Clinical Research

Analysis of Reasons for Extraction of Endodontically Treated

Teeth: A Prospective Study
Babacar Tour!e, DDS, PhD,* Babacar Faye, DDS, PhD,* Abdoul W. Kane, DDS, PhD,*
Cheikh M. Lo, DDS,† Bassirou Niang, DDS,* and Yves Boucher, DDS, PhD‡

Abstract
Introduction: The purpose of this prospective study
was to analyze the factors related to extraction of
endodontically treated teeth. Methods: One hundred
D espite progress in prevention and operative techniques, teeth extraction remains an
important part of therapeutics. Several studies investigating the reasons for teeth
extraction report predominance of carious and periodontal diseases (1–9). Because
nineteen cases of extraction of endodontically treated endodontic treatment is performed mainly to prevent tooth extraction, it is important
teeth were consecutively reviewed, and the following to evaluate the fate of endodontically treated teeth. Two longitudinal studies carried
items were recorded: type of tooth; presence and type out in the United States with a long follow-up period reported retention for endodon-
of coronal restoration; motive of consultation; reasons tically treated teeth in oral cavity of 94% and 97% (10, 11). A study in Taiwan followed
for extraction; patient’s age, gender, level of education; 1,557,547 teeth during a 5-year period after nonsurgical endodontic treatment and
smoking status. Association between factors was inves- found a retention rate in oral cavity of more than 92.3% (12). These studies have
tigated with c2 analysis. Results: Dental pain was the not specified the reasons for the extractions of the missing teeth. In fact, studies report-
main motive for consultation (68.9%). The teeth most ing the factors accounting for the extraction of endodontically treated teeth are scant. 乏しい
extracted were mandibular molars (51.3%), followed For instance, after chart examination of 147 extracted teeth after endodontic treatment,
by maxillary molars (16.1%). First molars were the Fuss et al (13) found that the reasons were related to the quality of the crown restoration
most frequently extracted (29.4%). Ninety-one teeth (43.5%), the endodontic treatment (40.2%), a vertical root fracture (10.9%), and peri-
(76.5%) were restored coronally with or without post, odontal diseases (5.5%). Vire (14) noted in a study of 116 endodontically treated teeth
and crowned teeth represented 5.9% of the sample. that in 59% of the cases, prosthodontics reasons motivated the extraction, followed by
The reasons for extraction were periodontal disease periodontal disease (32%) and endodontic treatment failure (9%). In another study,
(40.3%), endodontic failure (19.3%), vertical root frac- Zadik et al (15) found the following reasons: nonrestorable caries 61.4%, endodontic
ture (13.4%), nonrestorable cuspid and crown fracture treatment failure 12.1%, vertical root fracture 8.8%, iatrogenic perforations and strip-
(15.1%), nonrestorable caries (5.2%), iatrogenic perfo- ping 8.8%, periodontal diseases 4.6%, cusp fractures 2.4%, orthodontic factors 1.3%,
rations and stripping (4.2%), and prosthetic (0.8%). prosthetic factors 0.2%, and trauma 0.5%. When studying the associated factors, they
Analysis between gender, smoking status, and educa- noted that the periodontal causes were more prevalent among smokers than in
tion level showed no significant difference for reasons nonsmokers, which corroborates the results of Johnson and Guthmiller (16) on the
of extraction (P = .33 and .34). Conclusions: The impact of cigarette smoking on periodontal diseases. It is worthy of note that all these
mandibular first molar without crown was the most investigations were of retrospective design.
frequently extracted tooth. The main reasons for extrac- The purpose in this study was to prospectively investigate the reasons for the
tions were periodontal disease, endodontic failure, and extraction of permanent endodontically treated teeth.
nonrestorable tooth damage caused by fracture or
caries. (J Endod 2011;37:1512–1515) Materials and Methods
Data were collected consecutively during a 2-month period extending from April
Key Words 15–June 15, 2010. The information was obtained from 120 practitioners randomly
Endodontically treated teeth, extraction, factors selected from a list provided by the National Order of Dental Surgeons of Senegal. Prac-
titioners who had an exclusive and specialized practice were removed from this list.
Questionnaires were sent to the included practitioners by mail with a stamped envelope.
They were due to return at the end of the study. The questionnaire included information
From *Conservative Dentistry and Endodontics, University
Cheikh Anta Diop, Dakar, S!en!egal; †Dental Public Health, about the practitioner (age, gender, seniority); the patient (age, gender, level of educa-
University Cheikh Anta Diop, Dakar, S!en!egal; and tion, and smoking status); the motive for consultation (pain, mobility, esthetics, trauma,
‡
Conservative Dentistry and Endodontics, University Paris VII, other reasons to be specified); the tooth or teeth extracted (type, the preexisting coronal
Paris, France. restoration); and the reason for extraction (endodontic failure, caries, periodontal
Address requests for reprints to Dr Babacar Tour!e, Ma^ıtre
de Conf!erences Agr!eg!e Conservative Dentistry and Endodon-
disease, prosthetic, fractures, perforations, orthodontic, esthetic, or other reasons to
tics, PO Box 12465, Colobane Dakar, Faculty of Medicine Phar- be specified). The endodontic treatment was confirmed by a radiographic appearance
macy and Odontology, University Cheikh Anta Diop, Dakar, of some permanent root canal filling. Teeth that were extracted before the completion of
S!en!egal. E-mail address: [email protected] the endodontic treatment were not included in this study.
0099-2399/$ - see front matter Confidentiality and anonymity were respected throughout.
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.07.002 The aforementioned variables related to the practitioners, the patients, and the
teeth extracted were computed. The different quantitative variables are expressed in

