A 30-year retrospective cohort outcome study of periodontal treatment of stages III and IV patients in a private practice.

AIM: Tooth loss studies show that periodontal treatment is effective. However, it is not known whether these results can be projected into a lifetime of treatment. The aim of the study was to study all patients with stages III/IV of periodontitis over 30 years in a private practice. MATERIALS AND METHODS: All patients referred between 1986 and 1990 were monitored for 30 years for tooth loss and prognostic factors. All dropouts were accounted for. RESULTS: In all, 386 patients were followed, of whom 283 patients dropped out, leaving 103 patients (67 females and 36 males, average age 40.1 years) monitored over 30 years. Tooth loss was stable until 16 years, when the population was divided into groups of low (n = 65), moderate (n = 18) and high (n = 20) tooth loss, losing 1.05 (SD 1.27), 4.83 (SD 0.96) and 11.90 (SD 4.25) teeth, respectively. The strongest prognostic factors were first-degree relatives with periodontitis, periodontal treatment before the age of 35 years, diabetes and patients with teeth with initial hopeless prognosis. CONCLUSION: The majority of patients with stages III and IV periodontitis could be successfully treated with conventional periodontal treatment over a period of 30 years. The findings suggest that retrospective studies with shorter observation times cannot automatically be projected onto the outcome of a lifetime of periodontal treatment.

The PTEN hamartoma tumor syndrome: how oral clinicians may save lives.

INTRODUCTION: Patients with the PTEN hamartoma tumor syndrome (PHTS) have an 81%-90% cumulative lifetime risk of developing cancer. Around 90% of these patients have recognizable oral features. Receiving a diagnosis may save these patients' lives. This is the first presentation of a family with the PHTS diagnosis with focus on the oral and periodontal findings and treatments. CASE PRESENTATION: All three children (one son and two daughters) inherited the same heterozygous variant in the PTEN gene from their father. Gingival overgrowth was observed in all patients in addition to macrocephaly. Other findings included fissured tongue, high arched palate, papules, and trichilemmomas. The father had experienced severe tooth loss. Surgery was performed to treat the gingival overgrowth and periodontal pockets; however, the treatment was characterized by multiple recurrences of the overgrowth. CONCLUSIONS: Oral changes, macrocephaly, tumors, and/or a family history of benign or malignant lesions are important features that oral clinicians should be aware of for a possible PHTS diagnosis. Patients suspected of having PHTS should be referred to a medical practitioner, specifically a geneticist, for further diagnostic investigations. The periodontal problems seemed to be difficult to control for these patients. They will likely need an active and frequent maintenance therapy to control the persistent inflammation and gingival overgrowth. In addition, they need a thorough monitoring for benign or malignant changes in the orofacial regions. Why are these cases new information? Oral features are found in 90% of the cases with the PHTS diagnosis. The periodontal findings showed a persistent recurrence of gingival overgrowth with a strong probability of serious periodontal diseases. What are the keys to successful management of these cases? A suspicion of a PHTS diagnosis with a referral to a medical practitioner, specifically a geneticist, for complete workup may help save these patients' lives. Close monitoring during maintenance therapy with re-treatment as needed to prevent further periodontal complications. Continued monitoring and treatment throughout the patient's lifetime for development of recurrent or new, benign or malignant lesions at relevant sites. What are the primary limitations to success in these cases? A failure to identify the PHTS syndrome with the accompanying oral and periodontal complications. Complications may lead to a delay in appropriate treatment. Inability to control the persistent gingival overgrowth and a deteriorating periodontal condition. A failure to discover benign and malignant lesions in the orofacial region.

Proposing a model for auditing data quality of long-term periodontal outcome studies.

