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Reasons for non-third molar extractions in a military population.

The mission of the US Army Dental Command is to provide responsive and reliable oral health services and influence health to improve readiness and advance wellness in support of the force, their military families, and all those entrusted to our care. That mission is directly supportive

of the Dental Command's vision of strengthening the health of our nation by improving the oral health of our Army. (1)

Based on the fact that dental care is an essential and required component for readiness and is a cost-free benefit, one could assume that the number of non-third molar extracted teeth in the active-duty military population is low. That perception may be why the reasons for non-third molar extractions in a high-tempo Army population have not been extensively studied. The objective of this study was to examine the relationship between the frequency of non-third molar tooth extraction and the factors that contributed to extraction in a military population.

The reasons for and pattern of tooth loss in nonmilitary populations are well-documented. (2-18) The main reasons for permanent tooth loss varies among different countries. Dental caries predominates as the most common reason for tooth extraction in most countries. (2-7,12-14,17,18) In Germany and Canada, however, periodontal disease has been cited as the primary reason for tooth extraction. (10,11) In Italy and Singapore, caries and periodontal disease appear to affect the extraction rate equally. (8,9) The damage caused by dental caries is the main reason for tooth loss in younger populations, but periodontal disease is the primary factor for tooth loss in older populations. (2,3,6-13)


This retrospective study was reviewed by the Tripler Army Medical Center Regional Institutional Review Board (IRB) and was determined to be no greater than minimal risk. This project used existing data/records and collected information that was recorded in charts from January 1, 2000 to January 1, 2014. Individually identifying data elements were not recorded. The researcher did not keep a linking list of any sort. The IRB granted a waiver of consent process after it made the following determinations: the research involved no more than minimal risk to the subjects; the waiver did not adversely affect the rights and welfare of the subjects; the research could not be practicably carried out without the waiver; and, whenever appropriate, the subjects were provided with additional pertinent information after their participation. No personal identifiers were used and records were locked in the records room.

Power analysis determined that a sample size of 400 records was sufficient to detect significant differences between the different reasons for extraction. Inclusion criteria for records required that at least one non-third molar tooth was extracted. Four hundred dental records were selected (using online random number generators) from over 12,000 available records. To ensure that no records were duplicated, a stratified randomization scheme was used; 40 records were selected from each of the 10 color jackets used to sort records in the clinic. This process continued until the sample size of 400 non-third molar extraction cases was reached. Color jackets indicated differences in the second to last number of the patients' social security number. At no time was personally identifiable information recorded and social security numbers were not recorded. Data (without any identifiers) were recorded directly on an Excel spreadsheet. Patient records were not removed from the dental clinic. Research records were maintained on a secured (common access card) computer in the dental clinic; access to research records was restricted to authorized research personnel only.

The records were reviewed with the Corporate Dental Application and Digital Enterprise Viewing and Acquisition Application databases for information relating to the location of the tooth extracted, previous treatment performed, reason for extraction, gender and age of the patient. With a sample size of 400 subjects, the study was able to estimate the reasons for non-third molar extraction with 95% confidence at [alpha] = 0.05. The study had 80% power to detect a difference of 14% between rates for older and younger patients. Rates and reasons for extraction and location of tooth extracted were estimated at 95% confidence intervals. Rates were estimated separately for number of patients and for the total number of extractions. A 2-sided Fisher's exact test was used to compare reasons for extraction by age category, gender, caries risk and tooth location. A significance level of 0.05 was used for all analyses.


