You are on page 1of 8

Clinical Research

A Survey of Patients Preferences for the Treatment


of Teeth with Apical Periodontitis
Amir Azarpazhooh, DDS, MSc, PhD,* Thuan Dao, DDS, MSc, PhD,k
Rafael Figueiredo, DDS, MSc, Murray Krahn, MD, MSc, and Shimon Friedman, DDS, MSc*
Abstract
Introduction: This research aimed to investigate the
preference of patients in Toronto, Canada for management of a tooth affected by painful apical periodontitis
when considering its retention via root canal treatment
(RCT) and its extraction followed by no replacement,
replacement with an implant-supported crown, fixed,
or removable partial prostheses. Methods: Data were
collected through a mail-out survey of the University
of Toronto Faculty of Dentistry patients, which was complemented by a convenience sample of patients in 10
community practices in Toronto (n = 1000, response
rate = 43%). Participants were asked to select their
general preference for anterior and posterior teeth
with apical periodontitis between saving the tooth or
extraction and their specific preference for tooth retention via RCT or extraction. By using bivariate and logistic
regression analyses, we applied the Gelberg-Andersen
Behavioral Model for Vulnerable Populations to the preference questions to understand the influential factors
(P # .05). Results: Participants specific preference
for tooth retention via RCT was slightly but significantly
lower than their general preference (anterior tooth,
93.7% versus 97.2%; posterior tooth, 83.8% versus
89.6%; P < .005). Higher annual income, previous
RCT, functional dentition, good/excellent self-rated
oral health, and regular dental visits were associated
with higher preferences for tooth retention in response
to different questions. Conclusions: The high preference for retaining a tooth in general was moderated
by the specific consideration of RCT to retain the tooth.
When RCT and extraction are viable options, patients
should be advised about the treatment options in an
impartial manner and encouraged to communicate their
preferences. (J Endod 2013;39:15341541)

Key Words
Apical periodontitis, decision making, patient preference

pical periodontitis (AP) comprises a host defense response to infection of the root
canal systems of the affected teeth. This highly prevalent disease (1) can be treated
by way of root canal treatment (RCT) with the intent to retain the affected tooth or by
extraction of the tooth, leaving the space edentulous, or having it restored with a prosthetic device, a removable partial denture (RPD), fixed partial denture (FPD), or
implant-supported crown (ISC). Of the prosthetic options, ISC is often favored because
of its excellent survival potential without the necessity to invade the adjacent teeth
(24). Therefore, for a tooth with AP, dentists and patients currently often debate
the 2 contrasting treatment options of RCT to retain the tooth or ISC to replace it. A
trend has been reported (5, 6) that suggests an increasing preference of either
dentists or patients for replacement of affected teeth with ISC. Surveys of dentists
preferences (7, 8) have suggested that although dentists more frequently prefer RCT
over ISC for teeth with primary AP, they favor RCT less and ISC more for root-filled teeth
with persistent AP. Differences in the dentists preferences have also been related to
their engagement in general or specialty practice, suggesting a potential bias when
making clinical decisions regarding teeth with AP (7, 8).
Dentists preferences notwithstanding, the important ethical principle of patient
autonomy suggests that patients values should play a very substantial role in clinical
decisions (9). It appears that information on patients thought processes and preferences for the management of teeth with AP is lacking. This survey aimed to explore
patients preferences for management of a tooth affected by AP, when considering its
retention via RCT, its extraction without replacement, or its replacement with an ISC,
FPD, or RPD. We also set out to explore whether patients preferences would be associated with the factors predisposing individuals to use health services, factors that
enable or impede such use, and individuals need for care.

Materials and Methods


The study used a cross-sectional mail-out survey approved by the University of
Toronto Research Ethics Board. The sampling frame was created by using the adult
patients registry of the University of Toronto Faculty of Dentistry (Axium Software clinic
management system, version 4.41.12). To account for participants previous experiences with RCT or ISC, the sampling frame randomly selected 800 patients who had
previously been treated in the Graduate Endodontics, Periodontics, or Prosthodontics

