Even teeth deemed hopeless have been salvaged through thorough periodontal care and diligent supportive treatment. Patients treated for aggressive periodontitis have sustained their teeth for up to 15 years post-treatment. This editorial by Dr. Bianca Nazareth-Arya emphasizes how long-term follow-up can be a game changer in maintaining teeth, implants, and their surrounding tissues healthy.
What really is the value of a tooth? How do we determine its worth? We have often encountered patients in pain who will tell us - ‘Just extract the tooth doctor’ - while we are intent on weaving magical tales of root canals and flap surgeries. Now imagine a man in severe pain from a myocardial infarction saying a version of the same thing – ‘Just remove the heart doctor’. Leave apart the fact that it is a life and death situation for a minute – could it also be – what really is the value of one tooth when there are 31 more to spare?
But when faced with the imminent loss of ALL teeth – then the dynamics change. Patients show both willingness and commitment to save teeth. This is where our decision-making - with regard to options and treatment modalities - plays a significant role. Periodontal disease unlike caries does not have severe pain or any symptoms that a patient notices until it is severe, leading to a delay in seeking treatment, delayed diagnosis, and many a time insufficient treatment. By the time the patient reaches a point where he is truly aware of his condition – it invariably is the time for the periodontist in the dentist to step back and the implantologist in him to step forward.
Periodontal treatment – both surgical and non-surgical - has played a significant role in saving teeth however the onus of the success of the treatment ultimately falls on the patient. The maintenance phase of periodontal treatment is more tedious and the patient needs to be far more conscientious than with any other dental treatment. Unlike other dental treatments that may only require periodic check-ups and simple daily care routines, periodontal maintenance often involves more frequent visits to the dentist or periodontist, diligent oral hygiene practices at home, and specialized treatments such as deep cleanings or additional surgeries. Lifestyle changes like quitting smoking and stress management may be additional techniques to be adopted to support gingival health.
Keeping all the above in mind – the argument may be made that similar maintenance/management/ changes are to be made for a patient with dental implants. Unfortunately, patients are never made aware of this leading them to mistakenly believe that implants are magic pills that somehow will release them from their current issues with little or no need for maintenance in the future.
The critical stage of treatment planning is the determination of a tooth’s prognosis. There are several ways of helping with this decision-making – some quite elaborate and expansive taking into consideration both patient factors like willingness and finances and clinical factors like pocket depth, etc [1]. Unfortunately, though we make decisions based on bone loss, pocket depth, mobility, etc, – the truth is that the same teeth with the same conditions existing in different patients will have a different prognosis based on hygiene, maintenance, follow-up, masticatory loads, and a certain degree of unpredictability brought in by a wide range of variables that exist at any given time in a patient’s mouth. A clinician’s expertise with regard to both diagnosis and treatment will also determine the success of either treatment. Therefore, following a set flowchart to decide the fate of a tooth is not enough – a clinician needs to bring acumen, experience, something close to intuition, and knowledge of that particular patient to the table. Consolidate all the data and then decide the best course of action.
Even so-called hopeless teeth have been preserved successfully with adequate periodontal treatment followed by strict supportive periodontal treatment (SPT) [2,3]. Patients with treated aggressive periodontitis have also shown survival of teeth as long as 15 years after treatment [4]. This means that patients with seemingly hopeless dentition too could be given the option of holding on to their teeth. They need to be informed that it will just come with a caveat that they must take responsibility for their condition and strictly follow the dentist’s treatment plan and maintenance protocol. At such a time we need to refrain from glamorizing the alternative option of an implant – falsely presenting it in a way that suggests that it does not need as much care or that it would last forever. It holds to reason if presented in such a manner 100% of patients who could afford implants, would opt for implants. As soon as an implant is presented as an option it creates a bias in treatment planning as well [5]. An implant success rate of 98% and above is misleading as that only refers to its survival in the mouth and not a peri-implant disease, inflammation, or bone loss that afflicts a great number of those surviving implants [6]. Therefore, it becomes imperative to present dental implants in a responsible ethical manner – explaining the benefits but also the fact that it is NOT – A fill-it-and-forget-it – situation.
Fig 1. A. Pre-Op OPG of a patient showing bone loss and intra-bony defects
B. 10-year follow-up OPG of a patient following a full mouth flap surgery with regular recall every year. Bone levels stable and no active disease found.
For all patients who opt to save their teeth – the maintenance phase is not just important for the survival of teeth – it is also to ensure no deterioration to a point where it would compromise or jeopardize future implant treatment. We have often in our experience found patients stable for 4-6 years with regular SPT and suddenly be lost to recall until they turn up 10 years later where we are left with no bone to place implants in a conventional manner then resorting to extreme bone augmentation or zygomatic and pterygoid implants. Hence the delicate balance of when saving teeth versus extracting and implants needs to be revisited regularly in each patient to ensure that maintenance of the teeth is not risking the loss of residual bone.
Fig 2a. Patient detected with Aggressive Peridontitis in 2016
Fig 2b. Same patient in 2023 with severe deterioration of previous condition and no follow-up or SPT
<strong>Conclusion:</strong>
In conclusion, the long-term survival of teeth/implants after treatment of periodontal disease hinges on the partnership between patients and dental professionals. By prioritizing maintenance and hygiene, patients can significantly improve their chances of enjoying healthy and functional teeth and implants for years to come. The choice to save teeth must always be placed first keeping in mind age, health, and hygiene among others.
<strong>References:</strong>
1. Avila G, Galindo-Moreno P, Soehren S, Misch CE, Morelli T, Wang HL. A novel decision-making process for tooth retention or extraction. J Periodontol. 2009 Mar;80(3):476-91. doi: 10.1902/jop.2009.080454. PMID: 19254132.
2. Faggion CM Jr, Petersilka G, Lange DE, Gerss J, Flemmig TF. Prognostic model for tooth survival in patients treated for periodontitis. J Clin Periodontol 2007;34(3):226-231.
3. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49(5):225-237.
4. Graetz C, Dörfer CE, Kahl M, Kocher T, Fawzy El-Sayed K, Wiebe JF, Gomer K, Rühling A. Retention of questionable and hopeless teeth in compliant patients treated for aggressive periodontitis. J Clin Periodontol. 2011 Aug;38(8):707-14.
5. Clark D, Levin L. In the dental implant era, why do we still bother saving teeth? Dent Traumatol. 2019 Dec;35(6):368-375. doi: 10.1111/edt.12492. Epub 2019 Oct 14. PMID: 31132200.
6. Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM, Chen S, Cochran D, Derks J, Figuero E, Hämmerle CHF, Heitz-Mayfield LJA, Huynh-Ba G, Iacono V, Koo KT, Lambert F, McCauley L, Quirynen M, Renvert S, Salvi GE, Schwarz F, Tarnow D, Tomasi C, Wang HL, Zitzmann N. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018 Jun;45 Suppl 20:S286- S291.
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