Chart selection was random but stratified so that an equal distribution of charts was reviewed using the next to last digit scheme. For patients who had multiple reasons for extractions, all of the reasons were recorded. Therefore, the totals for some categories exceeded 100%. The reasons for extraction of non-third molar teeth, categorized by gender, age, inclusion or exclusion in the High Caries Risk (HCR) program, * and tooth location are presented in Tables 1, 2, 3, and 4, respectively. Based on the collected data, caries was the primary reason for extraction of 73% of non-third molar teeth followed by failed endodontic treatment (21%) and extraction of teeth which were originally planned for prosthodontic treatment (14%). Loss of teeth due to trauma was also 14%, while loss due to periodontal disease was 10%, followed by extractions for orthodontic reasons (3%) and extractions due to hyperocclusion (2%). A diagnosis was not recorded in 80 of the 400 records. Because of this, the sample size was adjusted to 320 records for all subsequent analyses.

The distribution of caries as the reason for extraction among gender reveals no statistical difference (69% female, 74% male). When comparing the reasons for extraction based on age groups, caries remain the leading cause at 80% for the group aged 19-29 years, 73% for the group aged 30-39 years, and 57% for the group aged 4060 years. Extraction due to caries across all age groups was significant (P=.003). Ninety-seven percent of the extractions due to caries were performed on patients who were identified as HCR according to the American Dental Association Caries Risk Criteria, shown on the following page. Posterior teeth were extracted more frequently than anterior teeth. Based on tooth location, significant differences were found for teeth extracted due to caries and for trauma. Posterior teeth were more likely to be extracted due to caries than anterior teeth, and anterior teeth were more likely to be extracted if trauma was involved.

The second most common reason for non-third molar tooth extraction was failed endodontic treatment. Based on gender, 23% of female Soldiers and 20% of male Soldiers required extraction due to failed endodontic treatment which was not appropriate for retreatment. All age groups showed similar percentages for the number of teeth extracted due to failed endodontic treatment with age groups 19-29 years (20%), 30-39 years (23%), and 40-60 years (17%). Thirty-one percent of the patients who were treated with extraction due to failed endodontic treatment were not in the HCR category, while 12% of those patients were in HCR category. This difference was significant (P<.001).

The next most common reason for extractions in the military population was divided equally between extractions on teeth which were originally planned for prosthodontic treatment and trauma. For the preprosthodontic and trauma categories, there was no difference based on gender or age group.

Based on HCR, 23% of preprosthodontic treatment extractions were performed on patients who did not qualify for HCR, while 6% of the extractions were performed on patients who qualify for the HCR program with a statistical significance of P<.001 (Table 3).

Analysis of the number of teeth extracted due to trauma revealed no apparent difference based on gender or age group. Twenty-six percent of patients treated with extraction due to trauma did not qualify for the HCR program, while 5% did qualify (P<.001). Also, 48% of the teeth extracted due to trauma were anterior teeth, while 11% were posterior teeth (P <.001) as shown in Table 4.

Periodontal disease was the reason for extraction of 31 of 320 teeth (10%). There was no statistical difference based on gender or tooth location. The majority of the patients who had extractions due to periodontal disease (17%) did not qualify for the HCR program, while 3% did qualify. Also, patients in the 40-60 year age group had 25% tooth loss due to periodontal disease versus 4% of patients in group aged 19-29 years and 8% in 30-39 year age group. This difference was significant (P< .001).


Many advances have been made in the etiology of dental caries and the importance of prevention. Awareness of the risks of high sugar diets and the importance of regular dental exams and daily brushing is well known. (19-21) However, the data collected from the current study indicate that the main reason for non-third molar extraction in our military patient population is still caries. In fact, 73% of non-third molar extractions in our study were due to caries. This supports other research findings that identified caries as the primary reason for tooth extraction in many other populations. (2-7,12-14,17,18) Caries was identified as the primary reason for emergency visits for deployed military members as well. (22,23) In their study, Richards et al (14) identified caries as the reason for 59% of the 558 tooth extractions in 417 visits. The distribution of extractions among age groups in the current study revealed that of the 233 extractions due to caries, 80% were in the 19-29 year age group, 73% were in the 30-39 year group and 57% in the 40-60 year group. This finding was statistically significant (P=.003). This distribution could be explained by the fact that most Army recruits are in the 19-29 year age group. The majority of these Soldiers had not received dental treatment prior to enlistment in the Army, so some teeth were inevitably deemed nonrestorable during their dental examination.