OBJECTIVE: The assessment of the success of conventional periodontal therapy is based on retrospective studies from private practice and university clinics. Due to their marked heterogeneity, it is difficult to assess the data quality and rate these studies. The aim is to test a model for auditing and rating the data quality of periodontal outcome studies. METHODS: The method was adapted from the NIH Health Care Systems Collaboratory model, which uses three data quality dimensions: completeness (including all the relevant variables), consistency (ensuring that the same variables are compared) and accuracy (proportion of data in error with a gold standard). The model was applied to studies from a Norwegian specialist practice and data from the Norwegian Health database to test if the auditing process was workable using real world data. RESULTS: Forty-seven risk and prognostic factors were included for completeness. Seven variables were specified for consistency: tooth loss, smoking, systemic conditions, oral hygiene, individual tooth prognosis, maintenance profiles and timing of extractions. The factors tested showed a 95.7% completeness and an average accuracy deviation from the gold standard of -2.3% for each of the risk/prognostic factors and an overall study score of 93.3%. CONCLUSIONS: It was possible to develop a method for auditing and rating the quality of periodontal outcome studies. The model was tested using both real world data including risk and prognostic factors from individual outcome studies and national big data. The application of the model to these sets of data showed a high accuracy of the risk/prognostic factors and a close relationship with national big data.

Provision of treatment for periodontitis in Norway in 2013 - a national profile.

BACKGROUND: Epidemiological studies have reported high levels of periodontal diseases worldwide. Over the last 40 years, Norway has introduced several measures including major financial support to reduce periodontal diseases. The aims of this study were to establish the present level of periodontal treatment, the treatment profiles for the nation, and to assess if long-term clinical data support the findings. MATERIALS AND METHODS: The database of the Norwegian Health Economic Administration for 2013 was analysed to establish the prevalence of treated periodontitis in a cross-sectional register-based study. Treatment profiles including patients' ages, gender, geographic distributions, treatment types, prosthetic tooth replacements and the treatment distributions between the dental health professionals were assessed. RESULTS: 4.4% of the 20 years and older age group was treated for periodontitis. More females (55%) than males (45%) were treated with predominance in the 60-69 year age group. Private general dental practitioners performed 43.8% of the total periodontal treatment, while dental hygienists performed 22.5%. Periodontists performed 32.8% of the non-surgical and 74.6% of the surgical treatment. Tooth replacements for teeth lost due to periodontal diseases were provided for 0.57% of the population. Clinical studies from Norway showed marked improvements in the periodontal parameters examined over the last 40 years. CONCLUSION: The frequency of periodontal treatments in Norway was low, but sufficient to maintain major tooth retention for the population. Long-term external clinical data supported these findings. The treatments were well distributed between private general dental practitioners, hygienists and periodontists.

Familial tendency as a determinant of tooth loss during long-term periodontal therapy.

AIM: Little evidence exists on how familial tendencies affect the long-term success of periodontal therapy. The aim of this study was to compare outcomes for two generations and their control patients treated in the same private practice. MATERIALS/METHODS: Parents and their children were observed for tooth loss between 1986 and 2017. Matching control groups were identified from the same practice, one for the parent and one for the children group. The control patients had no close family members with a history of periodontal diseases. Both the generations and control groups completed a similar course of periodontal therapy. The matching strategy aimed at making the groups as similar as possible with respect to well-known risk and prognostic factors. The data were analysed by multiple regression where the outcome was the number of teeth lost due to periodontal disease. RESULTS: A total of 435 patients were identified (148 parents, 154 children and 133 controls). 72 parents and 61 children (133) had more than 5 years follow-up (average 15.5 and 12.9 years, respectively). Balancing tests showed that the matching was successful. 65% of tooth loss was attributable to close family history. The regression showed that the parent generation lost 1.02 more teeth than the controls, while the children lost 0.61 more teeth. CONCLUSION: Having close family members with a history of periodontal diseases is a strong prognostic factor affecting the long-term outcome of periodontal therapy.

Adding smoking to the Fardal model of cost-effectiveness for the lifetime treatment of periodontal diseases.

