prevalence of periodontal disease
Conflict of interest and source of
funding statement
The authors declare that they have no
conflict of interest.
This investigation was supported by
Public Dental Health Care, County
Council of Östergötland, Linköping,
Sweden.
seems to decrease in the Swedish
population, still approximately 40%
of the population have been found
subjected to moderately advanced
periodontal disease. Approximately
10% of the population show severe
periodontal disease (Hugoson et al.
2005, 2008). The prevalence of
caries, especially root caries is an
increasing problem in the older
patients. Root caries has been found
to be one of the main reasons for
tooth loss in the ageing population
(Fure & Zickert 1997, Fure 2003). In
a recent study from Finland, it has
been shown that severe periodontal
disease and dental caries tend to
accumulate in the same patients
(Mattila et al. 2010). Previous stud-
ies in periodontally treated patients
have shown the cause of root caries
to be of multifactorial character (Ra-
vald et al. 1986, Fadel et al. 2011).
At the middle of the past century,
the main cause of periodontal disease
was considered to be the amount of
dental plaque and time of exposure
(Lövdal et al. 1958, Schei et al.

© 2011 John Wiley & Sons A/S 73

74 Ravald and Johansson
1959, Silness & Löe 1964). During
the 1970s and 1980s, it was shown
that specific microorganisms such as
Aggregatibacter actinomycetemcomi-
tans and Porphyromonas gingivalis
are of specific importance in the
pathogenesis of periodontal disease
(Socransky & Haffajee 1992, Slots &
Ting 1999). Today, it is widely
accepted that microbial dental bio-
films are the principal aetiological
factor of periodontitis. Several other
factors may, however, have modify-
ing influence on the pathogenesis.
The importance of smoking as a risk
factor and as a deteriorating factor
for periodontal disease has been
shown in a number of studies (Ax-
elsson et al. 1998, Albandar et al.
2000, Bergström et al. 2000). In an
earlier study in periodontally dis-
eased patients, we found root caries
to be more prevalent among smokers
than non-smokers (Ravald et al.
1986). During a 2 years experimental
study with intensive prophylactic
treatments, 3–4 times a year, we
found that approximately 50% of
the population developed new root
caries lesions. The periodontal condi-
tions were almost unchanged. Only a
few teeth were lost during the experi-
mental period. However, in the long
run, loss of teeth is evident even in
well-maintained populations (Hirsch-
feld & Wasserman 1978, Nabers
et al. 1987, Faggion et al. 2007, Car-
nevale et al. 2007a). Our working
hypothesis is that tooth loss exists in
the long run in previously treated
periodontal patients in spite of regu-
lar visits at dental hygienists and
general dental practitioners.
The aim of the present follow-up
was to study the periodontal condi-
tions, root caries status, numbers of
lost teeth and the causes for tooth
loss during a time period of 11–
14 years after active periodontal
treatment.
Material and Methods
Subjects
Of a sample of initially 147 patients
referred for treatment of periodontal
disease (Ravald & Birkhed 1991),
117 individuals got indicated to perio-
dontal-, restorative- and re-construc-
tive treatments during a time period
of 6–24 months. Thereafter, 99
patients were involved in a mainte-
nance programme consisting of peri-
odontal and root caries prophylactic
regimes during 24 months (Ravald &
Birkhed 1992). At the end of the
experimental period, the patients
were referred back to their general
practitioners and dental hygienists
for maintenance on an individual
basis. After 11–14 years, (Mean:
12.5 years) 64 individuals, 30 men
and 34 women aged 49–91 years
(Mean age: 64 years, standard devia-
tion, SD: 8.3), were re-examined. It
was not possible to examine 35 indi-
