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Tooth Loss in 100 Treated Patients With Periodontal
Disease
A Long-Term Study
Walter T. McFall, Jr.*

Accepted for publication 18 January 1982

A population of 100 patients with periodontal disease who had been treated and maintained
for 15 years or longer was studied for tooth loss. The patients averaged 43.8 years of age and
consisted of 59 females and 41 males. Patients were examined and their dental records were
reviewed. On the basis of response to therapy and tooth loss, the patients were classified as
Well-Maintained (77), Downhill (15), or Extreme Downhill (8). At the completion of initial
treatment, 2,627 teeth were present. Of this number, during the maintenance period, 259 teeth
(9.8%) were lost due to periodontal disease, while 40 teeth (1.5%) were lost due to other causes.
Evaluation was made as to patterns of tooth loss, loss of questionable teeth, loss of teeth with
furcations, surgical vs. nonsurgical therapy, and presence of fixed or removable prostheses.
Considerable variation occurred between response groups. Periodontal disease appears to be
bilaterally symmetrical and tooth loss emulated this pattern with greatest loss of maxillary
second molars and least loss of mandibular cuspids.

Periodic recall maintenance is an accepted preventive
measure for patients who have received periodontal care.
Because of the chronic nature of periodontal disease,
maintenance is required to mechanically remove etio-
logic factors, monitor tissue health, and encourage pa-
tients in personal oral hygiene. Microbial influences
appear to be the principal cause of periodontal inflam-
mation, and maintenance therapy may limit the destruc-
tive effect of these organisms.1'2
Several short-term studies (2 to 5 years) have reported
beneficial effects of various preventive approaches.3"7
Additionally, a number of longitudinal studies have
evaluated responses to several types of periodontal ther-
apy.8"18
In 1955 Marshall-Day et al.19 reported on the preva-
lence and incidence of periodontal disease in a large
cross-sectional survey. A number of reports have dealt
with loss of alveolar support or tooth mortality in relation
to periodontal disease.20"27 Evaluations of large numbers
of patients over long periods are limited. One such long-
term survey of tooth loss in 600 treated patients with
periodontal disease who were maintained over a period
of more than 15 years was reported by Hirschfeld and
Wasserman.28 The present study was inspired by that
*
Professor, Department of Periodontics, School of Dentistry, Uni-
versity of North Carolina, Chapel Hill, NC 27514.
publicationand follows the format outlined by Hirsch-
feld and Wasserman.
STUDY POPULATION
The study population consisted of 100 patients treated
and maintained for 15 years or longer. These patients
represented a sample from a periodontal practice con-
ducted on a 1 day per week basis in the Dental Faculty
Practice of the University of North Carolina School of
Dentistry. All patients had documentation during the
period of treatment.
All patients were on a periodic maintenance program
by the author, and most were originally treated by the
author. Some patients had been treated previously by
other faculty members of the school in the private prac-
tice. The majority of these patients had been under a
maintenance regime at 3-, 4- or 6-month intervals. A few
patients were seen on an annual basis, with an interim 6-
month maintenance appointment with their general den-
tist. The preponderance of the population was Caucasian
and from middle economic levels. There were more
females (59), than males (41), but the severity of disease
at the original examination was approximately the same,
regardless of sex.
The average age of the patients at the time of original
therapy was 43.8 years. Seventy-one of the patients were
below age 50, and 54 were between ages 35 and 49. At
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J. Periodontol.
540 McFall September, 1982

the initial treatment the ages ranged from 8 to 71 years Table 1

(Table 1). The average duration of maintenance was 19 Distribution of Sample by Age at Initial Treatment
years with a range from 15 to 29 years and the median Age
Number of
Percent
was also 19 years (Table 2). patients
Periodontal conditions were charted on anatomical 8-19 1 1
charts at both original and re-examination appointments. 20-29 4 4
30-39 24 24
Data included pocket depths, degrees of mobility, fur- 40^19 42 42
cation invasions, gingival levels, and mucogingival con- 50-59 27 27
siderations. Because of the variability of operators and 60-71 2 2
of probes, pocket depths could not be compiled accu-
Total 100 100
rately and no tabular information on pocket depths is
presented.
The criteria for a tooth to be given a questionable Table 2
prognosis were the same as those of Hirschfeld and Distribution of Sample by Years of Maintenance
Wasserman28: furcation invasion; a deep, noneradicable Years of Number of
Percent
maintenance* patients
pocket; extensive alveolar bone loss; or marked mobility
of 2° or more in conjunction with pocket depth and 15-19 61 61
20-24 27 27
alveolar bone loss.
25-29 12 12
Tooth loss was determined from the original and re-
examination chartings and careful review of treatment Total 100 100
history in the patients' records. Teeth lost as part of the *
Average 19 years; median 19.
initial therapy were not counted as being lost during the
longitudinal study period. The causes of tooth loss were varied in their post-treatment course to the extent that
noted as periodontal disease, caries, periapical pathosis, the initial classification proved somewhat misleading.
nonrestorable, endodontic failure, orthodontic treatment, The situation was the same in the present study, and the
or oral surgical extraction of partially erupted third
patients were subsequently classified on the basis of
molars. In those few instances where records were not response to therapy using the division devised by Hirsch-
definitive as to cause of tooth loss, such teeth were feld and Wasserman:
counted as lost due to periodontal causes.
Medical conditions were noted originally and during Well-Maintained (WM) group—lost 0 to 3 teeth.
the maintenance period. An attempt was also made to Downhill (D) group—lost 4 to 9 teeth.
evaluate the oral hygiene levels during the period of Extreme downhill (ED) group—lost 10 to 23 teeth.
study. Because definitive measures of plaque were not The study population, divided on this basis, was dis-
available in many instances, only an approximation of tributed in the following manner:
oral hygiene effectiveness could be evaluated. Profi-
Well-Maintained 77
ciency in oral physiotherapy was classified as good, fair, Downhill 15
or poor.
Extreme downhill
Severity of the periodontal condition at the time of the
original examination was classified as suggested by
Hirschfeld and Wasserman, in the following categories:
THERAPY
Early: Pockets of 4 mm or less, with gingival
All patients were treated similarly during the period
inflammation and subgingival calculus.
of intitial preparation. This consisted of supragingival
Intermediate: Pockets of 4 mm to 7 mm present about
a number of teeth.
and subgingival scaling with topical anesthetic, polishing
of teeth, oral hygiene instructions, and occlusal adjust-
Advanced: Pockets deeper than 7 mm, furcation
ment by selective grinding where indicated. Caries con-
involvement of at least one tooth.
trol or definitive restorative dentistry was accomphshed
Some patients classified in the early category presented during this period. In cases requiring fixed bridge work
with gingival hyperplasia and minimal subgingival cal- or partial dentures, this was generally deferred until
culus. periodontal treatment was completed. Many patients
Of the 100 patients, 36 were initially classified as were seen with fixed bridges initially.
having advanced periodontal disease. Fifty-three pa- Oral hygiene instruction varied, depending upon when
tients presented with disease of intermediate severity, the patient was initially treated. Patients who were seen
while 11 of the patients were in the early stages of prior to 1961 were primarily instructed in various roll
periodontal pathosis. Varying degrees of severity involv- techniques or Charters Technique.29 Those treated after
ing different teeth were characteristic in most patients. 1961 were instructed in either the Bass Technique30 or a
Hirschfeld and Wasserman28 suggested that patients scrub technique with a soft-bristled brush.31 A few pa-