BACKGROUND: Little is known about the financial costs that smoking adds to the lifetime treatment of periodontal disease. METHODS: The total lifetime cost of periodontal treatment was modeled using data from private periodontal practice. The costs of initial and supportive therapy, re-treatment and tooth replacements (with bridgework or implants) were identified using average dental charges from the American Dental Association survey. Smoking costs at $6 and $10 for 20 cigarettes were compared to the costs of lifetime periodontal treatment for stable and unstable compliant patients. RESULTS: Smoking added 8.8% to the financial cost of the lifetime cost of periodontal therapy in stable maintenance patients, 40.1% in patients who needed one extra maintenance visit, and 71.4% in patients who needed two extra maintenance visits per year in addition to added retreatment. The cost of smoking far exceeded the cost of periodontal treatment; For patients who smoked 10 to 40 cigarettes per day at the cost of $6 or $10 a pack, the cost of smoking exceeded the cost of lifetime periodontal treatment by between 2.7 and 17.9 times. Smoking 40 cigarettes at $10 a packet for 3.4 years would pay for the entire lifetime cost of periodontal treatment. CONCLUSION: Smoking adds considerable extra financial costs to the lifetime treatment of periodontal diseases. The cost of smoking itself exceeds the cost of periodontal therapy.

Using prognostic factors from case series and cohort studies to identify individuals with poor long-term outcomes during periodontal maintenance.

BACKGROUND: The accuracy of applying prognostic factors to individual patients is uncertain. AIM/METHOD: The aim was to apply prognostic factors from several outcome studies (case series and cohort) to identify: (1) patients who lost a tooth/teeth during periodontal maintenance; (2) patients who were non-responding to treatment; (3) patients needing re-treatment during periodontal maintenance. In addition, tooth loss was related to initial prognosis and it was determined which of the prognostic factors were also risk factors. Chi squared analysis was carried out for the outcomes of patients with-, and without prognostic factors. Significance level was set at p ≤ 0.05. Sensitivity and specificity was calculated for patients with and without prognostic factors. RESULTS: The prognostic factors only identified a small proportion of patients who lost teeth (34-38%). Combining the prognostic factors resulted in a lower accuracy. A higher proportion of patients with no prognostic factors lost teeth (53.8-96.2%). The chance of identifying a non-responding patient based on family history was 5.9%, for stress 32.4%, and for heavy smoking 8.7%. Significantly more patients (29/40 , χ² = 16.2 p < 0.05) with initial uncertain/poor prognosis and significantly fewer patients (11/40, χ² = 16.2, p < 0.05) with erratic/no compliance needing re-treatment were identified. 21 of 40 patients (52.5%) (p = 0.655) with family history needing retreatment were identified. Combining the prognostic factors identified 5-22% out of a total of 40% of patients needing re-treatment. six out of nine (67%) teeth with an initial hopeless prognosis were lost, 10/109 (9%) teeth with a poor prognosis were lost, 11/346 (3%) teeth with a moderate prognosis were lost and 9/1972 (0.46%) of teeth with a good prognosis were lost. None of the prognostic factors was found also to be a risk factor for developing periodontal diseases. CONCLUSION: Applying prognostic factors to identify individual patients with poor long-term outcomes is associated with low accuracy.

Management of periodontal disease in patients using calcium channel blockers - gingival overgrowth, prescribed medications, treatment responses and added treatment costs.

OBJECTIVES: Gingival overgrowth (GO) is an adverse drug reaction in patients using calcium channel blockers (CCBs). Little is known about the effects of CCBs on the management of periodontal diseases. The aim of this study was to assess how the use of CCBs affects the long-term supportive treatment and outcomes in patients undergoing periodontal therapy. METHODS: All patients using CCBs during the initial treatment and/or the supportive periodontal therapy (SPT) were selected from a periodontal practice. Patients were scored using a Gingival Overgrowth Index (GOI). The effects of CCB types and dosages were assessed in terms of the frequency and the severity of GO, treatment responses, substitutions and extra treatment costs. Mean values, Standard Deviation (SD) and range were calculated. The Mann-Whitney test was used to assess statistically significant differences (p < 0.05) for GO between patients with good and poor oral hygiene, differences between before and after terminating or replacing the CCBs, possible differences between drug dosages (Dihydropyridine 5 mg and 10 mg) and differences between three drug combinations (CCB and inhibitors of the renin-angiotensin system (IRAS), CCB and non-IRAS, CCB and statins). RESULTS: One hundred and twenty-four patients (58 females, 66 males, 4.6% of the patient population) were using CCBs. 103 patients were assessed. Average age was 66.53 years (SD. 9.89, range 42-88) and the observation time was 11.30 years (SD 8.06, range 1-27). Eighty-nine patients had GO, 75 of these required treatment for GO. Terminating or replacing with alternatives to CCBs resulted in significant decreases in GO (p = 0.00016, p = 0.00068) respectively. No differences were found between good and poor oral hygiene (p = 0.074), drug dosages or the various drug combinations. Surgical treatment was more effective than non-surgical treatment in controlling the GO. Long-term tooth loss was 0.11 teeth per patient per year. Forty-two patients needed re-treatments for GO, resulting in an extra life cost per patient of €13471 (discounted €4177). CONCLUSION: The majority of patients (86.4%) using CCBs experienced GO. 47.2% of these experienced recurrence(s) of GO during the SPT and needed re-treatments with resulting added costs. The long-term tooth loss was considerably higher for patients using CCBs than for other patients groups from the same practice setting.

