Clinical Research

A Prospective Study of the Extraction and Retention

Incidence of Endodontically Treated Teeth with Uncertain
Prognosis after Endodontic Referral
Nestoras E. Tzimpoulas, DDS, Michalis G. Alisafis, DDS, MSc, Giorgos N. Tzanetakis, DDS, MSc,
and Evangelos G. Kontakiotis, DDS, PhD

Abstract
Introduction: The present study was conducted with
the aim to assess the extraction and retention incidence
of endodontically treated teeth with an uncertain prog-
T he prevention and treatment of apical periodontitis is the main long-term purpose of
root canal therapy (1). The optimal results of endodontic treatment are the healing
of periradicular tissues and the achievement of functionality of the treated teeth (1, 2).
nosis after endodontic referral and to evaluate the The progress and continuous development of endodontic operative techniques have
factors related to the decision-making process. significantly contributed to those purposes offering a lot of benefits to the clinician
Methods: Two hundred seventy-five permanent teeth trying to achieve an appropriate treatment outcome (3–5).
were clinically and radiographically evaluated by 3 expe- Nevertheless, in everyday clinical practice, clinicians may decide to extract an
rienced endodontists. The type of tooth, age and sex of endodontically treated tooth for a number of reasons. Extraction still retains its validity
the patients, the motive of referral, and the main chief as a treatment option despite our improved knowledge about the biological and clinical
complaint were the initial recorded data. The associa- factors that determine the prognosis of an endodontically treated tooth and the advance-
tions between extraction reasons and the patients’ ment of novel endodontic techniques and materials (6–8).
age and sex or tooth type were analyzed using the Despite the fact that many clinical studies have been performed dealing with the
chi-square test. Results: Of the 275 teeth examined, success and failure of endodontic treatment, only a few have focused on the reasons
217 (79%) were finally extracted. The remaining 58 that might cause the loss of endodontically treated teeth (9–12). The majority of
(21%) teeth were endodontically retreated and restored. these studies have retrospectively found that the major issue regarding the retention
A questionable clinical status was the main motive for of endodontically treated teeth was the questionable or poor expected restorative
endodontic referral (57.1%). The teeth most extracted outcome. Periodontal disease and endodontic treatment failure were the other 2
were maxillary molars (36.2%) followed by mandibular most prevalent reasons for extraction, whereas a significant proportion of teeth were
molars (32.9%). The most prevalent reason for extrac- extracted because of the presence of a vertical root fracture (9–13).
tion was nonrestorable caries (37.1%). The majority of A recent prospective study has analyzed this issue with a different and more
the teeth retained in the oral cavity needed surgical peri- detailed approach, but the results were based on questionnaires answered by general
odontal or endodontic management. Conclusions: The dentists (12). It is also noteworthy that none of these studies has taken into consider-
most frequent reason responsible for the fate of ation patients’ wishes as an additional option for the decision-making process. Financial
endodontically treated teeth is the pronounced loss of issues and patients’ related factors (ie, preference and autonomy) appear to be the 2
dental tissues. Endodontic referral may aid in the main reasons that sometimes lead patients to decide to have teeth extracted rather than
survival of some carefully selected cases of endodonti- undergoing endodontic retreatment or periradicular surgery. Moreover, in a study like
cally treated teeth. (J Endod 2012;38:1326–1329) this, it is very important to collect data from endodontists in order to obtain more
precise information about the clinical and radiographic status of the teeth and also
Key Words to secure that all treatment options were exhausted before tooth extraction. The aim
Endodontically treated teeth, extraction, rationale, of the present study was prospectively 2-fold: first, to evaluate the extraction incidence
retention of endodontically treated teeth with an uncertain prognosis after endodontic referral
and second to define all the related factors affecting the decision for extraction and
retention of the same teeth.
From the Department of Endodontics, Dental School,
University of Athens, Athens, Greece.
Address requests for reprints to Dr Evangelos G. Kontakio-
Materials and Methods
tis, 2 Antheon Str, Patisia, 11143 Athens, Greece. E-mail Data were gathered from 275 endodontically treated permanent teeth of 270
address: ekontak@dent.uoa.gr patients referred to 3 different endodontic offices for clinical and radiographic evalu-
0099-2399/$ - see front matter ation regarding the possibility of teeth retention. The study took place from September
Copyright ª 2012 American Association of Endodontists. 5, 2010, to July 29, 2011. For each patient, a special file was completed in order to
http://dx.doi.org/10.1016/j.joen.2012.06.032
obtain the required information. Among the data collected were patients’ sex and
age, the main reason of referral, the type of the tooth, and the main chief complaint.
Each tooth was clinically and radiographically evaluated by 3 examiners
(endodontists) who had been previously calibrated mainly for the determination of
the clinical status of the teeth. The radiographic evaluation initially took place indepen-
dently based on the clinical experience of each examiner. Only 1 diagnosis could be

