Tooth Mobility and Periodontal Therapy 497

Journal of Clinical Periodoniology: 1980: 7: 495-505 Key wordsL Tooth mobility - periodontitis ~ therapy. Accepted for publication November 21, 1979

Tooth mobility and periodontai therapy

THOMAS I, FLESZAR, JAMES W, KNOWLES, EDITH C, MORRISON, FREDERICK G, BURGETT, ROBERT R, NISSLE AND SIGURD P, RAMFJORD The University of Michigan School of Dentistry, Department of Periodontics, Ann Arbor, Michigan, U, S, A,

Abstract. Data collected as part of an 8-year longitudinal study on periodontai therapy involving 82 patients and 1974 teeth were analyzed to determine if tooth mobility in- fluenced the results of treatment. For each patient, pocket depth, attachment level and tooth mobility were scored clinically at the initial appointment, and once a year for 8 years following periodontai therapy. The treatment consisted of scaling, oral hygiene instruction, occlusa! adjustment, periodontai surgery (curettage, modified Widman or pocket elimination), followed by recall prophylaxes every 3 months. Tooth mobility data on a scale of 0-3 were related to changes in attachment levels for three grades of severity of periodontai disease, based on initial pocket depth (1-3 mm, 4-6 mm, and 1+ mm). Mean patient attachment changes were calculated from teeth in the same severity category for each patient. The data were analyzed hy one-way analysis of variance and Scheffe's multiple comparison procedure to test the hypothesis of equal effects of tooth mohility on the results of the treatment for the three severity groups over 8 years. The results indicate that there is a statistically significant relationship between original tooth mobility and the change in level of attachment following treatment. Pockets of clinically mobile teetb do not respond as well to periodontai treatment as do those of firm teeth exhibiting the same initial disease severity.

The significance of tooth mobility in the responses to conventional periodontai treat- etiology and treatment of periodontai dis- ment, ease is controversial. Only a few studies have evaluated the influence of tooth mo- ,,,, , , c J • u Matertal and Methods biltty on the results of periodontai therapy (Glickman et al, 1966, Noyes & Clark The data used for this analysis had been 1968, Rosling et al. 1976b, Lindhe & Erics- collected over 8 years as part of a Michi- son 1976), As a consequence, clinical de- gan Longitudinal Study (Ramfjord et al, cisions relative to occlusal therapy as part 1973, 1975), Included are the results from of periodontics have tended to be subjec- 82 patients who had completed at least the tive. first 1-year recall and scoring. They had a This study was undertaken to determine total of 1974 teeth. At 5 years, 72 patients whether any relationship exists between remained, and after 8 years, 43 patients tooth mohility and clinically measurable with 1083 teeth still were available, O3O3-6979/80/O60495-n$02,5a'O © 1980 Munksgaard, Copenhagen 496 FLESZAR, KNOWLES, MORRISON, BURGETT, NJSSLE AND RAMFJORD

