Extractions in Patients with Periodontal Diseases and Clinical Decision-Making Process.

OBJECTIVES: To investigate the professional aspects and clinical and radiographic evidence that influences the decision for the extraction of teeth among periodontologists and general dentists.
MATERIAL AND METHODS: The sample consisted of 150 (n=106 females and 44 males) dentists (n=103 general dentists and 47 periodontologists) that responded to a questionnaire designed to retrieve cross-sectional information related mainly to their level of training and time of experience in practice, as well as their personal decision for managing four patients with periodontal disease. Bivariate analyses were performed to test the association between the clinical decisions and the professional information collected from the dentists.
RESULTS: In specific cases, periodontologists decided to maintain more teeth than general dentists (p<0.05). In other cases, dentists with more years of experience in practice decided to opt for more extractions (p<0.05). The level of periodontal disease (50-92%), poor oral hygiene (42.6-67.3%) and lack of alveolar bone structure (43.2-79.3%) were the most prevalent reasons behind the decision for extractions.
CONCLUSIONS: An advanced level of training in Dentistry, especially Periodontology, and more years of experience in practice may lead to more well-founded decisions on whether extracting teeth or not in case-specific scenarios.

Introduction

Periodontal disease is highly prevalent worldwide (-) and may lead to important consequences such as tooth loss (-). Early diagnosis and treatment founded on patient participation and plaque control contribute to better prognoses. Apart from the therapeutic approach, there is clinical evidence that plays an essential role in prognosis. Clinical attachment loss, probing depth, tooth mobility and furcation involvement are the relevant evidence of periodontal disease and as such may guide clinical decisions ().

Additionally, dentomaxillofacial imaging has proven to be a determinant tool for treatment planning in Periodontology (). More specifically, panoramic radiographs represent one of the most common types of dental examinations used in dental practice, thus offering an overview of the interface between the teeth and bones (). Over the last few years, dental images have become even more important among other advances in periodontal treatment. Initially focused on preventive care (), Periodontology has entered the spotlight of complex therapeutics that includes tissue regeneration, improvement of systemic conditions and oral rehabilitation ().

The scientific progress that has occurred in dentomaxillofacial imaging and Periodontology has benefited clinical performance but also culminated in a broad range of available therapeutic options. Deciding between these options has become a challenging task for dentists and patients. Professional training in the field, clinical experience and the patient’s socioeconomic condition are ranked among the decision-making factors in the scientific literature (-). Based on the hypothesis that radiographic exams contribute to the decision-making process and that several factors may influence the therapeutic approach in Periodontology, this study aimed to assess the decisions of dentists for maintaining or extracting teeth in patients with periodontal disease.

Material and methods

Study design

A quantitative questionnaire-based cross-sectional and observational study was designed and conducted after the approval of the local Committee of Ethics in Human Research (protocol: 64611317.6.0000.5083).

Setting and Participants

The target sample consisted of general dentists (Group 1) and periodontologists (Group 2) of Goiânia – a capital city in Central Brazil. The inclusion criteria for Group 1 consisted of dentists registered at the State Council of Dentistry AND (that work within general dentistry OR any other specialty different than Periodontology), In Group 2, the inclusion criterion consisted of dentists properly registered as specialists in Periodontology at the State Council of Dentistry. In both groups, the exclusion criterion consisted of dentists with professional practice outside the capital city. During sampling, 423 general dentists and 84 periodontologists were reached in their dental offices, professional meetings and in training courses.

Variables

The dentists reached in the sampling phase received soft- or hard-copies of an adapted questionnaire (). Questionnaires were designed to retrieve personal information from each dentists, such as, gender, age, field of practice (periodontologist or not), years of experience in practice and the type of undergraduate program (public or private). Additionally, four cases were presented to the dentists (Figures 1-4). Each of the cases had a brief description and a panoramic radiograph (Table 1).