viduals due to death (n = 18), illness
(n = 5), leaving the area (n = 4) or
not interested to participate (n = 8).
The study protocol was approved by
the Ethics Committee of the Univer-
sity of Linköping, Sweden, and the
patients gave their informed consent
to participate in the study.
Clinical examinations
The material and method used is in
this study are fully described in two
earlier publications (Ravald & Bir-
khed 1991, 1992). All dental examin-
ations at baseline (in the present
study at the termination of the previ-
ous clinical 2-years study) were per-
formed by one of the authors (NR).
The examinations at the final follow-
up were performed by two experi-
enced and calibrated examiners (NR
and CSJ).
Before the final clinical examina-
tion, the patients were called to a
specially trained dental assistant for
standardized dental colour photo-
graphs and a full-mouth radio-
graphic dental examination. Samples
were collected for determination of
salivary secretion rate (Heinze et al.
1983). Data were collected about
general health, medications, dental
habits, use of fluorides and tobacco
use.
The periodontal status was exam-
ined according to Lindhe & Nyman
(1975). The classification of furcation
involvements used by Hamp et al.
(1975) was performed. Pocket-prob-
ing depths were recorded as the dis-
tance from the gingival margin to
the bottom of the probed pocket
using a manual periodontal probe
(Hue Friedy PCP 11, Chicago, IL,
USA). Depth was scored to the
nearest whole mm at four surfaces
on each tooth. The severity of peri-
odontal disease was classified into
five categories in accordance with
Hugoson & Jordan (1982): Group 1:
Healthy or almost healthy gingival
units (<12 bleeding units in the
molar–premolar regions) and normal
alveolar bone height; Group 2: Gin-
givitis (  12 bleeding gingival units
in the molar–premolar regions) and
normal alveolar bone height; Group
3: Alveolar bone loss at the majority
of the teeth not exceeding 1/3 of the
length of the roots; Group 4: Alveo-
lar bone loss at the majority of the
teeth ranging between 1/3 and 2/3 of
the length of the roots; and Group
5: Alveolar bone loss at the majority
of the teeth exceeding 2/3 of the
length of the roots, presence of
angular bony defects and/or furca-
tion defects. All exposed root sur-
faces were identified, and the
distance from the gingival margin to
the cemento-enamel junction or
existing filling restoration was mea-
sured. The presence of bleeding after
pocket probing was assessed and
expressed in percentage of surfaces
examined (BoP%). The prevalence
of dental plaque was scored as the
percentage of surfaces showing
plaque either by direct visual inspec-
tion or by probing the surface
(O’Leary et al. 1972). Root caries
was recorded according to Hix &
O’Leary (1976), “a cavitation or
softened area in the root surface that
might or might not involve adjacent
enamel or existing restorations; (pri-
mary or recurrent lesions)”. In addi-
tion, a lesion was scored as active
when the surface was rough in tex-
ture, yellowish or light brownish,
and soft on light probing (Nyvad &
Fejerskov 1982). Inactive root caries
was recorded when a surface showed
a brown to black lesion with a
smooth surface, appearing hard on
probing with moderate pressure, and
predominantly without cavitation. If
both active and inactive lesions were
present on the same surface, only
the active one was recorded. A root
surface was recorded as filled if a
restoration was located entirely on
the root surface or obviously
extended from the coronal part
beyond the cemento-enamel junc-
tion. Secondary lesions on the roots
were recorded if they were diagnosed
adjacent to such restorations.
Crowns and fillings assessed, owing
to cervical wear or tooth brushing,
were not included. The marginal
© 2011 John Wiley & Sons A/S
 Tooth loss in periodontally treated patients 75

