Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2010 37; 545552

A clinical follow-up study of the periodontal conditions of RPD abutment and non-abutment teeth
. G . R O N C A L L I , B . A . D O A M A R A L * , A . O . B A R R E T O * , E . G O M E S S E A B R A , A A . D A F O N T E P O R T O C A R R E I R O & E . O . D E A L M E I D A *Federal University of Rio Grande do Norte,
Natal, RN, Department of Dentistry, Federal University of Rio Grande do Norte, Natal, RN, Arac atuba School of Dentistry, UNESP Univ. Estadual Paulista, Brazil

The purpose of this study was to evaluate the periodontal conditions of removable partial denture (RPD) wearers, comparing direct and indirect abutment teeth, and the teeth not involved in the denture design before denture placement and 1 year later. Fifty patients (32 women and 18 men), average age 45, were assessed by the same examiner at the moment of denture insertion and 3, 6, 9 and 12 months later. The following items were veried in each assessment: probing depth (PD), plaque index (PI) and gingival index (GI). PD and PI data were evaluated by ANOVA test for linear trend followed by TukeyKramer post-test, while GI data were analysed by Friedmans test. Results showed that the teeth not involved in the denture design
SUMMARY

were the least affected for all variables studied. It was also veried that PD and GI mean values increased from the initial assessment to 1 year of RPD wearing in every group, but that only PI showed a signicant increase. This study indicated that direct and indirect retainer elements tend to undergo more damaging periodontal effects associated with RPD wearing when compared with non-abutment elements. Plaque index values were signicantly higher after 1 year of denture use. KEYWORDS: dental plaque, oral hygiene, periodontal diseases, removable partial denture Accepted for publication 30 January 2010

Introduction
Removable partial dentures (RPD) are an alternative treatment for the restoration of edentulous areas; these dentures are conservative treatments and provide a rapid solution and accessible cost. However, longitudinal studies have shown that they have been associated with increased gingivitis, periodontitis and abutment teeth mobility (1, 2). Clinical studies (3, 4) have emphasized RPD-related periodontal tissue reactions, such as inammation, increase in probing depth, in dental mobility and in marginal bone loss. Drake & Beck (4) stated that RPDs have an unfavourable effect on patients periodontal conditions. In addition, it appears that abutment teeth suffer even more damaging effects, besides receiving
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clasps and being subject to additional loads, which could cause mobility. That is, abutment teeth are more susceptible to caries and periodontal problems than other teeth, as the clasps surrounding abutment teeth facilitate dental biolm accumulation. The adverse effects of RPD wearing on the teeth and periodontium could be minimized by dental biolm control programmes and with satisfactory denture design requirements (1, 5). However, Drake & Beck (4) reported that RPD wearing can alter the oral environment and cause some harm, especially to abutment teeth, which receive clasps. In contrast, authors such as Bergman et al. (6) have reported that RPD alone causes no additional oral pathology. For this, appropriate oral hygiene instructions, regular maintenance and control intervals for coronal-root
doi: 10.1111/j.1365-2842.2010.02069.x

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Table 1. Type of teeth (incisor, canine, pre-molar and molar) presented in the study Maxilla Incisor Direct Indirect Control Total 16 3 39 Canine 42 3 2 Pre-molar 27 7 9 Molar 48 22 19 Mandible Incisor 10 31 44 441 Canine 15 6 20 Pre-molar 34 2 14 Molar 23 1 4 Total 215 75 151

scaling and planning, as well as denture adjustments are necessary. Nonetheless, these results are inconclusive and sometimes contradictory (1). In view of this controversy, and considering the fact that numerous RPD wearers present periodontal alterations (7), the purpose of this study was to clinically evaluate for 1 year, the periodontal conditions of RPD wearers, associated with professional dental biolm control, comparing direct and indirect retainer and non-abutment teeth.

