The reasons for tooth extractions in adults

and their validation

In industrialized countries where the population has
access to dental care, caries is generally considered to be
the primary cause of tooth loss with periodontal disease
the next most frequent reason-13.
Ainamo et ~1.~ found dental caries to be the most
common reason given for tooth extraction in all age
groups but other studies have reported that periodontitis
becomes the most important cause after 408,14, 507
and 60 years of age.

In developing countries such as Kenya, Tanzania and

China, where the population has limited access to
dental care, dental caries accounts for most of the tooth
loss in all age groups5P17.
The reasons for extracting teeth in these studies have
been on the basis of the dentists opinion but it is
recognized that the criteria for caries and periodontal
disease vary between dentists. Some attempts have
been made to validate the dentists reasons for extraction
in respect of periodontal disease. Klock and
Haugejorden examined stained extracted teeth and
found that there was a weak association between attachment
loss and the dentists emphasis on periodontal
reasons for extraction.
The aim of this study was to investigate the primary
reasons for the extraction of permanent teeth and to
validate the dentists reasons for extraction.

MATERIALS AND METHODS

In 1991 all the 244 GDPs registered with the family

health services authorities of Manchester and Salford
were invited to take part in a longitudinal, cohort study
of adult dental care, and 24 of the 40 who volunteered
were selected. The selection of dentists was based on the
investigators examination of the practices to determine
the commitment of the dentist and to confirm that the
practice personnel and administration were suitable.
The present study formed part of this investigation and
21 dentists agreed to take part.
Descriptive data
The study was conducted in 1994. Details of the
patients age, sex and dental attendance pattern were
recorded. Patients were considered to be regular attenders
if they had attended,in the previous 12 months for a
check-up. Patients who attended only for relief of pain
were deemed to be irregular attenders. The dentist was
requested to document the primary reason for extraction.
In 81 patients (21%) more than one tooth was
extracted, and in these cases only one tooth per patient
was randomly selected for analysis to overcome the
clustering effect caused by the multiple extractions.
Reasons for extractions were divided into the following
categories based on those described by Kay and
Blinkhorn*.
1. : primary and secondary caries plus all sequelae
of caries including periapical abscess and
failed root treatments.
2. Periodontal disease: teeth that were extracted due
to deep pocketing and loss of periodontal support
resulting in drifting, mobility and pain.
3. Preprosthetic: teeth extracted because their removal
facilitated a better prosthetic restoration.
Orthodontic: teeth extracted to prevent or correct
malocclusion.
4. Trauma: teeth extracted as a direct result of acute
trauma.
5. Wisdom teeth: wisdom teeth extracted for reasons
other than caries or periodontal disease.
6. Patients request: teeth extracted because the
patient preferred extraction to other available
forms of treatment.
7. Others: teeth extracted for reasons not encompassed
by one of the above categories. The reason
for the extraction was recorded.

Validating criteria
Extracted teeth were stored in 10% neutral buffered
saline and examined by an examiner who was not aware
of the dentists reason for extraction.
The presence or absence of dentinal caries involving
the crown and/or root surface was assessedu sing visual

criteria. Coronal caries was defined as caries above

the cemento-enamel junction (CEJ) and root caries as
lesions predominantly on the root surface. Primary
caries was defined as independent carious lesions and
secondary caries as recurrence of caries at the margins
of restorations. Calculus was defined as present if
located below the CEJ.
Attachment loss was used to validate periodontal
destruction on 80 randomly selected teeth, half of which
had been extracted primarily because of caries and half
for periodontal reasons. These teeth were stained with
Gomoris stain and the distance from the CEJ to the
most coronal fibres of the connective tissue attachment
was measured at six sites per tooth (mid-buccal, mesiobuccal,
disto-buccal, mid-lingual, mesio-lingual and
disto-lingual) using the method described by Clerehugh
and Lennon.
Chi-square tests were used to assess whether there
were significant associations between the reasons for
treatment and gender, attendance, caries on the crown
and caries on the root. Independent sample t-tests were
used to compare the mean loss of attachment measurements
for two groups. The 0.05 level of significance was
used throughout, and the Bonferroni modification to
the P-value was used when pairwise comparisons were
made for the meap age of the patients between the three
groups, teeth extracted for caries, periodontal and other
reasons.
A linear regression was fitted to the dependent variable
loss of attachment, with the reason for extraction,
gender, attendance pattern and age as independent
variables.

RESULTS
Descriptive

A total of 389 extracted teeth were collected from 192

male and 197 female patients aged 16-86 years, with a
mean age of 48 years. The primary reasons for extraction
are given in Table I. 145 teeth (37%) were
reported to have been extracted due to caries and 114
(29%) due to periodontal disease. 130 teeth (33%)
were extracted for other reasons with trauma (46,
12%) and wisdom teeth (22, 6%) the most common of
the other reasons given. There were significantly more
wisdom teeth and teeth extracted for orthodontic
reasons from women and more extracted for trauma
from men (PcO.05).
Sixty-eight per cent of the patients were regular
attenders and 32% irregular attenders. Irregular attenders
had more extractions for caries and regular attenders
more extractions for other reasons (Table ZZ). There
was no difference in the proportions of teeth extracted
for periodontal reasons from regular and irregular
attenders.
Caries was the main reason for extraction of teeth in
patients 50 years or less, whereas periodontal disease
was the commonest cause of extraction in the over-50
age group (Table 114. The mean age for a periodontal
extraction was 56 years (s.~.=lO), which was significantly
greater than the 43 years for caries (s.~.=16), and
46 years (s.~.=19) for other reasons.

