When to Save or Extract a Tooth: A guide to Prognosis

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When to Save or Extract a Tooth A guide to
Prognosis Evaluation of Individual Teeth

• Dr Wael Al-Omari
• BDS, MDentSci, PhD

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• Predicting the long term serviceability of a
  tooth as a functional unit of an overall
  rehabilitation is one of the most challenging
  tasks in clinical dentistry.
• Evaluation of prognosis is a fundamental to solid
  treatment plan formulation
• Question to save or replace should be resolved

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• Questions to be resolved
• 1- Can a tooth be effectively restored?
• 2- Will endodontic treatment be successful?
• 3- Is periodontal therapy feasible?
• 4- Will a tooth be a suitable abutment?
• 5- What are the consequences of extraction?
• 6- Is the patient committed to good maintenance?
• 7- What are the alternate treatments available?
• 8- Are technical and financial support obtainable?

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• The ultimate decision to save or extract based on
  risks vs. benefits of alternate treatments.
• The decision is associated with many factors and
  cumulative risks assessment.
• Special considerations must be given to the
  esthetic zone.

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• Prognosis is defined as a prediction of the
  probable course and outcome of a disease, and the
  likelihood of recovery from a disease
• Unfortunately evidence-based published data as
  predictors for long-term prognosis are lacking in
  the dental literature.
• There is no accepted standardization tool for
  assessing the overall status of teeth

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The major factors that determine prognosis

• Periodontal Considerations
• Restorability
• Endodontic considerations
• Occlusal plane considerations
• Patient-level considerations

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Periodontal Considerations

• It is almost impossible to predict the chance of
  survival of a periodontally compromised teeth
  (Hirschfeld and Wasserman, 1978)
• Clinical parameters are ineffective in predicting
  any outcome other than good (McGuire et al,
  1996).
• Initial prognosis did not adequately predict
  tooth survival especially for posterior teeth
  (McGuire, 1991, McGuire Nunn, 1999)
• Interleukin-1 and smoking improve accuracy of
  predicting tooth loss (McGuire Nunn, 1999)

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• Predicting tooth survival in well-maintained
  patients is more accurate than in the
  poor-maintained ones (Becker et al, 1984)
• Maxillary molars more likely to be lost than
  mandibular
• Anterior teeth have better prognosis than
  posteriors.
• However, clinical criteria that results in
  increased risk of tooth loss included
• 1- Increasing probing depth
• 2- furcation involvement
• 3- Mobility
• 4- Percent of bone loss
• 5- Parafunctional habits
• 6- Smoking

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Mutilated Dentition
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Restorability

• Long term success of restoration of
  endodontically treated tooth is based on the
  amount of remaining sound coronal tooth
  structure.
• The critical issue is tissue preservation
• A tooth restorability index was developed by
  Bandlish et al (2006) that quantitatively
  assessed the remaining sound dentine and graded
  from 0-3.
• 12 of teeth with dowels have complications
  (Goodacre et al, 2003)
• Generally 5 mm of suprabony structure is
  required 2 mm biological width, 2mm for the
  ferrule and 1mm sulcus depth (Morgano,1996)

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Endodontic Considerations

• Success rates of endodontic therapy with respect
  to various
• (Messer HH (1999)
• Endodontic situations success
• Teeth without periapical lesions 96100
• Teeth with periapical lesions 82
• Meets technical standards of ideal treatment 94
• Inadequate technical standards 6876
• Calcified canals 6070
• Procedural problems Varied, 50 or less
• Restoration (posterior teeth) full occlusal
• Coverage 9095
• No occlusal coverage 5060
• Periodontal problems Dictated by the
  periodontal condition

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Occlusal Plane Considerations

• Super-erupted or tilted teeth
• Super-eruption could prevent normal occlusal
  contacts.
• Super-eruption may create problem when restoring
  opposing arch.
• Prevention of super-eruption should be planned.

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Occlusal Plane Considerations

• Treatment Options
• 1- Simple enameloplasty
• 2- Full coverage crowning to correct
• occlusal plane.
• 3- Orthodontic treatment
• 4- Extraction

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Periodontal eruption
Active eruption
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Classification System (Samet and Jotkowitz, 2009)

• Dental Evaluation involves 2 sequential phases
• 1- Takes patient-level considerations
• into account
• 2- Classify individual teeth

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Patient-level risk factors

• I. Biological risk factors
• 1- Medical conditions that impair immune
  function.
• 2- Impaired salivary flow/function
• 3- Medical condition or disability limiting oral
• hygiene
• 4- High Strep. Mutans and Lactobacillus salivary
• count
• 5- Positive for interleukin-1 genotype
• 6- Family history
• 7- Other missing teeth