Applying quality assurance in real time to compliant long-term periodontal maintenance patients utilizing cost-effectiveness and cost utility.

BACKGROUND: Little work has been done on quality assurance of long-term maintenance of periodontal therapy MATERIALS/METHODS: A quality assurance model was applied to 80 patients (50 females, 30 males) with an average age of 64.3 years (SD. 8.83, range 45-91) and with 21.6 (SD. 2.65, range 16-26) maintenance years. The main elements were patients' expectations, objectives and patient-based outcomes, human and financial costs and treatment deviations. For cost-effectiveness, this group was compared with a control group of 25 patients with an average of 9.96 years not complying with maintenance therapy. RESULTS: The patients' main expectations and reasons for seeking treatment were to save teeth and a desire for better oral health. The patients had a total tooth-year loss of 3.3%. 81.3% reported improved oral health. Total treatment discounted cost was €5842. The cost of buying an extra tooth year was €20.2. Patients reported anxiety of 4.6 (SD10.5, range 0-47) and discomfort of 11.8 (SD13.2 range 0-70) for the maintenance visits on the Visual Analogue Scale (VAS). Treatment deviations showed 3.8% extreme downhill patients, 6.3% with poor oral hygiene, 3.8% reported a worsening of their oral health, 3.8% had high anxiety whereas 5.0% experienced a high level of discomfort. CONCLUSION: It is possible to apply a number of elements of a quality assurance measure to a patient population of compliant maintenance patients in real time. The results obtained compare well with previous internal and external studies. This model should be useful to patients and practitioners as well as for larger population-based studies.

Incorporating severity and risk as factors to the Fardal cost-effectiveness model to create a cost-benefit model for periodontal treatment.

BACKGROUND: A previously described economic model was based on average values for patients diagnosed with chronic periodontitis (CP). However, tooth loss varies among treated patients and factors for tooth loss include CP severity and risk. The model was refined to incorporate CP severity and risk to determine the cost of treating a specific level of CP severity and risk that is associated with the benefit of tooth preservation. METHODS: A population that received and another that did not receive periodontal treatment were used to determine treatment costs and tooth loss. The number of teeth preserved was the difference of the number of teeth lost between the two populations. The cost of periodontal treatment was divided by the number of teeth preserved for combinations of CP severity and risk. RESULTS: The cost of periodontal treatment divided by the number of teeth preserved ranged from (US) $1,405 to $4,895 for high or moderate risk combined with any severity of CP and was more than $8,639 for low risk combined with mild CP. The cost of a three-unit bridge was $3,416, and the cost of a single-tooth replacement was $4,787. CONCLUSION: Periodontal treatment could be justified on the sole basis of tooth preservation when CP risk is moderate or high regardless of disease severity.

A comparison of teeth and implants during maintenance therapy in terms of the number of disease-free years and costs -- an in vivo internal control study.