Material and methods

Fifty patients (32 women and 18 men) participated in the study, after placement of RPD at the Dentistry Department of the Federal University of Rio Grande do Norte (RN, Brazil). Patients were between 26 and 66 years (average age, 45 years). Every patient received previous oral treatment and their mouths were specifically prepared for each case and planned using a dental surveyor. Assessment was conducted in accordance with the norms and guideline studies involving humans (resolution number 196, approved on 10 October 1996, by the National Health Council) and approved by the Federal University of Rio Grande do Norte Research Ethics Committee. All patients provided written informed consent authorizing their participation in the study, making their data available for evaluation and publication. The patients were divided into three groups: direct retainers (teeth close to the denture space that receive denture elements), indirect retainers (teeth further away from the denture space, but which also support denture elements) and control teeth (teeth with no denture elements). The kind of tooth (incisor, canine, pre-molar and molar), clasp design and missing area were presented in Tables 1, 2 and 3. At the moment of RPD insertion, an anamnesis was carried out, using clinical records to assess patients overall health condition, oral health, oral hygiene,

reasons for seeking RPD treatment, as well as previous experiences with other dentures. The intra-oral physical assessment, performed by a trained examiner, identied the dentures general characteristics: tooth function (direct and indirect retainers, and non-abutment) and periodontium conditions (probing depth, and plaque and gingival indexes). Probing depth (PD) was veried using a Williams periodontal probe* in the following locations: vestibular, disto-vestibular, mesio-vestibular, lingual, mesiolingual and disto-lingual. Gingival index (GI) was assessed by means of sulcular bleeding; that is, the bleeding that occurs after probing. Plaque index (PI) was veried using a disclosing solution Eviplac. For both indexes, each tooth on the record was also represented by a square and each dental surface by a triangle (vestibular, palatine lingual, mesial, and distal). Bleeding surfaces dyed by the disclosing solution were marked on the corresponding triangle. Subsequently, similarly to the gingival index, plaque indexes were obtained by means of the number of surfaces with plaque and bleeding, respectively, for each tooth, ranging from zero to four. PI and GI values (percentage) per patient were calculated using the modied OLeary Index, according to the formula: number of surfaces with plaque 100 number of teeth 4. The initial assessment was performed at the moment of RPD insertion. In addition to the assessment, patients received oral hygiene instructions, as well as a brief explanation about dental biolm pathogenicity and the importance of plaque control, coronal-root scaling and planing (CRSP) and prophylaxis using a micromotor, rubber cup or Robinson bristle brush with prophylactic paste. The entire assessment described previously, as well as CRSP, when necessary, was performed every 3 months for 1 year, totalling ve assessments, four of
, SP, Brazil. *Trinity periodontics, Jaragua mica Qu Biodina m. Farm. Ltda, Ibi pora, PR, Brazil. 2010 Blackwell Publishing Ltd

PERIODONTIUM OF ABUTMENT AND NON-ABUTMENT TEETH

Table 2. Clasp design (C-clasp or T-bar clasp) presented in the study Maxilla Clasp design C-Clasp T-bar clasp Total Incisor 7 8 Canine 22 10 Pre-molar 27 7 Molar 67 2 Mandible Incisor 1 4 219 Canine 3 11 Pre-molar 17 13 Molar 20 0 Total 164 55

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Table 3. Classication of arch and RPD support type presented in the study Classication Tooth support Tooth-mucosa-supported Total Maxilla 198 37 Mandible 97 103 Total 295 140 385

(direct and indirect retainers and control). However, Friedmans test was performed for the GI variable in the control group, because the data did not present a normal distribution.

Results
Variable behaviours were separately evaluated within 1 year (Tables 35, Figs 13). In general, there were no statistically signicant differences in the periodontal conditions across the three groups; however, the plaque indexes showed signicant difference.

which were for professional dental biolm control (before RPD insertion and after 3, 6, 9 and 12 months). The data were compiled on a database, using Microsoft Ofce Excel 2003. SPSS 13.0 was used for descriptive statistics and condence interval analysis, and Graph Pad InStat 3.05 for analysis of variance. ANOVA test for linear trend followed by TukeyKramer post-test was performed to evaluate quantitative (PD, GI, PI) dependent variable behaviours over time for each group

Probing depth (PD) Every group had increased PD values during the study. However, there were no statistically signicant differences between the initial assessment and at