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Patient-level risk factors

• II. Behavioural risk factors
• 1- Compromised or poor oral hygiene
• 2- Cariogenic diet
• 3- Low exposure to fluoride
• 4- Parafunctional habits
• 5- Adherence to long-term
• maintenance
• 6- Smoking

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Patient-level risk factors

• III. Financial/personal risk factors
• 1- Motivation for treatment
• 2- Available resources for dental care
• 3- Willingness to commit finances, time and
  effort.
• 4- Attitude toward loosing teeth
• 5- Understanding of patients condition and
  needed treatment.
• 6- Esthetic expectations
• 7- Low dental IQ
• IV. Quality of dental treatment and the frequency
  and quality of oral maintenance

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Patient-level risk factors

• Factors that are associated with high caries rate
  and periodontal diseases are those that challenge
  prognosis evaluation.
• Modifiable vs. Non-modifiable factors
• Multiple non-modifiable factors results in
  inferior case prognosis.
• Management of modifiable factors entails
  reassessment of overall prognosis

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Evaluation of Individual Teeth

• Criteria for analysis
• 1- Periodontal conditions and alveolar bone
• support
• 2- Restorability (remaining tooth structure)
• 3- Endodontic condition
• 4- Occlusal plane and tooth position
• Two additional factors
• 1- Anatomic irregularities
• 2- Iatrogenic compromising factors

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Classification Rules

• Five classes- A, B, C, D, and X
• Requires 3 steps
• Step 1 The single most severe criterion
• determines the tooths class.
• Step 2 Anatomic risk factors and/or iatrogenic
• compromising factors may result in a
  drop
• of a class for an individual tooth
  (more than
• 2 findings may result in a drop in
  class)
• Step 3 Patient-level risk factors may result in
  a
• decreased prognosis for the
  dentition.

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Class AGood prognosis(Minimal risk of being
lost in the foreseen future)

• Periodontal health and alveolar support 80-100
  bone support
• Remaining tooth structure 80-100 remaining
  sound tooth structure.
• Endodontic condition good endodontic therapy.
• Occlusal plane and tooth position correct or
  slightly deviated from ideal

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Class BFair prognosis(low risk of being lost in
the foreseen future)

• Periodontal health and alveolar support 50-80
  bone support, can be maintained, vertical defects
  and furcations can be treated.
• Remaining tooth structure 50-80 remaining sound
  coronal tooth structure, adequate ferrule, good
  crown-root ratio, minimally affect adjacent teeth
• Endodontic condition endodontic failures
  predictably managed, or difficult primary endo
  treatment.
• Occlusal plane and tooth position out of
  occlusal pane but can be adjusted.

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Class CQuestionable prognosis(Medium risk of
being lost in the foreseen future)

• Periodontal health and alveolar support 30-50
  bone support, no acute condition, maintenance
  cleansability is difficult, perio. treatment and
  maintenance sustains the tooth for acceptable
  period of time
• Remaining tooth structure 30-50 remaining sound
  tooth structure, minimal structure, achieving a
  ferrule jeopardize crown-root ratio or may affect
  adjacent structures
• Endodontic condition Acute/chronic failing
  treatment with unpredictable retreatment.
• Occlusal plane and tooth position Out of
  occlusal plane and requires multiple procedures
  to adjust.

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Class DCompromised prognosis(High risk of being
lost in the foreseen future)

• Periodontal health and alveolar support lt30
  bone support, or teeth that couldnt be cleans
  and has evidence of active periodontal disease.
• Remaining tooth structure lt30 remaining sound
  tooth structure, or extensive loss of structure
  that ferrule couldnt be achieved with
  compromising adjacent teeth or own/root ratio.
• Endodontic condition Failing endodontic
  treatment that cant be predictably retreated.
• Occlusal plane and tooth position Severely out
  of occlusal plane and after treatment will
  exhibit reduced crown-root ratio.

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Class X Nonsalvageable(Indicated for extraction)

• Periodontal health and alveolar support lt30
  bone support, couldn't be maintained or cleansed
  without acute outbreak of periodontal infection.
• Remaining tooth structure No remaining
  supragingival sound tooth structure, loss of
  tooth structure deep into the root dentine/canals
• Endodontic condition Vertical root fracture,
  retreated several times without resolution
• Occlusal plane and tooth position Far
  super-erupted or tilted out of occlusal plane,
  and interfere with restoration of the arch or
  opposing teeth.

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Factors that result in a drop of the determined
class

• Anatomic irregularities
• -Irregularly shaped roots
• -Multiple canals and/or roots
• -Thin and/or short roots
• -Excessively conical roots

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Factors that result in a drop of the determined
class

• Iatrogenic compromising factors
• Perforations
• Extensive post preparation
• Minimal remaining structure after preparation
• Dental materials that can not be removed

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The classification could be included into routine
clinical examination record
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• Thank you