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e r io d o n ta l c o n d i t io n s o f t e e th
a d ja c e n t t o e x t r a c t io n s i t e s
Markus GrassI, Roger Tellenbach
and Niklaus P. LangUniversity of Berne School of DentalMedicine Berne Switzerland
Grass M, TeUenbach R and Lang NP: Periodontal conditions of teeth adjacentto extraction sites. J Clin Periodontol 1987: 14: 334-339.
Abstract. The purpose of the present clinical study was to evaluate the effect oftooth extractions on the periodontal conditions of adjacent teeth. 40 patients wereselected for the study. Prior to the extractions, baseline data of the adjacent teethwere obtained. Plaque (Pll) and gingival indices {GI). pocket probing depths andprobing attachment levels were scored. In addition, the alveolar bone height wasdetermined radiographically in relation to the CEJ adjacent to the extractionsites. The conlralateral side of the jaw. where no tooth had to be removed, wasexamined as a control. A limited hygienic phase (scaling and root planing of allsurfaces examined) was performed immediately prior to the extractions, Usingthe same parameters, aJI sites were reexamined 2-4 months and 6-9 months
following the extractions.
After the hygienic phase, the teeth adjacent to the extraction sites indicated adecrease in the pocket probing depths by 0.5 to 1.5 mm. In shallow pocketsI 3 mm ), this decrease was less prono unced than in mod erate to deep pockets4-9 mm), where it was composed of shrinkage of the gingival tissues and gainf probing attachment. The radiographic level of the bony alveolar crest in
relation to the CEJ of the adjacent teeth was not altered by the extraction pro-cedure. The oral hygiene performances of the patients were not influenced duringthe 9-month observation period. Therefore, neither Pll nor GI scores showedrelevant improvements. Although the extraction had a beneficial effect on theperiodontal conditions of the adjacent teeth, decisions for or against removingteeth for periodontal reasons must be made in the light of a comprehensive
treatment plan and on the basis of individual patient considerations.
Key words: Tooth extraction - periodontalafatus.
Accepted for publication 1 Aufiust 1986
Following the initial or hygienic phaseof periodontal treatment, sites with ad-vanced periodontitis may still yield in-creased pocket probing depth. Hence,repeated scaling and root planing (Mor-rison, Ram fjord & Hill 1980, Lind he eta l 1982a) in combination with surgical
flaps (Ramfjord & Nissle 1974) and /or hemisections or root-amputations(Amsterdam & Rossman 1960) may beustified to obtain complete periodontahealth. In addition, extractions of peri-odontally or endodonticaliy diseasedteeth may be indicated. Also, partiallyand fully impacted third molars are ex-tracted at times because of patholog ical-ly deepened pockets on the distal aspectof the second molar teeth and/or incom-plete development of the alveolar sep-tum supporting these theeth {Ash 1964,Ash, Costich & Hayw ard 1962). Fur-thermore, the extraction of strategically
neighbouring teeth which may be ofspecial strategic importance for recon-structions {Silness, Hunsbeth & Figen-schou 1973). It would, therefore be ofinterest to be able lo predict the effectof a tooth extraction on the periodontalconditions of the sites adjacent to the
extraction site. Cross-sectional studieshave reported improved periodonfaicond itions on distal sites of the last teethof the denta arch when comp ared w ithcontralateral interproxima control sites(Silness et aJ. 1973). One recent studyhas commented on the effect of toothextractions on the periodontal con-ditions of neighbouring teeth (Wiskott1982). Generally, the pocket probingdepths of adjacent teeth decreased fol-lowing the extraction. How ever, shallowpockets (1-3 mm) appeared to looseperiodontal support. Baseline data werenot available in this report, and there
Results from the healing of extracsites date back to the beginning of century (Struck 1906. Euler 1924). sorptions in the coronal area of theveolar crest (Euler 1924) and the cstriction of the circumferential ligam{Hahn 1958) ma y also involve adjac
periodontal tissues.
