Periodontitis and tooth loss: the prosthetic options you actually have

Have you just been told you have periodontitis?

Perhaps you have already lost some teeth, perhaps some are loose, and it is entirely natural to worry about whether you will end up losing them all and wearing a denture.

In this article we look at how periodontitis relates to restoring your mouth: when teeth can be saved and when they cannot, whether you can have bridges, whether you can have implants, what the options are when all the teeth are lost, and how we decide which solution suits you.

What periodontitis does to your teeth

Periodontitis is an inflammation that destroys the bone around the teeth. It does not damage the tooth itself; it destroys the bone that supports it.

As the support diminishes, the teeth begin to move and may eventually be lost.

There are two mistakes that are frequently made with periodontal patients:

Mistake one: extracting teeth that could have been saved

Periodontitis can be treated. Teeth can be treated and remain in the mouth, provided they are healthy, even when they have lost a significant part of their support.

Classic Scandinavian studies from the 1970s showed that teeth with a reduced but healthy periodontium can function for decades, even as abutments for fixed restorations, when the disease has been controlled and maintenance is strict.

Mistake two: keeping teeth that have no future

The reverse is equally true. When periodontitis has severely affected certain teeth — bone support has been lost, there are recurrent abscesses, there is marked mobility — insisting on keeping them destroys the bone of the jaw.

That bone is what you will need later, if you decide to have implants.

A tooth-by-tooth assessment, clinical and radiographic, is required in order to decide the future of your teeth.

The three conditions for keeping your teeth

For the retention of periodontally compromised teeth to make sense, three things are needed at the same time:

1. Periodontal treatment. The inflammation must be controlled and the disease in remission.

2. Excellent oral hygiene on your part. Daily cleaning with interdental brushes, done consistently.

3. A recall system. Enrolment in a maintenance programme which, depending on the case, may be every three or every six months.

With these conditions in place, there is a very good chance of keeping your teeth for decades after periodontitis.

Periodontal treatment always comes first

No properly executed prosthetic work that is intended to last is carried out before periodontal disease has been stabilised.

Periodontal treatment is the first stage and an essential precondition before new teeth are placed in your mouth.

Can periodontal patients have bridges?

Yes, they can.

It has in fact been established for many years that a correctly constructed bridge can splint the treated teeth and help distribute forces more evenly across teeth that have already lost a significant part of their support, so that they last over time.

Who is suitable for a bridge

You are suitable provided that:

• the periodontitis has been treated and the teeth are stable
• the remaining teeth are distributed along the arch in positions that allow a bridge to be placed
• you are able to clean underneath the bridge

Can periodontal patients have implants?

Yes. The literature indicates that the treated periodontal patient can have implants placed.

These implants are, however, more susceptible to a different disease: peri-implantitis, an inflammation around the implant that can lead to its loss.

To reduce the likelihood of peri-implantitis, the periodontitis must remain treated and you must be enrolled in a programme of continuing recall appointments that will help you keep both your teeth and your implants healthy. At the same time, you yourself must remain meticulous about daily oral hygiene.

When all the teeth are lost: three solutions

If the disease has progressed to the point where all the teeth are being lost, there are three categories of solution.

1. Complete denture

With today’s methods we can remove the teeth that need to be removed and place a denture in your mouth on the same day.

A denture restores appearance and function. It is, however, a removable restoration: it goes in and out of the mouth, it has to be cleaned, and the lower denture in particular shows greater movement during chewing — something many patients find difficult to accept.

2. Implant-retained overdenture

An overdenture clips onto implants. Two implants are needed for the lower jaw and four for the upper.

It remains removable, but it does not move in function. Force is required to take it out of the mouth.

The lower overdenture on two implants is internationally regarded as the basic standard of care for the edentulous patient.

3. Fixed restoration on implants

You can also have a greater number of implants placed and a fixed prosthetic restoration.

The question here is always whether there is sufficient bone, because periodontitis is precisely what destroys the bone in which we want to place the implants. This is why many periodontal patients also need regenerative techniques, so that bone is created where there is none.

When conditions are favourable, however, with four to five implants in the lower jaw and six to eight in the upper, you can have an excellent fixed restoration.

How we decide which solution suits you

We assess:

1. Which teeth remain and what their prognosis is. This is usually decided in collaboration with the periodontist who treated you.

2. How much bone is present, in order to judge whether implants can be placed.

3. The level of oral hygiene you are able to maintain. None of these restorations will last if you cannot clean effectively. Your dentist will teach you how — but following those instructions is essential.

4. Your own preference. What would you like to have: removable teeth, fixed teeth? What cost can you take on? What is your greatest need?

Watch the video with English subtitles, for more information.

Dr Domna Evangelidou, DDS, MSc — Prosthodontist
DentArtistry, 80 Kifisias Avenue, Ambelokipi, Athens
Tel. +30 210 69 30 140

This article is for information only and does not replace clinical examination.