Loose tooth

For a tooth to be considered as pathologically mobile or loose, there are certain guidelines to check the severity of mobility in a tooth. The amount of mobility depends on the severity and distribution of bone loss around a tooth, shape and length of root and ratio of the crown to root length.

• Grade 0: Physiologic mobility only
• Grade ½: Clinical mobility greater than physiologic mobility but <1millimeter buccolingually (movement from cheek towards tongue and vice versa)
• Grade 1: mild pathologic mobility, approximately 1 millimetre buccolingually
• Grade 2: Moderate pathologic mobility, approximately 2 millimetres buccolingually but without displacement in the vertical direction
• Grade 3: Severe pathologic mobility, >2 millimetres buccolingually, mesiodistally or both combined with vertical displacement

The most obvious sign of loose tooth is its greater range of movement than normal. However, sometimes due to deposition of hard calculus around the tooth, mobility may not be as apparent to the patient.

A person having a loose tooth might feel:

• Difficulty in chewing
• Localised or generalised pain in the dentition due to heavy occlusal load on the teeth
• Unaesthetic appearance due to fanning out of anterior teeth
• Heavy calculus around the tooth
• Chronic gingival inflammation
• Receding gum line around the tooth
• Bone resorption around the tooth
• Increase in clinical crown length of teeth
• Malalignment of teeth in dental arches
• Pus or infection around the tooth

Increased mobility could be caused by one or several factors mentioned below:

Bone loss: Loss of supporting bone around a tooth can result in mobility. The amount of mobility in teeth due to bone loss depends on several factors like severity and distribution of bone loss around a tooth structure, shape and size of the root and crown to root length ratio.

For example, a tooth having short and conical root will show mobility earlier than a tooth with long or curved root with the same amount of bone loss.

A tooth undergoing orthodontic treatment should be closely observed for possible apical shortening of the root, which may be the cause of increased mobility because bone loss is a multifactorial outcome and rarely occur as a single finding. Grade of tooth mobility does not necessarily depend on the amount of bone loss.

Trauma from occlusion: It occurs due to injury to the supporting structures as a result of the excessive occlusal load or abnormal occlusal habits like bruxism, clenching or inability of the tooth to withstand normal occlusal force.

Mobility caused by trauma from occlusion initially results in resorption of cortical bone, which leads to loss of collagen fibre support and later manifested in the form of widening of periodontal ligament space as an adaptation of increased occlusal force.

Inflammation: Spread of inflammatory process from the gingiva or periapical area of the tooth to the periodontal ligament leads to changes that may cause mobility. Inflammatory changes extending from an acute periapical abscess can cause mobility of the concerned tooth in absence of periodontal disease. Similarly, chronic gingivitis can also result in periodontal tissue damage and tooth mobility.

Periodontal surgery: The immediate effect of periodontal surgery can be tooth mobility but it is transient in nature and will eventually subside after a short period of time.

Jaw pathology: Jaw diseases affecting the alveolar bone or the roots of the teeth could result in tooth mobility for example osteomyelitis, cysts or tumours of the jaw.

Pregnancy: Tooth mobility may increase during a certain physiological process of the body like pregnancy. Increased mobility could also be seen during menstruation or with the use of hormonal contraceptives pills. The associated factor for this mobility is physio-chemical changes in the body affecting periodontal tissues rather than periodontal disease.

Apart from the causes of tooth mobility, there are some factors which increase the possibility of damage to the periodontium resulting in tooth mobility.

Smoking: Tobacco smoking is an important risk factor for various periodontal problems like tooth mobility. Relation of smoking and periodontal disease is independent of oral hygiene or age. The post-treatment effect is also negative in smokers compared to non-smokers.

(Read more: Disadvantages of smoking)

Calculus and plaque deposits: Plaque and calculus accumulation around teeth also increases the risk of tooth mobility. Accumulation of plaque may cause gingivitis, which further extends into periodontitis and eventually results in the loosened tooth.

Increase in bacterial load: Increase in bacterial load in the periodontal pocket is another risk factor for increased tooth mobility. Periodontal pocket around the tooth with mobility shows a higher concentration of Campylobacter rectus, Peptostreptococcus micros and Porphyromonas gingivalis when compared to non-mobile teeth.

Diabetes: Uncontrolled diabetes is a well-established risk factor for the development of the periodontal disease. Epidemiologic data support a higher prevalence of bone loss in type 1 and type 2 diabetes than non-diabetic individuals and documents a direct relationship between control in diabetes with improvement in the condition.

Tooth mobility is mainly identified by physical examination by a dentist. Radiographs are also recommended in some cases to see the severity and extension of bone loss around the tooth in question.