The criteria for patient selection and the perimental unit thus allowing statistical test- experimental design of this Michigan Study ing of differences. Within each patient, the have heen published in previous papers means were calculated by first collapsing (Ramfjord et al, 1973, 1975), For clarity, into groups all sites of the same initial however, a summary is included. severity located on teeth of equal initial Pocket depth and attachment level were mobility. Then, a yearly mean ehange of at- recorded according to the criteria suggested tachment was calculated for each of these by Ramfjord (1959, 1967), Tooth mobility groups. Patient means, therefore, were cal- was seored as follows: culated for each level of mobility within a specific severity category. MO: Physiologic mobility; firm A one-way analysis of variance tooth (ANOVA) was used to test the hypothesis Ml: Slightly increased mobility of equal changes in level of attachment af- M2: Definite to considerable inter treatment in the four levels of tooth crease in mobility, but no mobility for each severity category (Ta- impairment of function bles 1, 2 and 3), If the hypothesis of equal M3: Extreme mobility; a "loose" levels of attachment was rejected at the tooth that would be uneom- 0,05 level of significance using ANOVA, fortable in function. Scheffe's method for multiple comparisons was used to detennine which of the con- Following initial scoring, scaling, root plan- trasts between categories of tooth mobility ing, oral hygiene instruction, and an oc- differed (Tables 4, 5 and 6), For the pur- clusal adjustment, all patients on a ran- pose of this study, data from all three domized basis had each half of their mouth modalities of periodontal treatment were treated with one of the following surgical pooled. procedures: (1) subgingival curettage, (2) modified Widman flap surgery, or (3) pocket elimination surgery. The patients were Results recalled every 3 months for prophylaxis by By the first year following treatment, a a dental hygienist and were scored annually separation of the mobility related attach- by the same periodontist. ment curves is evident at all levels of To facilitate data interpretation, initial severity (Figs, 1, 2 and 3), By the second disease severity was determined by creating year, the differences between the curves three severity categories based on initial become more distinct in the 1-3 and 4-6 pocket/sulcus depths: 1-3 mm, 4-6 mm, mm severity groups. The curves of the and 7-12 mm. 7-12 mm group fluctuate little during this Data analysis related to initial tooth same time period, however. mobility, initial disease severity and re- As evidenced in Tables 4, 5 and 6, most sponse to therapy (change in levei of at- of the differences between the curves are tachment) was then performed. To deter- statistically significant (/'<0,05), One ex- mine if significant relationships existed be- ception relates to the "0" and "I" mobility tween these factors, programs of the Michi- groups of the 1-3 and 4-6 mm severity gan Interactive > Data Analysis System levels. In spite of graphically distinct (MIDAS) were used. change in attachment curves, sites associated Patient means were generated satisfying with these groups are not significantly dif- the assumption of independence of the ex- ferent from one another. TOOTH MOBILITY AND PERIODONTAL THERAPY 497

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A lack of statistical significance (f < 0.05) also can be noted in many of the contrasts associated with the later years of the study and with the most severe level of tooth mobility ("3"). This is understand- able since fewer values comprise the com- puted means as time, mobility and severity in o vo fn (s increase. This circumstance leads to O\ (N p n rH greater discrepancies in the variances and T-( (S r4 r4 cj subsequently to decreased levels of significance. As with previously reported data (Ram- fjord et al. 1975, Knowles et al. 1979), "non-diseased" sites (1-3 mm) experience a loss of attachment (Fig. 1). In this analysis the amount of the loss can be related to the initial tooth mobility with both the (N o "2" and "3" mobility groups reflecting a 1—1 i-H I-H fN l-H loss of approximately 1 mm by the second

00 year. 1—< 1-H .2 0 .6 4 .5 9

S .3 7 •3 •- Close examination of the "moderately §• •o diseased" sites (4—6 mm) (Fig. 2) reveals 11 that only those sites associated with "0" 15 be. and "1" mobility evidence any gain in at- a CL 13 tachment. Tbe sites associated with a "2" •s C mobility gain initially, but then return to baseline, while those in the "3" category /•o/i i > r in i 1 actually lose attachment within the first 1 2 years post-therapy. e der I The most dramatic separation of the Iwert 1 change in attachment curves can be ob-

.1 iitte (^"lo ; served in the "severe" disease category S (7-12 mm) (Fig. 3). There is approximately mt 'c ^ a 0.5 mnn difference between each of the E .c curves. u In all severity levels relative stability of 1I'attach "eS •^ j« the change in attachment curves can be O observed after the second year. X

3 pert los s a •s DIscuulon c Reviewing the data from all severity levels, o ode 1 c s two observations can be made: the rela- 1 tionship between tooth mobility and the post-therapeutic level of attachment is es- TOOTH MOBILITY AND PERIODONTAL THERAPY 499

Table 4. Difference of the means for initial pocket depths of 1-3 mm Unterschied zwischen den Mittelwerten bei initlalen Tasehentiefen von 1-3 mm Difference entre les moyennes; profondeur initiate des culs-de-sac: 1-3 mm

Year Mobility groups 1 2 3 4 5 6 7 8

0 & 1 ,17 ,12 ,13 ,18 ,20 ,20 ,28 ,21 0 & 2 ,32»* ,43** ,38** ,45** ,78** .88** ,55** ,43*' 0 & 3 ,49*" 1,00** ,81** 1,03** ,96** ,70 1,22** ,47 1 & 2 ,21 ,31** ,25 ,28** ,58** ,68** ,27 ,22 1 & 3 ,37 ,88** ,68** ,86** ,77 ,50 ,94 ,26 2 & 3 ,17 ,57** ,43 ,58** ,18 -.18 ,67 ,04 Scheffe's P < 0,05 = **

