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J PakDentAssoc. 2011 (4) : 235-238
The aimof this studywas to investigate the primary reasons for simple extraction of permanent teeth in Dental Section of a tertiary care hospital and to identify themost frequently extracted teeth.
The patients selected for this study were identified by reviewing dental notes from medical records of patients who had undergone dental extraction at Dental clinic, at The Aga Khan University Hospital, Karachi. Total of 124 charts were reviewed retrospectively. Data regarding the age, gender, co morbid conditions, date of extraction, number and type of tooth extracted and the cause of exodontia were recorded in a proforma. Descriptive analysiswas done using SPSS version13.0.
Atotal of 147 teeth extracted from 77 patientswere included for analysis.Out of 77 patients, 56%were females and 44% were males.Average age was 49.7 + 16 years. (11-83 years). Reasons for extraction were: 42.2% extractions were due to caries, 30.6% were extracted for periodontal reasons, 6.1%for orthodontic reasons, 10.2% for mixed reasons, 6.1% for failed endodontics, 4.1% on account of tooth fracture and 0.7% for pre-prosthetic reasonsMaxillary secondmolars were themost frequently extracted teeth.More posterior teethwere extracted due to carieswhile periodontitiswas themain reason for extraction in the anterior teeth.
Caries was found to be the primary reason for exodontia of permanent teeth in all age groups, followed by periodontitis and orthodontic reasons. Maxillarymolarswere themost frequently extracted teeth.
Tooth extraction, dentition, permanent, Exodontia
Prior to the 17th century, tooth losswas considered an inevitable part of human life and was generally accepted . Long before dentistry emerged as a true profession, “tooth pullers” were a necessary part of most cultures . Tooth pullers or barber surgeons as they were called, traveled from one town to another in a carnival atmosphere, not only extracting teeth but also cutting hair, lancing boils and extracting kidney stones. As the profession of dentistry evolved during the19th century, much of the work of dentists was still devoted to tooth extraction since restorative work was crude and painful and prevention was unknown . In the absence of ways to treat infection in the pre-antibiotic era, people expected to loose teeth and dentists expected to extract them. More emphasis was given to conservation of teeth with time. Development of newer materials and techniques has significantly reduced the necessity for extraction. From 1990’s and onwards, tooth retention has further improved. Changes are coming with improvement in restorative work, rising attitude towards tooth retention and advances Studies on reasons for exodontia are important because exodontia is an indicator of dental caries and status of oral health of a population . Caries has been found to be the main reason for tooth extraction upto 40- 60 years of age and periodontal disease thereafter . Lindquist (1967) found caries and periodontal disease to be equally important reasons for exodontia from 50 years of age. The purpose of this study was to investigate the primary reasons for extraction of permanent teeth in a tertiary care dental setting and to identify the most frequently extracted teeth. This study will encourage practitioners to put more emphasis on prevention and treatment of caries.
This was a descriptive study with retrospective data collection. Patients were identified by their medical record numbers. All the patients who had registered for their treatment under the codes of “Simple extraction”, “Molar extraction” and “Broken down root extraction” and who had their firm or mobile, permanent teeth extractions done at the dental clinic of The Aga Khan University Hospital, Karachi (AKUH), were included in this study.
Datawas retrieved for the period of 12weeks. Out of 124 dental charts reviewed, 47 were excluded due to; third molar extractions, primary teeth extractions, surgical extractions and cases with incomplete records. Variables recorded were age, gender, any co morbid conditions, month of extraction, tooth extracted and the cause of the exodontias. The primary reasons for exodontias specified were caries, periodontitis, orthodontics, dental trauma/fracture, failed restoration, pre-prosthetic reason, mixed (combination of any of the reasons) and others.Definitions of these primary reasons for extraction were modified from a study by Klock KS and are given in table I.
Descriptive analysis of data was done using SPSS version 13.0. Frequency and percentage of etiology of extraction, age distribution, gender, tooth number and comorbidswere analyzed by the primary author.
Total of one hundered and forty seven(147) teeth were extracted from77 patients.Average numbers of teeth extracted per patientwere 1.9.Out of these,56%(43)were females and 44%( 34)weremales (Male: Female = 1:1.2). Mean age of patients was 49.7 + 16.6 years, ranging form 11-83 years. Caries and its sequelae accounted for 42.2% of extractions. Other causes of tooth extractions are given in Figure. I.