1512 Tour!e et al. JOE — Volume 37, Number 11, November 2011
 Clinical Research
TABLE 1. Distribution of the Sample According to Motive for Consultation sample (Table 1). There was no significant difference for these reasons
according to gender and education levels of the patients (P = .67
Motive for consultation
(n = 119) n % and .28, respectively).
The teeth that were the most often involved in the emergency
Pain 82 68.9 consultation were the first mandibular molars (29.4%), the second
Dental mobility 13 10.9
Trauma 10 8.5 and third mandibular molars (21.9%), the maxillary premolars
Esthetics 3 2.5 (11.7%), the incisors and maxillary canines (10.9%), the first maxillary
Other 11 9.2 molars (10.1%), the mandibular premolars (6.7%), the second and
third maxillary molars (6%), and the mandibular incisors and canines
(3.2%) (Fig. 1).
terms of their mean and standard deviation, whereas the qualitative vari- Ninety-one teeth (76.5%) were previously coronally restored.
ables are given as their absolute value and the percentage. Restorations without post represented 67.2% including amalgam
The association between qualitative variables was tested by using (58%), composite (6.7%), and glass ionomer cement (2.5%), whereas
c2. The level of significance was fixed at P # .05. The statistical analysis those with post accounted for 3.4%. Seven teeth (5.9%) were crowned
was performed with the SPSS software (Statistical Package for Social with or without post and core.
Sciences version 11.5; SPSS Inc, Chicago, IL). The reasons on which the decisions to extract a tooth were based
are presented in Figure 2; periodontal disease (40.3%) was the most
frequent. Other reasons included endodontic treatment failure
Results (19.3%), vertical root fracture (13.4%), nonrestorable cuspid and
Of the 120 dental surgeons asked to participate in this study, 33 crown fracture (15.1 %), nonrestorable caries 5.2%, iatrogenic perfo-
responded to the questionnaires, providing a response rate of 27.5%. rations and stripping 4.2%, prosthetic 0.8%, and total crown destruc-
The mean age was 43.85 ! 7.96 years; 72.7% were male. The mean tion (1.7%). Statistical analysis that looked at influence of gender and
professional practice was 14.06 ! 7.68 years. educational levels on these variables showed no significant differences
One hundred nineteen patients had a permanent tooth extracted (P = .33 and .34, respectively).
after an endodontic treatment during the study period. The mean age
of the patients was 37.5 ! 13.22 years, with 50.9% women. The level
of education was as follows: university 25.2%, secondary 24.4%, middle Discussion
school 17.6%, and elementary school 32.8%. Nonsmokers represented In the present study, 33 of 120 dental surgeons with a mean
76% of the sample. professional practice of 14.06 ! 7.68 years responded to the question-
Dental pain was the main motive for consultation (68.9%), fol- naires. In view of the high number of participants in the study, no cali-
lowed by dental mobility (10.9%), trauma (8.5%), and esthetics bration was performed. This is therefore a limitation for this study
(2.5%). The other reasons for consultation (coronal fracture, loss of because clinicians might have a different analysis of cases and take
restoration, periodontal abscess, total crown destruction, gingival different therapeutic decisions despite their important clinical experi-
bleeding, prosthetic treatment, and halitosis) represented 9.2% of the ence (17). One hundred nineteen endodontically treated teeth were

Figure 1. Distribution of the extracted endodontically treated permanent teeth. mand, mandibular; max, maxillary.

