Title: When to Save or Extract a Tooth: A guide to Prognosis
1When to Save or Extract a Tooth A guide to
Prognosis Evaluation of Individual Teeth
- Dr Wael Al-Omari
- BDS, MDentSci, PhD
2- 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
3- 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?
4- 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.
5- 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
6The major factors that determine prognosis
- Periodontal Considerations
- Restorability
- Endodontic considerations
- Occlusal plane considerations
- Patient-level considerations
7Periodontal 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)
8- 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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10Mutilated Dentition
11Restorability
- 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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13Endodontic 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
14Occlusal 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.
-
15Occlusal Plane Considerations
- Treatment Options
- 1- Simple enameloplasty
- 2- Full coverage crowning to correct
- occlusal plane.
- 3- Orthodontic treatment
- 4- Extraction
16Periodontal eruption
Active eruption
17Classification System (Samet and Jotkowitz, 2009)
- Dental Evaluation involves 2 sequential phases
- 1- Takes patient-level considerations
- into account
- 2- Classify individual teeth
18Patient-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
19Patient-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
20Patient-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
21Patient-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
22Evaluation 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
23Classification 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.
24Class 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
25Class 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.
26Class 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.
27Class 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.
28Class 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.
29Factors 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
30Factors 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
31The classification could be included into routine
clinical examination record
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