The Soldiers in the group aged 30-39 years had the same dental problems observed in the younger age group. One observation is that the average age of enlistment has increased over the past decade, perhaps reflecting the continuous operational nature of the military mission. Another important factor is multiple deployments lasting between 12 and 18 months (or longer) over the last 14 years with the increased deployment tempo from military operations. It was often difficult for some Soldiers to be seen at a dental clinic for routine care during deployment. The probability of a Soldier with an asymptomatic carious lesion receiving dental treatment during deployment was small as emergency care was often the only type of care available.

The extraction rate due to caries dropped in the 40-60 year age group. At this point in their military careers, Soldiers have been seen multiple times for annual exams and have most likely eliminated the active component of caries.

Soldiers are dentally categorized based on their risk of developing a significant dental problem over the next year. This type of categorization is common across the uniformed services. In 2006, the Department of Defense (DoD) published the latest policy letter on oral health and readiness. (24) Health Affairs Policy 06-011 set the guidelines for the updated Individual Medical Readiness requirements outlined in DoD Instruction 6025.19.25 Military departments perform annual dental readiness assessments to determine a service member's Dental Readiness Classification (DRC):

* Service members designated Class 1 (DRC 1) are those with a current dental examination who do not require dental treatment or reevaluation. As such, from a dental health standpoint, those personnel are deployable worldwide.

* Dental Class 2 (DRC 2) service members have a current dental examination and require nonurgent dental treatment or reevaluation for oral conditions that are unlikely to result in dental emergencies within 12 months. They are deployable worldwide.

* Dental Class 3 (DRC 3) service members require urgent or emergent dental treatment. They normally are not considered to be deployable worldwide.

* Dental Class 4 (DRC 4) are service members whose dental readiness classification is undetermined by virtue of being overdue for their annual dental examination.

Despite the efforts to ensure dental readiness in the Army, DRC 2 patients may progress to DRC 3 if no restorative intervention occurs in a reasonable amount of time. Another possible reason for the high percentage of Soldiers suffering from extensive caries is lifestyle. Many Soldiers resort to high caffeine, high sugar energy drinks to stay alert. This could help explain why caries remain a concern in the 40-60 year age group.

The second most common reason for non-third molar extraction, regardless of gender or age group, was failed endodontic treatment. The lack of a well-sealed restoration can lead to bacterial leakage into the root canal system, necessitating retreatment or extraction. The most common reasons for endodontic failure are missed canals, incompletely treated canals, and fractured roots. (26) From the data, it was difficult to accurately discern between true failed endodontic therapy and failed endodontic therapy due to a faulty restoration. The two are often inextricably linked. The success rate for root canal therapy is often cited as greater than 80%. (26) It is not uncommon that the lack of a quality restoration to cover the cusps of endodontically treated posterior teeth will lead to fracture of the tooth/restoration and subsequent exposure of the obturation material to oral fluids. Sorensen and Martinoff (27) determined that among 1,273 endodontically treated teeth, those treated with coronal coverage restorations (onlays, partial, or complete metal crowns; and metal ceramic crowns) survived much longer than endodontically treated teeth with no coronal coverage restorations. Coronal coverage did not significantly improve the success of endodontically treated anterior teeth. This finding supports the placement of crowns on posterior teeth that cover sufficient coronal tooth structure to prevent fracture when occlusal forces attempt to separate the cusp tips. Zadic et al (28) found that 57% of extracted teeth in their sample population did not have a permanent coronal restoration.