Figure 1

– Panoramic radiograph of the patient presented in case #1

Figure 2

– Panoramic radiograph of the patient presented in case #2

Figure 3

– Panoramic radiograph of the patient presented in case #3

Figure 4

– Panoramic radiograph of the patient presented in case #4

Table 1

– Description of the four cases presented to general dentists and periodontologists in the questionnaire

Case	Sex	Age	Generalhealth	Badhabits	Current prosthesis	Oralhygiene	Probingdepth	Toothmobility	Personalwill
1	F	55	No systemic diseases	None	A pair of maladaptive removable partial prostheses	Poor	Teeth #17,37,47: 6mm. 4mm in all the other teeth	All the teeth withgrade 2	Maintaining her teeth and further prosthetic rehabilitation
2	M	48	No systemic diseases	Smoking and drinking	A single maladaptive removable partial prosthesis in the maxilla	Poor	Teeth #13,15: 4mm; #16,17,18: 6mm; #27,37,36,48: 9mm	Teeth #35,45: grade 1; #36,48: grade 3. All the maxillary teeth: grade 2	Extracting all his teeth.
3	M	65	Obese	Sugar eating	A single maladaptive removable partial prosthesis in the mandible	Poor	Teeth: #38,34,47: 8mm;	Maxillary teeth: grade 1; mandibular teeth: grade 2	Having long-term better outcomes
4	F	80	Diabetes mellitus type I, chronic kidney disease and hypertension all controlled	None	Complete upper denture and partial lower denture, both removable and maladaptive	Poor	Teeth #33,42,43: 8mm; #32,41: 10mm	#33,42,43: grade 2; #32,41: grade 3 (both splint together)	Maintaining all her teeth

F: female; M: male; age expressed in years and probing depth representative for all tooth surfaces. Cases #1, 2, 3 and 4 are illustrated in Figures 1, 2, 3 and 4, respectively. Dental coding according to the International Dental Federation.

Data measurements

After reading the clinical cases, the dentists were required to provide their decision for treating each patient. Four options were offered to manage the remaining teeth of each patient: I) maintaining all the teeth; II) extracting 3 teeth or less; III) extracting more than 3 teeth; and IV) extracting all the teeth. To those who decided for extractions, additional justifications were requested. The available justifications were: a) the severity of periodontal disease, b) the lack of alveolar bone structure; c) poor oral hygiene; d) the cost-benefit relation; e) few teeth remaining; f) easiness to designing prostheses; g) esthetics needs; and h) the patient’s personal will. The dentists were free to provide justifications based on one or more options.

Statistical methods

The data was analyzed with descriptive statistics of the absolute and relative frequencies of the quantified decision of dentists who were for tooth extractions or against them. The Chi-square test and the Pearson’s correlation coefficient were used to assess the potential association between decisions for dental extractions according to the level of education and training of dentists (Periodontology or not), their time of experience in practice (expressed in years) and their type of undergraduate program (public or private). The statistical analyses were performed using the IBM SPSS 24.0 software package (IBM Crop., Armonk, New York, USA). The significance level was set at 5%.

Results

The questionnaire was reponded by 150 (35.5%) dentists, out of which 103 (68.7%) general dentists and 47 (31.3%) were Periodontologists. In total, forty-four (29.3%) dentists were males and 106 (70.7%) were females. One-hundred and two dentists (70.3%) were aged below 30 years and 43 (29.7%) were older than 30 years of age. Most of the dentists (n=123; 82%) had less than 15 years of experience in practice.

In case #1 (Figure 1), sixty-three (42%) and 84 (56%) dentists decided for maintaining all the maxillary and mandibular teeth, respectively. In case #2 (Figure 2), most of the dentists decided for the extraction of less than 3 teeth in the maxillary (n=86; 57.3%) and in the mandibular arches (n=139; 92.7%). In case #3 (Figure 3), seventy-two (48%) dentists decided for the extraction of less than three teeth in the mandibular arch. In case #4 (Figure 4), most of the dentists (n=125; 83.3%) decided for the extraction of all the teeth, while only 7 (4.7%) decided the opposite (maintaining all the teeth) (Table 2).