From the *Discipline of Endodontics, Faculty of Dentistry; Discipline of Dental Public Health, Faculty of Dentistry; Institute of Health Policy, Management and Evaluation, Faculty of Medicine; Toronto Health Economics and Technology Assessment Collaborative; and kDiscipline of Prosthodontics, Faculty of Dentistry, University of
Toronto, Toronto, Ontario, Canada.
Supported by grants from the Canadian Academy of Endodontics Endowment Fund, the International Federation of Endodontic Associations, and the Dental Research
Institute at the Faculty of Dentistry, University of Toronto.
Address requests for reprints to Dr Amir Azarpazhooh, Faculty of Dentistry, University of Toronto, Room 515-C, 124 Edward Street, Toronto, ON, M5G 1G6 Canada.
E-mail address: amir.azarpazhooh@dentistry.utoronto.ca
0099-2399/$ - see front matter
Copyright 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.07.012

1534

Azarpazhooh et al.

JOE Volume 39, Number 12, December 2013

Clinical Research
clinics (n = 200 per clinic) or who were scheduled to receive RCT or
ISC (n = 200). The participants were mailed a package that included
a cover letter outlining an introduction and aims of the research, the
survey tool, and a prepaid return postage envelope 3 times during
a period of 4 months. Between the 2 reminders, a follow-up postcard
reminder without the survey instrument was sent to all participants.
The university-based sample was supplemented by an external convenience sample (n = 200) that had 10 practicing dentists in Toronto
distribute the same survey package to 20 of their in-office patients.
These dentists were all affiliated part-time with the University of Toronto
Faculty of Dentistry. They were instructed to avoid providing explanations of the questions and reviewing participants responses. The
external participants were given the options to complete the survey
on site or to do so at home and use the prepaid return postage envelope.
No gift or remuneration was provided to the study participants.

Survey Instrument
The survey tool was developed on the basis of previous literature
(1012) and pilot-tested among 15 patients at the Faculty of Dentistry to
evaluate and validate the design, respondent burden, level of understanding, response rate, face validity, and feasibility of the planned
data analysis. After adjustments, the questionnaire was finalized on
the basis of 2 principal domains. Domain 1 included 4 questions
defined as the general preference for saving a tooth (anterior and posterior) with AP or extraction and the specific preference for tooth retention via RCT or extraction. For those who preferred extraction, we
further explored their preference for no replacement or replacement
with RPD, FPD, or ISC. To facilitate understanding, each treatment
option was described in detail in the cover letter by using lay terms
derived from the representative professional associations (1315).
In Domain 2, the Gelberg-Andersen Behavioral Model for Vulnerable
Populations (16) was applied to the preference questions of Domain
1. Considering this model (Fig. 1), it was hypothesized that decisionmaking of participants might be influenced by 4 components:
1. Variables that may predispose the person to use health services,
including gender, marital status, immigration status, age, education,
and employment status.
2. Variables that may enable or impede use of health services, including
the annual family income, its source, and the method of payment for
dental care.

3. Variables defining the persons need for care, which were related
to indicators of oral disease that can provoke a self-care response
or seeking professional care (17). The perceived need for dental
care was evaluated by asking participants whether they believed
they would need treatment if they visited the dentist. In addition,
participants were asked about their history of RCT or extraction
(yes/no questions), to self-rate their oral health on a 5-point Likert
scale (very poor, poor, satisfactory, good, or very good), and to
report the number of teeth they had (18). The latter was dichotomized at 21 teeth to represent a functional dentition with the
typical ability to eat, speak, and socialize (19). The survey tool
also included the oral health-related quality of life instrument
(OHRQoL) (10). Participants scored their experiences during
the past 12 months for each of 15 items by using a 4-point Likert
frequency scale (never, rarely, sometimes, and often). Subsequently, participants were asked about dental pain experiences
during the past 2 weeks and their impact (whether had to stay
in bed or limit activities).
4. Variables related to dental health behavior, which were characterized by participants responses to questions related to utilization
of dental services, with variables including the history of inability
to afford dental care, last visit to the dentist, the frequency of dental
visits, and having to take time off work for dental treatment.

