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REVIEW ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 12  |  Page : 1629-1638

Factors Affecting Clinical Decision-Making and Treatment Planning Strategies for Tooth Retention or Extraction: An Exploratory Review


1 Department of Prosthetic Dental Sciences, College of Dentistry, Jazan University, Jazan, Saudi Arabia
2 Division of Digital Dentistry, A.T. Still University Arizona School of Dentistry and Oral Health, Mesa, Arizona, USA
3 Department of Operative Dentistry, Nihon University School of Dentistry, Tokyo, Japan

Date of Submission30-Nov-2019
Date of Acceptance09-Mar-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. M E Sayed
Department of Prosthetic Dental Sciences, Jazan University College of Dentistry, Jazan 45142
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_649_19

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   Abstract 


Dentists are often confronted with challenges concerning the determination of the treatment type for questionable teeth (retention or extraction) in their routine dental practice. The objective of this review was to explore the available literature pertaining to the factors influencing clinical decision-making and treatment strategies of dentists regarding tooth retention or extraction. Explorative analysis of the literature was conducted based on its relevance to the subjected study area and scope. Primarily, the papers were extracted from sources such as ERIC, PubMed, Scopus, and Medline. The keywords used for searching articles include Clinical Decision-Making, Treatment Strategies, Tooth Extraction, and Tooth Retention. Papers published up to 2018 were extracted and evaluated. The analyzed studies highlighted that a successful treatment plan is based on the practitioner's knowledge, abilities, and skills as well as patients' preference, which is also a determinant of treatment success in restorative dentistry. Multidisciplinary dental treatment is generally adopted for decision making in dental clinics. Overall, the treatment plan should be based on the extensive learning and keen observation of the disease and the associated factors which enable long-term success of the treatment.

Keywords: Clinical decision-making, extraction, planning strategies, retention, treatment


How to cite this article:
Sayed M E, Jurado C A, Tsujimoto A. Factors Affecting Clinical Decision-Making and Treatment Planning Strategies for Tooth Retention or Extraction: An Exploratory Review. Niger J Clin Pract 2020;23:1629-38

How to cite this URL:
Sayed M E, Jurado C A, Tsujimoto A. Factors Affecting Clinical Decision-Making and Treatment Planning Strategies for Tooth Retention or Extraction: An Exploratory Review. Niger J Clin Pract [serial online] 2020 [cited 2023 Feb 2];23:1629-38. Available from: https://www.njcponline.com/text.asp?2020/23/12/1629/304435




   Introduction Top


Oral health and its maintenance are realized as the most significant issues given its prevalence and mistreatment, globally.[1] Selection of the case and the decision-making process holds significant importance in restorative dentistry as it is linked to the tooth functionality for life.[2] Primarily, decision-making is a customized process, which is chosen by clinicians based on the acquired knowledge and patients' profile.[3] The decision-making process in dentistry turns out to be more effective when a partnership approach is adopted between the doctor and patient, leading to successful treatment. It involves the integration of the patients' knowledge and their treatment concerns, along with the clinician's expertise, skills, and commands.[4] The question related to the retention or extraction of a tooth remains a dilemma, despite several technological inceptions.[5] Patients' inadequate knowledge and practice adversely affect their oral health, oral diseases, accessibility, and quality of life.[6],[7] Nevertheless, the difference in oral health between rural and urban areas leads to poor general health. This is particularly true for the population in the Middle East and Africa.[8] Studies have advocated that practitioners need to evaluate patient's dental conditions for improving diagnosis accuracy and executing effective treatment strategies. However, maintaining esthetics and saving the cracked or defected teeth can lead to several adverse consequences such as dental infections and/or malfunction.[9]

Dental practitioners are regularly confronted with difficult decisions related to tooth maintenance through endodontic microsurgery and restoration or implantation as a treatment alternative.[10] Generally, dental implants serve as a regular treatment choice for the replacement of missing, non-restorable, or periodontally involved teeth. On the other hand, periodontal disease may compromise bone quantity in the affected tooth area and the adjacent dentition, despite the increase in implant adoption.[11] Therefore, clinicians must consider an evidence-based approach, i.e. unbiased and complete information regarding their patients for determining the most effective treatment plan.[12] The choices made by the practitioners can result in a significant outcome posing a direct impact on the patient's oral health and tooth quality. The multifactorial risk involved with the patient's treatment decision is significant as it may affect the tooth functioning impacting the overall oral health of the patient.