bone level was measured on intra-
oral radiographs in each patient and
expressed in millimetres of the dis-
tance between inter-approximal bone
level and cemento-enamel margins or
existing fillings or restorations. The
reasons for tooth loss were calcu-
lated through the patients’ clinical
charts and by comparing the initial
and subsequent radiographs and
clinical photos. Fifteen different den-
tal teams were involved in the main-
tenance of the patients.
Statistical analysis
Statistical analysis was made using
the SPSS 13.0 software package
(SPSS for Windows NT 4.0, SPSS
Inc., Chicago, IL, USA). The Stu-
dent t-test was used to determine the
significant differences between two
independent groups. The Mann–
Whitney U-test was applied when
the conditions for t-testing were not
fulfilled. Intra-group comparisons
between baseline and final examina-
tions were analysed using a paired
t-test. To test the correlations
between single variables and tooth
loss, Pearson product-moment corre-
lation test was used. Stepwise logistic
regression analysis was performed to
evaluate the association between
individual tooth loss and a number
of conceivable variables. Prospec-
tively active and inactive root caries,
pocket probing depths 4–6 mm and
>6 mm, bleeding on probing (BoP
%), prevalence of plaque (PlI%),
prevalence of general diseases and
medications that might influence
tooth loss, were entered into the
analysis. Retrospectively, smoking
and number of annual visits at den-
tists and dental hygienists were also
entered. The level of statistical signif-
icance was set at 95%.
Table 1. Eighteen patients (28%)
reported daily smoking, of which 11
(17%) smoked more than 10 ciga-
rettes per day. In addition, 36 indi-
viduals reported intakes of one or
more prescribed medications. Seven-
teen individuals reported intakes of
blood attenuating medication, and
17 reported intake of medications
for cardiovascular diseases. Eighteen
individuals took drugs due to gastro-
intestinal problems. Finally, 15
reported intake of some other pre-
scribed drug. The dental histories at
the final examinations are summa-
rized in Table 2. Fifty-six patients
(88%) performed some kind of daily
inter-dental cleaning, and 45 individ-
uals (71%) reported that they visited
dental hygienists 1–4 times a year.
Periodontal status, root caries and tooth
loss during the observation period
The number of teeth and the peri-
odontal status at baseline and at the
final examinations are shown in
Table 3. The number of remaining
teeth decreased and the plaque
scores increased significantly between
the two examinations. The distribu-
tion of patients (groups 1–5) accord-
ing to the severity of periodontal
disease (Hugoson & Jordan 1982)
Table 1. Prevalence of general diseases and smoking habits at the final examination
Variable
Cardiovascular disease
High blood pressure
Asthmatic/allergic problems
Rheumatic disease
Diabetes (type 1 and 2)
Gastro-intestinal disease
Other medical problems
Smoking 1–9 cig/day
Smoking >10 cig/day
was: Group 2; 1 (1.5%), Group 3;
27 (42%), Group 4; 27 (42%) and
Group 5; 8 (13%). The distance
between cemento-enamel junction or
margins of fillings and marginal
bone levels calculated on intra-oral
radiographs and expressed in milli-
metres (Mean; SD) were for Group
3; 2.7 ± 0.6, Group 4; 4.4 ± 1.1 and
Group 5; 5.6 ± 1.3. One patient was
excluded due to loss of all teeth.
Root caries diagnosed as active
primary/secondary and inactive pri-
mary/secondary is shown in Table 4.
The prevalence of inactive root car-
ies had decreased at the final exami-
nation. During the observation
period, 19 patients got new active
root caries or fillings on the root sur-
faces. The prevalence of new DF
root lesions in each patient is shown
in Fig. 1.
The number of teeth at baseline
was 1537, including 361 molars
(23%). During the observation per-
iod, the number of lost teeth was
211, which represent a mean of
3.3 teeth/patient or 0.23 teeth/year
during the observation period.
Twenty-four individuals (38%) lost
no teeth. Seventeen patients
accounted for 167 lost teeth (77%).
Sixty-nine molars were lost. Molars
with initial furcation involvements
Number of Percentage of the
individuals studied subjects
8 13
14 22
16 25
4 6
(1 + 5) 9
10 16
12 19
7 11
11 17

Results

Subject characteristics Table 2. The dental histories at the final examination

The mean age of the examined Variable Number of Percentage of the

patients, 30 men and 34 women, was individuals studied subjects
52 years (range: 30–78, standard Bleeding gums 13 20
deviation, SD: 10.6) at the baseline Sensitive teeth 14 22
examination and 64 years (range: 49 Mouth dryness 17 27
–91, SD: 8.3) at the final examina- Tooth brushing  2/day 62 97
tion. The prevalence of medical Inter-dental cleaning  1/day 56 88
problems and smoking habits Use of “extra” fluorides 11 17
reported by the patients at the final Visits at dentists 1–2 times/year 58 91
Visits at dental hygienists 1–4 times/year 45 71
examination are summarized in
© 2011 John Wiley & Sons A/S
76 Ravald and Johansson