BACKGROUND: Little is known about the cost minimization and cost effectiveness involved in maintaining teeth and implants for patients treated for periodontal disease. MATERIALS & METHODS: A retrospective study was carried out encompassing all patients who had initial periodontal treatment followed by implant placement and maintenance therapy in a specialist practice in Norway. The neighbouring tooth and the contra-lateral tooth were used as controls. The number of disease-free years and the extra cost over and above maintenance treatment for both teeth and implants were recorded. RESULTS: The sample consisted of 43 patients with an average age of 67.4 years. The patients had 847 teeth at the initial examination and received 119 implants. Two implants were removed 13 and 22 years after insertion. The prevalence of peri-implantitis was 53.5% at the patient level and 31.1% at the implant level. The prevalence of periodontitis was 53.4% at the patient level and 7.6% at the tooth level. The mean number of disease-free years was: implants: 8.66; neighbouring tooth: 9.08; contra-lateral teeth: 9.93. These mean values were not statistically significantly different from each other. The extra cost of maintaining the implants was about five times higher for implants than for teeth. CONCLUSION: The number of disease-free years was the same for neighbouring teeth, contra-lateral teeth and implants. However, due to the high prevalence of peri-implantitis, the cost of maintaining implants was much higher than the cost of maintaining teeth.

Periodontal and general health in long-term periodontal maintenance patients treated in a Norwegian private practice: a descriptive report from a compliant and partially compliant survivor population.

BACKGROUND: There is weak evidence to support the benefit of periodontal maintenance therapy in preventing tooth loss. In addition, the effects of long-term periodontal treatment on general health are unclear. METHODS: Patients who were compliant and partially compliant (15 to 25 years' follow-up) in private practice were observed for oral and systemic health changes. RESULTS: A total of 219 patients who were compliant (91 males and 128 females) were observed for 19.1 (range 15 to 25; SD ± 2.8) years. Age at reassessment was 64.6 (range: 39 to 84; SD ± 9.0) years. A total of 145 patients were stable (0 to 3 teeth lost), 54 were downhill (4 to 6 teeth lost), and 21 patients extreme downhill (>6 teeth lost); 16 patients developed hypertension, 13 developed type 2 diabetes, and 15 suffered myocardial infarcts (MIs). A minority developed other systemic diseases. Risk factors for MI included overweight (odds ratio [OR]: 9.04; 95% confidence interval [CI]: 2.9 to 27.8; P = 0.000), family history with cardiovascular disease (OR: 3.10; 95% CI: 1.07 to 8.94; P = 0.029), type 1 diabetes at baseline (P = 0.02), and developing type 2 diabetes (OR: 7.9; 95% CI: 2.09 to 29.65; P = 0.000). A total of 25 patients who were partially compliant (17 males and eight females) were observed for 19 years. This group had a higher proportion of downhill and extreme downhill cases and MI. CONCLUSIONS: Patients who left the maintenance program in a periodontal specialist practice in Norway had a higher rate of tooth loss than patients who were compliant. Patients who were compliant with maintenance in a specialist practice in Norway have a similar risk of developing type 2 diabetes as the general population. A rate of 0.0037 MIs per patient per year was recorded for this group. Due to the lack of external data, it is difficult to assess how this compares with patients who have periodontal disease and are untreated.

The lifetime direct cost of periodontal treatment: a case study from a Norwegian specialist practice.

BACKGROUND: Successful periodontal treatment requires a commitment to regular lifelong maintenance and may be perceived by patients to be costly. This study calculates the total lifetime cost of periodontal treatment in the setting of a specialist periodontal practice and investigates the cost implications of choosing not to proceed with such treatment. METHODS: Data from patients treated in a specialist practice in Norway were used to calculate the total lifetime cost of periodontal treatment that included baseline periodontal treatment, regular maintenance, retreatment, and replacing teeth lost during maintenance. Incremental costs for alternative strategies based on opting to forego periodontal treatment or maintenance and to replace any teeth lost with either bridgework or implants were calculated. RESULTS: Patients who completed baseline periodontal treatment but did not have any additional maintenance or retreatment could replace only three teeth with bridgework or two teeth with implants before the cost of replacing additional teeth would exceed the cost of lifetime periodontal treatment. Patients who did not have any periodontal treatment could replace ≤ 4 teeth with bridgework or implants before a replacement strategy became more expensive. CONCLUSIONS: Within the limits of the assumptions made, periodontal treatment in a Norwegian specialist periodontal practice is cost-effective when compared to an approach that relies on opting to replace teeth lost as a result of progressive periodontitis with fixed restorations. In particular, patients who have initial comprehensive periodontal treatment but do not subsequently comply with maintenance could, on average, replace ≤ 3 teeth with bridgework or two teeth with implants before this approach would exceed the direct cost of lifetime periodontal treatment in the setting of the specialist practice studied.