Table 5. Difference of the means for initial pocket depths of 4-6 mm Unterschied zwischen den Mittelwerten bei initialen Tasehentiefen von 4-6 mm Difference entre les moyennes; profondeur initiale des culs-de-sac: 4-6 mm

Year Mobility groups 1 2 3 4 5 6 7 8

0 & 1 ,07 .19 ,14 ,19 ,22 ,09 ,37 ,24 0 & 2 ,38" ,51** 49** ,65** ,82** ,74** ,71 ,48** 0 & 3 ,79" 1,15** 1.13** ,96** 1,16** ,91 1,62 ,27 1 & 2 ,31** ,32** ,35** ,46** ,59** ,65** ,34 ,24 1 & 3 ,72** ,97** 99*. ,76** ,93** ,82 1,25 ,03 2 & 3 ,41 ,65** ,64** ,31 ,34 ,17 ,91 -,20

Scheffe's P < 0,05 = **

Table 6. Difference of the means for initial pocket depths of 7-12 mm Unterschied zwiscfwn den Mittelwerten bei Initialen Tasehentiefen von 7-12 mm Difference entre les moyennes: profondeur initiale des culs-de-sac: 7-12 mm

Year Mobility groups 1 2 3 4 5 6 7 8

0 & 1 ,67 ,76** ,79** ,85** ,83** ,66 1,15** ,42 0 & 2 ,94'"' 1,42** 1,39** 1,41** 1,55** 1,39** 2,25** 1,11 0 & 3 1,62** 1.57** 1,11 ,83 ,64 ,03 -1,38 — 1 & 2 ,27 ,66** ,60** ,55 ,72** ,73 1,11** ,69 1 & 3 ,95 ,81 ,32 -,03 -,19 -,63 -2.52 _ 2 & 3 ,68 ,15 -.28 -,58 -,91 -1,36 -3,63** - Scheffe's P < 0,05 = ** tablished by the first year with some minor In the previous reports, (Ramfjord et al, adjustment occurring by the second, and af- 1968, 1973, 1975, Ramfjord 1977, Knowies ter the second year only small changes in et al, 1979) teeth of different mobilities the attachment curves are observed. were always considered equal when treat.- 500 FLESZAR, KNOWLES, MORRISON, BURGETT, NISSLE AND RAMFJORD

Attachment Clwrge (Po1i«ii MMni) F Fig, tniliol P(jck«1» 4-6 MM

Attachmentverdnderung (Mittelwerte der Pati- Attachtnenfverdnderung {Mittelwerte der Pati- enten) bei initialen Taschentiefen von 1-3 mm. enten) bei initialen Taschentiefen von 4-6 mm. Modification de I'attachement (moyennes des Modification de I'attachement (moyennes des patients); culs-de-sac initiaux: 1—3 mm. Mo- patients)', culs-desac initiaux: 4-6 mm. Mo~ bilite initiale 0, 1, 2 ou 3. bilite initiale 0, 1, 2 ou 3.

Fig. 3. Fig. 4.

f ... if:—-^-

Attachmentveranderung (Mittelwerte der Pali- Attachmentverdnderung (Mittelwerie der Pati- enten) bei initialen Taschentiefen von 7-12 mm. enten) bei initialen Taschentiefen von 1-3 mm. Modification de I'attachement (moyennes des Modification de I'aitachement (moyennes des patients); culs-de-sac initiaux: 7-12 mm. Mo- patients); culs-de-sac initiaux: 1-3 mm. Mo- bilite initiale 0, 1, 2 ou 3. bilite initiale 0 et 1 ou 2 et 3.

ment results were evaluated. By reevaluat- et a], 1979) reported that some gain in ing the data for each level of tooth mobil- attachment occurred in these pockets fol- ity, a masking effect from pooling the lowing treatment. The present analysis teeth was eliminated. As an example, shows, however, that the gain is related to consider the moderate disease sites pockets initial tooth mobihty. Sites associated with 4-6 mm) (Fig, 2), Earlier studies (Ram- teeth of a "2" mobility do not appear to fjord et al, 1975, Ramfjord 1977, Knowles gain attachment. In fact, a slight loss can he TOOTH MOBILITY AND PERIODONTAL THERAPY 501

Fig. 5. Fig. 6.

St. ,4'" '••• «...