Sample Size Calculation


The study sample (n) was calculated on the basis of the size of the
population (N), the proportion of the population expected to choose 1
of 2 responses (P = .5 to allow for the maximum variance), the assumed
sampling error (C = 0.05), and the Z-statistic of 1.96 for the 95% confidence interval (20): n = [(N)(P)(1-P)] / [(N-1)(C/Z)2 + (P)(1-P)].
Assuming a 5% prevalence of AP in the population (21) and Toronto
population of 2.6 million, it was estimated that at least 130,000 subjects
in Toronto might have AP. Accordingly, the required sample size of 384
was calculated. The sample target was increased to 800 and complemented with a 200 convenience sample to 1000 to ensure an adequate
number of responses for analysis of the data.
Data Analysis
Data from the mail-out surveys were entered into the Statistical
Package for Social Sciences software 17.0 (SPSS Inc, Chicago, IL).

Figure 1. The study theoretical framework. Adapted from the Gelberg-Andersen Behavioral Model for Vulnerable Populations (16).

JOE Volume 39, Number 12, December 2013

Patients Treatment Preferences for AP

1535

Clinical Research
For the OHRQoL instrument, responses missing $2 items (n = 34)
were excluded from analysis. When computing severity scores for other
subjects, responses missing 1 item (n = 39) were replaced with the
mean value for that item, which was imputed from the values of valid
responses. These data were used to calculate 3 summary variables as
suggested by Slade et al (22):
1. Prevalence: The percentage of respondents reporting $1 impacts
having occurred sometimes or often. This variable identifies those
who perceive oral health affecting their life quality as being chronic
rather than transitory.
2. Extent: The number of items reported sometimes or often.
3. Severity: The sum of the ordinal response codes for the 15 items,
taking into account impacting events experienced at all levels of
frequency (never, rarely, sometimes, or often). Because of the
response codes of 03, the sum score can range from 045 (higher
values indicate more frequent impacts).
The bivariate odds ratio (OR) of associations between different
variables of the theoretical framework and the outcome of general
and specific treatment preferences for a tooth with AP was assessed
with c2 tests. Each independent variable was regressed on all of the
other independent variables to explore possible correlations among
and between the variables. A hierarchical stepwise logistic regression
approach based on the GelbergAndersen model (16) identified significant predictors of the preference outcomes by grouping predisposing
characteristics, enabling resources, need factors, and dental health
behavior factors in 4 horizontal levels. Subsequently, forward stepwise
regression analyses were used to eliminate variables from each horizontal level, with probabilities set at 0.25 to enter and 0.10 to remove
from the equation. As the final step, the significant variables from the 4
horizontal levels were entered into a final stepwise logistic regression
model and adjusted for other variables to test for independent effects,
where P # .05 indicated statistical significance. ORs computed for
horizontal-level stepwise regressions were adjusted for intralevel variables, whereas ORs for the final models were adjusted for all significant
variables entered from the horizontal regression analyses.

Results
Sample Characteristics
Of the 1000 total patients, 434 (43%) completed the mail-out
survey. The sample is characterized by 4 categories (16) in Table 1.
1. Predisposing (sociodemographic) factors: The majority of participants were female (58.9%), married (57.1%), immigrants to
Canada (62.4%), middle-aged (58.7%, aged 4564 years), with
less than a university degree (58.3%), and employed full-time or
part-time (66.2%).
2. Enabling factors: The majority reported receiving income from
wages, salaries, or self-employment (88.2%), receiving more than
$40,000 in annual family income (50.6%), and having no dental
insurance (56.5%).
3. Need factors: The majority reported a perceived need for dental
treatment (56.4%), had experienced tooth extraction (80.3%)
and RCT (76.9%), had a functional dentition (85.7%) with the
mean of 24.2  4.8 teeth, self-rated their oral health as good to
excellent (71.9%), had experienced at least one impact fairly often
or very often in the previous year (70.5%), and in the past 2 weeks
did not have to stay in bed (98.1%) or to cut down on normal things
(91.5%) because of dental pain. The mean severity score of reported pain was 10.5  9.5 (23% of the scale range of 45).
4. Dental health behavior factors: The majority had a history of
inability to afford dental care (69.2%), a dental visit in the past
1536

Azarpazhooh et al.

year (86.9%), attended regular or occasional checkups (88.2%),


and took time off work to see their dentists (54.2%).
The sample demographics were compared with those of Toronto
general population (Table 2). For those demographics that could be
compared, differences between the sample and the general Toronto
population were small.