The purpose of the present clinstudy was to examine the effectstooth extractions on the periodoconditions of the teeth adjacent to extraction site.
Material and Methods
40 patients, displaying at [east I toto be removed and yielding an identnumber of teeth, but not necessa
identical periodontal lesions in contralateral jaw, were selected. Ocompletely erupted and normally
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Periodontal condition after loolh extraction
Fig. 1. Localization of measurements in testand control sites.
study. The observations could be basedon 15 third molars, 16 first and secondmo lars and 10 incisor and bicuspidteeth. The sites adjacent to the teethto be extracted served as experimental(test) sites and w ere assessed on the buc-ca and lingual tine-angles as depictedin Fig. 1
Pocket probing depth (PD) and loss
of attachment (LA) from the cemento-enamet junction (CEJ) (Giavind & Loe
1967) were meas ured by means of a peri-odontal probe with a point diameter of0.34 mm (M ichigan no. M l) in the longaxis of the tooth.
Oral hygiene was evaluated using thecriteria of the plaqueindex system (PII)(Silncss & Loe 1964) and the gingivalhealth or disease scored according tothe criteria of the gingival index system(GI) (L6e& Silness 1963).
The distance of the bony alveolarcrest to the CEJ (or a margin of a recon-struction) was measured in mm on stan-dardized long-cone radiographs (Ash,Costich &Hayward 1962).
Prior to local anaesthesia (UUra-cain D-S, cartieaine 4%. epinephrine :200'000. Hoechst AG) and the extrac-tion of the predetermined tooth bymeans of a forceps, the surfaces of theteeth adjacent to the extraction siteswere scaled and root planed. However,no attempts were made to change the
oral hygiene habits of the patients. Fol-lowing the extraction, neither hemosta-tics (Schule 1971) nor special drainageprocedures (Meyer 1924) were used.
Clinical and radiographic parameterswere obtained immediately prior to. at
EXPERIMEHTAL DESIGN
H-RAV
PL i
G 1
PO
Q1
XX
X
XLOSS OF ATTACH. X
SCALTNG X
3M t 4 H t W t
XX
X
XX
Fig. 3. Mean values, standard deviation andstatistical analysis of pocket probing depth(PD) in gronp I (initial PD I-?, mm).
2-4 months (Short term) and 6-9months (completion of healing) follow-ing the tooth extraction (Fig. 2),
After the computation of the meansiind standard deviaitiot\s for each par-ameter, cross sectional and longitudinaltests for statistical significance using the
Student f-test and the Wilcoxon signedrank test (Hollander & Wolfe 1973)were performed.
Results
In the 40 patients, a total of 41 teethwere extracted, resulting in 114 measur-ing sites. These sites were grouped ac-cording to the baseline pocket probingdepth.s of the test areas;group 1: 1-3 mm - shallow pockets;
Fig. 5. Mean values, standard deviation anstatistical analysis of pocket probing dept(PD) in group 2 (initial PD -1-9 mm).
fig. 4. Mean values, standard deviation and
group 2; 4-9 mm mode rate to deepockets.
Gro up 1 comprised 58 test and 9control sites. Group 2 yielded 56 teand 22 control sites. Initially, a Jr
group of initial pocket probing depth o6-9 mm was formed for analysis. However, the separate analysis of the resulof pockets with 4 5 mm and 6-9 mminitial probing depth yielded identictrends. Since the latter group of pocke
comprised only 12 test and 5 contrsites, it was decided to analyze all tpathologically deepened pockets in group and hence, to present the 2 cat
gories mentioned.
Only one approximal measuremecould be determined on the radi
graphs, since the distinction of the bucal from the oral aspect is impossib(Lang & Hill 1977). Therefore, eacradiographic measurement was taketwice, representing both buccal and ligual aspects. In this way, the sam
sample size as for the clinical measurments was available for statisticanalysis.