Validation
Significantly more caries were present on teeth extracted
primarily for caries than for periodontal reasons
(P<O.OOl). Coronal caries were identified on 111 (77%)
of the 145 teeth extracted due to caries. Root caries
were also present on 33 (23%) of these teeth and one
tooth had only root surface caries. Sixty-one per cent of
teeth extracted for periodontal disease had coronal
caries and of these 29 also had caries on the root
surface. Two teeth had only root surface lesions
(Table IV).
Fifty-seven per cent of extracted teeth had calculus
(at least one root surface with calculus). There was a
significant influence of age on the presence of calculus
(P<O.OOl). The presence of calculus was not significantly
influenced by gender or attendance pattern.
Eighty-nine per cent of teeth extracted for periodontal
reasons had calculus as had 49% of teeth extracted for
caries (Table V,).
The highest mean loss of attachment on teeth extracted
for periodontal disease was 12 mm (s.~.=3.9)
which was significantly higher than the mean of 6.5 mm
(s.~.=4.7) for teeth extracted for caries (Table VI).
Older adults were also found to have significantly
greater mean loss of attachment measurements, but the
comparisons for gender and attendance pattern were
not significant. A linear regression model was fitted to
the dependent variable loss of attachment and the
independent variables, reason for extraction, gender,
attendance pattern and age. The P-values from the
linear regression were similar to those shown in Table
VI, except for gender, which reduced to 0.03 suggesting
that the teeth extracted from men had significantly
more loss of attachment than those extracted from
women.

DISCUSSION

In this study caries and its sequelae were the main

reasons for extractions (37% of all extractions) with
periodontal disease the next most frequent reason
(29%). The proportion of extractions due to caries is
lower than the 50% reported by Kay and Blinkhorn in
Scotland and the 48% reported by Agerholm and Sidi
in England and Wales. However, caution must be
exercised when comparing such data due to the smaller
sample size and the older age of the subjects used in this
study. The number of extractions due to periodontal
disease increased with age and in patients over 50 years
it became the main reason given for extraction. This
confirms the findings of others that extractions due to
periodontal disease do not exceed those due to caries
until at least 50 years7~*~r0.
Sixty-eight per cent of the subjects in the study were
regular dental attenders with the remaining 32% attending
only when symptoms were present. This is a similar
attendance pattern to the 1988 Adult Dental Health
Survey for England and Wales2, when 33% of subjects
only attended when in trouble. A significantly greater
percentage of teeth were extracted for caries from
irregular attenders (48%), but attendance pattern had
no influence on extractions due to periodontal disease.
This confirms the findings of Kay and Blinkhorn who
found that regular dental visits exerted a protective
effect against extractions as a whole and, in particular,
those due to caries. The present study also confirms
their finding that regular attenders had a similar
proportion of extractions for periodontal disease to
irregular attenders.
The examination of extracted teeth confirmed the
dentists diagnosis that a primary or secondary carious
lesion, involving either the crown or root, was present
on all the teeth extracted for caries or its sequelae.
These teeth also showed evidence of periodontal disease
with a mean loss of attachment of 6.5 mm. This degree
of periodontal attachment loss may reflect the attendance
pattern of the subjects or could indicate a significant
level of undiagnosed or untreated periodontal
disease. Only the primary reason for extraction was
considered in this study. Bouma et al. found a negative
relationship between caries and periodontal disease.
Previous studies22,23h ave shown that the presence of
calculus increases with age and that there is a strong
correlation between calculus deposits and the rate of
periodontal destruction. The finding that there was no
significant difference in the prevalence of subgingival
calculus between regular and irregular dental attenders
was in contrast to other studies24,25T. his study only
considered calculus formed on the root surface and may
reflect the failure to remove subgingival deposits in
general dental practice. A significantly greater number
of teeth extracted for periodontal reasons had calculus
present than teeth extracted for other reasons.
Schroeder26 considered subgingival calculus to be a
dependent rather than an independent variable. Subgingival
calculus could be the result rather than the cause
of the disease

The teeth extracted for periodontal reasons showed

extensive loss of attachment with a mean value of
12 mm per tooth. This contrasts with the findings of
Klock and Haugejorden who found that teeth collected
for validation of reasons for extraction did not
show advanced loss of attachment. They demonstrated
only a weak association between attachment loss and
the dentists emphasis on periodontal reasons for extraction.
The mean loss of attachment was not significantly
affected by attendance pattern or the sex of the
patient, a similar finding to Klock and Haugejorden18.
In contrast to the Norwegian study the mean loss of
attachment was significantly higher in patients over 50
(11.3 mm) compared with those under 50 years of age
(7 mm). However, it should be emphasised that the
dentists who participated in the present study comprised
a convenience sample and caution should be
exercised when making comparisons with other studies.
This study has shown that in this group of patients
caries was the most common reason for extraction of
teeth but periodontal disease became a more important
reason for extraction after 50 years of age. The study
validated the dentists given reason for extraction.