Attachmentverdnderutig (Mittelwerte der Pati- Attachmentverdnderung (Mittelwerte der Pati- enten) bei initialen Taschentiefen von 4-6 mm. enten) bei initialen Taschentiefen von 7-12 mm. Modification de I'attachement (moyennes des Modification de Vattachement (moyennes des patients); culs-de-sac initiaux: 4-6 mm. Mo- patients); culs-de-sac initiaux: 7—12 mm. Mo- bilite initiale 0 et I ou 2 et 3. bilite initiale 0 et 1 ou 2 et 3.

observed in pockets of highly mobile ("3") Like the regression phenomenon, level- teeth (Fig. 2). ing cannot be the entire explanation since While the mechanisms responsible for the change in attachment curves is strati- the separation of the mobility related at- fied throughout all severity levels. There tachment curves are unknown, some inter- must be, therefore, some process related pretation of the data is possible. It is to tooth niobility which affects all teeth known that the consistent loss of attach- during the first and possibly the second ment observed following treatment in 1-3 year following treatment. The implication mm pockets can be partially explained by seems to he that tooth mobility detrimen- a statistical phenomenon known as regres- tally affects healing. sion towards the mean (Knowles et al. Only two studies could be located which 1979), The regression phenomenon cannot have evaluated the effect of initial tooth explain, however, the stratification of the mobility on post-therapeutic levels of at- curves. tachment and neither study indicated any It could be that another process known significant relationship between mobility as 'leveling" may he involved. Based upon and therapeutic results (Rosling et al, clinical and radiographic observations, vari- 1976b, Lindhe & Ericsson 1976). Lindhe & ations in soft tissue and bone support tend Ericsson (1976) induced experimental to seek a compromise level following treat- periodontitis and trauma from occlusion ment. The deep defects will often show (Svanberg & Lindhe 1973) on both test gain, while adjacent high levels of support and control teeth in beagle dogs. On the may decrease (Rosling et al, 1976a), The 280th day, both tbe test and control teeth marked loss of attachment observed in were treated periodontaliy by removal of shallow pockets of highly mobile teeth ("2" plaque and accretions, surgical elimination and "3") may be the result of such a pro- of pathologically deepened pockets, and by cess. It is impossible from the present data controlled oral hygiene. Jiggling trauma to determine whether other pockets on the was continued only on the test teeth after highly mobile teeth were deeper than 1-3 this point. Ninety days later healing was mm, and how much leveling took place. evaluated through biopsy procedures. The 502 FLESZAR, KNOWLES, MORRISON, BURGETT, NISSLE AND RAMFJORD

authors concluded that the tissue alterations cause they had ideal control of plaque and caused by trauma from occlusion did not inflammation. A study by Poison et al. interfere with healing following periodon- (1976) would appear to support this postu- tal treatment, although the apical cells of late. the junctional epithelium in the control The separation of the attachment curves teeth were located more coronally to ref- which appeared 1 year after treatment must erence notches in the teeth than those in in some way indicate the influence of mo- the test (active trauma) teeth. The level of bility on healing. The subtle changes that the bone crest also was significantly more occurred between the first and second year coronal to the reference notches in the non- in 1-3 mm and 4-6 mm pockets may be traumatized than in the traumatized teeth. more a consequence of "leveling" than con- It thus appears that while the persistent tinued input from a "healing effect". trauma did not interfere with healing as As evidenced by the relatively horizontal such, it did inhibit significantly the amount attachment curves (after 1 year), pockets of regeneration of connective tissue attach- associated with mobile teeth can be success- ment and bone. fully treated and attachment maintained, Rosling et al. (1976b) reported that in regardless of the severity and associated a test group of humans who had received tooth mobility. modified Widman flap surgery and strict Some questions might arise relative to postsurgieal oral hygiene, all two and three the data gathering and analysis procedures wall osseous periodontal defects healed. It used in this study. For example, the use of was stressed "that the infrabony pockets site (pocket) analysis might be questioned located adjacent to hypermobile teeth ex- stating that use of individual teeth might hibited the same degree of healing as those be more appropriate in a mobility study. adjacent to initially firm teeth." Healing Since some leveling of support may occur, was assessed by probing to attachment site analysis may not completely reflect the levels, radiographic analysis, and reentry. relationship which exists between tooth However, specific data to support the state- mobility and periodontal attachment ment regarding equal healing of mobile changes around individual teeth. teeth were not included in the article. The fact that tooth mobility patterns are The differences between the Rosling et significantly reduced following traditional al. (1976b) and the present study in terms periodontal therapy (Lindhe & Nyman of the influence of mobility on treatment 1975, Mijhlemann 1967, Rateitschak 1963, results might possibly be explained by the Selipsky 1976) and occlusal adjustment degree of inflammation control. Many of (Miihlemann et al. 1957, VoUmer & Ra- the patients in the present study had iess teitschak 1975) might lead to the sugges- than ideal oral hygiene and all were sub- tion that yearly tooth mobility values jected to 3-month recalls rather than the rather than initial values should have been 2-week program of Rosling et al. (1976b). used in the analysis. While the data were It may be tbat the influence of mobility not presented in this paper, mobility levels on healing in the present study was related were reduced following treatment. How- to inflammation, and that with significant ever, these new levels related so closely to inflammation there is a stratified healing pretreatment mobility that no differences in response related to degrees of mobility. results were obtained when yearly tooth This stratification did not appear in the mobility values were used. study by Rosling et al. ()976b) perhaps be- Objections may also be raised relative to TOOTH MOBILITY AND PERIODONTAL THERAPY 503