1326 Tzimpoulas et al. JOE — Volume 38, Number 10, October 2012
 Clinical Research
noted for each examination. If more than 1 factor was documented
related to tooth extraction, the more untreatable condition was chosen
(eg, vertical root fracture over iatrogenic perforation). Disagreements
and different opinions were discussed among the examiners a second
time until a consensus was reached. The decision for teeth extraction
or retention was made after clinical and radiographic evaluations and
a consensus was reached among the 3 examiners regarding the radio-
graphic appearance of the teeth. In the majority of the cases, the clinical
evaluation included the isolation of the teeth with a rubber dam, caries
removal, access of the pulp chamber, and microscopic examination. An
additional parameter (patients’ wishes) was taken into account
regarding the treatment options (ie, conventional or surgical manage-
ment or extraction) of the examined teeth. Figure 1. Distribution of the extracted teeth according to tooth type.
Clinical conditions related to the extraction of endodontically
treated teeth were classified in 12 different categories (ie, vertical root
fracture, calcification plus patients’ wishes, cervical resorption plus The reasons for extraction of the teeth examined are diagrammat-
ically presented in Figure 2. Nonrestorable caries was the most preva-
patients’ wishes, dental trauma, endoperiodontal lesion, endodontic
failure plus patients’ wishes, iatrogenic perforation, nonrestorable lent reason (37.1%; 95% CI, 30.6%–43.6%). Other significant reasons
caries, orthodontic reasons, periodontal disease, prosthetic reasons, were nonrestorable cusp fracture (17.8%; 95% CI, 12.7%–23%) and
the presence of a vertical root fracture (10.3%; 95 CI, 6.2%–14.4%).
and an unrestorable cusp fracture). Additionally, teeth planned for
extraction were classified into 8 different categories according to the Other reasons were periodontal disease (8.5%), iatrogenic perforation
type of tooth (ie, maxillary incisor, mandibular incisor, maxillary canine, (6.6%) or the initial presence of a perforation (0.5%), endodontic
mandibular canine, maxillary premolar, mandibular premolar, maxillary failure (5.6%), a prosthetic reason (4.2%), an endoperiodontal lesion
molar, and mandibular molar). (2.8%), dental trauma (2.3%), orthodontic reasons (1.9%), calcifica-
Data were pooled and statistically evaluated by SAS version 9.0 tion (1.4%), and cervical resorption (0.9%).
(SAS, Cary, NC). Ninety-five percent confidence intervals (CIs) were No significant differences were found among the different group
calculated with the aim to estimate differences between proportions. ages (P = .679) and sex (P = .422) regarding the prevalence of the
The associations between extraction reasons (ie, nonrestorable caries, clinical condition of ‘‘nonrestorable caries.’’ Nonrestorable caries
vertical root fracture, periodontal disease, perforation, and so on) and were significantly more prevalent in molars than in premolars (P <
.001) but without differences between mandibular and maxillary
patients’ age and sex or tooth type (eg, maxillary vs mandibular molars
and so on) were analyzed using the Pearson chi-square test. The level of molars. The tendency for a decrease of the clinical condition of ‘‘unrest-