Volume 53
Number 9
tients preferred to use an automatic brush. A wide variety
of oral hygiene aids were employed dependent on the
individual needs of the patient.
Patients were questioned and evaluated as to their oral
habits. On the basis of subjective patient response and
clinical criteria such as wear facets, broadened occlusal
tables, fractured teeth, mobility patterns or migration, 33
of the 100 patients in this study were initially judged as
exhibiting bruxism. Many of these patients were supplied
with biteguards during initial therapy.
Surgical therapeutic procedures differed markedly de-
pending upon the nature of the periodontal pathosis and
the procedures available at the time of therapy. Fibrotic
tissues were more likely to receive surgical therapy than
edematous tissues which might respond to curettage.
Pockets which could be eliminated or markedly reduced
in depth were more often treated surgically. Factors
which limited surgery were esthetic considerations, poor
oral hygiene on the part of the patient, systemic or
emotional conditions, or resistance to surgery on the part
of the patient.
Patients treated surgically during the 1950s were pri-
marily managed by gingivectomy when pocket elimina-
tion was possible. Deep pockets were managed by closed
gingival curettage using local anesthetics. An occasional
frenectomy or vestibular fold extension was accom-
plished. During the early 1960s surgical management
consisted of gingivectomy and gingivoplasty for supra-
bony pockets. In the anterior region, when esthetics was
a concern, and in deep pockets, closed curettage was the
surgical methodology. Intrabony defects were treated by
ostectomy and osteoplasty when pocket elimination was
deemed feasible.
During the recall maintenance period patients were
evaluated as to medical and dental health, plaque control
was evaluated, and scaling and polishing of teeth were
routinely accomplished. Appropriate radiographs were
secured at appropriate intervals, or as situations de-
manded, in concert with the referring dentists.
Tooth mobility was assessed during the maintenance
period. Mobility remained after initial treatment in some
patients, while in others it was reduced. Increased mo-
bility was most marked in downhill and extreme down-
hill groups. Splinting of either the removable or fixed
variety was only occasionally employed, based on mo-
bility alone. Some teeth with moderate mobility main-
tained well. Selective grinding was accomplished as ap-
propriate. When teeth became so involved as to require
extraction, this was accomplished and fixed or removable
prostheses were constructed.
During the maintenance period, when pocket depth
increased to the extent that surgical intervention was felt
to be justified, patients were rescheduled for surgical
procedures. Throughout much of the 1960s, 1970s, and
early 1980s, this consisted of either closed curettage or
other surgical procedures. These other procedures were
full mucoperiosteal flaps with internal beveled incision
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Tooth Loss in Periodontal Disease 541
Table 3
Distribution of Sample by Number of Teeth Present at Completion of
Initial Treatment
Number of teeth Number of „
Percent
present patients
29-32 19 19
25-28 58 58
21-24 17 17
16-20 5 5
11-15 1 1
6-10 0 0
Total 100 100
and curettage, or full mucoperiosteal flap reflection and
ostectomy and osteoplasty. An occasional mucogingival
procedure was accomplished, but in the group studied
here, no free gingival grafts were used to increase the
amount of attached tissue. Root amputation was per-
formed on only five teeth. Other furcation invasions
were treated by osseous surgery or maintained with
closed or open flap curettage.
RESULTS*
After the completion of original therapy, the total
number of teeth present in the 100 patients was 2,627.
Most of the patients had relatively complete dentitions
with 77 having more than 24 teeth and 19 having more
than 28 (Table 3). During the maintenance period, an
average of 19 years, 259 teeth (9.8%) were lost due to
periodontal disease and 40 teeth (1.5%) were lost from
other causes. Types and percentages of teeth lost are
demonstrated in Table 4. Because of the reported bilat-
eral symmetry of periodontal disease and tooth
loss,20,21,28'32"34 the table combines right and left sides for
each tooth.
Of the total number of teeth lost due to all causes,
30.7% occurred in the Well-Maintained (WM) group,
30.7% in the Downhill (D) group, and 38.6% in the
Extreme Downhill (ED) group. Forty-five of the 77
patients comprising the Well-Maintained group, 45% of
the total population, lost no teeth over the maintenance
period.
All eight of the patients who comprised the Extreme
Downhill (ED) group and 13 of the 15 patients in the
Downhill (D) group originally had been determined to
have advanced periodontal disease. Fifteen patients orig-
inally classified as having advanced disease were in the
Well-Maintained (WM) group.
Because of the difference in tooth loss patterns in the
three response-to-therapy groups, and because of the
desire to conform with the previous survey,28 groups
were studied separately and in combination to aid inter-
pretation. In the Well-Maintained (WM) group of 77
patients, 53 teeth were lost due to periodontal disease,
*
Tabular material is numbered and titled to conform with that of
Hirschfeld and Wasserman.28
 J. Periodontol.