the subjective nature of the tooth mobility associated with firm teeth. This is ir- measurements. The Miller Index, (Miller respective of initial disease severity, 1938) which is similar to the one employed 4, Only minor changes in attachment levels in this study, has been designated as being within each mobility category occur af- useful for diagnewis and treatment planning ter the second year of observation. for practitioners, but of little value in clin- 5, Clinically mobile teeth can be success- ical research due to its inability to discrim- fully treated and maintained, inate accurately, and its subjectivity (O' Leary 1974). Zusammenfassung Recently, Laster et al, (1975) found the Miller Index, when modified, to be a highly Zahnbeweglichkeit und Parodontaltherapie Zur Beurteilung eventueller Abhangigkeit zwi- accurate, clinically acceptable method of schen der Zahnbeweglichkeit und dem paro- assessing horizontal tooth mobility on an dontalen Behandlungsresultat bei 82 Palienten averaged basis if sizable populations are in- und 1974 Zahnen, wurden anlasslich einer acht- volved and the examiners are calibrated. jahrigen Langzeitstudie Daten gesammelt und The present study meets these criteria. anaiysiert Die Taschentiefe, das Attachment- niveau und die Zahnbeweglichkeit wurden an- In order to avoid disagreements regard- lasslich der Ausgangsuntersuchung bei jedem ing the impact of degrees of mobility, einzelnen Patienten klinisch registriert. Diese data from mobility "0" and "1" were Untersuchung wurde dann wahrend der Beob- achtungszeit von acht Jahren nach der Paro- pooled since tbeir differences are not sig- dontaitherapie, einmal jahrlicb wiederholt. Die nificant generally (Tables 4, 5 and 6), Behandlung bestand aus Zahnsteinentfemung, Data from mobility "2" and "3" were also Instruktion in oraler Hygiene, einer okklusalen pooled since it may be assumed that any Belastungsausgleichbehandlung, Parodontalchi- clinician would designate these as abnormal rurgie (Kurettage, modifizierter Widmanopera- tion oder chirurgischer Taschenentfemung) mobility. The results from this arrangement und danach, in 3-nionatUchen Intervallen, in of the data are depicted in Fig, 4, 5 and 6, der Nachsorgeprophylaxe, Die Daten iiber die These graphs clearly illustrate that pockets Zahnbeweglichkeit, gemessen anhand einer Be- of clinically mobile teeth do not respond weglichkeitsskala von 0-3, wurden mit den Ver- anderungen des Attachmentniveaus (gemessen as well to periodontal treatment as do in den 3 Graden der Schwere der Parodontal- those of firm teeth exhibiting the same krankheit) korreliert und als Basis dieser Zu- initial disease severity. sammenstellung wurden die ursprunglichen Taschentiefen (1-3 mm, 4-6 mm und 1+ mm) gewahlt. Die mittleren Attachmentveranderun- gen wurden anhand von Daten von Zahnen Conclusions der gleichen "Schwerekategorie" fiir jeden ein- 1, The change in level of attachment fol- zelnen Patienten berechnet. Die erhaltenen Da- ten wurden mit Hilfe der Einwegs-Varianzana- lowing periodontal therapy is related lyse und Scheffe's multipler Vergleichsprozedur significantly to initial degrees cf tooth anaiysiert, um die Hypothese des gleichen Ef- mobility at all levels of disease severity, fektes der Zahnbeweglichkeit auf die Behand- 2, Tbe influence of mobility on response lungsresultate bei den drei Gruppen mit unter- schiedlich schwerem Krankheitsbefall, wahrend to treatment can be noted by the first einer Beobachtungszeit von 8 Jahren zu testen. year post-treatment and generally be- Die Resultate zeigen statistisch signifikante comes more pronounced by the second, Abhangigkeit zwischen der Ursprungsmobilitat 3, Pockets associated with clinically mo- und den nach der Behandlung eintretenden Veranderungen des Attachmentniveaus, Die bile teeth do not respond to periodontal Taschen klinisch mobiler Zahne antworten therapy as favorably, in terms of clini- nicht so giinstig auf die Parodontaltherapie cal attachment gain or loss, as do those 504 FLESZAR, KNOWLES. MORRISON, BURGETT, NISSLE AND RAMFJORD wie das bei klinisch festen 2^hnen, mit ur- pour tester l'hypothese que l'influence de la spriingiich gleicher Schwere des Krankheitsbe- mobilite dentaire sur les resultats du traite- failes, beobachtet wurde, ment est la meme