Essay: Investigate the reasons for primary teeth extraction

Objectives: The aim of this study was to investigate the reasons for primary teeth extraction and to identify the most frequently extracted teeth among Jordanian children.
Methods: a cross-sectional study include 222 males (48.3%) and 238 females (51.7%) were evaluated. Their ages ranged from 2 to 13 years, who were seen at a pedodontic out clinics of King Hussein Medical Center in Amman – Jordan. All children who had one primary tooth extracted during the six months period (1- March to 31-Augest 2015) were included in the study. Descriptive statistics were used, including the patient’s age, gender, the number of teeth, tooth type extracted, and reasons for extraction were recorded.
Results: A total of 460 primary teeth were extracted. The results appear that the most common cause of primary tooth extraction was dental caries (47%). First primary molars were the most common tooth type extracted and comprised (48.7%) of all teeth extracted. Central incisors were the next common tooth type extracted and accounted for (23.5%) of the extractions. There was no significant difference, by gender, in the extraction of tooth type but there were notable differences according to age. Primary central incisors were the most common teeth extracted in the age group (2-5 years) old and account (59.3%) while first primary molars were the most common extracted tooth in the age group (6-9 and 10-13 years) and comprised (56.4%) and (59.7%) respectively.
Conclusions: Dental caries was found to be the most common reason for extraction of primary teeth in pediatric patients. Educating parents and children about dental preventive programs are needed to reduce the prevalence of dental caries which is the main cause of dental extractions in a pediatric clinic.
Key words: dental caries, pattern, prevalence, reasons, tooth extraction, tooth loss.
Reasons for tooth extraction in pediatric patients in Jordan
Introduction
Primary teeth are important for aesthetics, mastication and speech development of the children. They are also important for the normal development of occlusion in the permanent dentition. (1-3)  Premature loss of primary anterior teeth may affect esthetics, phonics, and self-esteem of the child while the premature loss of primary molars may lead to malocclusion as a result of delayed eruption, malposition, drifting and rotation of permanent teeth. Loss of several teeth in children can result in psychological disturbances. (1-3) Data on tooth extraction gives information about the prevalence of dental diseases and availability of dental care. In order to limit premature tooth loss, it is essential to identify the reasons for tooth extraction. Several studies have been carried around the world and showed that dental caries and its consequences are the main causes for permanent teeth extraction. (4-7)
A survey in Jordan done by Taani (2003) (8)showed that dental caries and its consequences are the principal reasons for tooth loss in patients younger than 40 years of age, whereas extractions due to periodontal diseases increase with age.
To date, few studies have investigated the reasons for primary tooth extraction in children. (4, 9-13)
The majority of these studies have reported that dental caries is the main reason for tooth extraction. Alsheneifi and Hughes found that 53% of primary teeth in American children were extracted because of caries.(9) Esan et al. also observed that 55% of teeth were extracted due to caries in a group of Nigerian children. (13) The other common reasons for extraction of primary teeth in children are trauma, mobility, orthodontic treatment, over retention, root resorption, periodontal disease and parents’ request. According to the several investigators, the primary first molars were the most common tooth type extracted in children. (4, 9) The pattern and the reasons for tooth extraction vary among different populations. In Jordan, several studies have investigated the reasons for permanent teeth extraction (7, 8, 14-16) while very few studies have investigated the reasons for primary tooth extraction. (17, 18)  Therefore, the aims of this study were to investigate the reasons for primary teeth extraction and to identify the most frequently extracted teeth among a group of Jordanian children.
Methods
This study was carried out in pedodontics department at out clinics of King Hussein Medical center in Amman-Jordan, during the period of six months (1- March to 31-Augest 2015). Permission to carry out the study was obtained from the ‘Medical Research Committee’ in the hospital.
Inclusion criterion: children between 2 to 13 years of age who had one tooth extracted under local anesthesia in our pedodontics clinic during the period of the study.
Exclusion criteria: patients with a history of syndromes and systemic illness.