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542 McFall September, 1982

Table 4 and incisors. Mandibular cuspids and first bicuspids

Percentage of Each Tooth Type Lost During Maintenance Period were most resistant to loss.
Number lost The eight patients comprising the Extreme Downhill
Present after
Tooth type initial treat- during main- Percent lost group completed initial therapy with proportionately
tenance pe-
ment
riod fewer molar teeth than either of the other two groups.
32.6
Molars were the teeth primarily lost during the mainte-
49 16
nance phase, with maxillary molars the most commonly
160 36 22.5
lost teeth. Even with the rather extensive loss of teeth
169 27 15.9
seen in the group (Table 8), mandibular cuspid loss was
170 15 8.8
rare.
186 19 10.2
9 4.7
The loss of individual teeth is summarized in Table 9.
192
178 14 7.9 Frequency of tooth loss is presented for the total sample
183 15 8.2
and by response group in a descending order of rank.

199 18 9.0
Table 6
199 13 6.5
Well-Maintained Group (77 Patients)— Tooth Loss from Periodontal
200 1 0.5
Disease, by Tooth Type
190 11 5.8
175 10 5.7
Tooth type Initially present Lost Percent lost
39 20.5
140 22 15.7
128 12 9.4
170 22 12.9
133 9 6.8
67 11 16.4
131 1 0.8
145 3 2.1
Table 5
148 0 0.0
Distribution of Teeth Lost According to Response Group 136 0.0
0
Initial prognosis of WM(77) D(15) ED (8) Total (100) 141 2 1.4
teeth
Questionable 23 55 56 134 153 1 0.6
Favorable 30 36 59 125 153 1 0.6
154 0 0.0
Total 53 91 115 259
145 1 0.7
Average per patient 0.68 6.7 14.4 2.6 136 1 0.7
110 4 3.6
7
an average of 0.68 teeth per patient (Table 5). Of those 136 5.1
thatwere lost, 43.3% had been originally designated as 49 3 6.1
questionable. In the Downhill group 60.4% of the teeth
with a questionable prognosis were lost, while the Ex- Table 7
treme Downhill group lost 48.7% of the teeth deemed Downhill Group (15 Patients)—Tooth Loss from Periodontal Disease,
questionable. by Tooth Type
At the completion of treatment, most of the patients Tooth type Initially present Lost Percent lost
in the Well-Maintained group (WM) had reasonably 6 5 83.3
complete dentitions. Third molars were the teeth most 24 17 70.8
commonly missing, though lower first molars were also 26 9 34.6
missing to a lesser degree. The number of teeth originally 25 4 16.0
present, and the number of teeth lost, are listed in Table 26 5 19.2
6. Over the period of maintenance therapy averaging 19 28 1 3.6
years, no cuspids were lost in the WM group, and loss of 28 5 17.9
incisors and bicuspids was very slight. Tooth loss in the 28 4 14.3
WM group consisted primarily of maxillary second and
third molars. 30 9 30.0
Patients in the Downhill (D) group finished initial 30 4 13.3
30 0 0.0
treatment with proportionately fewer molar teeth than
29 3 10.3
the WM group. Over the maintenance period this group
lost a high percentage of molar teeth, particularly max- 27 5 18.5
21 10 47.6
illary second molars (Table 7). Only one cuspid tooth 2! 7 33.3
was lost during maintenance. In comparison with the
WM group, patients of the D group lost more bicuspids 10 3 30.0
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Volume 53
Number 9 Tooth Loss in Periodontal Disease 543
Table 8 Table 10
Extreme Downhill Group (8 Patients)—Tooth Loss from Periodontal Loss of Teeth Originally Marked Questionable by Response Group
Disease, by Tooth Type
Questionable WM (77) D (15) ED (8)
Total (100
Tooth type Initially present Lost Percent loss teeth patients)
3 75.0 Initially present 83 71 61 215
7 17 7 87.5 Lost 23 55 56 134
6 I 6 10 9 90.0 Percent Lost 27.7% 77.5% 91.1 62.3%
5 1 5 14 10 71.4
4 I 4 15 11 73.3 for an average of 14.4 per patient. Of the teeth lost,
3 I 3 16 8 50.0 48.7% originally had been assigned a questionable prog-
2 I 2 14 9 64.3 nosis.
1 I 1 14 9 64.3 A clearer view of the distinction between response

11 16 50.0
groups can be seen in Table 10. A rather high percentage
of the total teeth receiving a questionable prognosis
2 I2 16 50.0
3 I 3 16 6.3
(62.3%) were lost during the maintenance period. The
Downhill group, (77.5% of questionable teeth lost), and
4 I 4 16 43.8
the Extreme Downhill group (91.8% of the questionable
TTT 12 33.3
teeth lost) accounted for 111 of the total teeth lost. The
9 88.8
WM response group lost only 27.7% of the teeth which
~TJT 13 61.5
had received a questionable prognosis originally.
62.5
LOSS OF TEETH WITH FURCATION INVASION
Table 9
Ranking of Individual Teeth by Frequency of Loss Of the total sample, 163 maxillary and mandibular
All pa- molars and maxillary first bicuspids were diagnosed as
Tooth WM D ED
tients having furcation invasion (Table 11). This consisted of
103 maxillary teeth and 60 mandibular teeth. A total of
Maxillary second molar 1* 1 1 11.5
Maxillary first molar 2 2 3.5 4 94 teeth (56.9%) initially diagnosed as having furcation
Mandibular second molar 3.5 4 5 invasion were lost. Maxillary molars and bicuspids ac-
Mandibular first molar 3.5 5 2 counted for loss of 59 teeth, while 35 mandibular molars
Maxillary first bicuspid 5 6.5 7.5
were lost.
Mandibular central incisor 6 11 3.5
Maxillary third molar 7 3 7.5 15 The smallest percentage of loss occurred in the WM
Maxillary second bicuspid 8.5 9.5 11 2 group where only 18 teeth (27.3%) were lost. The Down-
Maxillary central incisor 8.5 8 11 4 hill group lost 68.9% of the teeth with probable furcations
Maxillary lateral incisor 10 15 7.5 4
initially. The Extreme Downhill group lost 92.3% of the
Mandibular lateral incisor 11 11 11 8
Mandibular third molar 12.5 6.5 13.5 11.5
furcated teeth. Though only a few third molars presented
Mandibular first bicuspid 12.5 11 13.5 13 with furcation invasion, these exhibited a high loss rate.
Mandibular second bicuspid 14 11 7.5 14
Maxillary cuspid 15 15 15 8 LOSS OF NONFURCATED QUESTIONABLE TEETH
Maxillary cuspid 16 15 16 16
*
Indicates most frequently lost tooth.
Sixty-seven teeth in this study were given a question-
ableprognosis on the basis of pocket depth, extreme
mobility, or extensive alveolar bone loss, but without
LOSS OF QUESTIONABLE TEETH furcation invasion. Of these 67 teeth, 43 (64.2%) were
The distribution of teeth lost in the various response lost during the maintenance period (Table 12). In the
WM group 26 teeth were assigned to. the questionable
groups is presented in Table 5. The WM group of 77
patients lost a total of 53 teeth (0.68 per patient). Teeth category, and only 9 (38.5%) of these teeth were removed.
with a questionable prognosis numbered 23 (43.4% of Principal tooth loss occurred in the maxillary incisors.
the loss). All questionable teeth were so designated be- No cuspids or bicuspids were lost. In the Downhill group
cause of deep pockets (7-10 mm), furcation invasion, 89.5% of the questionable teeth were lost, while 77.3%
were lost in the Extreme Downhill response group. The
severe mobility, or loss of alveolar support. Thirty teeth
which had been given a favorable prognosis were also maxillary incisors were the predominant teeth lost in
lost. This accounted for 56.6% of the teeth lost in the these less resistant patients.
WM group.
The teeth marked questionable in the Downhill group
SURGICAL INTERVENTION
(56) represented 60.4% of the teeth lost. The Downhill Patients in all three response groups received surgical
group lost an average of 6.1 teeth per patient. In the therapy. One or more operations were performed on 63
Extreme Downhill group 115 teeth were eventually lost, of the 100 patients in the total population (Table 13).
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J. Periodontol.
544 McFall September, 1982