Impact of anxiety on pain perception associated with periodontal and implant surgery in a private practice.

BACKGROUND: There are limited data on pain perception after periodontal or implant surgery or how pain perception is affected by presurgical anxiety. METHODS: Presurgical anxiety and surgical pain perceptions were measured by visual analog scale (VAS) scores and by interview of patients (N = 102) undergoing periodontal or implant therapy in a private periodontal specialty practice in Norway. RESULTS: Patients reported that bad taste, receiving the local anesthetic, and excessive fluid in the mouth were the most uncomfortable experiences associated with periodontal or implant surgery. Analysis of identical responses to these questions showed that there was low intrapatient agreement for uncomfortable experiences (κ = 0.18), but there was reasonably good agreement for comfortable experiences (κ = 0.76). There were no significant differences between repeated VAS scores for pain perception (P = 0.91) or anxiety (P = 0.75) from two consecutive surgeries. There were no significant differences of VAS scores for perception of discomfort for periodontal surgery (9.9 ± 17.0) compared to implant surgery (16.7 ± 24.2; P >0.2). Presurgical anxiety scores were higher for implant surgery (45.5 ± 33.4) than for periodontal surgery (19.5 ± 28.1; P <0.01). Patients with high pretreatment anxiety scores reported that periodontal and implant surgery were more uncomfortable than patients with low anxiety scores (20.5 ± 25.6 versus 0.45 ± 1; P <0.001). VAS perception and anxiety scores did not change on first-time through fourth-time surgeries, but retreatment surgery patients recorded higher perception and anxiety VAS scores than patients undergoing surgery for the third or fourth time (P <0.01). Females recorded significantly higher anxiety scores than males (P = 0.04). CONCLUSION: For periodontal surgery and implant treatments pain perception is affected by the level of presurgical anxiety.

Periodontal maintenance--overcoming the barriers.

UNLABELLED: Periodontal maintenance therapy is the most important stage of periodontal treatment, yet compliance is low. Overcoming the barriers associated with the low compliance involves a complex set of problems relating to the patient, the clinician and the interactions between them. It is therefore important to create a periodontal maintenance treatment programme which takes into consideration the needs of each individual patient. In addition, regional variations and differences in practice profiles are also factors to be accommodated in a maintenance programme. CLINICAL RELEVANCE: Good co-operation between the referring dentist and the specialist is required when recommendations are made to the patient regarding maintenance therapy.

Long-term outcomes for cross-arch stabilizing bridges in periodontal maintenance patients--a retrospective study.

BACKGROUND: Cross-arch bridges are used to stabilize teeth for patients with reduced periodontal support. Little is known about technical or biological complications, whether teeth and implants can be combined in this type of bridge and the long-term effects on tooth loss. MATERIALS AND METHODS: All patients treated in a specialist periodontal practice who received cross-arch stabilizing bridgework and were subsequently maintained for at least 7 years were included in the study. The patients were selected from all patients who underwent initial periodontal therapy after 1986 in a Norwegian periodontal practice. The bridges were assessed for biological and technical complications. Bridges retained by teeth or by a combination of teeth and implants were included in the study. RESULTS: Ninety-four rigid fixed bridges (77 teeth supported, 17 teeth and implant supported) in 80 patients (46 females, 34 males) were observed for an average of 10 years (range 7-22 years). In four patients, a bridge became loose and had to be re-cemented, and in one case the metal framework of a bridge fractured and the bridge had to be remade. In total, eight abutment teeth were lost from five patients but no implant abutments were lost. Overall, a higher rate of tooth loss was observed for patients provided with stabilizing bridges compared with control maintenance patients not treated with bridgework (p<0.0001); however, the rates in both groups were very low. CONCLUSION: Cross-arch stabilizing bridges constructed for periodontal patients as part of their periodontal maintenance therapy had few complications and were associated with low rates of abutment tooth loss. Combining teeth and implants did not affect the performance of these bridges.