Physical examination:

There are some mechanical or electronic devices to measure tooth mobility precisely. However, these devices are not used commonly.

As a general rule, the extent of mobility is evaluated clinically by holding a tooth between the handle of two metallic instruments or with one metallic instrument or one finger and grading is done as per the tooth mobility classification.

While examining the tooth in question for mobility, finger or instrument is moved in all directions to elicit the direction and extent of movement and graded as per the grading rules.

Radiographic examination:

• Horizontal or vertical alveolar bone loss can be seen on the radiograph. It could vary in the extent and appearance. Horizontal bone loss occurs parallel to the alveolar bone level whereas vertical bone loss appears as a triangular shaped gap between the teeth and alveolar bone.
• Widening of periodontal ligament space is a notable change seen with the loosened teeth. It appears as a wedge shaped radiolucency on the mesial or distal surface of the tooth.
• Reduced interdental bone height is another radiographic diagnostic criteria to ascertain the provisional diagnosis. Height of interdental bone appears to shift in apical direction due to the spread of inflammation and resorption of bone.
• Loss of lamina dura is seen in cases mobile tooth due to trauma from occlusion in the apical, furcation and marginal areas of the tooth.

Treatment of loose tooth is based on the cause of mobility. Eliminating the cause of mobility makes the tooth stable and assures fair prognosis of the disease.

• Tooth mobility due to alveolar bone loss is usually irreversible. The relationship between the prognosis of tooth mobility depends on the severity of supporting bone loss. If the bone loss is minimal around the tooth, the prognosis is considered fair. A longitudinal study on response to treatment of a tooth with varying degrees of mobility demonstrates that pockets on teeth having clinical mobility do not show significant response on treatment as compared to pockets on teeth with zero mobility but with same initial disease severity. On the contrary, another study reveals similar healing response with mobile and firm teeth.
• Splinting of the teeth with mobility enhance the functional as well as the structural integrity of the individual tooth and overall dentition.
• Occlusal reduction or adjustments can be effective in patients having tooth mobility due to trauma from occlusion causing an increase in width of the periodontal ligament.
• Maintaining good oral hygiene by scaling and root planning can reverse back initial tooth mobility. Healthy periodontium will allow healthy tissues to proliferate instead of harbouring bacteria for further destruction of supporting structures.
• Treatment of periapical infection will lead to stabilisation of mobile tooth. The dentist might recommend root canal treatment alone or a combination of endodontic treatment with periodontal therapy if the underlying cause of mobility is due to endo-perio lesion.
• If the mobility is caused by bone or root resorption due to excessive orthodontic force, change in magnitude and direction of the force can stabilize the tooth back to its normal position and function.
• Your dentist may recommend you periodontal flap surgery to reduce tooth mobility as well as to enhance the overall health of supporting structures. Periodontal flap surgery will stop the progression of the receding gum line and increases the width of attached gingiva.
• Periodontal reconstruction surgery can also be done with the placement of the bone graft. Use of bone graft to reduce mobility and for the restoration of periodontal health has greater significance in vertical bone loss as compared to horizontal bone loss. Commonly used bone grafts in periodontal reconstruction surgeries to fill the bone defects are made of sterile synthetic hydroxyapatite and beta-tricalcium phosphate. Periodontal flap surgery and bone reconstruction can be done in combination as a single surgical procedure.
• Periodontal regeneration therapy can also be done to stimulate new attachment formation by adequate debridement of plaque and calculus, papilla preservation flap surgery and bone graft with platelet-rich fibrin. All of these treatment modalities ensure the reproduction of lost periodontal structures and restoration of structure and function of the periodontium.
• Treatment of underlying jaw diseases like cyst and tumour of the maxillary or mandibular jaw by enucleation or marsupialization will ensure otherwise healthy detention.

Prognosis of a loose tooth might vary depending upon the underlying cause and oral hygiene.

• Right after periodontal surgery, the loose tooth may show an increase in mobility grade but stable function and occlusion is established within a week as tissues start healing.
• A loose tooth without any definitive intervention may show a gradual increase in movement and loss of supporting structures. As a result, saving such teeth from destruction and restoration of tooth structure may become an impossible job for a dentist. In this case, the tooth needs to be extracted.
• If you lose a tooth due to tooth mobility, it makes a significant impact on your health, however indirectly, leading to an inability to chew food. Tooth loss may also disturb the whole dentition by disturbing the occlusal balance. If the anterior tooth gets extracted, it will affect the aesthetics of your smile and face.

(Read more: Artificial teeth)