Table 11
Teeth With Furcation Involvement Lost by Response Group
WM (77) D(15) ED (8) Total group
Tooth
type Lost/pres- ^ Lost/pres- Lost/pres- ^ Lost/pres- t
ent ent ent ent

1/2 50.0 2/2 100.0 1/1 100.0 4/5 80.0

7 I 7 8/24 33.3 15/20 75.0 5/5 100.0 28/49 57.1
6 I 6 6/19 31.6 7/12 58.3 8/10 80.0 21/41 51.2
41 4 0/1 0.0 1/2 50.0 5/5 100.0 6/8 75.0
0/7 0.0 9/13 69.2 8/8 100.0 17/28 60.7
TTT 3/12 25.0 5/8 62.5 8/9 88.8 16/29 55.2
0/1 0.0 1/1 100.0 1/1 100.0 2/3 66.6

18/66 27.3 40/58 36/39 92.3 94/163 56.9

Table 12
Nonfurcated Questionable Teeth Lost
WM (77) D(15) ED (8) Total group (100)
Tooth type Lost/ Percent Lost/pres- r
Percent
Lost/pres-
r
Percent
Lost/pres- Percent
present _
ent _
ent _
ent _

X Incisors 4/5 80.0 4/5 80.0 6/6 100.0 14/16 87.5

Incisors 2/8 25.0 6/6 100.0 4/6 66.7 12/20 60.5
Cuspids 0/3 0.0 0/0 0.0 2/2 100.0 2/5 40.0
J. Bicuspids 0/0 0.0 0/1 0.0 4/4 100.0 4/5 80.0
Bicuspids 0/0 0.0 2/2 100.0 0/1 0.0 2/3 66.7
Molars 3/10 30.0 5/5 100.0 1/3 3.4 9/18 50.0

Totals 9/26 38.5 17/19 17/22 77.3 43/67 64.2

Table 13
Surgical Procedures Performed Per Patient, By Response Group
Number Total
of proce- WM (77) Percent D (15) Percent ED (8) Percent group Percent
dures (100)
1 10.4 6.6 0.0 9 9.0
2 7 9.1 20.0 12.5 11 11.0
3 10 12.9 0.0 12.5 11 11.0
4 7 9.1 20.0 0.0 10 10.0
5 5 6.5 13.3 25.0 9 9.0
6 3 3.9 6.6 0.0 4 4.0
7 0 0.0 0.0 0.0 0 0.0
8 5 6.5 6.6 0.0 6 6.0
9 0 0.0 0.0 0.0 0 0.0
10 1 1.3 6.6 12.5 3 3.0

46 59.7 12 79.7 62.5 63 63

For this study, surgical procedures were defined as gin- Table 14

Patients Having Surgery During Initial Treatment and Maintenance
givectomy, gingivoplasty, ostectomy, mucogingival pro- Phase
cedures, and flap operations with either curettage or with
ostectomy-osteoplasty. During the maintenance period, WM(77) D(15) ED (8) °^™
closed subgingival curettage was accomplished in se-
lected areas, but this procedure was not tabulated in the Initial treatment 22 8 3 33
Maintenance only 8 0 1 9
surgical data presented in Tables 13 and 14. Both initial and 16 4 1 21
In the active treatment period 33 of the total of 100
maintenance
patients had some surgery. During the follow-up phase Root amputations 4* 1* 0 5*
an additional nine patients had surgical treatment, and
21 patients had surgery during both active treatment and 46 12 5 63

maintenance. *
Included with other surgery and not listed in totals.
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Volume 53
Number 9 Tooth Loss in Periodontal Disease 545
Table 15
Teeth Lost After Surgical Treatment
WM (77) D(15) ED (8) Total group (100)
Tooth type
Lost/treated Percent Lost/treated Percent Lost/treated Percent Lost/treated Percent

Maxillary Molars 14/114 12.3 23/34 67.6 5/8 62.5 42/156 26.9
Bicuspids 1/80 1.3 5/29 17.2 9/14 64.2 15/123 12.2
Cuspids 0/33 0.0 1/15 6.6 3/6 50.0 4/54 7.4
Incisors 1/46 2.2 6/31 19.4 7/8 87.5 14/85 16.5
Mandibular Incisors 1/74 1.4 6/27 22.2 12/12 100.0 19/113 16.8
Cuspids 0/31 0.0 0/14 0.0 1/6 16.6 1/51 2.0
Bicuspids 0/78 0.0 4/23 17.4 5/11 45.5 9/112 8.0
Molars 2/99 2.0 13/26 50.0 12/13 92.3 27/138 19.6