Table 4. Sample size (n), mean, standard deviation, median, minimum, maximum, inferior limit and superior limit (95% condence interval) for probing depth (PD) in the studied groups CI (95%) Lower

Time Point Direct Retainer Base line 3 months 6 months 9 months 12 months Indirect Retainer Base line 3 months 6 months 9 months 12 months Control Base line 3 months 6 months 9 months 12 months

Mean* 211a 226a 225a 262b 233a 190a 207a.c 216a.c 236b.c 217a.c 184a 199a 196a 199a 200a

Standard deviation

Median

Minimum

Maximum

Upper

141 141 141 141 141 58 58 58 58 58 99 99 99 99 99

05062 05613 05300 1450 05600 05573 04788 06446 1383 06006 04406 04428 04861 05221 04987

2000 2170 2170 2330 2170 1830 2000 2085 2000 2000 1830 2000 2000 2000 2000

1170 1000 1330 1330 1500 1170 1330 1330 1330 1330 1000 1170 1000 1000 1170

3830 4500 4330 9000 4500 4330 4000 5170 9000 3830 4000 4330 4000 4830 4830

2028 2176 2164 2386 2239 1759 1946 1995 2001 2014 1759 1908 1872 1894 1907

2195 2361 2339 2864 2424 2052 2198 2334 2729 2330 1935 2084 2067 2103 2106

*TukeyKramer test: same letters indicate statistically equal values.

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Table 5. Sample size (n), mean, standard deviation, median, minimum, maximum, lower and upper limits (95% condence interval) for gingival index (GI) in the studied groups CI (95%) Lower

Time Point Direct Retainer Base line 3 months 6 months 9 months 12 months Indirect Retainer Baseline 3 months 6 months 9 months 12 months **Control Time point Baseline 3 months 6 months 9 months 12 months

Mean* 27199a.c 34021b 24695c 30518a 32000a 28293a 36379b 27621a 30397a.b 33138a.b

Standard deviation

Median

Minimum

Maximum

Upper

141 141 141 141 141 58 58 58 58 58

12253 18373 13314 17510 18742 13679 16538 14503 13470 15539

25000 29000 25000 33000 28000 29000 33000 23500 28000 29000

3000 7000 0000 6000 9000 3000 7000 5000 6000 9000

62000 69000 57000 75000 96000 62000 68000 57000 65000 59000

25176 30989 22497 27628 28906 24695 32029 23806 26854 29051

29221 37054 26893 33408 35094 31891 40729 31435 33939 37225

Ranks 104 104 104 104 104

Sum of ranks 31950a 34250a 22200b 31600a 36000a

Median 25000 28000 17000 33000 33000

Minimum 3000 7000 5000 8000 9000

Maximum 59000 69000 54000 75000 96000

*TukeyKramer test: same letters indicate statistically equal values. **Friedmans test.

12 months. There was a statistically signicant difference across groups in terms of time-points: the direct retainer group had greater PD values at 9 months when compared with the other time-points; in the indirect retainer group, PD values increased signicantly from initial assessment to 9 months. The direct retainer group presented greater probing depth averages than the other groups at all times, whereas the control group had the lowest values. Every group demonstrated a linear trend; that is, values increased over time, as veried by the ANOVA test for linear trend (P < 0001) (Table 4, Fig. 1).

28

26

Probing depth

24

22

20

18 Baseline 3 months 6 months

Time

9 months

12 months Control

Gingival index (GI) GI values increased from initial assessment to 12 months, with no statistically signicant difference between groups. At 3 months, there was a signicant increase in GI in the direct and indirect retainer groups. At 6 months, the direct and indirect retainer groups presented a signicant reduction when compared with values at 3 months, and the control group presented a signicant reduction at 6 months when compared with

Direct retainer

Indirect retainer

Fig. 1. Groups behaviour (function) in relation to mean values for probing depth during the study.

the rest of the period. At 9 months, these values increased again, resulting in higher values at 12 months than at initial assessment; however this difference was not statistically signicant. Regarding the linear trend,
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PERIODONTIUM OF ABUTMENT AND NON-ABUTMENT TEETH

400

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350
Gingival index

the direct retainer group and, most of the times, they were also lower than in the indirect retainer group. This was not observed, however, at 3 months, when the control groups value was slightly higher than that of the indirect retainer group (Table 6, Fig. 3).