Torabinejad et al.,[12] documented that implants are successful when executed in an ideal position, with adequate prosthesis design and proper maintenance. Modern dentistry relies on single missing teeth and high survival rates of all exogenous devices. When a tooth is compromised by periodontal, pulpal, traumatic, or carious pathology, many treatment options are available to save the tooth. However, when the tooth is hopeless, then there is no other option except for tooth extraction and placement of a dental implant. This confusion tends to create a dilemma in implant dentistry, where practitioners are uncertain whether to retain it or to extract it and replace it with a prosthesis.

Accordingly, studies have highlighted that therapeutic preferences must be considered along with the provided options.[1],[2],[3],[4],[5],[6],[8] Some researchers concluded that clinical limitations and factors should be considered to outline a definitive plan for proper dental care. As patients trust their dentists regarding their oral health; therefore, the adequate maintenance of effective oral health must be prioritized. Despite it, various researches have concluded that determination of the extraction and retention is unsatisfactorily answered in clinical dentistry.[10],[12] Thereby, this study discusses the clinical decision-making and treatment planning strategies for tooth retention or extraction. The finding would be useful for policymakers to outline the standard procedures for dental treatment.


   Methodology Top


Explorative analysis of the literature was conducted based on its relevance to the subjected study area and scope. Primarily, the papers were extracted from sources such as ERIC, PubMed, Scopus, and Medline. The reason for choosing these sources was based on their quality and authenticity. The selected studies had addressed clinical decision-making as well as treatment planning strategies for tooth retention and extraction. The keywords used for searching articles include Clinical Decision-Making, Treatment Strategies, Tooth Extraction, and Tooth Retention. Papers published up to 2018 were extracted and evaluated.


   Results Top


In clinical practice, tooth retention or extraction is still a major dilemma although with advanced modern dentistry.[13] Several new approaches have been developed replacing conservative therapeutic approaches. In majority cases, surgical interventions are necessary for the treatment[14] that are significantly influenced by several oral health factors. These factors include; patients' choice, the extent of dental caries, periodontal therapy risk, the medical profile of patients, and esthetics.[14] Al-Qarni et al.[15] identified the effectiveness of the decision-making process for tooth retention or extraction in Saudi Arabia. It revealed that the majority of patients preferred restorative treatment for all clinical conditions, as saving the original tooth is their priority. Thus, the decision should be based on careful examination. Such as, concerned clinicians should develop an individual-based treatment plan for patients; however, these treatment plans are likely to be influenced by unvalidated claims regarding the patient's treatment plan in the field of orthodontics.[13]

Laegreid et al.[16] investigated the dentist's decision-making concerning the problems of experience in restoring a molar tooth. Results indicated that the remaining tooth substance was an important stimulator in the decision-making process of dentists. However, some factors were considered by female dentists such as patient request, economic status, and oral hygiene. Avila et al.[17] provided a restorability chart considering the process of clinical decision-making. The decision was categorized into six levels, which assisted practitioners in devising the right decisions [Figure 1]. The levels include initial assessment, followed by determination of periodontal disease severity, examining the furcation involvement, assessing the etiologic factors, assessing the restorative factors, and lastly, assessment of other important determinants.
Figure 1: Levels of tooth assessment for determination of extraction or retention clinical decision

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Various new tools have been devised to assist practitioners to perform endodontic treatment with great precision and in an error-free method. Nevertheless, the decision needs to be made for the extraction and osseointegrated implantation, when the particular treatment cannot be performed. [Figure 2] presents the chart for decision-making of tooth retention and endodontic treatment or tooth extraction and implantation.[18] Patient's motivation towards receiving treatment is the primary concern that affects the selection of treatment modality. Factors affecting patient's motivation for adopting a specific treatment modality include oral hygiene, financial status, esthetic appearance, dental history, and other local factors. As indicated in [Figure 2], after taking an appropriate decision, the treatment is either proceeded by general practitioners or is referred to a dental specialist.
Figure 2: Interaction between dentist, patient, and CDSS in the decision-making process