Table 2

– Absolute and relative frequencies of clinical decisions for extractions in the maxilla and mandible

Decision	Case #1		Case #2		Case #3		Case #4
	Maxilla	Mandible	Maxilla	Mandible	Maxilla	Mandible	Mandible
Maintaining	42%(63)	56%(84)	4.7%(7)	4% (6)	98%(147)	8.7%(13)	4.7%(7)
<3 extractions	32.7%(49)	22%(33)	57.3%(86)	92.7%(139)	0.7%(1)	48%(72)	11.3%(17)
>3 extractions	9.3%(14)	6%(9)	36%(54)	1.3%(2)	0%(0)	18.7%(28)	0.7%(1)
Extract all	14.7%(22)	14.7%(22)	2%(3)	2%(3)	0%(0)	23.3%(35)	83.3%(125)

Cases #1, 2, 3 and 4 are illustrated in Figures 1, 2, 3 and 4, respectively.

Statistically significant associations were observed between the clinical decision in case #1 and the level of education and training of the dentists (p<0.05). More specifically, periodontologists decided more often for maintaining the teeth (Table 3). In cases #2 and 3, time of experience in practice played a significant role in clinical decision making (p<0.05). More experienced dentists decided for more extractions (Tables 4 and 5). In case #4, the association did not result in statistical significance (p>0.05, Table 6). Statistically significant associations were observed between the level of education and training and the time of experience in practice (p<0.05). I.e. Most of the periodontologists had more experience, while most of general dentists had less time of experience (p=0.001).

Table 3

– Comparison between the level of education and training, time of experience in practice and type of undergraduation program and the decision for extractions or not in case #1

Variables		Decision
		Maxilla				Mandible
		Maintaining	<3 teeth	>3 teeth	p	Maintaining	<3 teeth	>3 teeth	p
Level of education	General dentist	35.9%(37)	35.9%(37)	26.2%(27)	0.22	47.6%(49)	26.2%(27)	24.3%(25)	0.01*
	Periodontologist	54.2%(26)	25%(12)	18.75%(9)		72.9%(35)	12.5%(6)	12.5%(6)
Time of experience	<15 years	39%(48)	35.77%(44)	23.6%(29)	0.26	54.5%(67)	22%(27)	22%(27)	0.86
	>15 years	55.5%(15)	18.5%(5)	26%(7)		63%(17)	22.2%(6)	14.8%(4)
Undergrad. program	Public	43.4%(33)	34.2%(26)	21.1%(16)	0.90	56.6%(43)	25%(19)	17.1%(13)	0.80
	Private	40.5%(30)	32%(23)	27%(20)		55.4%(41)	18.9%(14)	24.3%(18)

*Statistically significant outcome with a significance level of 5%.

Table 4

– Comparison between the level of education and training, time of experience in practice and type of undergraduation program and the decision for extractions or not in case #2

Variables		Decision
		Maxilla				Mandible
		Maintaining	<3 teeth	>3 teeth	p	Maintaining	<3 teeth	>3 teeth	p
Level of education	General dentist	4.8%(5)	61.2%(64)	33.1%(34)	0.17	3.9%(4)	91.3%(94)	4.8%(5)	0.30
	Periodontologist	4.3%(2)	46.8%(22)	48.9%(23)		4.3%(2)	95.7%(45)	0%(0)
Time of experience	<15 years	5.7%(7)	61%(75)	33.3%(41)	0.03*	4.9%(6)	91.1%(112)	4%(5)	0.27
	>15 years	0%(0)	40.7%(11)	59.3%(16)		0%(0)	100%(27)	0%(0)
Undergrad. program	Public	5.3%(4)	57.9%(44)	36.8%(28)	0.91	3.95%(3)	92.1%(70)	3.95%(3)	0.91
	Private	4.1%(3)	56.7%(42)	39.2%(29)		4.1%(3)	93.2%(69)	2.7%(2)

*Statistically significant outcome with a significance level of 5%.