300

Baseline comparison (BL)

250

200 Baseline 3 months 6 months

Time

9 months

12 months Control

Direct retainer

Indirect retainer

Fig. 2. Groups behaviour (function) in relation to mean values for gingival index during the study.

800 750 700 650 600 550 500 450 400 Baseline 3 months 6 months 9 months 12 months

Plaque index

Comparison between baseline and quantitative results demonstrated that considering the probing depth (PD), the direct retainer group exhibited statistically signicant higher values than the control group. The three groups presented no statistically signicant difference for the gingival index (GI) and plaque index (PI). So, there was no difference in GI and PI across groups at baseline Table 7. The KruskalWallis test was used to analyse the timepoint data, as irregular distribution and no association between the variables were noted Table 8. There was no statistically signicant difference between 12-month follow-up and baseline for all groups considering the following variables: probing depth (PD) and plaque index (PI). Considering the gingival index (GI), there was statistically signicant difference across groups with lower results for the control group in comparison with the direct and indirect retainer groups.

Discussion
The present study shows that teeth involved in RPDs (direct and indirect retainers) are more affected by gingival diseases than non-involved teeth. This result is in accordance with Akaltan & Kaynak (8), who also afrmed that gingival recession is more common on denture-support teeth. However, in the present study, abutment teeth were already damaged before RPD insertion because of the surrounding dental loss, which causes bone reabsorption, or to previous use of inadequate dentures. The increase in probing depth noted in the present study suggest that this occurs because of the gingival oedema caused by dental biolm accumulation and consequent gingival inammation, given that 1 year is not sufcient to afrm that there was insertion loss. With regard to plaque index (PI), mean values increased signicantly in the three groups. It was also observed that the control group presented lower values than the direct and indirect retainer groups for both GI and PI. In line with these results, several authors (4, 8,

Time
Direct retainer Indirect retainer Control

Fig. 3. Groups behaviour (function) in relation to mean values for plaque index during the study.

the direct and indirect retainer groups presented no signicant correlation (P > 005). For the control group, ANOVA test for linear trend could not be performed as the data did not present normal distribution (Table 5, Fig. 2). For this reason, Friedmans test was employed.

Plaque index (PI) PI increased from initial assessment to 12 months, with statistically signicant differences in the three groups. The control group PI values were always lower than in
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Table 6. Sample size (n), mean, standard deviation, median, minimum, maximum, inferior and superior limits (95% condence interval) for plaque index (PI) in the studied groups CI (95%) Lower

Time Point Direct Retainer Base line 3 months 6 months 9 months 12 months Indirect Retainer Baseline 3 months 6 months 9 months 12 months Control Baseline 3 months 6 months 9 months 12 months

Mean* 47991a 58573b 62436b 63329b 71049c 51076a 53709a.c 63975b.c.d 58911a.c.d 66924d 44130a 55599b 57611b 56920b 68728c

Standard deviation

Median

Minimum

Maximum

Upper

225 225 225 225 225 79 79 79 79 79 162 162 162 162 162

25457 17126 23718 24313 17562 27608 22129 23651 27046 16703 23935 15328 25809 24303 18375

46000 58000 62000 59000 69000 45000 56000 69000 55000 66000 43000 56000 55000 52000 68000

0000 17000 12000 9000 40000 0000 17000 21000 9000 40000 0000 20000 12000 9000 40000

10000 95000 99000 99000 99000 10000 95000 99000 99000 99000 99000 86000 99000 99000 99000

44665 56336 59336 60152 68754 44882 48744 58669 52844 63177 40444 53238 53637 53177 65899

51317 60811 65535 66506 73344 57270 58673 69281 64979 70671 47815 57959 61586 60662 71558

*TukeyKramer test: same letters indicate statistically equal values.