Treatment Preferences
Responses to the 4 preference questions are summarized in
Table 3. The majority of participants reported a general preference
for treatment and retention over extraction of an aching tooth at a significantly higher rate for anterior than for posterior teeth (97.2% and
89.6%, respectively; Fisher exact test, P = .003). Likewise, the majority
of participants reported a specific preference for RCT over extraction of
an aching tooth, which also differed significantly for anterior and posterior teeth (93.7% and 83.8%, respectively; Fisher exact test, P < .005).
Participants preference for retaining the tooth by using RCT
(specific preference) was slightly but significantly lower than their overall preference for saving the tooth without mention of treatment
(general preference) (93.7% versus 97.2% for an anterior tooth;
83.8% versus 89.6% for a posterior tooth; Fisher exact test, P < .005).
Significantly fewer participants were willing to extract anterior
teeth than posterior teeth (27 and 69 participants, respectively;
P < .001). Although replacement was uniformly preferred for an anterior tooth, 27 of 69 participants (39%) preferred to not replace a posterior tooth. To replace an anterior tooth, ISC was the most preferred
option reported by 21 of 27 participants (77%), with less preference
for RPD (19%) and FPD (4%). By comparison, to replace a posterior
tooth, ISC was preferred by 28 of 69 participants (41%), with less preference for RPD (12%) and FPD (8%).
Predictors of Treatment Preferences
The variables identified with horizontal stepwise logistic regression analyses as having a strong impact on preferences are summarized
in Table 4. Those variables were then entered into the final logistic
regression models to identify significant predictors for preferences at
the multivariate level, while accounting for potential confounding and
interaction effects (Table 5). As can be seen in Table 5, having a history
of RCT and functional dentition were significantly associated with higher
general and specific preferences for saving a posterior tooth versus
extraction. In addition, regular/occasional dental visits were associated
with higher general preference, whereas annual family income between
$40,000 and $79,999 and $$80,000 was associated with higher
specific preference for saving a posterior tooth. Fewer factors significantly affected the preferences for saving an anterior tooth versus
extraction. The general preference was affected only by self-rated oral
health status; participants who rated their oral health status as good
to excellent had higher general preference rates for saving anterior teeth
than those who rated their oral health status as poor to fair. Participants
who had a history of RCT and regular/occasional dental visits reported
higher specific preference rates for saving an anterior tooth.

Discussion
This survey study aimed to elicit the generic preferences of patients
in selecting treatment options for teeth with painful AP. Potentially confounding variables or influences, such as cost, number of visits, time
spent in the dental chair, and the likelihood of success, were excluded
from the detailed explanation of the disease and its treatments. These
considerations and the clinical complexities typically presenting in teeth
JOE Volume 39, Number 12, December 2013

Clinical Research
TABLE 1. Sample Characteristics Categorized in Accordance with the Gelberg-Andersen Behavioral Model for Vulnerable Populations (16)
Variables
Predisposing factors

Gender
Marital status
Immigration status
Age

Education completed

Employment status

Enabling Factors

Annual source of income

Annual family income


Method of dental payment
Need Factors

Perceived need for dental


treatment
History of extraction
History of RCT
Functional dentition
Self-rated oral health
OHRQoL: Prevalence

Dental health
behavior factors

OHRQoL: Severity*
Had to stay in bed because of
dental pain during the past 2
weeks
Had to cut down on normal
things because of dental pain
during the past 2 weeks
History of inability to afford
dental care
Last dental visit
Dental visit frequency
Taking time off work to see
dentist

252
176
182
242
266
160
35
46
82
119
131
13
108
138

58.9
41.1
42.9
57.1
62.4
37.6
8.2
10.8
19.2
27.9
30.8
3.1
25.6
32.7

125
51
183
87
16
6
31
85
38

29.6
12.1
44.9
21.3
3.9
1.5
7.6
20.8
11.8

285

88.2

205
121
79
227
11
164
186
241
85
346
99
329
56
335
121
309
282
118

50.6
29.9
19.5
56.5
2.7
40.8
43.6
56.4
19.7
80.3
23.1
76.9
14.3
85.7
28.1
71.9
70.5
29.5

8
420

1.9
98.1

Yes
No

36
389

8.5
91.5

Yes
No
More than 1 year ago
In the last year
Only for emergency care
Regular/occasional checkups
Yes
No