Four hundred and sixty healthy pediatric patients who attended pedodontic clinics over six month’s period were selected for a study. For each patient, the following information was obtained including national number, date of birth, gender, tooth number and the reason for extraction. The oral examination was carried out by using a mouth mirror, dental probe and with appropriate dental lighting. Periapical radiographs, if needed, were taken. All treatments were carried out by two specialist pediatric dentists in the clinic.
Reasons for extraction were divided into the following categories based on those described by Kay and Blinkhorn. (19)
Caries: Primary and secondary caries plus all sequelae including periapical abscess and failed pulpotomy.
Orthodontic: Tooth removed to prevent or correct the malocclusion.
Trauma: Tooth extracted as a direct result of acute trauma.
Loss: Tooth extracted because of its mobility; time for exfoliation.
Over-retention: Prolonged retention of primary teeth.
Root resorption.
Other reasons; includes periodontal disease and parent’s requests.
Statistical analysis
Descriptive statistics were calculated for the data from all groups, a chi-square test was performed on the collected data using a 0.05 significant level to test the data reliability. The test performed was considered statistically significant since the probability showed less than 0.05.
Results
Dental examination of 460 pediatric patients, comprising 222 males (48.3%) and 238 female (51.7%) were included in this study. The patient’s age was ranged from 2 to 13 years old. Table I shows the gender distribution of the patients illustrating that there were no statistical differences in assessment by gender.
Table II shows a distribution of reasons for extraction for all tooth type; dental caries was the predominant cause of tooth extraction among patients comprised (47% )of them while the periodontal disease and the parents request reveal the least causes and account for (2.6%).
Table III shows the type of teeth extracted, first primary molar were the most common tooth type extracted (48.7%) while the lateral incisors were the least common to be extracted (2.2%).
Table IV provides distribution of extracted primary teeth by tooth type and age. There were differences in the extraction of the teeth type by the patients age, between ages (2 to 5 years), more than half of primary teeth extracted were central incisors (59.3%), while for the patients aged between (6-9 and 10-13 years) the first primary molars were the most common tooth type extracted (56.4%) and (59.7%) respectively.
Table V shows the percentage distribution of primary teeth type according to the reason of extraction. For central incisor, dental caries, followed by mobility were the most common reason for extraction (35.2%) and (29.6%) respectively. For lateral incisors, dental caries was the most common reason for extraction (40%). While for primary canine they are most commonly extracted for an orthodontic reason (41.7%). First and second primary molars were more commonly lost due to caries (56.2% and 46.8%).
Discussion
Dental extraction is most probably the common surgical procedure in pediatric dental practice. Several investigators have studied the reasons and pattern of tooth loss in different parts of the world. These investigations have primarily focused on the frequency and causes of permanent tooth extraction, (5-8, 14, 16, 20) while few publications have been presented the reasons for extractions of primary teeth. (9, 13, 17, 21)
The results of this study demonstrated that tooth extractions show no significant differences were observed between genders. This finding supports the observations in other studies (9, 13, 22, 23) but not in agreement with the findings of Chukwumah et al (24), and Anyanechi et al., in Nigeria (4) who reported more extractions in females.