statistical significance was set at 95% (P < .05). orable cusp fracture’’ as patients’ ages increased (P = .063) was also
evident.
Of the 58 teeth retained, 28 needed a surgically crown-lengthening
Results procedure. All these teeth were endodontically retreated and restored
Of the 275 endodontically treated teeth examined, 217 (79%) using either a cast or a prefabricated post. Fifteen teeth were only
were extracted. The remaining 58 (21%) teeth were endodontically re- conventionally retreated and permanently restored with a single crown.
treated, permanently restored, and programmed for recall examination Ten teeth were surgically retreated using a microscope and mineral
every 6 months for at least 2 years. A questionable clinical status of teeth trioxide aggregate (MTA) as retrofilling material. MTA was also used
was the main motive for endodontic referral (57.1%) followed by a high as a repair perforation material in the remaining 5 teeth.
suspicion of the presence of a vertical root fracture (13.8%), iatrogenic
perforation (10.9%), endodontic failure (9%), an endoperiodontal
lesion (4%), and calcification (2.9%). The remaining 2.2% included Discussion
other reasons for referral such as dental trauma, periodontal disease, The present study was conducted with the aim to investigate more
and cervical resorption (Table 1). precisely the reasons that determine the decision-making process
The distribution of the extracted teeth is shown in Figure 1. The regarding the retention or extraction of endodontically treated teeth
most commonly extracted teeth were maxillary molars (36.2%) and with an uncertain prognosis. This was performed in 2 different ways.
mandibular molars (32.9%). Other categories of teeth followed with First, the procedure was completed using a prospective approach in
lower percentages such as maxillary premolars (12.7%), mandibular order to minimize the risks and limitations as a result of the interpre-
premolars (11.3%), maxillary incisors (2.8%), mandibular incisors tation of retrospective data. Second, the clinical and radiographic eval-
(2.8%), mandibular canines (0.9%), and maxillary canines (0.5%). uations of the teeth were performed by 3 experienced endodontists after
patient referral to their private clinic. However, the calibration of clin-
ical examiners remains a major difficulty and is a common limitation in
TABLE 1. Distribution of the Teeth According to the Main Motive for these types of studies (14). Another serious limitation is also that a great
Endodontic Referral number of endodontically treated teeth are probably extracted by
Main motive (N = 275) n % general dentists for various reasons without previous referral to
endodontists. All these teeth are automatically excluded from a study
Questionable clinical status 157 57.1
Possible presence of a vertical root fracture 38 13.8
like this without the appropriate analysis of the extraction reasons.
Iatrogenic perforation 30 10.9 The main motive for endodontic referral of endodontically treated
Endodontic failure 25 9 teeth with an uncertain prognosis was found to be their questionable
Endoperiodontal lesion 11 4 clinical status. In the majority of cases, caries of the pulp chamber floor
Extensive calcification 8 2.9 were evident during clinical microscopic examination. This finding was
Other 6 2.2
considered to be crucial in the decision of retention of the tooth in the