295
131
56
373
49
367
230
194

69.2
30.8
13.1
86.9
11.8
88.2
54.2
45.8

Female
Male
Single
Married
Born abroad
Born in Canada
1824 y
2534 y
3544 y
4554 y
5564 y
$65 y
High school education or less
Community college or technical
school
Undergraduate degree
Graduate degree
Full-time employed
Part-time employed
Self-employed
Retired
Student
Unemployed
Income from social assistance/
welfare
Income from wages, salaries,
self-employment
<$40,000
$40,000$79,999
$$80,000
No insurance (cash/credit)
Public insurance
Private insurance
Checkup or cleaning
Other dental needs
No
Yes
No
Yes
No (<21 natural teeth)
Yes ($21 teeth)
Poor to fair
Good to excellent
At least one impact
No impact
Mean score 10.5  9.5
Yes
No

*OHRQoL severity is a continuous variable.

with AP would have been difficult to capture in this generic survey of


patients preferences.
The response rate of 43% exceeded that in previous surveys of dental
patients in Ontario, Canada (23, 24). With recruitment by using the
random sampling techniques, the participants could be considered as
representative of the university clinicbased population that was
supplemented with an external convenience sample from Toronto to
JOE Volume 39, Number 12, December 2013

improve the external validity of the study. The general comparability of


the participants demographics and Toronto population (Table 2) for
all parameters except immigration and family income further strengthened the external validity, even though the sample might not be representative of Toronto general population.
Subjective measures of oral health are widely used in oral health
research, and there is growing recognition that quality of life is an

Patients Treatment Preferences for AP

1537

Clinical Research
TABLE 2. Comparison of Demographics of the Study Participants with the City of Toronto General Population
City of Toronto

This study
Demographic

Reference

Male
Single
Immigrant
1844 years of age
More than a university degree
Annual family income < $40,000
Full-time employed
Income from social assistance/welfare

41.1
42.9
62.4
38.2
41.7
50.6
44.9
11.8

48.1
36.7*
52.1
38.9
35.2
35.5
40.0k
12.8

2006 Canada Census (n = 2,503,281)

2001 Toronto Social profile (n = 663,180)


2009 Toronto Employment survey (n = 2,503,281)
Canadian Council on Social Development

*n = 2,093,660 population older than age of 15.

Age category of 2044 years.

n = 2,067,445 population older than age of 15.

2001 City of Toronto Social profile (www.toronto.ca/demographics/pdf3/all_toronto.pdf).


k
2009 City of Toronto Employment survey (www.toronto.ca/demographics/surveys.htm).

Based on number of Ontarians on welfare in 1995 (www.ccsd.ca/factsheets/fs_welno.htm) divided by the 1996 Census population of Ontario (10,084,885).

important outcome of dental care. In this study, we used an endodonticspecific quality of life instrument that was previously applied by our
group on a similar population (10). This 15-item instrument, adapted
from the 49-item Oral Health Impact Profile (25), includes elements
that can be related to endodontic disease, while addressing the 7
conceptual dimensions in the Oral Health Impact Profile instrument
(functional limitation, physical pain, psychological discomfort, physical
disability, psychological disability, social disability, and handicap)
during the previous 12 months. This instrument was validated and
confirmed as having high reliability as the first attempt to assess a populations perception of the impact of endodontic disease on its quality of
life and the extent to which such impact can be moderated by
endodontic treatment (10).
Overall, the study participants reported a definitive preference for
retaining teeth over extraction. Retaining an anterior tooth emerged as
having greater value than retaining a posterior tooth. Similarly, all
participants who preferred extraction to retention also preferred to
replace an anterior tooth, whereas replacing a posterior tooth was
only preferred by 39% of participants. These findings suggested that
the participants might have perceived that a missing posterior tooth
was not a distressing health state, in agreement with a previous study

(26) where patients reported that a missing posterior tooth impacted


less on negative feelings and daily activities than a missing anterior
tooth. These observations echoed other recent studies (27, 28)
where patient-centered utilities (numeric indications of the desirability
of a health state, ranging from 0.0 for best to 1.0 for worst) were
lowest for patients missing a maxillary central incisor and highest
for patients with a missing maxillary second molar. Indeed, a systematic review (29) suggested that posterior tooth loss without replacement, which resulted in moderately shortened dental arches, had
little or no impact on occlusal stability, tooth loading, temporomandibular disorders, interdental spacing, periodontal disease, patients
comfort, and masticatory function. Furthermore, an interrupted dental
arch or an enclosed posterior space (similar situation as presented in
our clinical scenarios) caused by the loss of a single posterior tooth
had little effect on shifting, decrease in alveolar support for adjacent
teeth, or loss of adjacent teeth (29). The agreement of our findings
with other related research (29) highlighted the content validity of
the survey tool, the face validity of the outcomes, and the reliability
of the participants responses.
It is of interest that in our recent survey of a sample of Ontario
dentists preferences for the treatment of teeth with AP (7), none of

TABLE 3. Treatment Preferences


Preference question
General preference questions

Specific preference questions

1538

Azarpazhooh et al.