Table 3. Number of teeth (Mean values and standard deviations, SD), plaque score, bleed- Table 5. Correlation coefficients (r)
ing on probing score (BoP) and periodontal pocket probing depth (PPD) in the study group between tested variables, periodontal pocket
(n = 64) at baseline and at the final examination probing depths (PPD), bleeding on probing
scores (BoP), plaque scores (PlI) active and
Variable Baseline Final examination p-value
inactive root caries at baseline and tooth
loss during the observation period among
Mean SD Mean SD 64 patients completing the study
No. of teeth 23.4 4.8 20.8 6.7 0.0001 Variable r p
Plaque (%) 23 23.2 39 26.1 0.02
BoP (%) 17 17.6 21 19.4 NS PPD 4–6 mm 0.54 0.000
PPD PPD >6 mm 0.37 0.003
4–6mm (no) 13 11.6 13 8.3 NS BoP (%) 0.38 0.002
>6mm (no) 2 5.5 1 1.8 NS PlI (%) 0.25 0.045
Root caries – active 0.38 0.002
Root caries – inactive 0.37 0.003

Table 4. Root caries prevalence (Mean values and standard deviations, SD) at baseline and
final examinations (n = 64)
Variable Baseline Final examination p (Table 6) that the prevalence of
probing pocket depths 4–6 mm
Mean SD Mean SD (p = 0.01) and the number of
remaining teeth at baseline (p = 0.05)
Decayed active prim. 0.4 0.87 0.6 1.81 0.57 significantly contributed to explain
Decayed active sek. 0.3 0.97 0.4 1.19 0.60
Decayed inactive prim. 1.6 2.83 0.9 1.42 0.06
tooth loss. Retrospectively, smoking
Decayed inactive sek. 0.8 2.24 0.3 0.79 0.04 (p = 0.01) with an odds ratio of 8.0
Restored root surfaces 4.5 6.49 5.5 6.72 0.17 (CI; 1.6–39) and the number of visits
at dental hygienists (p = 0.03) signifi-
cantly contributed to explain tooth
loss.
25
Root caries
Filled root surface Discussion
20
No of new DF root surfaces

The main findings from this longitu-

dinal study in periodontally treated
patients were that the patients, to a
15
considerable extent, continued to
lose teeth after active periodontal
10 therapy during the maintenance
phase at general practitioners and
their dental hygienists. In the studied
5 population, 64 teeth (22 molars, 13
with furcation involvements grade II
0
and III) were extracted during the
No of individuals active periodontal and restorative
treatment (Ravald & Birkhed 1991,
Fig. 1. Nineteen of 64 individuals got new root caries lesions or fillings on the root 1992). Loss of teeth in connection
surfaces (new DF root surfaces) during the observation period of 11–14 years. Each
with periodontal therapy is in accor-
bar represents one individual.
dance with other studies (Nyman &
Lindhe 1979, Nabers et al. 1987,
(Grade I-III) were lost significantly (31%) were classified as healthy, and Carnevale et al. 2007b, Eickholz
more often than molars without fur- 29 (45%) showed periodontal prob- et al. 2008). During the beginning of
cation involvements (p < 0.001) and lems of various degree. Two patents the observation period of 2 years
non-molar teeth (p < 0.001). The (3%) had mainly caries problems, with intensive maintenance at the
main reason for tooth loss was peri- and 13 (20%) showed a combination specialist clinic, no teeth were
odontal disease (n = 153). Due to of periodontal and caries diseases. extracted due to periodontal disease.
root caries and endodontic complica- Root caries development was
tions 28 and 17 teeth, respectively, arrested, however, not completely in
Tooth loss and potential risk factors
were lost. Thirteen teeth were spite of the intensive prophylactic
extracted for other reasons (e.g. root The correlations between tooth loss treatments (Ravald & Birkhed 1992).
fractures). At the final examination, during the observation period and Totally, 211 teeth were lost during
the patents were clinically classified tested dental variables at baseline the observation period of 11–
according to their existing or previ- significantly associated are shown in 14 years in the 64 patients remaining
ous (during the observation period) Table 5. Stepwise logistic regression in the study. A majority (73%) were
dental diseases. Twenty patients analysis showed prospectively lost due to periodontal disease. Only
© 2011 John Wiley & Sons A/S