The reasons for tooth extractions were based on the criteria suggested by Kay and Blinkhorn (19) which involved extraction due to caries, orthodontic considerations, trauma, mobility, over –retention, root resorption, and periodontal disease and parents request. For the present study it was evident that caries was considered the principal cause of extraction for all age groups, and accounting for (47%) of primary tooth extraction in children. This is in agreement with the majority of similar studies.  (24-28) A study done by Rajab and Hamdan in (2002) (29) among 5-year-old children in Amman demonstrated that (48%) of the children suffered from early childhood caries and the mean number of decayed, missing and filled teeth (dmft) was 3.22. A recent study was done in Jordan in 2013 by Hamdan et al., showed a marked decline in caries prevalence (41.6%) and the mean number of (dmft) was 2.59 in children from different socioeconomic backgrounds. (30) Hamdan showed that dental caries level among Jordanian children was higher than that of children in industrialized countries and lower than that in children of the Middle Eastern Arab countries. (30)
Despite the dramatic improvement in pediatric oral health over the last decades, dental caries remains the most common causes of tooth loss in pediatric populations. (9, 13, 1 7, 20, 31, 32) Data from surveys carried out in the Arabian countries have shown that there is a change in dietary patterns of mothers and children, with a trend towards the consumption of food rich in refined sugar (33), which leads to increased dental caries. In addition to the type of food used, eating habits, feeding practices, as well as the lack of awareness of daily brushing teeth benefits and the pattern of dental visits have an important role in increasing the prevalence of dental caries.
In Royal Medical Services pediatric clinic, most of the patients come to the clinic because of severe pain and always missed routine checkup visits. In these cases severely carious teeth are found which are often unrestorable so the radical treatment will be extraction. The second most common reason for tooth extraction was mobility of primary teeth which comprising (19.6%) this finding is higher than the result of the study done in Jordan by Nsour and Masarweh in 2013 (17) which account for (12%). In the current study, orthodontic consideration was responsible for (12.2%) of tooth extraction, this finding is in accordance with the previous study reported by Alsheneifi and Huges 2001 in Boston (9) , while another study done by Nsour and Masarweh (2013), (17) in Jordanian children showed that (16%) of primary teeth were extracted due to the orthodontic reason which is slightly higher than our result. Regardless of the exact number of tooth extractions in the present study which were required as a result of caries, the data clearly demonstrate that dental caries remains a significant cause of tooth extraction. Nevertheless, a significant percentage of tooth loss arose from causes related to mobility and orthodontic considerations. Likewise, root resorption, trauma and over retention continue to be another significant reason for tooth loss in pediatric populations. Periodontal disease is not a common disease in children.(34) This has been shown in our results, where we found that (2.6%) of primary teeth were extracted due to the periodontal disease and parents request, this finding is in agreement with a previous study done  in Jordan. (17)
The most common tooth type lost in the study is the first primary molars and comprised of (48.7%) of the total, this finding is in agreement with previous studies. (9, 17, 27, 31, 35) As one would expect, the chronology of dental eruption, with regard to the specific teeth extracted differences existed within different age groups. In the age group (2-5 years), primary central incisors were the most commonly extracted teeth (59.3%), this is due to the pattern of early childhood caries while, mobility is the second most important cause of extraction of primary incisors because of the chronology of dental development in this age group account for (29.6%), this result in agreement with other previous studies. (21, 28) While in the older age group (6-9 and 10-13 years), the first primary molars more frequently extracted (56.4%) and (59.7%) respectively due to frequent involvement of these teeth in dental caries.
The frequency of extraction of the primary first molar is more than the primary second molar. This finding is similar to the result of other previous studies (31, 35, 36) this can be referred to the chronology of tooth eruption, where the first primary molars have been present in the oral environment before the second primary molars. Also from a clinical point of view, many clinicians would restore grossly carious second primary molars in order to maintain space, especially before the eruption of first permanent molars while they extract the carious first primary molars as the success rate of root canal therapy is considered lower. (36) ) 41.7% (primary canines were mostly extracted due to orthodontic considerations and rarely extracted due to caries or trauma. Our findings are in agreements with a study done by Kuthy et al. (37) they reported that “orthodontic considerations are more frequently the reason for extraction of primary canines”. (37)
It is recommended to increase the awareness of the oral health of children by educating parents and caregivers about the importance of primary dentition. Further preventive programs are needed such as the use of fluoride, pit and fissure sealants and improvement of diet intake in order to decline the prevalence of dental caries as well as decrease extraction of teeth.
Conclusions
Educating parents and children about dental preventive programs are needed to reduce the prevalence of dental caries which is the main cause of dental extractions in a pediatric clinic