Saving an anterior tooth versus extraction:


If you develop an ache in a FRONT tooth, would you prefer to
treat the tooth and retain it or to pull it out?
Treat and retain it
Pull it out
Saving a posterior tooth versus extraction:
If you develop an ache in a BACK tooth, would you prefer
to treat the tooth and retain it or to pull it out?
Treat and retain it
Pull it out
Saving an anterior tooth via RCT versus extraction:
If you develop an ache in a FRONT tooth, would you prefer
to treat the tooth and retain it or to pull it out?
RCT and restoration
Pull it out
Saving a posterior tooth via RCT versus extraction:
If your dentist said this aching BACK tooth would have to
receive root canal treatment and restoration to be retained
or be extracted, what would you prefer?
Root canal treatment and restoration
Pull it out

413
12

97.2
2.8

381
44

89.6
10.4

399
27

93.7
6.3

356
69

83.8
16.2

JOE Volume 39, Number 12, December 2013

Clinical Research
TABLE 4. Summary of Horizontal Stepwise Logistic Regression Analyses Identifying the Significant Variables (P < .25) Predicting Preference for Saving a Tooth in
General or Specifically via RCT versus Extraction for Each of the 4 Outcomes
Outcome
General
preference

Specific
preference

Saving an anterior
tooth versus
extraction
Saving a posterior
tooth versus
extraction
Saving an anterior
tooth via RCT
versus extraction
Saving a posterior
tooth via RCT
versus extraction

First level:
predisposing factors

Second level: enabling


factors

Third level: need


factors

Fourth level: dental


health behavior

Immigration status

Annual source
of income

Self-rated oral
health, OHRQoL:
Prevalence
History of RCT,
self-rated oral
health, functional
dentition, OHRQL:
Severity
History of RCT, selfrated oral health,
OHRQL: Severity
History of RCT,
self-rated oral
health, functional
dentition, OHRQL:
Severity

Dental visit
frequency

Education
completed

Annual family
income, method
of dental payment

No significant variables
Education completed

the dentists preferred extraction of a posterior tooth without replacement, suggesting that dentists may be disposed to provide treatment
for any edentulism, anterior and posterior alike. It is important for
dentists to recognize that the preferences of patients can differ from
their own. Although the reasons for these discrepancies are not the
focus of this study, this awareness is important for avoiding potential
conflicts in treatment planning.
When the participants specifically considered RCT as the means
to retain a tooth, a small yet significant drop in preference rates for
tooth retention was observed. This finding may be explained by the
reported patients apprehension of RCT, which is considered as one
of the most stress-inducing procedures in dentistry (30, 31), even if
the anticipated pain from RCT is commonly overestimated (32, 33).

Annual family
income, annual
source of income

Dental visit
frequency

Dental visit
frequency, last
dental visit
Dental visit
frequency, history
of inability to
afford dental care

As suggested by the multivariate analysis, the preference for RCT


was less restrained for participants who had higher income that
made RCT affordable (an enabling factor), functional dentition that
they likely wanted to keep intact (a need factor), and previous RCT
experience that may have alleviated concerns about the procedure
(a need factor).
To our knowledge, this study was the first published attempt to
apply the Gelberg-Andersen Behavioral Model (16) to investigate dental
preferences. This model, a major revision of the original Behavioral
Model, provides a well-validated theoretical framework for understanding the determinants of healthcare use (17). According to Andersen (17), not only might each component of the model be conceived of
as making an independent contribution to predicting healthcare use,

TABLE 5. Adjusted Final (vertical) Stepwise Logistic Regression Model Presenting Significant Predictors for the Preference of Saving a Tooth with AP versus
Extraction in General or Specifically via RCT
Adjusted final model, OR (95% confidence interval), P value
Predisposing
factors