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Trust between clinician and patient is necessary before carrying out any treatment procedure.[19] Shared decision making is a term, which is endorsed by critical care organizations; however, it has not been fully understood. The shared decision making process consists of conceptual clarifications for the patients to meet ethical requirements and preferences.[20] Shared decision making is significant as it brings both the parties on the same page through negotiation. It can be considered as a treatment, which involves long-term decisions, especially in terms of chronic illness. The treatment procedures for dental care involve several options; such as implant-supported fixed partial dentures (FPDs), implant-retained overdentures, or conventional complete dentures.[21] Patients often face difficulties in selecting treatments due to their fear of dental procedures, lack of awareness of the available different options of treatment, or their lack of awareness of the subsequences of a given treatment option. Reese et al.[22] focused on the linkage between patients' demographic attributes for root canal treatment (RCT) and implant placement (IP) since insurance status and demographics attributes influence the receipt of RCT and IP. Therefore, clinician's awareness, related to the patient's demographics and insurance, play a significant role in dental treatment.

Factors determining retention or extraction clinical decision-making

Remaining tooth structure

The remaining, disease-free, tooth structure is the most critical factor to be considered for the restoration of severely damaged teeth. The vertical dentinal wall or in other words the ferrule effect is important to provide structural reinforcement that could resist heavy masticatory stresses, wedging stresses of tapered posts, and lateral post cementation stresses.[23] Among the literature that support the importance of ferrule effect, Libman and Nicholls[24] reported that a minimum dimension of 1.5 mm of the vertical dentinal wall is crucial for RCT teeth restored with cast posts and cores and full coverage crowns. However, Ng et al.[25] found that a minimum of 2.0 mm of the vertical dentinal wall is important to increase their structural durability and strength. The presence of 360° remaining dentinal wall is the best-case scenario to ensure optimum fracture strength and structural integrity for RCT anterior teeth.[26] These minimum dimensions are basic constituents of factors that determine tooth prognosis, in which clinical decision-making is based to retain or extract teeth in question.[27] Failure of obtaining the above requirement would indicate extraction and future tooth replacement with either implant, FPD or removable partial denture (RPD) per given case and planned treatment.

Crown-to-Root Ratio (C/R Ratio)

The alveolar bone support, among a series of other determinants, is critical to determine the overall restorative prognosis of teeth in question utilizing the concept of crown-to-root ratio.[28],[29],[30] Several studies have investigated the value of this ratio to determine the prognosis of periodontally compromised teeth, hence periodontitis is the main factor that controls this ratio.[31],[32],[33] Among the theoretical and clinical guidelines concerning this ratio, an ideal crown-to-root ratio of 2:3 or 1:2 was proposed for abutment to support FPD. However, clinically, this is seldom presentation.[33],[34] Despite the need for utilizing teeth as abutments to support planned fixed prostheses, teeth with more than 1/3 loss of bone support should, in fact, be of questionable value as abutments.[35] However, when the opposing occlusion presented tooth or implant-supported prosthesis, a crown-to-root ratio of more than 1:1 should be considered to resist excessive vertical and horizontal occlusal forces. Treatment plans and clinical procedures may directly affect the crown-to-root ratio. An occlusal reduction of overdenture abutment tooth to within 2 mm above the gingival tissues could change this ratio from 1:1 to 1:3.[36] Also, the reduction of the coronal tooth structure near the gingival vicinity helps to shorten the corresponding lever arm length, naturalizes the negative lateral stresses transmitted to supporting structures, and therefore diminishes the abutment tooth mobility.[34],[37]

Extrusion

The current literature is lacking clear guidelines to relate the extent of tooth extrusion, relative to the presented occlusal plan, to its restorability or viability of utilizing it as an abutment to support prostheses. However, the currently adopted principles[38] suggest that corrective and/or restorative procedures are indicated to achieve an ideal occlusal plan and optimum occlusion between teeth since extrusion and mal-alignment may sometimes disrupt esthetics and causes occlusal interferences upon functional and parafunctional jaw movements.[39],[40],[41] Clinicians should pay attention to planning such cases. Hence, dramatic corrective procedures, i.e. tooth devitalization and surgical crown lengthening, may compromise the structural integrity and crown-to-root ratio of the tooth in question and cause irreversible periodontal damage to its adjacent teeth.[42] The risks of performing such procedure may include series of irreversible intraoral changes that surpasses clinicians ability for correction when compared to simple treatment option of extraction and prosthetic management with either implant-supported prosthesis or tooth-supported FPD or RPD treatment options per the quality and quantity of available bone and condition of adjacent dentition.