dans les trois groupes de Ober die Bedeutung der Zahnbeweglichkeit gravite pendant les huit annees, fiir die Atiologie und die Behandlung der Pa- Les resultats indiquent qu'il existe un rap- rodontopathien bestehen gegensatzliche Auf- port statistiquement signifieatif entre la mobi- fassungen, Nur einige wenige Arbeiten haben lite dentaire initiale et la modification du ni- die Bedeutung der Zahnbeweglichkeit fiir die veau de l'attachement apres traitement, Les Resultate parodontaler Therapie studiert culs-de-sac des dents qui presentent une mobi- (Glickman et al, 1966, Noyes & Clark 1968, lite clinique ne reagissent pas aussi bien au Rosling et al, 1976b, Lindhe & Ericsson 1976), traitement que les culs-de-sac de dents non Das hat zur Folge. dass bei klinischen Ent- mobiles pour lesquelles le degre initial de gra- scheidungen iiber die Notwendigkeit okklusaler vite etait le meme. Therapie als Bestandteil parodontaler Behand- lung, subjektive Tendenzen solche Entschei- dungen beeinflussen konnen, References Diese Studie wurde durchgefiihrt um festzu- Glickman, L, Smulow, J. B,, Vogel, G, & Pas- stellen, ob Beziehungen zwischen der Zahn- samonti, G, (1966) The effect of occlusal mobilitat und der klinisch messbaren Antwort forces on healing following mucogingival auf konventionelle parodontale Therapie be- surgery. Journal of Periodontology 37, 319- stehen. 325, Knowles, J, 'W,, Burgett, F, G,, Nissle, R, R,, Shick, R, A,. Morrison. E. C, & Ramfjord, S, P, (1979) Results of periodontal treatment Mobilite dentaire et traitement parodontal related to pocket depth and attachment level. Des donnees recueillies au cours d'une etude Eight years. Journal of Feriodontology 50, longitudinale de huit annees, coneernant le 225-233, traitement parodontal et portant sur 82 pa- Laster, L,, Landenbach, K, W, & Stolier, N. H, tients et 1974 dents, ont ete analysees afin de (1975) .'\n evaluation of clinical tooth mo- determiner si la mobilite dentaire exerce une bility measurements. Journal of Feriodonto- influence sur les resultats du traitement. logy 46, 603-607, Pour chaque patient, la profondeur des culs- Lindhe, J, & Ericsson, 1, (1976) The influence de-sac, le niveau de l'attachement et la mobi- of trauma from occlusion on reduced but lite dentaire ont ete mesures par un examen healthy periodontal tissues in the dog. Jour- clinique, iors du rende2,,vous initial et une fois nal of Clinical Feriodontology 3, 110-122, par an pendant les huit ans suivant le traite- Lindhe, J, & Nyman, S. (1975) The effect of ment parodontal. Ce traitement consistait en: plaque control and surgical pocket elimina- detartrage, instruction en matiere d'hygiene tion on the establishment and maintenance bucco-dentaire, rectification de Tocclusion, of periodontal health, A longitudinal study traitement parodontal chirurgical (curetage, of periodontal therapy in cases of advanced operation de Widman modifiee ou elimination disease. Journat of Clinical Feriodontology chirurgicale des culs-de-sac), suivi de seances 2, 67-79, regulieres de nettoyages des dents tous les trois Miller, S, C, (1938) Textbook of Feriodontia, mois, Les donnees coneernant la mobilite den- 1st ed,, Philadelphia: Blakiston, taire, exprimees suivant utie echelle allant de 0 Miihlemann, H, R. (1967) Tooth mobility: A a 3, ont ete mises en relation avec les modifica- review of clinical aspects and research find- tions des niveaux de l'attachement pour trois ings. Journal of Feriodontology 38, 686-713, degres de gravite de l'atteinte, en se basant Muhlemann, H, R,, Herzog, H, & Rateitschak, sur la profondeur initiale des culs-de-sac (1-3 K, (1957) The quantitative evaluation of the mm, A-d mm et 7+ mm). La moyetine des therapeutic effect of selective grinding. Jour, modifications de l'attachement des patients a nal of Periodontology 28, 11-16, ete cakulee pour les dents appartenant chez Noyes, D, & Clark, J, (1968) Mechanical mo- chacun des patients a la meme categorie de bility of human teeth in vivo, Abs, I,A,D,R., gravite, Les donnees ont ete analysees par une March, p. 76, analyse de variatice a une direction et par la O'Leary, T, J, (1974) Indices for measurement methode de comparaison multiple de Scheffe of tooth mobility in clinical studies. Journal TOOTH MOBILITY AND PERIODONTAL THERAPY 505