Based on data from the current study, it appears that 31% of the extractions due to endodontic failure were performed on patients who did not qualify for HCR program, while 12% were performed on patients who did qualify (P <.001). This supports the idea that the clinical failure of most endodontically treated posterior teeth is not an active caries issue, but rather a mechanical issue where immediate cuspal coverage is necessary to support teeth that have lost a considerable amount of supporting dentin. Vire (29) found that prosthetic failure of teeth restored with a crown occurred after an average of 87 months. Without a crown, the average prosthetic failure occurred at 50 months. Fourteen percent of the non-third molar extractions occurred prior to prosthodontic treatment. These teeth received endodontic treatment but fractured before receiving prosthodontic restoration. The data collected showed no association with gender, age, or tooth location. Most patients treated with tooth extraction prior to prosthodontic treatment did not qualify for the HCR program (23%), while 6% qualified for the program. Full cuspal coverage following endodontic treatment is a practice guideline for posterior teeth. However, some long wait times can be experienced before the patient is seen. We suspect that some of the extracted teeth were from patients waiting to be seen for cuspal coverage.

Trauma was the cause for extracting 14% of non-third molar teeth. There was no association between extraction due to trauma and gender and age. Based on tooth location, most teeth extracted due to trauma were anterior teeth in patients who did not qualify for the HCR program. Some reported reasons for trauma included falling due to seizures, vehicle accidents, sports-related trauma, or fights. Anterior teeth were involved in trauma much more than posterior teeth. This difference was statistically significant (P <.001).

The percentage of periodontally involved teeth that were treated by extraction ranged from 4% in the group aged 19-29 years to 25% in the 40-60 year group (P<.001). This is consistent with results of other research that indicate that periodontal disease is the main reason for extraction in older age groups. (10,11,30-33) Albandar et al (34) conducted a study to estimate the prevalence and extent of periodontal disease in the United States using data from the third National Health and Nutrition Examination Survey ( In their study, they used the data from a sample size of 9,689 dentate persons aged 30 to 90 years who received a periodontal examination. The data collected included periodontal attachment loss, probing depth, and furcation involvement in 2 randomly selected quadrants per person. Based on the analysis of the results, Albandar et al reported that the overall number of teeth lost increased with age from 1.49 teeth in the group aged 30-34 years to 11.29 teeth in the group aged 85-90 years. (34)

Based on caries management by risk assessment, (35) the criteria for which is shown on page XX, patients who qualify for the HCR program were more likely to have extractions due to caries as shown in Table 3. Ninety-seven percent of the patients who were treated by extraction due to caries qualifed for the HCR program. On the other hand, caries was responsible for 43% of extractions among those not qualified for HCR (P<.001). These results emphasize the importance of the HCR program in the prevention of tooth extraction due to caries. The findings from the extractions categorized by HCR are interesting in that every factor (reasons for extraction) was statistically significant. Unfortunately, the statistical tests can only show that there was a difference but cannot explain why those differences occurred. Some reasons are intuitive--patients with teeth extracted due to caries were much more likely to be enrolled in the HCR program. There were significant differences for all other reasons for extraction, based on whether the patient was enrolled in HCR, but it is difficult to speculate why these differences occurred. Patients were much more likely to have teeth extracted for failed endodontics, preprosthetic reasons, trauma, periodontal issues, orthodontics, and hyperocclusion if they were not enrolled in the HCR program. More than half of the study population was enrolled in the HCR program, but patients in the HCR category were less likely to have teeth extracted for reasons other than caries.

An incidental finding was that 80 extractions were performed without recording the reason for the extraction. Because the treatment was tooth extraction, it was necessary to record a diagnosis, communicate treatment options with the patient, and also have the patient sign and authorize consent to show that the patient understood and agreed with the provider about the treatment plan. From a legal standpoint, the dental record is a medicolegal document that should be comprehensive, easy to use, clear, legible, and retrievable. The dental record should contain a record of diagnoses and findings, record of treatment, and prescriptions including all diagnostic aids, recommendations, and patient responses. The lack of a recorded diagnosis is a serious breach of proper record keeping. It is difficult to believe that 20% of the providers did not have a diagnosis prior to extracting the teeth. It is reasonable to assume that the error was administrative, caused by inadequate attention to the details of accurate record keeping. However, such does not diminish the seriousness of the error.