Leftmaxillary secondmolarwas themost commonly extracted tooth followed by rightmaxillary firstmolar and then mandibular molars. Right and left mandibular canines were the least extracted teeth. We divided the patients into 3 age groups. Distribution of these groups was < 30 years(representing younger age group): 16.3%, 31- 50 years (representing middle age group patients): 40.8% and > 50 years(representing elderly patients): 42.9 %. Age group wise distribution of etiology of extraction is given in table II.
For the sake of simplicity, we divided the permanent dentition into 6 sextants: upper right, upper anterior, upper left, lower right, lower anterior and lower left sextants. Distribution of etiology in tooth sextants is given in table III.Most of the teeth extracted due to caries were in lower left and upper left sextants, which represent posterior teeth, while the teeth extracted due to periodontitis were mostlymaxillary andmandibular anterior teeth.
50% of our patients did not have any comorbids, while 12.2% had hypertension, 8.25% had diabetes, and 12.2 % had both diabetes and hypertension.17% patients had some medical problems other than these two. An important finding was that patients who had diabetes had extractions mainly due to periodontitis. Relation of comorbidswith etiology is given in table IV.
Caries turns out to be the predominant (42.2%) reason for tooth extraction among patients attending the clinics atAgaKhanUniversity Hospital. This finding is in line with reports from various other parts of the world where different authors have studied determinants related to exodontias including the reasons for those extractions. Caries was the main reason for 35- 69 % of extractions in different studies in different countries all over the world given in table V.
Extraction due to both caries and periodontitis were more common in middle age group. The results concur with the classical view that caries and periodontitis are
equally important cause for extraction in older age groups but differs from those who found that caries as the most important cause before 40 years of age and periodontal disease above that age Maxillary second molar was found to be the most frequently extracted tooth. Reason could be that it is a far reached tooth, which is difficult to clean. Also, it is difficult to restore complicated carious lesion in a maxillary posterior tooth as compared to similar lesion in a mandibular molar. Mandibular anterior teeth were more frequently extracted due to periodontitis. The reason is that caries is less prevalent in anterior teeth and long standing calculuss in this area makes teeth more afflicted by periodontitis.
Corbet et al1 investigated reasons given for permanent tooth extraction of 8516 teeth in Hong Kong. They found that caries was most common reason for extraction (60%) followed by periodontitis. Most commonly extracted teeth were molars. Mandibular incisors were most commonly extracted due to periodontitis. Our results are also comparable with this study A number of patients who had extraction due to periodontitis had diabetes alone, or in combination with other comorbids, this result reflects the known association of diabetesmellituswith periodontal diseases There is very limited literature, published in Pakistan on this subject. Rehman et al studied factors affecting tooth extraction among dental patients in Sandeman provincial hospital, Quetta and found caries to be themost common cause of extraction (77.6%). This rate is significantly high as compared to our study. The reason as mentioned by the author were that most patients wanted extraction due to expensive conservation treatment and lack of awareness.
Salman et al found that 72.7% of extractions were due to caries which is similar to our study in which caries was themost common reason for extraction. Patients reporting to the dental clinic of The Aga Khan Hospital generally represent the more privileged group of community. The treatment rendered there, is more inclined towards conservation of teeth. If such conservative treatment requires multiple visits, patients usually refuse and do not comply for the complete treatment. In such situations only, the dentist might opt for dental extraction, which can also contribute to the rate of exodontia. The results of this study, therefore could be generalized to the entire population with caution because it may not be a true sample of community.
Screening of high risk population, implementing preventive measures and promotion of health education for early and periodic dental checkups are the strategies that need to be vigorously implemented.
Despite the advancements in preventive and restorative dentistry in Pakistan over the last two decade, caries still remains the primary reason for exodontia of permanent teeth. This is followed by periodontitis and extractions due to orthodontic reasons. Mandibular and maxillary anterior teeth aremore frequently extracted due to periodontitis. Posterior teeth are more frequently extracted due to caries. Maxillary molars followed by mandibularmolars are themost frequently extracted teeth. It is recommended that efforts should be made on prevention and treatment of caries tominimize tooth loss.
The conclusions of this study from this part of the world, have added to the world wide representation of the two main reasons of exodontia in permanent dentition. This information will help clinicians in further emphasizing the need for implementing measures for preventing caries and periodontitis to avoid or at least delay tooth loss.
The author thanks Dr. Ninette Banday, Dr.Munawar Rahman and Dr. Ahsan Raza for their continuing support and guidance. I thank Dr. Raziuddin Biyabani and Miss Sana Baig for critically reviewing this article. I also thank the dental desk for help in data collection.
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