Table 5

– Comparison between the level of education and training, time of experience in practice and type of undergraduation program and the decision for extractions or not in case #3

Variables		Decision
		Maxilla				Mandible
		Maintaining	<3 teeth	>3 teeth	p	Maintaining	<3 teeth	>3 teeth	p
Level of education	General dentist	98.05%(101)	0%(0)	0%(0)	0.14	8.7%(9)	52.4%(54)	36.9%(38)	0.18
	Periodontologist	97.9%(46)	2.1%(1)	0%(0)		8.5%(4)	38.3%(18)	53.2%(25)
Time of experience	<15 years	99.2%(122)	0%(0)	0%(0)	0.03*	9.8%(12)	51.2%(63)	38.2%(47)	0.09*
	>15 years	92.6%(25)	3.8%(1)	0%(0)		3.7%(1)	33.3%(9)	59.3%(16)
Undergrad. program	Public	100%(76)	0%(0)	0%(0)	0.30	10.6%(8)	44.7%(34)	44.7%(34)	0.54
	Private	95.9%(71)	1.4%(1)	0%(0)		6.7%(5)	51.3%(38)	39.1%(29)

*Statistically significant outcome with a significance level of 5%.

Table 6

– Comparison between the level of education and training, time of experience in practice and type of undergraduate program and the decision for extractions or not in case #4

Variables		Decision
		Mandible
		Maintaining	<3 teeth	>3 teeth	p
Level of education	General dentist	3.9%(4)	10.7%(11)	85.4%(88)	0.72
	Periodontologist	6.4%(3)	12.8%(6)	80.8%(38)
Time of experience	<15 years	4.9%(6)	13%(16)	82.1%(101)	0.68
	>15 years	3.7%(1)	7.4%(2)	88.9%(24)
Undergrad. program	Public	5.3%(4)	11.8%(9)	82.9%(63)	0.91
	Private	4.1%(3)	10.8%(8)	85.1%(63)

*Statistically significant outcome with a significance level of 5%.

The severity of periodontal disease, the lack of alveolar bone structure and poor hygiene figured as the most prevalent reasons that justified the decisions for extractions. The severity of periodontal disease reached a prevalence of 50%, 92%, 83.3% and 86% in cases #1, 2, 3 and 4, respectively. The lack of alveolar bone structure reached 43.2%, 59.3%, 50.7% and 79.3%, in the same cases, while poor hygiene reached 42.6%, 67.3%, 43.3% and 60%.

Discussion

Periodontal disease may be manifested as destruction of tooth-supporting tissue () and may culminate within functional and esthetic damage to affected patients (). In the new era of scientific development, the decision for extracting teeth with periodontal disease is a challenging task, especially because many therapeutic alternatives are available in dentistry, such as tissue regeneration biomaterials (). Recent studies have demonstrated how positive is the prognosis of teeth maintained and treated. In a recent systematic literature review (), the survival rate of periodontally affected teeth was compared to the survival rate of dental implants. The authors showed that patients undergoing optimal therapeutics had a tooth survival rate which is not inferior to the survival rate of implants. These outcomes suggest that extractions followed by implant rehabilitation should be considered as case-specific. In other words, patients with previous periodontal disease may evolve into patients with peri-implant disease ().