Pockut probing depth PD) and I O H ofprobtng •ttachmvn t LA)
The results for the different data categries are presented in Figs. 3-6 and we
normalized in order to provide a basfor comparison, i.e,, the difference the values between test and control sitat the baseline examination was sutracted or added to the means of tcontrol sites at all observation period
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Grassi el al.
Fig. 6. Mean values, standard deviation and
statistical analysis of loss of probing attach-
ment (LA) in group 2 (initiftt PD 4-9 mm),
duction iti pocket probing depth (Fig.
3) but by a decreased level of clinical
attachment of 0,19 mtn (Fig. 4), Scalingadjacent to the tooth extraction sites(test) showed a signiilcant (/)<0.0i) re-
duction of the mean pocket probingdepth of 0.5 mm (Fig. 3) and a gain of
probing attachment of 0.24 mm (Fig,
4) .
Significant (p<Q.O5) reductions in
pocket probing depths of 0.86 mm (Fig.
5) and increased levels of probing at-
tachment of 0,41 mm (Fig. 6) werenoted following scaling and root plan-ing of the control sites in group 2 (PD:
4-9 mm). After the additional removalof the adjacent tooth in the test sites.pocket probing depths were reduced by
1.46 mm (Fig, 5) and a gain of probingattachment of 0,67 mm (Fig. 6) was
demonstrated.
Radiograph ic find ingi
Neither at baseline nor at any of the
subsequent observation periods was
there a difference in the level of
alveolar bone between test and contsites (Tables 1, 2), However, in bgroups , a significantly increa{p<O.QS) distance of the CEJ to
alveolar bone crest was noted at
short-term examination in the contgroups when compared with the ba
line levels. On the other han d, the radgraphic level of the alveolar crest w
not affected by the extractions at
test sites.
Plaqua nd gingivitis
PII and GI scores tended to decre
(Tables 1. 2) as a result of scaling a
root planing in both test and con
sites. In group 1, the mean PII was 1
at baseline and decreased to 1.28 a
1.24, respectively, following the extrtion of the neighbouring tooth (Ta
1), On the control sites, the PII sco
remained almost unaffected. Simila
Table 1. Mean values, standard deviations and statistical analysis of PII. GI and measurements on radiographs in group 1 (initial PD
mm): A tesl: 58, N contmi: 92
Parameter
Plaque index
PLI test
PLI control
Signifieance test-control
Gingival index
GI test
GI control
Signifieanec test-conlrol
X-ray
RX test
RX control
Significance tcst-coiurol
Baseline
Mean
1.45
1.40
N S
I..52
1.29
/xO.05
1.81
1.59
N S
Standard
deviation
0 . %
0.77
0.73
0.64
1.73
1.35
.lup 1-3 mm
Short-term
Mean
1.28
1.36
N S
1.35
1.38
N S
1.90
1.70
N S
Standard
deviation
0.95
0.85
0.72
0.74
1.71
1.33
Long-lerm
Mean
1.24
I..39
N S
1.19
1.23
N S
1.95
1.63
NS
Standard
deviation
0.84
0.95
0.81
0.73
1.70
I..30
Baseline
short-term
N S
N S
N S
N S
N S
/'<0.05
Significance
Baseline iihort-t
long-term Long-t
N S
N S
p<0.0\
N S
N S
N S
N S
N S
N S
p<0.0
N S
N S
Table 2. Mean values, standard deviations and statistical analy;
mm); .V test: 56. N control: 22
of PII. G and measurements on radiographs in group 2 (initial PD
Parameter
Plaque index
PLI test
PLI control
Significance test-eontrol
Gingival index
GI test
GI controlSignificance test-control
X-ra,
Baseline
Mean
1.64
2.09
p<0.05
1.63
1.77NS
Standard
deviafioti
0.70
0.68
0.65
0.53
Groiup 4-9 mm
Short-term
Mean
1.20
1.50
N S
1.27
1.45N S
Standard
deviation
0.84
0.74
0.86
0.67
Long-term
Mean
1.29
1.05
NS
1.16
1.27N S
Standard
devjafion
1.00
0.90
0.85
0.63
Baseline
Significance
Baseline
short-ferm Jong-term
P<omp<0.05
/ K O . 0 5
N S
/)<0.05
p<O.Q\
p<O.OI
p<O.a\
Short-t
Long-t
N S
/)<0.
