grassi 1987 perio pocket healing following extraction

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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



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



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



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



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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plan de traitemenl et des considerations indi-viduelles concernant le patient en question.

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Dr. Markus Grassi

University of Berne

School of Dental MediciFreibvTgstrasse 7

CH-30I0 Berne

Switzerland

grassi 1987 perio pocket healing following extraction

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