In the first case, the patient had moderate general chronic periodontitis. The dentists mostly took a conservative approach. Their decision for maintaining the maxillary (42%) and mandibular teeth (56%) was probably influenced by the lower severity of the disease compared to other cases. From a periodontal point of view, these teeth could be maintained and treated with a good prognosis. For those who opted for extractions, a combination of factors seems to have influenced their decision such as poor oral hygiene and a lack of alveolar bone structure. It is important to note that the cost-benefit relation justified the decision for the extractions in 30.4% of the cases. However, the scientific literature shows that periodontal treatment may have a better cost-benefit relationship when compared to extractions followed by rehabilitation with implants and prostheses (-). Furthermore, a deeper look into the first case showed statistically significant differences between periodontologists and general dentists. Decisions for fewer extractions were made by periodontologists, while general dentists took more invasive approaches. These outcomes show the important role of education and training in dentistry in order to opt for more conservative therapeutic approaches (, ).

In the second case, the patient had generalised advanced chronic periodontitis. Despite the advanced disease, the patients had more teeth compared to those in the first case. Grade 3 tooth mobility, the exposure of the root bifurcation and smoking and drinking habits played a big role in a bad prognosis (, ). Most of the dentists decided to extract less than 3 teeth in the maxillary (57.3%) and mandibular (92.7%) arches. Interestingly, 2% of the dentists decided to extract all of the teeth (including those able to be maintained with periodontal treatment), a decision not supported by the scientific literature. The popularisation and availability of dental implants have made extractions more prevalent and the alternative choice for patients that want short-term solutions. In this context, the number of teeth recommended for extractions was associated with the time of experience in practice (p<0.05). Dentists with more than 15 years of experience in practice opted to extract a larger number of teeth. In general, these dentists were mostly periodontologists, and due to their personal experience with similar cases, they could predict a lack of success under the described intraoral conditions and the additional smoking and drinking habits reported by the patient.

In the third case, the patient had a stable periodontal condition in the maxillary teeth but periodontitis in the mandibular teeth. Differently, the patient was more demanding about the treatment time and longevity. In the maxillary arch, only a single dentist decided to extract teeth #17 and 27. In the mandibular arch, most of the dentists (48%) decided to extract less than 3 teeth. The severity of the periodontal disease (83.3%) and the lack of alveolar bone structure (50.7%) were the most prevalent reasons behind the decisions for extractions. These outcomes show that the clinical aspects of the disease are relevant factors for deciding on whether to extract or not. Periodontologists may be more well-founded when deciding on extractions as they have a better understanding of the clinical evidence of periodontal disease. This fact is confirmed with the association of the time of experience in practice and the number of extractions, which shows that periodontologists may indicate more extractions in specific cases because of their knowledge and experience in the field.

In the fourth case, the patient had no teeth in the maxillary arch and poorly supported teeth in the mandible. In spite of the fact that a periodontal treatment was carried out (surgical or not), a bad prognosis was expected. Most of the dentists (83.3%) opted to extract all of the teeth. Those who decided to maintain the teeth could be supported by the Bioethics’ principle of autonomy (), which lets the patient participate in the clinical decision process (the patient wanted to maintain her teeth). The severity of the periodontal disease (86%), a lack of alveolar bone structure (79.3%) and poor oral hygiene (60%) were the most prevalent reasons that led to the decision for extractions. These factors in association with the patient’s age and her clinical condition could justify the decision for extractions.

As in most of the questionnaire-based surveys, this study was designed to simulate a clinical scenario with four cases to investigate and illustrate the decision-making process in periodontology. Future studies should be structured to investigate more specifically the level of knowledge in periodontology and its influence in deciding on more complex and more detailed clinical cases. Additionally, the developed questionnaire should be tested and validated in other populations in order to have a broader range of data collected and to enable population-specific comparisons in the future.

Conclusion

Regarding tooth extractions, the clinical decision-making process made by general dentists and periodontologists was influenced by the level of periodontal disease, the level of oral hygiene of the patient and the level of the remaining alveolar bone.

As expected, case-specific circumstances influenced on the clinical decision-making process, but in most of the cases periodontologists were less invasive and decided more often to maintain the teeth with proper therapeutic follow-up.