Totals 19/555 3.4 58/199 29.1 54/78 69.2 131/832 15.8

Table 16
Splinting in Individual Dental Arches
WM (154) D (30) ED (16) Total (200)

Number Percent Number Percent Percent Number Percent

Extensive 3 1.9 1 3.3 0 0 4 2.0

Limited 14 9.1 0 0.0 0 0 14 7.0
Bridges 49 31.8 10 33.3 0 0 59 29.5

Surgical procedures were accomplished on 46 (59.7%)
of the 77 patients in the Well-Maintained group during
the initial treatment period, the maintenance period or
both. Thirty one patients in the WM group received no
surgical treatment. In many instances, surgery, in the
Well-Maintained group consisted of gingivectomy due
either to gingival enlargements or suprabony pockets.
In the Downhill group, 8 of the 15 patients initially
received some surgical treatment. Four patients had
surgical therapy in both the initial treatment period and
subsequently during the period of maintenance care.
Due to the advanced nature of the periodontal condition
in patients of the Extreme Downhill group, only three of
the eight patients were initially managed with some
surgical therapy. One of these received additional sur-
initialtherapy and maintenance, the additional surgery
usually occurred in the maxillary arch. This pattern was
true for all response groups, with the region of the
maxillary molars being the most common. In the WM
group, 18 maxillary and 6 mandibular areas which ini-
tially had been treated surgically, received additional
surgery during maintenance.
The number and location of the teeth which were lost
following surgical treatment are presented in Table 15.
The failure rate for 832 teeth managed surgically was
15.8% of the total of all response groups. Only 19 (3.4%)
of the 555 teeth in the WM group which had received
surgery were subsequently lost. The highest tooth loss
occurred in the Extreme Downhill response group where
a 69.2% failure occurred. Molar teeth, particularly max-

gery during maintenance, and one patient, not originally
treated surgically, did receive surgical care to facilitate
prosthetic therapy.
Surgical experience differed among the response
groups, though some patients in all groups received
surgery (Table 13). In the WM group, 59.7% of the
patients received surgery, in the Downhill group this was
80.0%, and in the Extreme Downhill group, 62.5% of the
patients had surgical therapy.
The number of surgical procedures performed on in-
dividual patients within the total group varied, depend-
ing upon the specific needs of the patient. Surgical
procedures performed per patient by response groups are
outlined in Table 13. This ranged from a single operation
in one area to as many as 10 such procedures accom-
plished during both initial and maintenance phases.
When an area was treated more than once, during both
illary molars, represented the highest percentage of teeth
lost following surgical treatment. Mandibular cuspids
had the best survival rate in all groups.
FIXED AND REMOVABLE PROSTHESES
For the purpose of evaluating prosthetic replacements
in the patients of this study, it was necessary to consider
both dental arches (Table 16). Extensive splinting was
not a common modality of therapy, particularly in the
WM group, since splints were not required. Only four
arches in the 100 patients had extensive splinting. More
often, limited splinting of segments of arches occurred.
This was sometimes combined with removable prosthe-
ses. A total of 14 such limited splints were present, all in
the WM group. Though many fixed bridges had double
abutments, these were not considered as splints, and
were tabulated as bridges. Most of these were fixed