N S
N S
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Periodonial condition after tooth extraction 33
the mean values corresponded to base-line throughout the study, while themean GI decreased significantlylj)<:0.0]) from baseline on the test sites(Table 1).
In group 2. more pronounced re-ductions from baseline in mean Pll wereseen both for short-term as well as ob-
servations following the completion ofhealing (p<0.05). Also , the test sitesyielded lower mean Pil scores than didthe control sites at baseline (/7<O.O5)and 2-4 months following the tooth ex-tractions (Table 2). Similar changeswere observed for the mean GI scoresin this group. Not only did the meanGl scores decrease for both test(/7<0.01) and control sites ( / J < 0 . 0 1 ) atthe short-term as well as observationperiod following completion of healing,but also, the mean GI scores were (not
significantly) lower for the test sites atboth observation periods (Table 2).
Discussion
The present investigation evaluatedclinical periodontal and radiographicchanges up to 9 months following ad-jacent tooth extractions. Baselinevalues were determined just prior to theextractions, which was supplementary
to previous studies (Silness et al. 1973,Wiskott 1982).
The clinical measurements of pocketprobing depth and loss of probing at-tachment were performed by means ofa calibrated periodontal probe to thenearest mm, a fact which should betaken into consideration when discus-sing the statistical and/or clinical signifi-cance of resu lts b ased on. me an i^cores.Furthermore, it has been realized thatlevels of attachment may not be accu-rately determined by periodontal prob-
ing (Armitage et al. 1977. Fowler ei al.1982. Jansen et ai. 1981. Lindbe ct al.i9g2b, Listgarten. Mao & Robinson1976, Magnusson & Listgarten 1980,Poison et al. 1980, Saglie, Johansen &Fl0tra 1975, Sivert.son & Burgett 1976.Van der Velden 1980. Van der Velden &lansen 1981). Factors such as inflam-mation (Magnusson & Listgarten 1980,Armitage et al, 1977, Sivertson & Bur-gett 1976). probing force (Poison et al.1980. Van de r Velden 1980. Van der Vel-den & Jans en 1981, Van der Veiden &de Fries 1980) and the diameter of theprobe tip {Listgarten et al. 1976) may
case of gingival health, the probe tipmay not reach the most apical ceil ofthe junctio nal epithelium (Arm itage etal . 1977), while in the case of gingivitis,it may be located at the apical extent ofthe epithelial attachment (Jansen et al.1981). However, in the case of period on-titis, the probe tip generally penetrates
into the underlying connective tissueand is stopped by the first healthydento-gingival fibers (Magnusson &Listgarten 1980). It is therefore of greatimportance that in clinical studies,conditions are created which minimizethese factors affecting measurement er-ror. In the present study, an attemp t wasmade to fullfil these criteria by assessingpocket probing depth and loss of prob-ing attachment by the same investigatorwho h-dd been calibrated for intra-exam -iner variation. Furthermore, a set of
identical periodontal probes were used.Since in previous studies standardizedprobing forces did not always show bet-ter reproducibility (Van der Velden & deFries 1980), no such probes were usedin the present study. On the other hand,the limited hygienic phase treatment ofthe test and control sites performed inthe present trial without special homecare instruction, co ntribu ted to a signifi-cant improvement of the gingivaL andperiodontal conditions, and hence infiu-enced the subsequent probing measure-ments (Armitage et nl. 1977, Fowler etal. 1982).
