J Clin Periodontol 2012; 39: 7379 doi: 10.1111/j.1600-051X.2011.01811.

Tooth loss in periodontally

treated patients. A long-term
study of periodontal disease and
root caries

Nils Ravald and Carin Starkhammar

Johansson
Division of Cardiovascular Medicine,
Department of Medical and Health Sciences,
Linkoping University, Center for Oral
Rehabilitation, County Council of
stergotland, Linkoping, Sweden
O

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: 7379. 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 1114 years after active periodontal treatment.
Material and Methods: Sixty-four patients participated in the follow-up study.
Reasons for tooth loss were identied through previous case books, radiographs
and clinical photos. To identify factors contributing to tooth loss, a logistic multilevel regression analysis was used.
Results: The number of lost teeth was 211. The main reason was periodontal disease (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, 46 mm (p = 0.01) at
baseline, smoking (p = 0.01) and the number of visits at dental hygienists
(p = 0.03) during maintenance, signicantly 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.
Tooth loss was signicantly more prevalent among smokers than non-smokers.
Tooth-related risk factors were smoking, low numbers of teeth and prevalence of
periodontal pockets, 46 mm.

Epidemiological studies have shown

that periodontal disease and caries
are the main reasons for tooth loss
in dierent populations. Although
the prevalence of periodontal disease
Conflict of interest and source of
funding statement
The authors declare that they have no
conict of interest.
This investigation was supported by
Public Dental Health Care, County
Council of Ostergotland, Linkoping,
Sweden.
2011 John Wiley & Sons A/S

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

Key words: extraction; periodontal disease;

root caries; smoking
Accepted for publication 23 September 2011

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 studies in periodontally treated patients
have shown the cause of root caries
to be of multifactorial character (Ravald 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
(Lovdal et al. 1958, Schei et al.

73

74

Ravald and Johansson

1959, Silness & Loe 1964). During

the 1970s and 1980s, it was shown
that specic microorganisms such as
Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis
are of specic importance in the
pathogenesis of periodontal disease
(Socransky & Haajee 1992, Slots &
Ting 1999). Today, it is widely
accepted that microbial dental biolms are the principal aetiological
factor of periodontitis. Several other
factors may, however, have modifying inuence 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 (Axelsson et al. 1998, Albandar et al.
2000, Bergstrom et al. 2000). In an
earlier study in periodontally diseased 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, 34 times a year, we
found that approximately 50% of
the population developed new root
caries lesions. The periodontal conditions were almost unchanged. Only a
few teeth were lost during the experimental period. However, in the long
run, loss of teeth is evident even in
well-maintained populations (Hirschfeld & Wasserman 1978, Nabers
et al. 1987, Faggion et al. 2007, Carnevale et al. 2007a). Our working
hypothesis is that tooth loss exists in
the long run in previously treated
periodontal patients in spite of regular visits at dental hygienists and
general dental practitioners.
The aim of the present follow-up
was to study the periodontal conditions, 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 periodontal-, restorative- and re-constructive treatments during a time period
of 624 months. Thereafter, 99
patients were involved in a mainte-

nance programme consisting of periodontal 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 1114 years, (Mean:
12.5 years) 64 individuals, 30 men
and 34 women aged 4991 years
(Mean age: 64 years, standard deviation, SD: 8.3), were re-examined. It
was not possible to examine 35 individuals 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 University of Linkoping, 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 & Birkhed 1991, 1992). All dental examinations at baseline (in the present
study at the termination of the previous clinical 2-years study) were performed by one of the authors (NR).
The examinations at the nal followup were performed by two experienced and calibrated examiners (NR
and CSJ).
Before the nal clinical examination, the patients were called to a
specially trained dental assistant for
standardized dental colour photographs and a full-mouth radiographic 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 uorides and tobacco
use.
The periodontal status was examined according to Lindhe & Nyman
(1975). The classication of furcation
involvements used by Hamp et al.
(1975) was performed. Pocket-probing depths were recorded as the distance 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 periodontal disease was classied into

