Periodontal regeneration versus extraction and dental implant or prosthetic replacement of teeth severely compromised by attachment loss to the apex: A randomized controlled clinical trial reporting 10-year outcomes, survival analysis and mean cumulative cost of recurrence

Abstract

Background: Periodontal regeneration can change tooth prognosis and represents an alternative to extraction in teeth compromised by severe intra-bony defects. The aim of this study was to compare periodontal regeneration (PR) with tooth extraction and replacement (TER) in a population with attachment loss to or beyond the apex of the root in terms of professional, patient-reported and economic outcomes.

Methods: This was a 10-year randomized controlled clinical trial. 50 stage III or stage IV periodontitis subjects with a severely compromised tooth with attachment loss to or beyond the apex were randomized to PR or TER with either an implant- or a tooth-supported fixed partial denture. Subjects were kept on a strict periodontal supportive care regimen every 3 months and examined yearly. Survival and recurrence analysis were performed.

Results: 88% and 100% survival rates were observed in the PR and TER groups. Complication-free survival was not significantly different: 6.7-9.1 years for PR and 7.3-9.1 years for TER (p = .788). In PR, the observed 10-year attachment gain was 7.3 ± 2.3 mm and the residual probing depths were 3.4 ± 0.8 mm. Recurrence analysis showed that the 95% confidence interval of the costs was significantly lower for PR compared with TER throughout the whole 10-year period. Patient-reported outcomes and oral health-related quality-of-life measurements improved in both groups.

Conclusions: Periodontal regeneration can change the prognosis of hopeless teeth and is a less costly alternative to tooth extraction and replacement. The complexity of the treatment limits widespread application to the most complex cases but provides powerful proof of principle for the benefits of PR in deep intra-bony defect.

Trial registration: ClinicalTrials.gov NCT04227964.

Keywords: dental implants; fixed partial dentures; health economics; periodontal regeneration; randomized controlled clinical trial; recurrence analysis; survival analysis.

FIGURE 1

10‐year survival of regenerated teeth and tooth replacement. Kaplan–Maier 10‐year survival plot (a) and complication‐free survival plot (b) of regenerated teeth (blue line) and prosthetic tooth replacement after extraction (red line). Events and censored observations (loss to follow‐up is displayed for each curve)

FIGURE 2

(a and b) Recurrence during the 10‐year follow‐up. Panel 2a illustrates the mean cumulative cost (Euro) of managing recurrences during the 10‐year follow‐up of regenerated teeth (blue line) and prosthetic tooth replacement (red line). Amounts do not include the initial cost of treatment and the costs of regular supportive periodontal care. The 95% confidence intervals (dashed lines) of the two groups overlap for the entire observation period. Panel 2b displays the mean cumulative cost (Euro) of initial treatment and managing recurrences during the 10‐year follow‐up of regenerated teeth (blue line) and prosthetic tooth replacement (red line). Figures do not include the costs of regular supportive periodontal care. Dashed lines represent the 95% confidence intervals

FIGURE 3

(a–d) Frequency distribution of OHIP scores group at baseline. Frequency of response for the 14 questions of the OHIP‐14 questionnaire for the regeneration group (a) and the extraction and tooth replacement group (b) at baseline and the 1‐year follow‐up (C for regeneration and D for extraction and tooth replacement groups). Colour keys: dark red = very often, light red = fairly often, yellow = occasionally, light green = hardly ever, dark green = never

FIGURE 4

(a and b) Frequency distribution of patient‐reported outcomes in terms of concerns for masticatory function over the 10‐year observation. Data are expressed as frequency distribution of the responses across the five points of the Likert scale for the regeneration group (a) and the extraction and tooth replacement group (b). Green = no concern, light blue = some concern, grey = concerned, yellow = clearly concerned, red = very concerned

FIGURE 5

(a and b) Frequency distribution of patient‐reported outcomes in terms of concerns for aesthetics over the 10‐year observation. Data are expressed as frequency distribution of the responses across the five points of the Likert scale for the regeneration group (a) and the extraction and tooth replacement group (b). Green = no concern, light blue = some concern, grey = concerned, yellow = clearly concerned, red = very concerned

FIGURE 6

Frequency distribution of patient satisfaction with treatment at 1 year. Data are expressed as frequency distribution of the responses across the five points of the Likert scale. Green = extremely satisfied, light blue = very satisfied, grey = satisfied, yellow = moderately satisfied, red = not satisfied. No significant differences were observed between the two groups (p = .464, NS)