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 in- ter 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) pock- et 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 O ;^SI I I I I I I '? 3 o I I I ; I ill l 1 ""; in r~- c~~ c^ I r i" r t' r r r r 1 Mo , e/tve • », 1 5 ' •c o / —' c en •% •^ 00 »n ^ r- r- S8 I Is I i" r r r i" r .2 .3 a 6 S I I •I fe ,1 6 S 498 FLESZAR, KNOWLES, MORRISON, BURGETT, NISSLE AND RAMFJORD 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 signif- icance. 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 anal- ysis 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 0 4 year. 7 00 9 1—< 1-H .2 .6 .5 S .3 •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 i i mobility gain initially, but then return to in r baseline, while those in the "3" category /•o/i > 1 actually lose attachment within the first der 1 2 years post-therapy. e 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 s 3 pert los 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*.