Table 6. Results of the stepwise logistic regression analysis with tooth loss as the dependent
variable. Only the variables significantly contributing to explain tooth loss are presented
p-value
Prospectively
Pocket depths 4–6mm 0.01
Number of teeth 0.05
Retrospectively
Smoking (yes) 0.01
No. of hygienist visits/year 0.05
13% and 7%, respectively, were lost
due to root caries and endodontic
problems. In the present study, the
patients were referred back to their
general dentists and hygienists with
careful instructions about mainte-
nance and follow up. At the final
examination, 91% of the patients
reported regular visits to dentists
(once or twice a year), and 71%
reported 1–4 visits a year at dental
hygienists. Obviously, the recom-
mended numbers of visits were ful-
filled. Surprisingly, the numbers of
visits at hygienists were positively
correlated with the number of lost
teeth. It seems reasonable to assume
that the patients with the most
advanced periodontal disease and
caries problems were the most fre-
quently called patients for mainte-
nance treatments. However, the
quality of the supportive treatments
might be questioned. It is also rea-
sonable to speculate that the daily
plaque-control by the patients them-
selves have been insufficient over
time. The studied group showed at
the final examination, a mean plaqu-
index of 39%. This was higher than
reported in earlier studies. A number
of studies (Axelsson & Lindhe 1981,
Axelsson et al. 2004, Eickholz et al.
2008) have shown the importance of
regular maintenance with good qual-
ity. In the studies on well-maintained
populations with regular scaling and
root planing procedures (SPT) in
combination with low plaque levels,
the annual tooth loss per patient
have been reported low (Fardal et al.
2004, Carnevale et al. 2007a, b). In
the studies on less-maintained popu-
lations, a higher annual tooth loss
has been shown, comparable to our
findings (Eickholz et al. 2008). In a
study with a natural history of peri-
odontal disease in humans (Neely
et al. 2005), the prevalence of tooth
loss was approximately two times as
high as in our study.
© 2011 John Wiley & Sons A/S
Tooth loss in periodontally treated patients
Odds ratio (95% CI)
1.11 (1.02–1.20)
0.87 (0.76–1.0)
8.0 (1.6–39.0)
2.1 (1.1–4.2)
In the present study, the reason
for tooth loss was predominantly
periodontal disease. This is in accor-
dance with other long-term studies
in patients treated for periodontal
disease (Hirschfeld & Wasserman
1978, Checchi et al. 2002, Fardal
et al. 2004). However, other reasons
for tooth loss have been reported
(Nyman & Lindhe 1979, Axelsson
et al. 2004, Carnevale et al. 2007b).
Root fractures have been reported to
be the most prevalent reason for
tooth extractions (Nyman & Lindhe
1979, Axelsson et al. 2004, Carne-
vale et al. 2007b). In geriatric popu-
lations, root caries seems to be the
main reason for tooth loss (Fure &
Zickert 1997, Slade et al. 1997, Luan
et al. 2000). Problems with root car-
ies in periodontal patients have been
shown in previous studies (Ravald
et al. 1986, Reiker et al. 1999).
Recently, Fadel et al. (2011) pre-
sented in a study of a risk model for
root caries that about one-fifth of
the patients referred for periodontal
treatment showed an increased risk
which is in accordance with our find-
ings. In the present study, popula-
tion the problem with root caries
exists, but seems not to be the main
reason for tooth loss. However, in
elderly and disabled individuals with
periodontal problems, root caries
must be considered as a risk factor
for tooth loss (Takano et al. 2003,
Avlund et al. 2004).
An attempt was made to classify
the patients in periodontal and root
caries patients or a combination of
both. Patients with ongoing peri-
odontal problems are far more pre-
valent (49%) than patients with only
root caries problems (3%). A combi-
nation with periodontal disease and
root caries is evident in 20% of the
patients. In the present patient cate-
gory, it is of importance to be aware
of both diseases and act accordingly
in the maintenance and follow-up
77
programmes. In this respect, not
only oral hygiene regimens but also
Step fluoride applications are of outmost
value (Ekstrand et al. 2008). In our
study, all patients reported that they
1 used toothpaste containing fluorides.
2 In addition, 11 individuals reported
at the end of the study that they
1
2
used extra fluoride rinsing or tablets.
No positive correlations with use of
different fluorides, as an adjunct to
fluoride containing tooth paste and
root caries development was seen in