Tooth loss and implant outcomes in patients refractory to treatment in a periodontal practice.

AIM: The aim of this study was to investigate the factors associated with continued significant tooth loss due to periodontal reasons during maintenance following periodontal therapy in a specialist periodontal practice in Norway. MATERIAL AND METHODS: A case-control design was used. Refractory cases were patients who lost multiple teeth during a maintenance period of 13.4 (range 8-19) years following definitive periodontal treatment in a specialist practice. Controls were age- and gender-matched maintenance patients from the same practice. Characteristics and treatment outcomes were assessed, and all teeth classified as being lost due to periodontal disease during follow-up were identified. The use of implants in refractory cases and any complications relating to such a treatment were recorded. RESULTS: Only 27 (2.2%) patients who received periodontal treatment between 1986 and 1998 in a specialist practice met the criteria for inclusion in the refractory to treatment group. Each refractory subject lost 10.4 (range 4-16) teeth, which represented 50% of the teeth present at baseline. The rate of tooth loss in the refractory group was 0.78 teeth per year, which was 35 times greater than that in the control group. Multivariate analysis indicated that being in the refractory group was predicted by heavy smoking (p=0.026), being stressed (p=0.016) or having a family history of periodontitis (p=0.002). Implants were placed in 14 of the refractory patients and nine (64%) of these lost at least one implant. In total, 17 (25%) of the implants placed in the refractory group were lost during the study period. CONCLUSIONS: A small number of periodontal maintenance patients are refractive to treatment and go on to experience significant tooth loss. These subjects also have a high level of implant complications and failure. Heavy smoking, stress and a family history of periodontal disease were identified as factors associated with a refractory outcome.

Perceptions of patients' smiles: a comparison of patients' and dentists' opinions.

BACKGROUND: Little information has been published regarding the difference between how patients perceive their own smiles and how dentists view them. METHODOLOGY: The authors interviewed 78 consecutively seen patients in a general dental practice in Norway about esthetic features of their faces. The patients were not actively seeking esthetic treatment. Patients rated themselves using a 100-point visual analog scale (VAS), and then two dentists (the patients' regular dentist and an independent periodontist), working with photographs of the patients, used the same VAS in rating the patients' smiles. RESULTS: The average age of the patients was 51.2 years (range, 22-84 years). There were 50 women (average age, 51.5 years; range, 22-84 years) and 28 men (average age, 52 years; range, 30-78 years). Patients' satisfaction with their own smiles reached an average of 59.1 (standard deviation [SD], 21.1; range, 5-100) on the VAS. The dentists' scores (38.6 and 40.7) were significantly lower than the patients' scores. The authors observed poor correlation between the periodontist's scores of dentogingival features and the patients' scores. Patients were most satisfied with the gingiva when smiling and least satisfied with tooth shade. Patients younger than 50 years were most satisfied with their smiles. Patients rated teeth and eyes as the most important features in an attractive face. Women gave teeth and hair significantly higher scores and head shape lower scores than did men. CONCLUSION: Patients' opinions of their own smiles were significantly higher than the two clinicians' assessments of their smiles. Dentists should be aware that patients who seek esthetic services may have different perceptions of their smiles than may patients who do not express such desires.

Interviewing self-reported highly anxious patients during periodontal treatment.

BACKGROUND: Little information exists on highly anxious patients referred for periodontal therapy. METHODS: All patients referred for periodontal therapy between November 1, 2002 and April 1, 2004 were included in this study. Patients who perceived themselves as extremely anxious were interviewed further, and their anxiety levels were observed during the various stages of periodontal therapy. RESULTS: Twenty-one (19 females and two males, average age, 49.76 years) of 176 patients (12.1%) reported extreme anticipatory anxiety. The main reasons for their anxiety were fear of pain and previous bad experience(s). CONCLUSIONS: Average anxiety levels decreased with the progress of the periodontal therapy. However, individual responses varied greatly and were unpredictable.