RETAIN OR EXTRACTTHE DECISION PROCESS

JAMES F, S IMON, DDS, MED

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Dr Simon is Professor and Chair of the De-partment of Operative Dentistry at the Uni-vfifsity of the Pacific Scliool of Dentistry inSan Francisco, He graduated from tlie Uni-versity of Iowa College of Dentistry in 1969and received his master's degree in educa-tion from the University of New Orleans in1982. He was previously on the faculty ofLouisiana State University SCIIOQI of Den-tistry in New Orleans.

W h e n does a tooth become "hopeless," and when is further treatment nolonger a viable option^ When is it time to cut our losses and make the deci-sion to extract the questionable tooth? Becker et al' suggest that if at leasttwo of the following conditions exist, then a tooth is hopeless and furthertreatment is futile: H) loss of bone support over 75%, (2) probing depthsgreater than 8 mm, e ; class 111 furcation involvement, M,) class III mobility withmovement in the mesial, distal, and vertical directions, (5) a poor crown-rootratio, (6) root proximity with minimal interproximal bone, ¡71 evidence of hori-zontal bone loss, or (8) a history of repeated periodontal abscess formation.

What about the tooth with a horizontal or vertical fracture? What aboutthe tooth that does not lend itself to endodontic or restorative procedures?Is it a tooth that the patient has neither the desire nor the money to retain?

Webster's dictionary defines hopeless as "having no expectation of, orshowing no sign of, a favorable outcome." The prognosis of a tooth is de-fined as the prediction of the duration, course, and termination of a diseaseand the likelihood of its response to treatment.^ It then becomes the re-sponsibility of the dentist to decide the prognosis of the tooth, determine ifit is truly hopeless, and make an educated recommendation to the patient.

Everyday, the practicing dentist must make a decision as part of the diag-nosis and treatment planning process, whether it is for a new patient, a pa-tient who has been with the practice for many years, or for the emergencypatient for whom the decision must be made quickly. What are the guide-lines for deciding to treat and maintain or to stop the progression of the dis-ease and extract the tooth^

Patient involvement. Sometimes the decision is easy. Patients whoshow very little motivation by exhibiting poor oral hygiene or chronicallymissing appointments may be poor candidates for extensive, heroic typesof treatment. Third-party payers may also be a deciding factor due to theirpolicy on which procedures can be reimbursed. The responsibility, there-fore, falls on the patient, who may be either unwilling or unable to pay forthe procedure without outside help. This, however, does not relieve the pro-fessional from his or her obligation to inform the patient of the various treat-ment options, the cost and possible sequelae from each of the options, andto represent the patient's best interest to any third party.

As the ultimate decision maker, the patient may decide that the risk/ben-efit ratio is not in his or her best interest, and decide on less-than-ideal treat-ment. On the other hand, some patients will wish to maintain the tooth nomatter how hopeless it may be. The professional should not let practice pro-ductivity, practice setting, or environment influence his or her recommenda-tions, but let standard of care and professional judgment guide the recom-mendations on the proper treatment.

In an ideal world, dental professionals would prefer to rely on scientificresearch to guide them in this decision-making process. Unfortunately,many times our "best guess" guides us in our recommendation since thisprocess often becomes an art determined by experience rather than a sci-ence determined by research.

Another deciding factor in treatment selection should be patient compli-ance. Even the most routine treatment can become a problem to completesatisfactorily when the patient exhibits a difficult or uncooperative personal-ity. Claustrophobia or fear of radiation, pain, or needles can impair a patient'sability to behave well in the dental office.- This may make any treatment dif-ficult and deem the patient a poor candidate for any extensive treatment,because it may lead to an uncertain outcome with unknown longevity.

In a recent study by Reich and Hiiler,̂ it was found that from the patients'perspective, pain was usuaily tbe major reason for seeking extraction of theoffending tooth. When the dentist was consulted, periodonta! disease wasthe most frequent cause of tooth extraction for people over 40 years of age.

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As the ultimatedecision maker, thepatient may decidethat the risk/benefitratio is not in his or

her best interest, anddecide on less-than-

ideal treatment.

while for patients below 40 years of age, caries and third molar extractionswere the most frequent reasons for exodontia.