the present study, which is in agree-
ment with earlier observations (Ra-
vald & Birkhed 1992).
In estimations of risk for progres-
sion of periodontal disease leading
to tooth loss, both site- based and
subject-based variables have been
studied (Persson 2005, Eickholz
et al. 2008, Pretzl et al. 2008). In our
study, we found the patient-related
parameter smoking to be signifi-
cantly correlated with tooth loss.
Obviously, tooth loss is more preva-
lent among smokers than non-smok-
ers (OR: 8). Smoking must be
considered as an important risk fac-
tor for tooth loss in this patient cate-
gory. This is in accordance with
findings from earlier studies in peri-
odontally diseased populations
(Haber et al. 1993, Bergström & Pre-
ber 1994, Fardal et al. 2004, Danne-
witz et al. 2006). In contrast to
earlier studies, (Axelsson & Lindhe
1981, Fardal et al. 2004, Eickholz
et al. 2008) we found a positive cor-
relation between the number of self-
reported visits at dental hygienists
and loss of teeth. The plausible
explanation is that patients with
severe periodontal disease in general
practice are paid attention and trea-
ted more frequently than patients
with not so evident periodontal
problems. Tooth-related factors con-
tributing to explain tooth loss over a
period of 11–14 years after peri-
odontal treatment, identified using
logistic multilevel regression analysis,
were prospectively the number of
existing teeth and prevalence of 4
–6 mm periodontal pockets. This is
in accordance with earlier studies in
treated (Claffey et al. 1990, Matuli-
ene et al. 2008) and untreated
populations with periodontal dis-
ease (Neely et al. 2005). In a
study by Pretzl et al. (2008), baseline
bone loss, furcation involvements
and teeth used as abutments were
78 Ravald and Johansson
significantly correlated with tooth
loss. Accordingly, during analysis of
data of furcation involved teeth in
the present study, we found initially
furcation-involved molars to be at
higher risk for loss than single
rooted teeth and molars without fur-
cation involvements. The decision
for tooth extraction may also reflect
the experience, knowledge, skill of
the dentist and economical aspects
of the treatment and not only the
factors related to the tooth or the
patient.
The results from the present
study have shown, in a group of
previously treated patients with
advanced periodontal disease, in
spite of repeated regular mainte-
nance performed by general practi-
tioners and dental hygienists that
future tooth loss is not prevented.
The main reason for tooth loss is
periodontal disease. A lifelong main-
tenance programme, individually
adapted to each patient, should be
designed by the specialist and when
possible be performed by a hygienist
in close connection with the peri-
odontist.
Conclusions
Periodontally treated patients are in
a longer perspective at risk of fur-
ther tooth loss. Maintenance per-
formed at general practitioners and
dental hygienists seems not to be
sufficiently effective for prevention of
tooth loss. Smokers with low num-
bers of remaining teeth and deep-
ened periodontal pockets are at
higher risk for future tooth loss.
Acknowledgements
The authors thank Dr. Birgit Ljung-
quist for the assistance with statisti-
cal analyses. The excellent assistance
of the dental assistants Kerstin Can-
nerborg, Kicki Ahlin and Gun Nils-
son is gratefully acknowledged. This
study was founded by the Research
Council of Public Dental Service,
Östergötland County, Sweden.
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Clinical Relevance
Scientific rationale for the study:
Studies in periodontally treated
patients have shown that mainte-
nance performed at University- or
Specialist clinics can prevent tooth
loss. Maintenance in general prac-
tice has been less successful. The aim
© 2011 John Wiley & Sons A/S
Tooth loss in periodontally treated patients
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was to study the long-term loss of
teeth in treated periodontal patients
maintained in general practice.
Principal findings: Patients treated
for periodontal disease are in the
long run at risk for tooth loss due to
periodontal disease in spite of regu-
lar maintenance.
79
South Australians aged 60+ years. Community
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Address:
Nils Ravald
Centre for Oral Rehabilitation
SE – 581 85 Linköping
Sweden
E-mail: nils.ravald @lio.se
Practical implications: Smokers
with few remaining teeth and deep-
ened pockets are at higher risk.
This should be considered when
the maintenance programmes are
designed.