Based on collected data, caries was the major cause of non-third molar extraction in this military population. Even though Soldiers are entitled to dental care at no monetary cost and must make mandatory annual dental visits, dental caries remains the primary reason for non-third molar tooth extraction. This trend could be related to the fact that many Soldiers are from lower socioeconomic families. It has been established that low socioeconomic status is a risk factor for caries. (36-38) Many Soldiers enter the military with little dental information and are unaware of the causes of dental caries and the importance of prevention. Many Soldiers have never seen a dental care provider prior to joining the military and subsequently never received oral hygiene instruction. Explaining the importance of oral hygiene and demonstrating the proper brushing and flossing technique to Soldiers are important steps toward improved oral health. Additionally, when diagnosed with caries, some Soldiers lack the motivation to follow up with the necessary appointments in order to receive treatment. If enough time lapses, Soldiers may wait until the only treatment option is extraction. Further study is needed to address the high caries rate in active duty military populations and to investigate why so many providers apparently do not enter a diagnosis for tooth extractions.


The results of this retrospective study of a high-tempo Army unit show that the primary reason non-third molar teeth were extracted was due to caries, followed by endodontically treated teeth failures, failures of teeth prior to definitive prosthodontic care, trauma and periodontal disease. Loss of teeth due to caries was not related to gender, but was significant for Soldiers aged less than 40 years, for location of the teeth (posterior more common than anterior), and highly significant for those persons enrolled in a High Caries Risk program. Loss of teeth due to periodontal disease accounts for approximately 10% of non-third molar tooth loss and is highly correlated with advancing age. Based on tooth location, posterior teeth are more likely to be extracted rather than anterior teeth due to caries, and anterior teeth are more likely to be extracted due to trauma.

Caries Risk Criteria

Low Risk Criteria

No incipient or cavitated primary or secondary carious lesions during current exam and no factors that may increase caries risk. *

Moderate Risk Criteria (any of the following)

One or two incipient or cavitated primary or secondary carious lesions during current exam.

No incipient or cavitated primary or secondary carious lesions during current exam but presence of at least one factor that may increase caries risk. *

High Risk Criteria (any of the following)

Three or more incipient or cavitated primary or secondary carious lesions diagnosed during current exam.

Presence of multiple factors that may increase caries risk.

Xerostomia (medication, radiation, or disease induced).

Suboptimal fluoride exposure (inadequate/no systemic fluoride, inadequate topical fluoride exposure).

Poor oral hygiene.

Irregular dental visits.

Incipient lesions are noncavitated localized or generalized white spots and/or interproximal radiolucencies.

* Risk Factors: factors that increase the risk of developing caries include, but are not limited to:

Deep pits and fissures.

Exposed root surfaces.

Frequent sugar intake (>5 times per day).

Active orthodontic treatment.

Developmental or acquired enamel defects.

Inadequate salivary flow, as determined from PMH or unstimulated salivary flow testing (<0.2 mL/min).

Many multisurface restorations.

Eating disorders.

Restoration overhangs and open margins.

Chemotherapy or radiation therapy.

Physical disability that impedes oral hygiene.

Source: American Dental Association

MAJ Hanane Jamghili, DC, USA

COL William J. Greenwood, DC, USA

COL Peter H. Guevara, DC, USA

Col William J. Dunn, DC, USAF


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MAJ Jamghili is with the Kimbrough Ambulatory Care Center, Fort George G. Meade, Maryland.

COL Greenwood is Commander, Fort Benning Dental Activity, Fort Benning, Georgia.

COL Guevara is Program Director, Advanced Education in General Dentistry Two-Year Program, Schofield Barracks, Hawaii. He is also the General Dentistry Consultant to the Army Surgeon General.

Col Dunn is Commander, Detachment 1, 711 Human Performance Wing, Joint Base San Antonio, Texas, and is Military Consultant to the Surgeon General for Dental Research.