Strategic value. Ultimately, one of the first decisions that must be madeIS the strategic value of a tooth. This will have a bearing on whether thetooth IS retained or extracted. For example, a third molar in an arch withmany missing teeth may need to be saved so that it can be used as an abut-ment for a partial denture. A third molar with an otherwise full complementof teeth may not be worth the time or effort to restore, and the decision toextract would be the correct decision.

This same decision process can be made for other strategic abutmentteeth. A full denture is a poor substitute for natural teeth; however, an aver-age patient is usually satisfied with a maxillary complete denture after someperiod of adjustment. The same cannot be said for many mandibular com-plete dentures, A mandibular complete denture is much more difficult toadapt to, and every effort should be made to maintain strategic abutmentteeth as long as possible to provide retention for a partial denture. This isespecially true if the patient is a poor candidate for a dental impiant.

The next area to consider is the restorability of the tocth. Sometimes thedecision is made to rebuild a badly broken-down tooth with some kind otpost and core (ie, cast gold, prefabricated, or one of the new flexible sys-tems). This would be the wrong decision if a lack of tooth structure pre-cludes an adequate ferrule. The ability to create a ferrule of 1.5 to 2 mm inheight with 1 mm of dentinal wall thickness in the area of greatest resis-tance is the key to long-term predictability of the restoration. The inability todo so may mean the tooth should be removed, especially in a mouth withheavy occlusal function.'"

Vertical fractures. Another diagnostic problem is the fractured tooth.Most vertical fractures into the root make the decision easy; The tooth shouldbe considered hopeless and scheduled for extraction. Experience shows thatonly rarely will any heroic attempt to save this tooth be successful.'

The signs and symptoms of the fractured tooth may mimic those of peri-odontal disease or a failed root canal treatment, complicating diagnosis. AnIsolated, narrow, and sharply defined periodontal pocket, which prevents theprobe from moving laterally, usually indicates a late-stage vertical fractureThis iS unlike the broad pocket associated with periodontal disease. Themost frequent clinical and radiographie sign and symptom of a vertical frac-ture is the presence of a periodontal pocket.

Many of the teeth referred to the endodontist for treatment are actuallyfractured teeth that should be considered for extraction. If, at the time cfthe endodontic access, it is noticed that the fracture extends into the pulpalfloor, then the prognosis is poor and further treatment is questionable.

With the present knowledge in the field of endodontics, there are fewtrue contraindications to endodcntic treatment. Severe root caries, furcationcaries, severe internal or external résorption, and poor crown-root ratio pre-sent problems with restoration and may contraindícate endodontic treat-ment. Calcified or blocked canals used to be problems for treatment, butnow With use of a microscope, these situations are less troublesome. This isan area where general dentists may wish to refer the patient to a specialist.

Periodontal disease. Determining the prognosis for a periodcntallyhopeless tooth is difficult. If a tooth has little periodontal involvement and isinitially given a good prognosis, then dentists are generally correct in theirprojections. However, when any other prognosis (fair, poor, questionable, orhopeless) is initially assigned, projections are often incorrect ' In fact, manyteeth remain in function for long periods of time even when initially classi-fied as hopeless.

Several factors must be taken into consideration during the initial evalua-tion of the patient: (I) a deep initial probing depth, (2) severe initial furcation

852 Voiume 30 Mumhor 12, 1999

It is difficult to giveup attempts to save

a tooth and decide toextract.

involvement, OJ malposition of the tooth, (4) initial unsatisfactory root form,Í5I initial endodontic involvement, (6) patient history of smoking or diabetes,(7) parafunctional habits without using a biteguard, (8) poor oral hygiene,and (9) infrequent recall visits. If these factors are ignored, the periodontalcondition may deteriorate more rapidly than anticipated.

Wojcik et al' found that periodontally hopeless teeth that are retained donot significantly affect the proximal periodontium of adjacent teeth whentreated with scaling and root planing, oral hygiene instructions, occlusal ad-justments, and periodontal surgery. Their success was correlated to sup-portive periodontal treatment at least twice per year. However, without peri-odontal treatment, retention of hopeless teeth has a destructive effect onthe periodontium of adjacent teeth. '

Many teeth previously regarded as hopeless due to their periodontal con-dition are now salvageable by means of guided tissue regeneration (GTR),New surgical procedures make it more practical to retain the marginal tooth,even some teeth with badly involved class II furcation, large three-walled in-frabony defects, and osseous craters that had been previously untreatable,A recent study evaluated clinical outcomes 4 to 8 years after surgery andfound that GTR is a predictable and effective option for the treatment of se-verely compromised abutments.'"