Table 7. Descriptive statistical analysis of probing depth (PD), gingival index (GI) and plaque index (PI) at baseline. P-values obtained from analysis of variance. LL, lower limit; UL, upper limit Group Probing depth Direct retainer Indirect retainer Control Total Gingival index Direct retainer Indirect retainer Control Total Plaque index Direct retainer Indirect retainer Control Total n Mean Standard deviation Minimum Maximum LL (95%) UL (95%) P

218 79 152 449 218 79 152 449 218 79 152 449

21047 19536 18794 20019 104 109 093 101 190 192 163 182

050559 057854 045114 051122 0976 0936 0896 0942 1224 1196 1280 1243

117 117 100 100 0 0 0 0 0 0 0 0

383 433 400 433 4 4 3 4 4 4 4 4

20372 18240 18071 19544 091 088 079 093 174 166 143 170

21722 20832 19517 20493 117 130 108 110 207 219 184 193

0000

0414

0081

9) agree with the idea that RPDs lead to an increase in dental biolm accumulation, especially on the surface of teeth in direct contact with the denture. Other studies (1012) have reported the occurrence of increased dental biolm accumulation in the region surrounding abutment teeth, as well as gingival inammation in regions covered by the RPD (13, 14). This increased bleeding on probing associated with deeper

probing depth in abutment teeth is closely related to quantitative alterations in the dental biolm, thus increasing the risk of developing gingival inammation and periodontitis. This nding is important, as retainers receive denture elements and are more susceptible to accumulate greater amounts of dental biolm, besides impairing the self-cleansing action performed by saliva, tongue and cheeks. Hence, if patients are not aware and
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PERIODONTIUM OF ABUTMENT AND NON-ABUTMENT TEETH

Table 8. KruskalWallis test for comparison across groups considering the difference between 12-month follow-up and baseline for probing depth (PD), gingival index (GI) and plaque index (PI) Group Probing depth Direct retainer Indirect retainer Control Gingival index Direct retainer Indirect retainer Control Plaque index Direct retainer Indirect retainer Control Rank Sum of ranks Mean Median Minimum )1000 )1170 )05000 )43000 )43000 )15000 )37000 )37000 )31000 Maximum P

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141 58 99 141 58 104 225 79 162

21587 94845 13480 19535 89345 17587 53014 16129 39669

15310 16353 13616 13854 15404 16911 23562 20416 24487

01700 03300 01700 3000 6000 8000 25000 15000 25000

1500 2330 1170 71000 28000 71000 99000 63000 99000

01203

00255

00833

motivated about oral hygiene, they may be at high risk for developing periodontal diseases and dental caries. Finally, there is a correlation between gingival and plaque indexes. In fact, in the present study, a positive, statistically signicant correlation between these variables was found (r = 06510 and P < 00001). That is, as PI increases, GI also tends to increase. The increase in GI, observed at 3 months, in the direct and indirect retainer groups is suggestive of the increased PI effect, as they were the rst contact with the new denture, for some patients, indicating an initial adaptation. On the other hand, reductions in GI at 6 months may have occurred because of the effect of the motivation performed at baseline and at 3 months. Later, some lack of care possibly occurred, as values increased again at 9 months. Thus, data indicate that alterations in the periodontium resulting from RPD wearing are more evident in teeth involved in the denture design. Moreover, these teeth are more prone to forming dental biolm, as the denture is a host for dental biolm bacteria (1, 2). The increased PD values in every group suggest that RPD causes changes, and that these changes are not irreversible, as the difference was not signicant during this study. This indicates that the four professional dental biolm control treatments performed every 3 months were able to minimize the effect of high plaque indexes, which, in turn, signicantly increased over time. Therefore, it is extremely important that RPD wearers be instructed about biolm pathogenicity, and that dental surgeons be concerned with professional dental biolm control. Moreover, it should be explained to the patients that treatment does not end with denture
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placement. There should be an equal concern with the technical principles involved in planning and performing RPD clinical and laboratory execution. Although the number and distribution of remaining abutment teeth is similar when planning any removable partial denture, some particular characteristics of each case may inuence the design of the metallic framework. The guide plane, retentive area, esthetics, and mucosa and bone interferences are factors that contribute to surveying and may individualize the metallic framework design (1). In some situations, the design of the retainers increases plaque accumulation, probing depth and gingival index. However, if the patient receives proper instruction and maintains satisfactory oral hygiene, the differences on planning will not signicantly inuence the periodontal indexes. The results of this study show that restorative treatment by means of RPDs, when well planned and executed, combined with dental biolm control, is a feasible alternative treatment, recommended to rehabilitate edentulous patients, although RPDs do not eliminate the chance for new problems to appear. Thus, prognosis mostly depends on appropriate biolm control. However, as the present study shows that these changes were observed during a 12-month period, it cannot be afrmed that RPD causes damage to the periodontium, because many alterations were not signicant. It may be suggested, however, that RPDs increase dental biolm accumulation, which, if not correctly removed, can cause some damage. Therefore, further studies are needed, as well as the continuation of the present study, to follow patients for longer periods and verify whether this linear trend of