546 McFall
Table 17
Dentures in Individual Dental Arches
WM (154)
Num-
Percent
ber
Complete dentures 1 0.65
Partial dentures 2 1.29
Distal extension 9 5.84
dentures
Nesbitt bridges 1 0.65
bridges (59), and all of the bridges were in the dental
arches of patients in the Well-Maintained and Downhill
groups. No splinting was accomplished in the Extreme
Downhill group. Splinting was not needed in some pa-
tients. Other patients in this group had teeth which were
not considered good risks for extensive restorations.
Removable prosthetic appliances were placed in 39
dental arches out of the total of 200 (Table 17). This
represented 19.5% of the total arches. Complete dentures
were placed in only six arches and four of these were in
the Extreme Downhill group where the greatest tooth
loss occurred. Partial dentures of the distal extension
type were the most common removable prostheses in all
groups, with a total of 29 such appliances placed. Tooth-
borne partial dentures and Nesbitt bridges represented
only a small percentage of the prosthetic appliances.
DISCUSSION
In the present study, tooth loss following therapy was
the principal parameter investigated. As suggested by
Hirschfeld and Wasserman,28 tooth loss represents only
one facet of success or failure. It is, however, a very
objective and definitive criterion. Since the essential goal
of therapy remains the preservation of a healthy denti-
tion, a low rate of tooth loss is reflected as a positive
tooth retention factor. Patterns and rates of tooth loss
may provide a convenient measure of the success of
patient response to periodontal therapy when compared
with other studies in which patients received no peri-
odontal treatment. Study of tooth loss patterns also may
aid in selection of preservation techniques for those teeth
which seem particularly susceptible to periodontal de-
struction.
A comparison of the results of this study with those of
the long-term survey of Hirschfeld and Wasserman28
reveals marked similarities as well as some contrasts. The
population sample size of 100 patients represents exactly
one-sixth that of the previous survey. The average and
median number of years of maintenance was similar, 22
years in the Hirschfeld and Wasserman survey and 19
years in this study. Male and female patients were
slightly more evenly distributed in the current study. The
average age of patients in this study was 43 years. In the
previous population28 the average age was 42 years at
the time of initial therapy. A slightly older population
participated in this study, with 71% of the patients below
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J. Periodontol.
September, 1982
D (30) ED (16) Total (200)
Num-
Number Percent Percent Number Percent
ber
1 3.3 25.0 6 3.0
1 3.3 0.0 3 1.5
12 40.0 50.0 29 14.5
0 0.0 0.0 0.5
age 50 at initial therapy and 54% between the ages of 35
and 49. In the Hirschfeld and Wasserman survey 83% of
the sample was below age 50 and 60.3% between ages 35
and 49.
More patients in the Hirschfeld and Wasserman sur-
vey were initially diagnosed as having advanced disease,
76.5%, as compared with 36% in this study. Conversely,
53% of the population studied here was diagnosed as
having intermediate disease, as compared with 16.5% in
their study. Both studies had a similarly small incidence
of patients with early periodontal disease. It is important
to recognize that the population in both studies was
composed of patients who had shown enough suscepti-
bility to periodontal disease to warrant referral to a
periodontist.
Of more importance than the original classification
was the similarity in the two studies based on patient
response to therapy. Patients in the Well-Maintained
category comprised 77% of the population here and
83.2% in the previous survey. Downhill response patients
were represented here by 15%, while 12.6% of the patients
were designated Downhill in the Hirschfeld and Wasser-
man study. The Extreme Downhill group consisted of 8
patients (8%) of the present population and 25 patients
(4.2%) in the Hirschfeld and Wasserman sample. The
Extreme Downhill response group of patients repre-
sented a small number and percentage of the population
in both studies, but they did account for most of the
tooth loss. Not only were tooth loss figures affected by
this small group, but all other factors studied were also
influenced.
It was also considered more important to focus on the
positive results of therapy and maintenance in the Well-
Maintained group and to a lesser degree in the Downhill
patients. These response groups, which comprised the
large majority of patients in both study populations,
provided reassurance of the value of periodontal treat-
ment.
Pattern of Tooth Loss
A bilateral pattern of osseous destruction has been
noted previously.20, 21- 28, 32-34 The pattern of bone loss
reported in 1942 by Miller and Seidler20 was very similar
to the pattern of tooth loss reported by Hirschfeld and
Wasserman,28 and to that found in this study.
Wasserman and Geiger33'34 in a study of 516 patients
Volume 53
Number 9
noted the presence of disease in association with specific
teeth and listed the teeth in a decreasing order of fre-
quency of occurrence. That listing was almost exactly
the same as the list of tooth loss presented in the survey
by Hirschfeld and Wasserman.28
The present study offers additional support for the
concept of the bilateral nature of tooth loss. Although
this pattern was not applicable for each patient, due to
differences in local factors, studies of large population
groups clearly indicate this tendency. The descending
order of the frequency of tooth loss listed by Hirschfeld
and Wasserman28 was also found in the present investi-
gation, with a few exceptions. The same exact order of
tooth loss occurred with regard to first and second mo-
lars. In the current study third molars were included in
the listing. They were not listed in the previous investi-
gations.28' 33'34 Also, a reversal in order occurred with loss
of maxillary bicuspids. More maxillary first bicuspids
than maxillary second bicuspids were lost here, while the
previous survey28 showed the opposite. No clear expla-
nation emerges for this, though the furcation arrange-
ment and use of the first bicuspids as removable pros-
thetic abutments may have been contributory.
High mortality rates for maxillary and mandibular
molars also have been reported in treated cases by
Ramfjord et al.35 and in untreated patients by Becker et
al.27 Up to age 40 the loss of first molars in both arches
at the onset of initial therapy in this study was most
likely attributable to dental caries. Modern preventive
measures, including fluoridation, will decrease the vul-
nerability of this dental unit in the future. Loss of
maxillary second molars in people over age 40, however,
appears to be governed more by periodontal disease than
dental caries.
Various factors contribute to the high mortality of
maxillary posterior teeth. These include difficulty of
plaque removal, anatomic design of the roots, occlusal
stresses, lack of distal bone support, problems of root
proximity, and iatrogenic problems. It would seem pru-
dent to minimize as many of these factors as feasible.
Patients should be instructed to initiate oral physiother-
apy in posterior segments. Destructive forces on molar
teeth with lack of support should be decreased by occlu-
sal therapy. Supporting structures should be carefully
evaluated before being used as prosthetic abutments.
Mandibular molar loss appears to be influenced by
factors other than caries or periodontal disease. Unfor-
tunately, the mere presence of radiographie bone loss in
mandibular furcations has resulted in unwarranted ex-
traction. A tendency by some practitioners to employ
bilaterally symmetrical removable prostheses and free
end mandibular partíais also has compromised these
mandibular posterior units.
Incisor tooth loss also is related to elements other than
lost periodontal support. Accidental trauma, caries, re-
storative and esthetic considerations are more likely to
jeopardize maxillary incisors than periodontal destruc-
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Tooth Loss in Periodontal Disease 547
tion. Mandibular incisors too often have been extracted
because a practitioner erroneously decided that a com-
bination of gingival recession, accumulation of local
etiologic agents, and radiographie evidence of lost alveo-
lar support justified their removal. Results of this and
previous investigations28,35 suggest that mandibular in-
cisors survive quite well.
The excellent retention rate of cuspids, particularly
mandibular cuspids, provides additional evidence for the
maintenance and use of these teeth. Mandibular bicus-
pids also seem to be resistant to loss. Because mandibular
cuspids and bicuspids have a minimal band of attached
gingiva in many instances, these teeth have often re-
ceived gingival grafts. A longitudinal study of soft tissue
grafts vs. nontreatment has been published.15 In view of
the results of that study and the survival rate of these
teeth, the need for such surgical procedures should be
carefully assessed.
Furcations
Mortality rates of maxillary and mandibular molars
focused attention on the role of furcation invasion in
tooth loss. In this study 94 out of 163 teeth (56.9%)
originally diagnosed as having furcation invasion were
lost, while Hirschfeld and Wasserman28 reported a 31.4%
loss. In both studies the vast majority of tooth loss
occurred in the Downhill and Extreme Downhill re-
sponse groups. In the Well-Maintained group here only
27.3% of such teeth were lost, and Hirschfeld and Was-
serman28 listed 19.3% tooth loss in their Well-Maintained
group. Ramfjord et al.35 reported that molars and max-
illary bicuspids had a poorer prognosis compared to
other teeth. Ross and Thompson11 studied retention of
maxillary molars with furcation involvement in 100 pa-
tients with chronic periodontal disease and reported the
loss of only 12% of 341 teeth with furcation involvement
over a period of 5 to 24 years after treatment. At the
time of extraction more than one-half of the teeth had
been present 6 to 18 years after initial treatment. In a
later study Ross and Thompson17 indicated that furcation
involvements were more common in maxillary teeth than
in mandibular molars, and that many teeth survived and
were functional many years after treatment. In the pres-
ent study an assessment was made of the survival dura-
tion of the teeth which originally had presented with a
furcation invasion and were eventually lost. In the Well-
Maintained group this averaged 14 years; in the Down-
hill group IOV2 years, and in the Extreme Downhill group
almost 9 years. It should be noted that although 56.9%
of questionable teeth with furcations were lost, 64.2% of
nonfurcated questionable teeth were also lost. This
would seem to suggest that prognosticating ability and
premature extraction of teeth with furcation require
reexamination.
Surgical Therapy
Surgical treatment was accomphshed on 63% of the