In addition, chlorhexidine-containing mouthwashes, new formulations oftoothpaste that reduce the bacterial insult, and powered toothbrushes makeit easier to retain the tooth through improved home care. These aids areavailable to patients who are motivated to use them and who want to main-tain those teeth with questionable prognosis.

In some cases, it may be better to extract a questionable tooth and leavea larger amount of natural bone. The process of bone ioss around periodon-tally compromised teeth diminishes the chances of successful implantplacement. This argument for early extraction can be made because the pre-dictability of implants has increased. The cumulative success rate of im-plants was reported in one study at 98.9% after 10 and 15 years." Anotherstudy reported a success rate of 95.5%," These are very impressive resultsand make implants a viable part of any treatment decision, if sufficient boneis available for implant placement.

Summary- It is difficult to give up attempts to save a tooth and decide toextract. Sometimes the decision is easy because experience allows thedentist to evaluate the patient and the situation and make an educated prog-nosis for the tooth The thought process is extremely involved and manyvariables must be taken into consideration, some of which the dentist hasvery little control over The process was much less involved when therewere fewer options available to the patient and the dentist.

Teeth in themselves are very rarely hopeless; it is the desires of the pa-tient, the expertise of the dentist, and the conditions of the oral environ-ment that lead to a hopeless prognosis. A tooth can be moved to anotherplace in the mouth or even into another patient's mouth, and the treatmentdecision changes, making it not as hopeless. The wish of the patient is usu-ally the final, determining factor for how treatment is carried out. Patientsmake the decision whether to spend their time and money to save the toothwith extraordinary effort or whether to cut their losses and give up on thetooth.

References1 Becker W, Berg L, Becker BE, The long-term evaluaticn of periodontal treatment

and maintenance in 95 patients. Int J Periodontics Restorative Dent 1984;4(2¡:54-71,

2. Carranza F, Newman M. Clinical Periodontology, ed 8, Philadelphia: Saunders,1996:390-398.

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3. Cohen S, Burns R. Pathways of the Pulp, ed 7, St Louis: Mosby, 1998:62-63.4. Reich E, Hiller KA. Reasons for tooth extraction in the western states of Ger-

many. Community Dent Oral Epidemiol 1993;21:379-383.5. Spear F. When to restore, when to remove: The single debilitated tooth. Com-

pendium 1999:20:316-328.6. Weine F. Endodontic Therapy, ed 6. St Louis: Mosby, 1996:5-8.7. McGuire M. Prognosis versus actual outcome: A long-term survey ot 100 treated

periodontal patients under maintenance care. J Periodontol 1991:62.51-58,8. WojcikMS, DeVoreCH, Beck FM, Horton JE, Retained "hopeless" teeth: Lack of

effect periodontally treated teeth have on the proximal periodontium of adjacentteeth 8 years later, J Periodontol 1992:63:663-666

9. Machtej EE, Hopeless teeth without periodontal treatment jeopardize adjacentteeth. J Periodontol 1989:60:512-515

10, Cortellini P, Stalpers G, Pini Prato G, Tonetti Ivl, Long-term clinical outcomes ofabutments treated with guided tissue regeneration. J Prosthet Dent 1999:81:305-311,

11, Lindquist LW, Carlsson GE, Jemt T A prospective 15-year follow-up study ofmandibular fixed prostheses supported by osseointegrated implants. Clin OtalImplants Res 1996:7 329-366,

12, Nevins Ivl, Langer B The suocessful application of osseointegrated implants tothe posterior jaw: A long-tern retrospective study, Int J Oral Maxillofac Implants1993:8:428-432

For reprints contact: Dr James F, Simon, Department of Operative Dentistry, Uni-versity of the Pacilic, School of Dentistry, 2155 Webster Street, San Francisco, Cali-fornia 94115,

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m^mm Answers to Ql 9/99 Questions =^ ^ l ^ E ^ ^ 1 . C

2, B3. C4. D

5. C6. B7. A8. D

9. B10. A11. C12. D

13.14.15.16.

DBDA

854 Volume 30, Number 12, 1999