Vertical root fracture and location of the finish line

The current dental literature has placed vertical root fracture (VRF) as the 3rd most common causative factor for the extraction of RCT teeth.[43] VRF is undeniably crucial to determine the overall tooth prognosis before, during, or following RCT. Moreover, accurate detection and differentiation from other dental condition are important as its management vary significantly from periodontal and endodontic-related lesions. Radiographic characteristics of VRF can widely be varied per clinical cases. The apical radiolucency 'halo effect' was recognized as the diagnostic feature of VRF in some cases.[44] The majority of VRF cases require tooth extraction as the first line of management.[45] While root hemisection can be used to retain posterior (multirooted) teeth, the potential fate for anterior teeth in the case of VRF is extraction in almost 11%–20% of cases.[46] Treatment planning should take place as soon as VRF is diagnosed and confirmed. Since proper management of such cases is complex and requires special expertise, predictable management relied on the location of the tooth in the arch, the degree and direction of the fracture line, duration between fracture and subsequent treatment, and the location of fracture line on the root surface. The location of the finish line in relation to adjacent bone crest should carefully be considered during treatment planning of teeth with VRF or large carious lesions. Although placing the margin slightly below the gingival margin may be acceptable, the depth of margin extension in the gingival sulcus is critical as deep placement causes disruption of biologic width and subsequent periodontal disease, pain, and bone loss. Sub-gingival placement of restorative margins attribute to plaque retention and complicate the accessibility to gingival sulcus to achieve proper supportive therapy. In addition, it exhibited higher chances for bleeding on probing.[47] An agreement in literature was noted regarding the destructive effects of deep sub-gingival margin placement, including chronic inflammation, gingival recession, and crestal bone loss.[48],[49],[50]

Root canal treatment complexity and need for retreatment

The significance of RCT, as one factor among many others affecting tooth prognosis, is associated with the complexity of the presented case and expertise of the treatment provider.[51] The factors that attribute to increasing endodontic case difficulty, include but not limited to: presence of intracanal calcifications, difficulty of tooth isolation, presence of internal or external root resorption, abnormal root anatomy, extra or hidden canals, need for surgical RCT, presence of restorative posts, dentinal wall ledges, and root perforations. Another factor affecting the endodontic prognosis is the presence of a periapical infection. The present clinical evidence indicated reduced long-term success rates for endodontic cases presented with periapical infection due to prolonged exposure to causative pathogenic factors.[52] Therefore, the long-term prognosis of a tooth that has been endodontically treated multiple times is poor. The presence of quality coronal seal is also important for long-term success and survival of root canal treated teeth.[53],[54],[55] In a clinical setting, it will not matter which one of them is more important than the other, quality coronal seal should be attempted immediately following RCT to maximize the success rate of delivered treatment and avoid possible failure complications.

Tooth mobility

Tooth mobility is one of the most important periodontal parameters that are widely used to determine individual tooth prognosis.[56] Whilst several studies[57],[58] proposed that mobility negatively affects the overall prognosis and survival rate of periodontally involved teeth, other studies disregarded the conceptual association between tooth mobility and treatment outcomes.[59] The conceptual variations between available studies could be explained by its multifactorial nature of and variation of methodologies that have been used to determine the extent and direction of tooth mobility. Regarding the impact of mobility on tooth prognosis, it has been suggested that teeth showing Miller's Class III mobility are indicated for extraction as such teeth present hopeless long-term prognosis and are more likely to cause discomfort upon masticatory function.[60] However, teeth that are exhibiting Miller's Class II mobility require careful evaluation and investigation of all relevant factors to determine the appropriate treatment protocol to address such conditions. Furthermore, clinicians must keep in mind that there are physiologic ranges of mobility that may present in the elderly population or all others at variable time during the day.[61],[62] These literature-based facts should always be kept in mind and employed in diagnosis, prognosis, treatment planning, and maintenance of teeth that experienced tooth mobility, whatever the causative factor may be, to achieve successful long-term treatment outcomes.