In agreement with recent reports(Mo rrison et a . 1980, Pihistrom et al.1982), the scaling ^fter the baselineexamination was nol followed by anynoticable change in pocket probingdepth but by a slightly increased lossof probing attachment at sites iniViaUyscoring 1 3 mm. The removal of theneighboring tooth, however, reducedpocket probing depth after 3 months
by about 0.5 mm. This reduction wasmaintained for 6 nionths, indicatingthat this was a sequellae of the extrac-tion and/or the absence of the adjacenttooth, facilitating access for oral hy-giene procedures. In disagreement withano ther report (W iskott 1982), a signifi-cant gain of cHnica) attachment wasfound at the tooth surfaces adjacent tothe extraction sites at the completion ofhealing 6-9 months following the ex-traction. Most likely this was of minorclinical importance. However, it is evi-dent from these data that tooth extrac-tion in periodontally healthy areas wilt
creased loss of attachment at the siteof neighbouring teeth.
Although no efforts had been madto improve the oral hygiene practices othe patien ts, a decrease in GI scores wanoted on the test sites documenting thathe improved gingival conditions werthe result of a newly established tigh
connective tissue cuff adjacent to thextraction sites. When periodontapockets of 4-9 mm probing depth abaseline were evaluated 2 -4 month s an6-9 months following the extraction othe adjacent tooth, a mean reduction iprobing depth of 1.46 mm was seenObviously, this value was significantlgreater than what had been achieveby scaling and root planing alone. Iagreement with previous studies (Morrison et al. 1980, Pihistrom et al. 1982a reduction of 0.86 mm could be attr
buted to the hygenic phase procedurewhile the additional 0.6 mm were thresult oi ' the improved gingival conditions following the extraction of thneighboring tooth. These additionabenefits were observed in conjunctiowith decreased plaque and gingival index scores at the test sites, suggestinthat oral hygiene practices were also facilitated by the tooth extractions.
D ue X.Q the fac that iha coiWiol K
had to be homologous teeth on th
contralateral side, it has to be realizethat the data set for the group opockets with 6-9 mm initial probindepths was rather limited in size aninterpretation subject to speculationGenerally, similar results were obtainein these deep pockets as in the 4-5 mmcategory which lead to the collapse othese 2 categories.
In conclusion, it may be slated thafollowing tooth extraction, no permanent injury was observed on healthperiodontal tissues of adjacent neighbouring teeth. Furthermore, a reductioin pocket probing depth following tootextraction in addition to that obtaineby scaling and root planing could bdemonstrated at sites adjacent to thedentulous area. This reduction was thresult of gingival shrinkage and wagreater at sites of deep than at sites witmoderate pocket probing depth. Thbenefical effects of tooth extractions tthe adjacent periodontium should bconsidered when patients with advance
periodontal disease are treated comprehensively. Also, these results demand careful re-evaluation of the periodonta
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3 3 6 Grass et at.
lowing extraction of periodontally or
endodonticaily diseased teeth of minor
strategic importance.
Acknowledgements
We wish to thank Dr. A. Joss, D. D. S.,
for the statistical analyses and Dr. H.
Berthold, D. D. S., M. D.. for support-ing this study. Furthermore, the adviceof Dr. B. H. Siegrist, D. D. S., MS, in
preparing the manuscript and the com-
petent typing by Mrs. B. Frutig is highlyappreciated.
Zusam menf assu ng
Parodontale Befunde an Ztihncn. die Extrak-
tiomlUcken begrenzen
Mit dieser klinischen Studie wurde bcabsich-
tigt. die Einwirkung von Zahnextraktloneiiauf die parodontalcii Verhaltnissc der die Lii-
ckc begrenzenden Nachbaraahne zu beuriei-
len. Fur die Studie wurden 40 Patienten aus-
gewahlt. Vor den Extraktionen wurden die
Basisdaten der akluellen Ziihnc registriert.
Die Beurtellungseinheilen der Plaque (PIT)
und Gingivalindizes (GI) wurden Testgestellt
sowie die Taschentiefen und die Attachment-
niveaus sondiert. Zusalzlich wurde die Hohe
des alveolaren Knochens in Bezug auf die der
Extraktionsseite zugekehrten Schmelzze-
mentgrenze bestimmt. Als Kontrollseite wur-
de die konlralaterale Scite des Kiefers ohne
Extraktionslucken untcrsucht. Eine begrenz-te Hygienephase (Zahnsteinentfernung und
Wurzelglattung alier untersucfiten Oberda-
chen) wurde direkt vor der Extraktion durch-
gefiitirt.