of Periodontai Research 9 (Suppl), 94-105, tic criteria, I, Changes in tooth mobility. Poison, A, M,, Meitner, S, W, & Zander, H, Journal of Periodontology 34, 540-544, A, (1976) Trauma and progression of margi- Rosling, B,, Nyman, S,, Lindhe, J, & lem, B, nal periodontitis in squirrel monkeys, IV, 1976a) The healing potential of the perio- Reversibility of bone loss due to trauma dontai tissues following different techniques alone and trauma superimposed upon perio- of periodontai surgery in plaque-free denti- dontitis, Journal of Periodontai Research 11, tions, A 2-year clinical study, Journai of 290-298, Clinical Periodontology 3, 233-250, Ramfjord, S, P, (1959) Indices for prevalence Rosling, B,, Nyman, S, & Lindhe, I, (1976b) and incidence of periodontai disease. Journal The effect of systematic plaque control on of Periodontology 30, 51-59, bone regeneration in infrabony pockets. Ramfjord, S, P, (1967) The periodontai dis- Journal of Clinical Periodontology 3, 38-53, ease index (PDI), Journal of Periodoniology Selipsky, H, (1976) Osseous surgery. How 38, 602-610, much need we compromise? Dental Clinics Ramfjord, S, P, (1977) Present status of the of North America 20, 79-106, modified Widman flap procedure. Journal Svanberg, G, & Lindhe, I, (1973) Experimental of Periodontology 48, 558-565, tooth hypermobility in the dog, A methodo- Ramfjord, S, P,, Nissle. R, R,, Shick, R, A, & logical study, Odontologisk Revy 24, 269- Cooper, H, Ir, (1968) Subgingival curettage 282, versus surgical elimination of periodontai Vollmer, W, H, & Rateitschak, K, (1975) In- pockets. Journal of Periodontology 39, 167- fluence of occlusal adjustment by grinding 175. on gingivitis and mobility of traumatized Ramfjord, S, P,, Knowies, J, W,, Nissle, R, R,, teeth. Journal of Clinical Periodontology 2, Shick, R, A, & Burgett, F, G, (1973) Longi- 113-125, tudinal study of periodontai therapy. Journal of Periodontology 44, 66-77, Ramfjord, S, P,, Knowies, I, W,, Nissle, R, R,, Burgett, F, G, & Shick, R, A, (1975) Re- Address: sults following three modalities of perio- Dr. Thomas J. Fleszar dontai therapy. Journal of Periodontology The University of Michigan 46, 522-526, School of Dentistry Rateitschak, K, (1963) Therapeutic effect of Department of Periodontics local treatment on periodontai disease as- Ann Arbor, Michigan 48109 sessed upon evaluation of different diagnos- U.S.A.