Furcation involvement

It is well documented in contemporary dental literature that furcation lesions influence the clinical decision-making of whether to retain or extract a particular tooth. This clinical condition is frequently linked with moderate alveolar bone loss, recession, and loss of attachment. Furcation lesions are often considered clinically challenging even for an experienced periodontist due to their potentially complex anatomy, difficult accessibility, especially for second molars and distal lesions, and other anatomical variations. Consequently, proper treatment of furcation lesions requires corrections of all potential local factors such as root concavities; root surface irregularities and approximation. Even though the current literature supports the long-term predictability of treating such conditions utilizing advanced regenerative procedures and maintenance,[63],[64] stability at these areas depends on the type of treatment that constitutes a significant concern.[65] For these reasons, careful diagnosis, planning, and progression through treatment must be followed. Thus, tooth extraction is considered the first line in the management of teeth with Class III and Class IV furcation lesions.[17] Clinicians must differentiate between furcation lesions of endodontic and/or periodontal origins, as the former necessitates RCT to achieve treatment success.

Treatment expectations and risk tolerance

Successful treatment planning requires consideration of all patient-related clinical factors. Among these factors are patient's desires, expectations, and risk tolerance relative to treatment outcomes. These factors should be clearly identified, documented, and involved in the clinical decision-making process. For instance, teeth that are diagnosed with poor prognosis after comprehensive evaluation and are indicated for extraction, however, the patient expresses desire and interest to retain them, patient decision for retaining these teeth should be respected, although the patient should be informed and consented about all possible outcomes and risks associated with this decision. Independent to all other factors controlling the decision-making of retention or extraction of questionable teeth, patient's desires, expectation, and risk tolerance are major determinants for this decision and should be satisfied for teeth with questionable (fair, poor) prognosis, excluding teeth with hopeless prognosis that should be extracted regardless of presented desires and expectations. On the contrary, if the patient shows no interest in retaining questionable teeth, low treatment demands and risk tolerance, then extraction may be the right option.

Financial ability

Patient's financial status is a key factor that controls decision-making regarding retention or extraction of questionable teeth to a great extent. Tooth replacement options, whether conventional or implant-assisted, are often more expensive than retaining a tooth. In fact, a significant portion of the patients seeking implant treatment is not aware of the additional cost and time involved in such procedures.[66] In addition, a recent study indicated that poor financial status is the most contributing factor the population refrains from required dental care.[67] In case financial limitations exist, retaining a tooth of questionable condition may present a viable option given that the patient agrees to this decision; whilst a patient with financial ability who presented with the same condition tooth, extraction, and restorative replacement may present an ideal treatment option. In both cases, careful treatment planning while taking into account patient's financial status is crucial.

Tooth involvement in planned treatment

While the loss of abutment teeth may present negative treatment outcomes, it may have been positive and meaningful to patients whose treatment objective is retaining natural teeth as long as possible. Several studies have evaluated the load applied on abutment teeth per their involvement in prosthetic designs. It has been reported that abutment teeth that support FPDs receive the higher load in comparison to free standing teeth supporting single crowns.[29],[68],[69] However, the abutment teeth that are used to support RPDs were reported to receive the highest amount of load in comparison to other prosthetic designs.[70],[71] In comparison to abutment teeth in bounded edentulous spaces, the distal abutment tooth in a distal-extension partial denture design receives significantly higher axial and non-axial loads.[72],[73] These loads may cause trauma-induced mobility, exacerbate existing periodontal disease, or cause fracture, especially in RCT teeth with large postspace preparation.[74]

Opposing occlusion

It is undeniably important to consider opposing occlusion upon treatment planning as it affects the short and long-term prognosis of questionable teeth in the opposite arch. Occlusal loads, applied on questionable teeth, are expected to be the highest in cases with opposing natural dentition and fixed restorations on either teeth or implants followed by opposing occlusion of RPDs, overdentures, and conventional complete dentures.[28],[29],[30]