JOE — Volume 38, Number 10, October 2012 Extraction and Retention of Endodontically Treated Teeth with Uncertain Prognosis 1327
Clinical Research

Figure 2. A diagrammatic presentation of the extraction reasons of the endodontically treated teeth examined.

oral cavity. The second most frequent reason was the possible presence total agreement with the respective data provided by some important
of vertical root fracture. In all cases in which a vertical fracture was and relevant large epidemiologic studies (18, 20, 21). In the present
finally diagnosed, a localized deep periodontal pocket was detected study, endodontic failure was definitely diagnosed as post-treatment
along the fracture line. apical periodontitis. Sinus tracts and clinical symptoms (spontaneous
Maxillary molars were found to be the most commonly extracted pain or pain to percussion) were also present in the majority of the
teeth followed by mandibular molars, however, without statistically cases. The quality of endodontic treatment and the coronal restoration
significant differences. This finding is in contrast with the results of played an important role concerning the treatment options proposed to
previous similar studies that have noted a significant predominance the patients. If the endodontic treatment was evaluated as insufficient,
of extraction for endodontically treated mandibular molars (11, 12). the first option was conventional retreatment. If the treatment was eval-
Despite these minor differences among the studies performed, it is uated as sufficient or a cast post was present, then the first option was
very important to notice the great tendency of molars to fracture, periapical surgery. In the present study, all these teeth were finally ex-
especially in cases in which an adequate prosthetic restoration is tracted because patients did not consent to any further treatment such as
absent. This observation has also been bibliographically documented conventional retreatment or periradicular surgery. The patients’ wishes
by previous similar studies showing the significance of full-crown also played an important role in the decision-making process in teeth
coverage for the survival of endodontically treated teeth (15–18). with extensive calcification and cervical resorption. This parameter is
Under the conditions of the present study, it was also shown that presented as an additional factor for the first time confirming how
the key factor in the decision to extract or retain endodontically treated important patients’ consensus is during the treatment decision process
teeth is the pronounced loss of dental tissues. This result is in contrast and also the respect of the concept of ‘‘patient autonomy’’ (22, 23).
with the findings of a recent prospective study that was based on a ques- Additionally, it should be noted that patients’ wishes have only been
tionnaire survey answered by general dentists (12). This study by Toure included in 3 of the 12 classifications. This is because it was initially
et al (12) concluded that the main reason for the extraction of endodon- considered that patients’ wishes could not play any role in vertical
tically treated teeth by general dentists is severe periodontal disease fol- root fractures, in severely periodontally involved teeth (ie, a severe en-
lowed by endodontic failure and vertical root fracture. These doperiodontal lesion or periodontal disease), in large iatrogenic perfo-
contradictory findings show the subjectivity that characterizes this rations, or when unrestorability is diagnosed (ie, nonrestorable caries
matter as well as the major dilemma that general dentists encounter and unrestorable cusp fracture). Dental trauma was also important in
when they have to decide about restorative issues of endodontically 5 cases of severe horizontal midroot fractures in which the treatment
treated teeth. Another serious reason that possibly explains this finding decision was extraction and implant placement. Orthodontic and pros-
is, as previously stated, that a number of endodontically treated teeth are thetic reasons represented 13 cases of endodontically treated teeth (4
extracted without previous referral to endodontists including severely and 9, respectively) in which endodontic failure occurred. Endodontic
periodontally involved teeth with a high degree of mobility. retreatment or endodontic surgery was feasible, but the orthodontist
Vertical root fractures steadily possess a high rate among the and prosthodontist did not wish to take a risk using these teeth in their
extraction reasons of endodontically treated teeth as revealed by the treatment planning, so the extraction was necessary independently of
literature (19). The present study showed that almost 1 out of 10 patients’ wishes.
endodontically treated teeth with a questionable prognosis is extracted Finally, the majority of the retained teeth needed surgical manage-
because of the presence of a vertical root fracture. This result is in ment of both soft and hard dental tissues. This fact shows the usefulness
total agreement with the results of the majority of previous similar of microsurgical endodontic and periodontal techniques toward the
studies whose respective percentages range between 8.8% and aim of survival of endodontically treated teeth with an uncertain prog-
13.4% (9–12). Only Sjogren et al (13) reported a significantly higher nosis. MTA was also the material of choice for all surgical endodontic
incidence (31%) of vertical root fractures among endodontically techniques. The further improvement of the already existing techniques
treated teeth (13). and the development of novel techniques and materials will certainly aid
It is also of great interest that a small number of teeth were only in the efforts regarding the survival of more and more endodontically
extracted because of endodontic treatment failure. This finding is in treated teeth with a questionable or uncertain prognosis.

1328 Tzimpoulas et al. JOE — Volume 38, Number 10, October 2012
 Clinical Research
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