ve categories in accordance with

Hugoson & Jordan (1982): Group 1:
Healthy or almost healthy gingival
units (<12 bleeding units in the
molarpremolar regions) and normal
alveolar bone height; Group 2: Gingivitis (  12 bleeding gingival units
in the molarpremolar 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: Alveolar 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 furcation defects. All exposed root surfaces were identied, and the
distance from the gingival margin to
the cemento-enamel junction or
existing lling restoration was measured. 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 inspection or by probing the surface
(OLeary et al. 1972). Root caries
was recorded according to Hix &
OLeary (1976), a cavitation or
softened area in the root surface that
might or might not involve adjacent
enamel or existing restorations; (primary or recurrent lesions). In addition, a lesion was scored as active
when the surface was rough in texture, 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 lled if a
restoration was located entirely on
the root surface or obviously
extended from the coronal part
beyond the cemento-enamel junction. Secondary lesions on the roots
were recorded if they were diagnosed
adjacent to such restorations.
Crowns and llings 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

bone level was measured on intraoral radiographs in each patient and
expressed in millimetres of the distance between inter-approximal bone
level and cemento-enamel margins or
existing llings or restorations. The
reasons for tooth loss were calculated through the patients clinical
charts and by comparing the initial
and subsequent radiographs and
clinical photos. Fifteen dierent dental teams were involved in the maintenance 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 Student t-test was used to determine the
signicant dierences between two
independent groups. The Mann
Whitney U-test was applied when
the conditions for t-testing were not
fullled. Intra-group comparisons
between baseline and nal examinations were analysed using a paired
t-test. To test the correlations
between single variables and tooth
loss, Pearson product-moment correlation test was used. Stepwise logistic
regression analysis was performed to
evaluate the association between
individual tooth loss and a number
of conceivable variables. Prospectively active and inactive root caries,
pocket probing depths 46 mm and
>6 mm, bleeding on probing (BoP
%), prevalence of plaque (PlI%),
prevalence of general diseases and
medications that might inuence
tooth loss, were entered into the
analysis. Retrospectively, smoking
and number of annual visits at dentists and dental hygienists were also
entered. The level of statistical significance was set at 95%.

Table 1. Eighteen patients (28%)

reported daily smoking, of which 11
(17%) smoked more than 10 cigarettes per day. In addition, 36 individuals reported intakes of one or
more prescribed medications. Seventeen individuals reported intakes of
blood attenuating medication, and
17 reported intake of medications
for cardiovascular diseases. Eighteen
individuals took drugs due to gastrointestinal problems. Finally, 15
reported intake of some other prescribed drug. The dental histories at
the nal examinations are summarized in Table 2. Fifty-six patients
(88%) performed some kind of daily
inter-dental cleaning, and 45 individuals (71%) reported that they visited
dental hygienists 14 times a year.
Periodontal status, root caries and tooth
loss during the observation period

The number of teeth and the periodontal status at baseline and at the
nal examinations are shown in
Table 3. The number of remaining
teeth decreased and the plaque
scores increased signicantly between
the two examinations. The distribution of patients (groups 15) according to the severity of periodontal
disease (Hugoson & Jordan 1982)

75

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 llings and marginal
bone levels calculated on intra-oral
radiographs and expressed in millimetres (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 primary/secondary is shown in Table 4.
The prevalence of inactive root caries had decreased at the nal examination. During the observation
period, 19 patients got new active
root caries or llings on the root surfaces. 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 period, 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

Table 1. Prevalence of general diseases and smoking habits at the nal examination
Variable
Cardiovascular disease
High blood pressure
Asthmatic/allergic problems
Rheumatic disease
Diabetes (type 1 and 2)
Gastro-intestinal disease
Other medical problems
Smoking 19 cig/day
Smoking >10 cig/day

Number of
individuals

Percentage of the
studied subjects

8
14
16
4
(1 + 5)
10
12
7
11

13
22
25
6
9
16
19
11
17

Results
Subject characteristics

Table 2. The dental histories at the nal examination

The mean age of the examined

patients, 30 men and 34 women, was
52 years (range: 3078, standard
deviation, SD: 10.6) at the baseline
examination and 64 years (range: 49
91, SD: 8.3) at the nal examination. The prevalence of medical
problems and smoking habits
reported by the patients at the nal
examination are summarized in

Variable

2011 John Wiley & Sons A/S

Bleeding gums
Sensitive teeth
Mouth dryness
Tooth brushing  2/day
Inter-dental cleaning  1/day
Use of extra uorides
Visits at dentists 12 times/year
Visits at dental hygienists 14 times/year

Number of
individuals

Percentage of the
studied subjects

13
14
17
62
56
11
58
45

20
22
27
97
88
17
91
71

76

Ravald and Johansson

Table 3. Number of teeth (Mean values and standard deviations, SD), plaque score, bleeding on probing score (BoP) and periodontal pocket probing depth (PPD) in the study group
(n = 64) at baseline and at the nal examination
Variable