* The High Caries Risk Program is designed to improve overall oral health by customizing dental treatment for the individual Soldier to meet his or her needs. It seeks to create a partnership between the Soldier and the dental professional and help break the decay-repair-decay cycle. The program helps the Soldier identify risk factors and receive nutritional counseling, oral hygiene instructions, intensive treatment to help prevent future decay, and treatment for any cavities. The program follows Soldiers as they are assigned to various locations throughout their Army careers.
Table 1. Reasons for extraction by gender. Percentages may
sum to greater than 100% because an extracted tooth may
match more than one category. Note: study sample = 320.

Reason for         Total      Gender                        P value
Extraction       (% sample)

                               Male N=268    Female N=52
                              [84% sample]   [16% sample]
                                 n (%N)         n (%N)

Caries           233 (73%)     197 (74%)       36 (69%)      .610
Failed Endo       66 (21%)      54 (20%)       12 (23%)      .708
Preprosthetic     14 (14%)      34 (13%)       10 (19%)      .269
Trauma            45 (14%)      37 (14%)       8 (15%)       .827
Periodontal       31 (10%)      24 (9%)        7 (13%)       .310
Orthodontics      11 (3%)       10 (4%)         1 (2%)       1.000
Hyperocclusion     7 (2%)        6 (2%)         1 (2%)       1.000
No Diagnosis      80 (20%)

Table 2. Reasons for extraction by age group. Percentages may
sum to greater than 100% because an extracted tooth may
match more than one category. Note: study sample = 320.

Reason for                     Age Group                   P value

                 19-29 Years   30-39 Years   40-60 Years
                 N=128 [45%    N=131 [41%     N=61 [19%
                   sample]       sample]      sample] n
                   n (%N)        n (%N)         (%N)

Caries            103 (80%)     96 (73%)      34 (57%)      .003
Failed Endo       25 (20%)      30 (23%)      10 (17%)      .583
Preprosthetic     17 (13%)      19 (15%)       7 (12%)      .865
Trauma            15 (12%)      17 (13%)      12 (20%)      .289
Periodontal        5 (4%)        11 (8%)      15 (25%)      <.001
Orthodontics       3 (2%)        6 (5%)        2 (3%)       .614
Hyperocclusion     4 (3%)        2 (2%)        1 (2%)       .648

Table 3. Reasons for extraction, displayed by
qualification for High Caries Risk (HCR) category
(yes or no). Percentages may sum to greater than
100% because an extracted tooth may match more
than one category. Note: study sample = 320.

Reason for       Category                       P value

                 HCR No N=143   HCR Yes N=177
                 [45% sample]   [55% sample]
                    n (%N)         n (%N)

Caries             62 (43%)       171 (97%)      <.001
Failed Endo        45 (31%)       21 (12%)
Preprosthetic      33 (23%)        11 (6%)
Trauma             37 (26%)        8 (5%)
Periodontal        25 (17%)        6 (3%)
Orthodontics       11 (8%)         0 (0%)
Hyperocclusion      7 (5%)         0 (0%)        .003

Table 4. Reasons for extraction by tooth location.
Percentages may sum to greater than 100% because an extracted
tooth may match more than one category. Note: study
sample = 320.

Reason for                 Tooth Location              P value

                 Anterior N = 23   Posterior N = 297
                  [7% sample] n     [93% sample] n
                      (%N)               (%N)

Caries               2 (26%)           227 (76%)        <.001
Failed Endo          5 (22%)           61 (21%)         .796
Preprosthetic        2 (9%)            42 (14%)         .753
Trauma              11 (48%)           34 (11%)         <.001
Periodontal          3 (13%)            28 (9%)         .477
Orthodontics         2 (19%)            9 (3%)          .183
Hyperocclusion       0 (0%)             7 (2%)          1.000
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Author:Jamghili, Hanane; Greenwood, William J.; Guevara, Peter H.; Dunn, William J.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Jan 1, 2016
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