548 McFall
patients in this study, which is a higher percentage than
the 39.2% of the Hirschfeld and Wasserman survey.28
Additionally, the number of surgical procedures per-
formed in each response group was proportionally higher
in the present study. This probably reflects a difference
in philosophy, and the fact that a variety of surgical
techniques were available during the period of treatment
in the present study as compared with the time period of
the Hirschfeld and Wasserman study.28 Following sur-
gical treatment 131 out of 832 teeth so treated were
eventually lost (15.8%). By comparison 128 teeth not
treated surgically also were lost. More surgery was per-
formed in the maxillary than mandibular arch. This is a
reversal of the surgical experience reported by Hirschfeld
and Wasserman.28 Most of this maxillary surgery oc-
curred as the result of retreatment by flap techniques in
the molar region.
Tooth loss in all groups seemed to follow an irregular
cyclic pattern. Individual patients could have several
years without apparent change and then have a period
of periodontal destruction resulting in loss of several
teeth. This phenomenon occurred in all groups and
seemed unrelated to response grouping or oral hygiene
effectiveness. This sudden increase in destruction, in
some patients, was associated with changes in systemic
health, interruptions in social patterns, or heightened
stress, but more often no such factor could be deter-
mined. Loss of key teeth often prompted extraction of
other teeth to accommodate prosthetic construction.
Comparison of cross-sectional surveys of tooth loss
due to untreated periodontal disease with long-term
studies of treated cases may have but limited value. It
does provide, however, a measure of the worth of peri-
odontal treatment and maintenance care. Marshall-Day
et al.,19 in a cross-sectional survey, attributed loss of most
teeth between ages 30 and 60 to periodontal disease.
Only 7% of the people studied had had any periodontal
care. People in the 40-year age span had lost an average
of 10 teeth each. Becker et al.27 evaluated untreated
periodontal disease in a longitudinal study and reported
that the study population lost 7.7% of the total number
of teeth over a 3.7 year average time period.
Oliver22 reported on 442 patients treated and main-
tained in his practice from 5 to 17 years, with an average
maintenance period of 10.1 years. He reported a tooth
loss rate of 1.6%. This compares with the 7.1% tooth loss
in the total population survey of Hirschfeld and Wasser-
man,28 and the 9.8% tooth loss of the total population
reported here. An explanation for the discrepancy in the
tooth loss experience in the three studies may lie in the
maintenance time. Oliver's average maintenance period
was 10.1 years, Hirschfeld and Wasserman maintained
their patients on an average of 22 years, and the popu-
lation in this study was maintained an average of 19
years. These additional years of maintenance in the
longer-term studies may have resulted in the loss of more
teeth as well as allowing for development of new peri-
odontal destruction.
J. Periodontol.
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September, 1982
In the Well-Maintained group of the previous survey28
the average tooth loss per patient was 0.68. Coinciden-
tally, the Well-Maintained group in the present study
also averaged a tooth loss of 0.68 per patient. Compared
to the extensive tooth loss in untreated patients19,27 this
represents a substantial benefit to the patient who accepts
periodontal treatment and periodic maintenance care.
ACKNOWLEDGMENT
The author gratefully acknowledges the aid of Mrs. Nancy M.
Swank in preparation of the manuscript and the assistance of the
Learning Resources Center of the School of Dentistry with the tabular
material.
REFERENCES
1. Socransky, S. S.: Microbiology of periodontal disease—present
status and future considerations. J Periodontol 48: 497, 1977.
2. Tanzer, J. M.: International Conference on Research in the Biology
of Periodontal Disease, pp. 155-182, Chicago, College of Dentistry,
University of Illinois, 1977.
3. Lovdal, ., Arno, ., Schei, O., and Waerhaug, L: Combined
effect of subgingival scaling and controlled oral hygiene on the inci-
dence of gingivitis. Acta Odontol Scand 19: 537, 1961.
4. Lightner, L. M., O'Leary, T. J., Drake, R. B., Crump, P. P., and
Allen, M. F.: Preventive periodontic treatment procedures: Results
over 46 months. / Periodontol 42: 555, 1971.
5. Suomi, J. D., Leatherwood, E. C, and Chang, J. J.: A follow-up
study of former participants in a controlled oral hygiene study. J
Periodontol 44: 662, 1973.
6. Rosling, B., Nyman, S., Lindhe, L, and Jem, B.: The healing
potential of the periodontal tissues following different techniques of
periodontal surgery in plaque-free dentitions. A 2-year clinical study.
J Clin Periodontol 3: 233, 1976.
7. Axelsson, P., and Lindhe, J.: Effect of controlled oral hygiene
procedures on caries and periodontal disease in adults. J Clin Perio-
dontol 5: 133, 1978.
8. Lindhe, J., and Nyman, S.: The effect of plaque control and
surgical pocket elimination on the establishment and maintenance of
periodontal health. A longitudinal study of periodontal therapy in
cases of advanced disease. J Clin Periodontol 2: 67, 1975.
9. Ramfjord, S. P., Knowles, J. W., Nissle, R. R., Burgett, F. G.,
and Schick, R. .: Results following three modalities of periodontal
therapy. J Periodontol 46: 522, 1975.
10. Hamp, S., Nyman, S., and Lindhe, J.: Periodontal treatment of
multirooted teeth. Results after 5 years. J Clin Periodontol 2: 126, 1975.
11. Ross, I. F., and Thompson, R. H.: A long term study of root
retention in the treatment of maxillary molars with furcation involve-
ment. J Periodontol 49: 238, 1978.
12. Nyman, S., and Lindhe, J.: A longitudinal study of combined
periodontal and prosthetic treatment of patients with advanced peri-