Caries risk

The current dental literature is unclear regarding the accurate determination of caries risk indicators and individual's caries risk level. While caries risk varies between patients, preventive measures and frequent recall visits should be undertaken to avoid future development or progression of caries.[75],[76] It is very crucial for practitioners to carefully evaluate the following risk indicators: (1) white patches or spots on smooth tooth surfaces, (2) dental restorations performed within the past 3 years, (3) superficial proximal lesions (within enamel) seen on bitewing radiographs, (4) active carious lesion (s) identified by cavitation limited to enamel or extended to dentine that are detected clinically and confirmed by periapical and/or bitewing radiographs. The presence of one or more of these four risk indicators put the patient in high caries risk category unless preventive measures and restorative therapy are well-planned, executed and disease progression has been controlled. A high caries risk patient may present with cavitated lesions that act as a local reservoir for cariogenic pathogens. Excavation of such lesions and restoring the tooth alone are not sufficient to control these pathogens and their activities in the mouth, therefore an adjunctive preventive measure is indicated. It has been reported that the long-term prognosis of questionable teeth for patients in high and extreme high caries risk categories is poor, especially for ignorant patients who do not follow oral hygiene instruction, preventive measures, or frequently missed recall visits. For this clinical instance, tooth extraction is the treatment of choice and tooth replacement relies on patients' attitude afterward.[75],[76]

Oral hygiene status and compliance

It has been well documented that the presence of pathogenic bacteria in a prone host is the most important causative factor in the pathway to develop periodontal disease. The abundant presence of dental plaque and active periodontal pathogens are key factors not only for periodontal disease progression but also failure of maintenance following periodontal therapy. It has been indicated that compliant patients, who were treated and kept excellent oral hygiene, may have improved tooth prognosis in comparison to negligent patients.[77] It does not matter which technique was utilized to evaluate the patient's ability for plaque control when a patient cannot meet adequate standards of oral hygiene, the long-term success of periodontal treatment and tooth prognosis are questionable. Even though the pathogenesis of periodontal disease is multifactorial and risk of recurrence remains high especially in patients with previous disease history, tooth preservation can be predictable with long-term success rate in patients with excellent oral hygiene in comparison to poor hygiene patients. Nevertheless, the option of tooth extraction and replacement with implant-assisted crowns or prosthesis may not be the first option to consider for every patient, therefore, careful assessment of the patient's current and anticipated oral hygiene status, adequate diagnosis, and treatment planning to address patient's needs and desires are crucial in all clinical scenarios.[17]

Bruxism

In general, the occlusal contact between teeth upon normal jaw activities, mastication, and swallowing, generate an average load within the physiologic level and therefore the incidence of tooth wear is minimum. However, the presence of parafunctional jaw activities or habits (e.g. bruxism) increases the amounts of load on teeth extensively resulting in wear or fracture. It would make sense that when occlusal load exceeds physiologic limits, it might present negative effects on periodontal attachment apparatus; however, such theory was not reported in the study conducted by Shefter et al.,[78] who found minimum to no effect on initiation and continuation of periodontal disease in healthy patients and periodontium. Therefore, the presence of parafunctional jaw activities may have presented negative effects on unhealthy patients and periodontium. There have been no documented studies in literature to investigate the relationship at unhealthy conditions because some periodontal parameters (e.g. mobility and furcation) are difficult to be managed and since periodontal disease is a complex multifactorial disease, accurate identification of occlusion-related factors is impossible. The need for occlusal management can be of extreme value especially in cases with advanced periodontal disease. Thus, the presence of parafunctional jaw activities could shift the prognosis of questionable teeth to poor especially when patients show no interest to cooperate in occlusal splint therapy.[79]