Baseline

No. of teeth
Plaque (%)
BoP (%)
PPD
46mm (no)
>6mm (no)

Final examination

Mean

SD

Mean

SD

23.4
23
17

4.8
23.2
17.6

20.8
39
21

6.7
26.1
19.4

13
2

11.6
5.5

13
1

p-value

0.0001
0.02
NS

8.3
1.8

NS
NS

Table 5. Correlation
coecients
(r)
between tested variables, periodontal pocket
probing depths (PPD), bleeding on probing
scores (BoP), plaque scores (PlI) active and
inactive root caries at baseline and tooth
loss during the observation period among
64 patients completing the study
Variable
PPD 46 mm
PPD >6 mm
BoP (%)
PlI (%)
Root caries active
Root caries inactive

0.54
0.37
0.38
0.25
0.38
0.37

0.000
0.003
0.002
0.045
0.002
0.003

Table 4. Root caries prevalence (Mean values and standard deviations, SD) at baseline and
nal examinations (n = 64)
Variable

Baseline

Decayed active prim.

Decayed active sek.
Decayed inactive prim.
Decayed inactive sek.
Restored root surfaces

No of new DF root surfaces

25

Final examination

Mean

SD

Mean

SD

0.4
0.3
1.6
0.8
4.5

0.87
0.97
2.83
2.24
6.49

0.6
0.4
0.9
0.3
5.5

1.81
1.19
1.42
0.79
6.72

0.57
0.60
0.06
0.04
0.17

Root caries
Filled root surface

Discussion

20
15
10
5
0

No of individuals

Fig. 1. Nineteen of 64 individuals got new root caries lesions or llings on the root
surfaces (new DF root surfaces) during the observation period of 1114 years. Each
bar represents one individual.

(Grade I-III) were lost signicantly

more often than molars without furcation involvements (p < 0.001) and
non-molar teeth (p < 0.001). The
main reason for tooth loss was periodontal disease (n = 153). Due to
root caries and endodontic complications 28 and 17 teeth, respectively,
were lost. Thirteen teeth were
extracted for other reasons (e.g. root
fractures). At the nal examination,
the patents were clinically classied
according to their existing or previous (during the observation period)
dental diseases. Twenty patients

(Table 6) that the prevalence of

probing pocket depths 46 mm
(p = 0.01) and the number of
remaining teeth at baseline (p = 0.05)
signicantly contributed to explain
tooth loss. Retrospectively, smoking
(p = 0.01) with an odds ratio of 8.0
(CI; 1.639) and the number of visits
at dental hygienists (p = 0.03) signicantly contributed to explain tooth
loss.

(31%) were classied as healthy, and

29 (45%) showed periodontal problems of various degree. Two patents
(3%) had mainly caries problems,
and 13 (20%) showed a combination
of periodontal and caries diseases.
Tooth loss and potential risk factors

The correlations between tooth loss

during the observation period and
tested dental variables at baseline
signicantly associated are shown in
Table 5. Stepwise logistic regression
analysis
showed
prospectively

The main ndings from this longitudinal study in periodontally treated

patients were that the patients, to a
considerable extent, continued to
lose teeth after active periodontal
therapy during the maintenance
phase at general practitioners and
their dental hygienists. In the studied
population, 64 teeth (22 molars, 13
with furcation involvements grade II
and III) were extracted during the
active periodontal and restorative
treatment (Ravald & Birkhed 1991,
1992). Loss of teeth in connection
with periodontal therapy is in accordance with other studies (Nyman &
Lindhe 1979, Nabers et al. 1987,
Carnevale et al. 2007b, Eickholz
et al. 2008). During the beginning of
the observation period of 2 years
with intensive maintenance at the
specialist clinic, no teeth were
extracted due to periodontal disease.
Root caries development was
arrested, however, not completely in
spite of the intensive prophylactic
treatments (Ravald & Birkhed 1992).
Totally, 211 teeth were lost during
the observation period of 11
14 years in the 64 patients remaining
in the study. A majority (73%) were
lost due to periodontal disease. Only
2011 John Wiley & Sons A/S

Tooth loss in periodontally treated patients

Table 6. Results of the stepwise logistic regression analysis with tooth loss as the dependent
variable. Only the variables signicantly contributing to explain tooth loss are presented

