Harald Rylander

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.

Dentitions damaged by severe periodontal disease often cause problems not only to the patient but also to the dentist, not least regarding the choice of therapy. Today!s arsenal of therapeutics makes the choice of best treatment strategy for the individual patient very sophisticated. Advanced periodontal breakdown will call for extensive cause-related treatment of the disease to achieve and maintain periodontal health. It may also require comprehensive prosthetic reconstruction to restore function and aesthetics to the patient (19, 20). It is well documented that properly treated natural teeth with healthy but markedly reduced periodontal support are capable of carrying extensive fixed prostheses for a very long time with survival rates of about 90%, provided the periodontal disease is eradicated and prevented from re-occurring (16, 20, 29, 31). However, this knowledge seems to have penetrated only minor parts of the dental society. During the last decades careful scientific documentation has provided a solid base for implant therapy as a reliable treatment modality to replace lost teeth (14, 17, 24, 25). Today we know that treatments including implant-supported single crowns or fixed partial dentures as part of a comprehensive therapy will generally have a good prognosis when performed on the correct indications and followed by proper oral hygiene measures and supportive care. The acquired knowledge related to implant-supported reconstructions has markedly penetrated dental society, gaining support from dentists and patients as well as from the dental implant industry. The treatment is often spectacular with rapid and clearly visible results both for the dentist and the patient. This, together with business-based promotion, may partly explain the widespread application of dental implant therapy. There are opinions among clinicians that the prognosis of complex, often time-consuming, and trying periodontal therapy may not match the high levels of success of treatment with implants. As a consequence more and more teeth are extracted and replaced with implants in patients suffering from moderate to advanced periodontal breakdown. This approach is based on the assumptions that implants perform better than periodontally compromised teeth and that their longevity is independent of the individual!s susceptibility to periodontitis. As a consequence, teeth that could be saved and used as supports for fixed partial dentures are extracted and replaced with implants, sometimes on doubtful indications.

Mandibular dysfunction and periodontitis. A comparative study of patients with periodontal disease and occlusal parafunctions.

Fifty-one patients (mean age, 47.3 years) with moderate to severe periodontal disease and 40 patients (mean age, 48.9 years) with symptoms related to bruxism (occlusal parafunctions such as grinding and/or clenching of the teeth) were compared with regard to periodontal conditions and signs and symptoms of mandibular dysfunction. The bruxists reported more symptoms of pain and dysfunction of the masticatory system than the periodontal patients. The clinical dysfunction index was significantly higher among the bruxists, while there was a similarity between the groups in the variation of occlusal conditions, except for occlusal wear, which was more pronounced in the bruxist group. Attrition was in general positively correlated to alveolar bone height. This correlation was stronger (and statistically significant) for the canines than for other teeth. Attrition was negatively correlated to tooth mobility. It is concluded that patients with moderate to severe periodontal disease and patients with bruxism/occlusal parafunctions are distinctly different with regard to signs and symptoms of mandibular dysfunction. The results support the opinions that there is no or only weak correlation between periodontal disease and bruxism, and between bruxism and occlusal status.