JOE — Volume 37, Number 11, November 2011 Factors Related to Extraction of Endodontically Treated Teeth 1513
Clinical Research
extracted during the study period. In this study, pain was the main Sjogren et al (20) reported a prevalence of 31% of vertical frac-
motive for consultation (68.9%), as already observed in a prior study tures in teeth after endodontic treatment. This contrasts with the
related to emergencies (18). Mandibular molars were the most ex- results obtained in the present study, which are similar to those of
tracted teeth (51.3%), followed by maxillary molars (16.6%) and Vire (14) with 13%. Zadik et al (15) and Tamse et al (21) noted
maxillary premolars (11.7%). The predominance of mandibular a higher prevalence of fractures in the mandibular molars, but
molars was also noted by Zadik et al (15), in which they represented this tendency was not found in the present study, in which the maxil-
44.6% of the sample. No mandibular incisor or canine was extracted lary premolars were the teeth that were the most subject to fracture.
in their study, as opposed to the present study in which these teeth rep- With 19.3% of endodontically treated teeth extracted because of
resented 3.2% of the sample. Among the molars, the first mandibular endodontic treatment failure and 4.2% for technical endodontic
molars represented 29.4% of the extracted teeth. This great prevalence problems, ie, iatrogenic perforations and stripping, this study points
was noted in almost all of the studies and is associated, above all, to its out the need for advanced endodontic treatment in Senegal where
susceptibility to caries and the frequency of treatments. there are very few specialists in endodontics. Although no indication
In the present study, periodontal diseases were the primary reason related to the status of the endodontically treated teeth was available,
for extraction (40.3%). This high rate is a peculiarity, because it rarely ie, initial endodontic treatment or retreatment, we can speculate that
exceeded 5% in the other studies (13–15), except for those an endodontic retreatment or a surgical endodontic treatment could
performed by Chen et al (12) and Vire (14), who noted that 26.8% have been attempted before extraction.
and 32%, respectively, were periodontal causes. Despite the high rate Coronal restoration was presented on 70.6% of the teeth. The rela-
of periodontal causes noted in this study and the causes related to the tion between apical periodontitis and coronal restoration has been
impossibility of restoration of the teeth, the results of this study are not explored in several retrospective clinical studies suggesting that coronal
very different from those found in the literature. Fuss et al (19) noted restoration is a factor associated with the presence of apical periodon-
a low frequency of periodontal reasons (5.5%) and a predominance titis (22–25). A recent meta-analysis highlighted the difficulty when
of reasons related to the impossibility of restoring the tooth and to evaluating the relative contribution of coronal and endodontic seal
endodontic failures (63%). Reasons related to nonrestorable caries and emphasized their synergy for periapical health (26).
were the primary causes of extraction in the study by Zadik et al (15). Coronal restorations were dominated by direct core build-up tech-
Other reasons mentioned are endodontic failures (12.1%), iatrogenic niques (amalgam, composite resins, and glass ionomer cement)
fractures and perforations (17.6%), and periodontal diseases (4.6%). without post in 67.2% of the cases. Only 5.9% of teeth with root canal
In this study, an analysis of factors related to gender, educational treatment were restored by crowns; this finding corroborates the results
level, or smoking status did not show any differences when compared of Tour!e et al (27), who noted a prevalence of 0.95% of crowns in
with reasons for extraction, in contrast to the findings of Zadik et al Senegal. This low prevalence of crowns might be explained by several
(15), who noted that the reasons related to periodontal diseases were factors including the cost, the low refund by insurance, and lack of moti-
5.8 times more important with smokers than with nonsmokers. The vation from the patient.
reasons related to endodontics represented 36.9% and were composed Several studies have investigated the relation between the type of
of endodontic failures (19.3%), vertical fractures (13.4%), and iatro- coronal reconstruction and the survival rate of teeth after endodontic
genic perforations and stripping (4.2%). Fuss et al (13) found treatment (10, 14, 28, 29). They concluded that teeth without full
endodontic reasons in 51%, Vire (14) noted 59% for the same reasons, cuspal coverage were lost at a rate that was 5 or 6 times higher than
and 19% were found in the study conducted by Zadik et al (15). fully covered teeth. Sorensen and Martinoff (30) further investigated

Figure 2. Reasons for extraction of the 119 extracted endodontically treated teeth.

1514 Tour!e et al. JOE — Volume 37, Number 11, November 2011
 Clinical Research
the survival rate according to the group of teeth and found that the rate 10. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population
of clinical success was significantly improved with coronal coverage of in the USA: an epidemiological study. J Endod 2004;30:846–50.
11. Lazarski MP, Walker WA 3rd, Flores CM, Schindler WG, Hargreaves KM. Epidemi-
posterior teeth but not for anterior. ological evaluation of the outcomes of nonsurgical root canal treatment in a large
In the present study, 94% of the extracted teeth never had a final cohort of insured dental patients. J Endod 2001;27:791–6.
restoration with full cuspal coverage. This finding is similar to that of 12. Chen SC, Chueh LH, Wu HP, Hsiao CK. Five-year follow-up study of tooth extraction
Zadik et al (15), who noted that 85% of the extracted endodontically after nonsurgical endodontic treatment in a large population in Taiwan. J Formos
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of extraction of teeth without full cuspal coverage might be explained tically treated teeth. Int Endod J 1999;32:283–6.
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16. Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease
Conclusion and treatment. Periodontol 2000 2007;44:178–94.
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extraction of endodontically treated teeth. The mandibular first molar 18. Tour!e B, Kane AW, Diouf A, Faye B, Boucher Y. Preoperative pain and medication
without a crown was the most frequently extracted tooth. The main used in emergency patients with irreversible pulpitis or acute periodontitis:
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technical quality of the root filling and the coronal restoration. Int Endod J 1995;28:
able help with the editing of this manuscript. 12–8.
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