   Discussion Top


Decision-making for tooth retention and extraction has occupied serious attention among dentists. The clinicians make decisions using certain strategies, approaches, and factors to ensure patient's healthcare quality. Keen observation is a base for effective decision-making. Therefore, the majority of patients prefer to save their tooth instead of losing it. However, shared decision making can also serve as a tool for an effective decision in the treatment, referring to tooth retention and extraction. Patients should have an explicit understanding of the disease and its preferred treatment. The decision-making process needs to identify all the essential requirements. Moreover, the demographics between the receipts of RCT and implant placement help to identify the choices involved in the process. Clinicians should be aware that the patient's demographics and insurance play a vital role while deciding the dental treatment. Dental experts are suggested to adopt effective treatment strategies for patients with dental problems. However, the treatment strategies require considering certain factors such as abilities, skills, patients' preference, and knowledge. There is no similarity in the treatments for all the patients since significant differences lie in the patient's oral conditions. The factors that are mainly considered by clinicians before deciding a treatment plan include: furcation, mobility, systematic diseases, bone loss, socio-economic possibilities, and presence of periodontics lesions.

Treatment planning is a critical step in the field of dentistry. Clinicians are required to implement the most effective treatment strategies for their patients based on their abilities, skills, knowledge, and patients' preference. Also, the same treatment plan cannot be executed for all, as patients vary in terms of their medical conditions.[80],[81],[82] Moreover, clinicians are usually concerned about mobility, furcation involvement, systematic diseases, socio-economic possibilities, bone loss, and the existence of periodontal lesions.[9] Schützhold et al.[83] examined the clinical factors that assess the prosthetic status and periodontal condition of self-perceived oral hygiene between two age groups. Factors contributing to the process of decision-making include filled teeth, unplaced teeth, decayed teeth, removable denture, and attachment loss. Whereas, the factors affecting the selection of treatment modality among the older population include removable denture, decayed teeth, filled teeth, attachment loss, and bleeding on probing. Explicit examination of these factors is essential to understand patient's perceptions of their oral health. Rocha et al.[84] analyzed the understanding of mothers about the clinical as well as socio-behavioral factors concerned with oral health. The majority of the mothers thought that their oral health was in poor condition; whereas, the oral health of their children was in good condition. The study concluded that clinical and behavioral factors are associated with perceived oral health.

Moreover, several factors are causing severe complications for patients, such as periodontal disease. It is an infectious disease, and its severity may vary in degrees. The extraction of a tooth is one of the treatment options used to treat periodontal disease.[85] Other treatment options include; surgical periodontal treatment, defect elimination by resection, regenerative procedures, non-surgical periodontal treatment, and maintenance of the area without or with minimal bone resection.[86] The remaining structure of the tooth is also considered before the formation of the treatment strategy.[87] A study stated that the treatment plan for a specific tooth differs based on its structure. A minimum of 1.5 mm ferrule is an adequate requirement for the restoration of the treated root canal with a good restoration prognosis.[87] The treatment plan requires restoration of the tooth with a single crown, followed by surgical crown lengthening or forced orthodontic. Milosavljevic[88] identified the treatment strategies made by dentists for patients with periodontal conditions. It revealed that the prime objective of treatment was to enhance oral health awareness among patients. It observed the respective treatment as a standardized workflow, rather than individually planned treatment. Overall, it concluded that patient's self-awareness and oral hygiene are important; whereas, the mechanical control for infection is considered to be a successful yet difficult process.

Hochadel[89] suggested the integration of the system, which represents the knowledge classification approach integrating the algorithms, statistics, and image processing. The integration of the system in the clinical environment serves as a supportive platform to outline the treatment plan, supplementing the comprehensive decision-making process, and producing predictable results. Santamaria et al.[90] studied the pain perception of children and the techniques for the dentists to handle that. Moreover, proximal dental lesions in the children aged 3-8 years in the primary molars were treated using three strategies including; conventional restorations (CR), hall technique (HT), and non-restorative caries treatment (NRCT). However, dentists have observed unfavorable behavior in the CR group. The pain perceptions of children and adults seemed to be similar in dental care.


   Conclusions Top


The extraction or retention of a tooth is a debatable question encountered by dentists regularly. However, the decision for dental treatment requires multidisciplinary and complete awareness of the treatment and disease. The decision-making process depends also on the level of knowledge among patients regarding the disease and its treatment to attain a positive outcome. Future studies need to conduct detailed research to provide more conclusive evidence through randomized controlled trials or prospective longitudinal research.

Acknowledgment

The authors are very thankful to all the associated personnel in any reference that contributed in/for this research.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

The authors declare no conflicts of interest.



 
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