odontal disease. J Periodontol 50: 163, 1979.
13. Knowles, J. W., Burgett, F. G., Nissle, R. R., Shick, R. .,
Morrison, E. C, and Ramfjord, S. P.: Results of periodontal treatment
related to pocket depth and attachment level. Eight years. J Periodontol
50: 225, 1979.
14. Caffesse, R. G., and Guinard, . .: Treatment of localized
gingival recessions. Part IV. Results after three years. J Periodontol 51:
167, 1980.
15. Dorfman, H. S., Kennedy, J. E., and Bird, W. C: Longitudinal
evaluation of free autogenous gingival grafts. J Clin Periodontol 7: 316,
1980.
16. Yukna, R. ., and Williams, J. E.: Five year evaluation of the
excisional new attachment procedure. / Periodontol 51: 376, 1980.
17. Ross, I. F., and Thompson, R. H.: Furcation involvement in
maxillary and mandibular molars. J Periodontol 51: 450, 1980.
18. Pihlstrom, B. L., Ortiz-Campos, C, and McHugh, R. B.: A
randomized four year study of periodontal therapy. J Periodontol 52:
227, 1981.
Volume 53
Number 9
19. Marshall-Day, C. D., Stephens, R. G., and Quigley, L. F., Jr.:
Periodontal disease: Prevalence and incidence. / Periodontol 26: 185,
1955.
20. Miller, S. C, and Seidler, . .: Relative alveoloclastic experi-
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22. Oliver, R. C: Tooth loss with and without periodontal therapy.
Periodontal Abst 17: 8, 1969.
23. Ross, I. F., Thompson, R. H., and Galdi, M.: Results of treat-
ment. A long term study of one hundred and eighty patients. Parodon-
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history of periodontal disease in man. The rate of periodontal destruc-
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26. Loe, H., Anerud, ., Boysten, ., and Smith, M.: The natural
history of periodontal disease in man. Tooth mortality rates before 40
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27. Becker, W., Berg, L., and Becker, . E.: Untreated periodontal
disease. A longitudinal study. J Periodontol 50: 234, 1979.
28. Hirschfeld, L. I., and Wasserman, B.: A long-term survey of
Announcement
THE UNIVERSITY OF PENNSYLVANIA SCHOOL OF
DENTAL MEDICINE
The University of Pennsylvania School of Dental Medicine an-
nounces the following continuing education courses:
Title: Expanding the Practice of Orthodontics: Adult Orthodon-
tics
Dates: Friday and Saturday, October 15-16, 1982
Faculty: Manuel H. Marks, D.D.S., Associate Professor of Perio-
dontics
Herman Corn, D.D.S., Professor of Periodontics
Robert Vanarsdall, Jr., D.D.S., Associate Professor of
Orthodontics and Periodontics
I. Stephen Brown, D.D.S., Assistant Professor of Perio-
dontics, University of Pennsylvania
This course is for orthodontists, periodontists and restorative dentists
who are involved in treating adults with orthodontic needs. This course
will focus on the implications of orthodontic treatment for patients
with missing teeth, periodontal disease, occlusal problems and plans
for extensive restorative dentistry. Main topics of interest include goals
and objectives of adult orthodontics; fractured teeth—forced eruption;
posterior bite collapse; inadequate anchorage; plaque control; inade-
19433670, 1982, 9, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1902/jop.1982.53.9.539 by University Of California, San, Wiley Online Library on [22/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tooth Loss in Periodontal Disease 549
tooth loss in 600 treated periodontal patients. J Periodontol 49: 225,
1978.
29. Charters, W. J.: Proper home care of the mouth. J Periodontol
19: 136, 1948.
30. Bass, C. C: An effective method of personal oral hygiene. J La
State Med Soc 106: 100, 1954.
31. Allen, D. L., McFall, W. T., Jr., and Hunter, G. C, Jr.:
Periodontics for the Dental Hygienist, ed 3, Chap 7, Philadelphia, Lea
and Febiger, 1980.
32. Wade, A. B.: Validity of anterior segment scores in epidemio-
logica! studies. J Periodontol 37: 55, 1966.
33. Wasserman, B. H., Geiger, A. M., Thompson, R. H, Jr., Good-
man, S. F., Pomerantz, J., Turgeon, L. R., and Beube, F. E.: Relation-
ship of occlusion to periodontal disease, Part II. Periodontal status of
the study population. J Periodontol 42: 371, 1971.
34. Wasserman, B. H., Geiger, A. M., Thompson, R. H, Jr., and
Turgeon, L. R.: Relationship of occlusion to periodontal disease. Part
IV. Relationship of inflammation to general background characteristics
and periodontal destruction. J Periodontol 42: 547, 1972.
35. Ramfjord, S. P., Knowles, J. W., Morrison, E. C, Burgett, F.
G., and Nissle, R. R.: Results of periodontal therapy related to tooth
type. J Periodontol 51: 270, 1980.
Send reprint requests to: Dr. Walter T. McFall, Jr., Department of
Periodontics, School of Dentistry, Chapel Hill, North Carolina 27514.
quate attached gingiva; dental and anatomical considerations; patient
management; current methods of retention and stabilization.
Title: Free Gingival Grafts: How, When, Why, Where To Do and
What Not To Do
Date: Wednesday, September 29, 1982
Faculty: Jay Seibert, D.D.S., M.S.D., Professor and Chairman of
Periodontics, University of Pennsylvania
This course is designed for practitioners who want to utilize the
technique of gingival grafting with confidence. An in-depth course
designed for periodontists and generalists who practice periodontics
and employ surgical procedures in practice. The presentation will
include slide-illustrated lectures and demonstrations. Main topics of
interest include: review of literature and current state of surgical
procedure; diagnosis, indications and contraindications; instruments,
types of suturing, and protections and management of the donor and
recipient sites; management of postoperative problems; hints and how
to's you won't find in any textbook; presentation of clinical cases;
mistakes and how to avoid them.
For more information contact: Eileen Bliss, Assistant Director,
Continuing Education Department, University of Pennsylvania School
of Dental Medicine, 4001 Spruce Street, Philadelphia, PA 19104.