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4. Drake CW, Beck JD. The oral status of elderly removable partial denture wears. J Oral Rehabil. 1993;20:5360. 5. Muraki H, Wakabayashi N, Park I, Ohyama T. Finite element contact stress analysis of the RPD abutment tooth and periodontal ligament. J Dent. 2004;32:659665. 6. Bergman B. Caries, periodontal and prosthetic ndings in patients with removable partial dentures: a ten-year longitudinal study. J Prosthet Dent. 1982;48:506510. 7. Kern M, Wagner B. Periodontal ndings in patients 10 years after insertion of removable partial dentures. J Oral Rehabil. 2001;28:991997. 8. Akaltan F, Kaynak D. An evaluation of the effects of two distal extension removible partial denture designs on tooth stabilization and periodontal health. J Oral Rehabil. 2005;32:823 829. 9. Schwalm CR, Smith DE, Erickson JD. A clinical study of patients 1 to 2 years after placement of removable partial dentures. J Prosthet Dent. 1977;38:380391. 10. Brill N, Tryde G, Stoltze K, El Ghamrawy EA. Ecologic changes in the oral cavity caused by removable partial denture. J Prosthet Dent. 1977;38:138148. 11. EL Ghamraywy E. Quantitative changes in dental plaque formation related to removable partial dentures. J Oral Rehabil. 1976;3:115120. 12. EL Ghamraywy E. Qualitative changes in dental plaque formation related to removable partial dentures. J Oral Rehabil. 1979;6:183188. 13. Carlsson GE, Hedegard B, Koivumaa KK. Studies in partial denture prosthesis. IV. Final results of a 4-year longitudinal investigation of dentogingivally supported partial dentures. Acta Odontol Scand. 1965;23:443472. 14. Yusof Z, Isa Z. Periodontal status of teeth in contact with denture in removable partial denture wearers. J Oral Rehabil. 1994;21:7786.
Correspondence: Erika Oliveira de Almeida, Departamento de gicos e Pro tese, Rua Jose Bonifa cio, 1195, Vila Materiais Odontolo Mendonc a, Arac atuba SP, Brazil. E-mail: erikaunesp@gmail.com

increasing periodontium damage becomes signicant or continues to cause controlled inammatory episodes, without leading to insertion loss.

Conclusions
1 Direct and indirect retainer elements tend to undergo more damaging periodontal effects associated with RPD use when compared with non-abutment elements, with greater probing depth, gingival index and plaque index values. 2 Following 1 year of denture use, plaque index values were signicantly higher than before its placement.

Acknowledgments
The authors thank the Coordinators of the Master of Science in Dentistry Program from the Federal University of Rio Grande do Norte (UFRN) for the support in the experimental part of this study.

References
1. Jorge JH, Giampaolo ET, Vergani CE, Machado AL, Pavarina AC, Cardoso de Oliveira MR. Clinical evaluation of abutment teeth of removable partial denture by means of the Periotest method. J Oral Rehabil. 2007;34:222227. 2. Zlataric DK, Celebic A, Valentic-Peruzoc M. The effect of removable partial dentures on periodontal health of abutment and non-abutment teeth. J Periodontol. 2002;73: 137143. 3. Bergman B. Periodontal reactions related to removable partial dentures: a literature review. J Prosthet Dent. 1987;58: 454457.

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