Prospectively
Pocket depths 46mm
Number of teeth
Retrospectively
Smoking (yes)
No. of hygienist visits/year

p-value

Odds ratio (95% CI)

Step

0.01
0.05

1.11 (1.021.20)
0.87 (0.761.0)

1
2

0.01
0.05

8.0 (1.639.0)
2.1 (1.14.2)

1
2

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 maintenance and follow up. At the nal
examination, 91% of the patients
reported regular visits to dentists
(once or twice a year), and 71%
reported 14 visits a year at dental
hygienists. Obviously, the recommended numbers of visits were fullled. 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 frequently called patients for maintenance treatments. However, the
quality of the supportive treatments
might be questioned. It is also reasonable to speculate that the daily
plaque-control by the patients themselves have been insucient over
time. The studied group showed at
the nal examination, a mean plaquindex 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 quality. 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 populations, a higher annual tooth loss
has been shown, comparable to our
ndings (Eickholz et al. 2008). In a
study with a natural history of periodontal 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

In the present study, the reason

for tooth loss was predominantly
periodontal disease. This is in accordance 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, Carnevale et al. 2007b). In geriatric populations, 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 caries in periodontal patients have been
shown in previous studies (Ravald
et al. 1986, Reiker et al. 1999).
Recently, Fadel et al. (2011) presented in a study of a risk model for
root caries that about one-fth of
the patients referred for periodontal
treatment showed an increased risk
which is in accordance with our ndings. In the present study, population 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 periodontal problems are far more prevalent (49%) than patients with only
root caries problems (3%). A combination with periodontal disease and
root caries is evident in 20% of the
patients. In the present patient category, 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
uoride applications are of outmost
value (Ekstrand et al. 2008). In our
study, all patients reported that they
used toothpaste containing uorides.
In addition, 11 individuals reported
at the end of the study that they
used extra uoride rinsing or tablets.
No positive correlations with use of
dierent uorides, as an adjunct to
uoride containing tooth paste and
root caries development was seen in
the present study, which is in agreement with earlier observations (Ravald & Birkhed 1992).
In estimations of risk for progression 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 signicantly correlated with tooth loss.
Obviously, tooth loss is more prevalent among smokers than non-smokers (OR: 8). Smoking must be
considered as an important risk factor for tooth loss in this patient category. This is in accordance with
ndings from earlier studies in periodontally
diseased
populations
(Haber et al. 1993, Bergstrom & Preber 1994, Fardal et al. 2004, Dannewitz et al. 2006). In contrast to
earlier studies, (Axelsson & Lindhe
1981, Fardal et al. 2004, Eickholz
et al. 2008) we found a positive correlation between the number of selfreported 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 treated more frequently than patients
with not so evident periodontal
problems. Tooth-related factors contributing to explain tooth loss over a
period of 1114 years after periodontal treatment, identied 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 (Claey et al. 1990, Matuliene et al. 2008) and untreated
populations with periodontal disease (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

signicantly 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 furcation involvements. The decision
for tooth extraction may also reect
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 maintenance performed by general practitioners and dental hygienists that
future tooth loss is not prevented.
The main reason for tooth loss is
periodontal disease. A lifelong maintenance 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 periodontist.
Conclusions

Periodontally treated patients are in

a longer perspective at risk of further tooth loss. Maintenance performed at general practitioners and
dental hygienists seems not to be
suciently eective for prevention of
tooth loss. Smokers with low numbers of remaining teeth and deepened periodontal pockets are at
higher risk for future tooth loss.
Acknowledgements

The authors thank Dr. Birgit Ljungquist for the assistance with statistical analyses. The excellent assistance
of the dental assistants Kerstin Cannerborg, Kicki Ahlin and Gun Nilsson is gratefully acknowledged. This
study was founded by the Research
Council of Public Dental Service,
Ostergotland County, Sweden.
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Clinical Relevance

Scientific rationale for the study:

Studies in periodontally treated
patients have shown that maintenance performed at University- or
Specialist clinics can prevent tooth
loss. Maintenance in general practice has been less successful. The aim

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79

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South Australians aged 60+ years. Community

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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 regular maintenance.

Practical implications: Smokers

with few remaining teeth and deepened pockets are at higher risk.
This should be considered when
the maintenance programmes are
designed.

Address:
Nils Ravald
Centre for Oral Rehabilitation
SE 581 85 Linkoping
Sweden
E-mail: nils.ravald @lio.se