Nach der Hygienephase wurde an den der
Extraktionslucke zugekehrten Seiten eine
Verringerung der sondierten Taschentiefen
von O..5-l,5 mm beobachtet. Bei flachen Ta-
fichen (1-3 mm) trat diese Verringerung weni-
ger deutlich auf als bei vertieften bis tiefen
Taschen (4-9 mm), bei dener dieser Vorgang
duTch Schrumpfung der gJngivalen und
des sondierten Attach men Igewcbcs iiberla-
gerl wurde. Das durch das Riintgenbild in
Bezug auf die CEJ bestimmte Niveau der
alveolaren Knochenleiste wurde durch die
Extraktion nicht ver&ndert. Die oralen Hy-
gienemassnahmen der Patienten wurden
durch die 9-monat(ge Beobachfungszeit nichl
bceinflusst. Das scheint der Grund dafur zu
sein, dass die Beurteilungseinheiten der Pi]
und der GI keine verbesserten Werte zeigten.
Obwohl die Extraktion einen gunstigen Ein-
riusB auf die parodontale Situation der den
Lucken angrenzenden Zahne hatte. mussen
Entscheidungen fiir oder gegen eine Exlrak-
tionsindikation aus parodontalen Griinden,als Teil eines Gesamt-Behandlungsplanes ge-
fiillt werden und von Uberlegungen ausge-
Resume
Eiat pawdomal des dents voisines de dent.s
exiraiies
Le but de la presente 6tude clinique etait
d'cvaluer I'effet des extractions dentaires sur
Tetat parodontal des denls voisines. L'etude
a porte sur 40 patients selectionnes a eet edet.
Avant de pratiquer les extractions, les don-nees suivanles concernant les dents voisines
on e e etabJies; Indice de Plaque (Pll). Indice
Gingival (GI). profondeur des poches au son-
dage et niveau de I'attache memre par s
ge . De plus, a l'aide de radiographies,
determine la hauteur de l'os alveolaire
rapport a la limite email-cement (CEJ) a
des dents a extraire. Le cote controla
de la meme machoire, ou aucune extrac
n'etait prevue, servait de temoin el subi
les memes examens. Une phase hygien
iimitee (detartrage et surfapage radiculair
toutes les surfaces examinees) a prie p
immediatement avanl les extractions. En
lisant les memes parametres, on a prat
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Periodontal condition after tooth extraction 338
des examens de rappel 2-4 mois et 6-9 mois
apres )es extractions.
Apr es la phase hygienique, les dents vois i-
nes des dents a extraire presentaient une re-
duction de la profondeur des poches au son-
dage de 0.5 ^ J .5 mm. Dans les poches pe u
profondes (1-3 mm) cette ditninutioti e laii
moins prononcee que dans les poches de pro-
fondeur moderee a importan te (4 -9 mm), o ii
il s 'agissait d'u n retrait des tissus gingivauxet d' un gain con cernant la profo ndeur d 'a tta-
che. L e niveau radiogritphique le la crete aJ-
veolaire osseuse par rapp ort a a limite CKJ
des dents voisines n'etait pas altere par les
extractions, Le niveau de l'hygiene buccale
atteint par les patients restait sans change-
ment pendant les 9 mois de la periode d 'ob-
servation. Ni PlI, ni G l ne presenlaienl done
une amelioration significative de leurs scores.
Malgre l 'action favorable des extractions sur
I 'e tat parodontal des dents vois ines , il
convient de prendre les decisions pour ou
contre les extractions pour raison d 'ordre pa-
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Dr. Markus Grassi
University of Berne
School of Dental MediciFreibvTgstrasse 7
CH-30I0 Berne
Switzerland
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