Enabling factors

Saving an anterior
tooth versus
extraction

None

None

Saving a posterior
tooth versus
extraction

None

None

Saving an anterior
tooth via RCT
versus extraction
Saving a posterior
tooth via RCT
versus extraction

None

None

Outcome
General
preference

Specific
preference

None

Annual family
income (5)
$40,000$79,999
2.70 (1.166.30)
P = .022
$$80,000
2.79 (1.047.51)
P = .042

Need factors
Self-rated oral
health good to
excellent (1)
6.20 (1.1134.58)
P = .037
Previous RCT (2)
2.78 (1.206.42)
P = .017
Functional
dentition (3)
4.35 (1.7310.97)
P = .002
Previous RCT (2)
2.81 (1.117.10)
P = .029
Previous RCT (2)
2.79 (1.305.97)
P = .008
Functional
dentition (3)
4.38 (1.8810.18)
P = .001

Dental health
behavior
None

Visit frequency (4)


2.84 (1.047.70)
P = .041

Visit frequency (4)


5.86 (2.2315.36)
P < .005
None

Reference categories: (1) Self-rated oral health as poor to fair, (2) No previous RCT, (3) Nonfunctional dentition with <21 natural teeth, (4) Dental visit frequency: only for emergency care, and (5) Annual
family income < $40,000.

JOE Volume 39, Number 12, December 2013

Patients Treatment Preferences for AP

1539

Clinical Research
but also the overall model suggests an explanatory process whereby the
predisposing factors might be exogenous, some enabling resources are
necessary, and some need factor must be defined for a healthcare
service to actually be used. By using the GelbergAnderson model
(16), we explored the potential impacts of factors in 4 categories on
participants preferences. Andersen (17) argues that in many contexts
the enabling and need factors explain the majority of variations in the
use of health services; in particular, the discretionary dental services
are more likely explained by social structure, beliefs, and enabling
factors. In our study, the final multivariate analysis suggested no impact
on participants preferences by any of the predisposing factors. Thus,
gender, age, marital status, education, immigration, and employment
status appeared not to impact on preferences for tooth retention or
extraction.
A single enabling factor, higher annual family income, was associated with a higher rate of participants preferring RCT to retain a posterior tooth, which, at 84%, had the lowest preference rate of all
questions. This finding suggested that with a relatively low motivation
to retain a posterior tooth, having adequate income could be a decisive
consideration. Indeed, it has been shown that enabling factors such as
disposable income and dental insurance plans increase dental care
utilization by reducing financial barriers (34, 35).
Three need factors, previous RCT, a functional dentition, and
good/excellent self-rated oral health, were associated with higher
rates of participants preferences to retain teeth; the former two
were in 3 questions and the latter in the fourth question. The universal
impact of the need factors was consistent with the suggestions by Anderson (17). Previous positive experience with RCT has been shown
to ease patients anxiety before another treatment (33, 36) and to
better dispose patients to choose RCT again if their dentist
recommends it (37). Self-perception of oral health and the presence
of a functional dentition are recognized general predictors of dental
care utilization (38). It could be suggested that participants with functional dentition were those who had been more inclined to retain
teeth, compared with participants who had already had many extractions because of financial constraints, apprehension of treatment, or
both.
The sole dental health behavior factor, dental visit frequency, was
associated with higher preference rates, in general to retain a posterior
tooth and specifically for RCT to retain an anterior tooth. It could be
suggested that regular dental visits were reflective of participants
regular care for their teeth, which would also be reflected in higher
preferences to retain teeth compared with participants who lacked
regular dental care.
In recent years, a trend has been reported of teeth with AP being
replaced with ISC (5, 6, 8), which may be considered to reflect
preferences of patients or of dentists. The results of this survey did
not support the former possibility, because the majority of
participants preferred retention of teeth to extraction and
replacement. The question may then be asked whether dentists
preferences influence the current trend, either by not affording
patients adequate opportunities to express their preferences or by
way of biased representation of treatment options that favors one
option; such was shown to influence the patients to select that very
treatment option (39). In consideration of these possibilities, it should
be regarded critical to represent treatment options in an impartial
manner and to encourage patients to exercise their autonomy by allowing them adequate time to conceptualize and weigh benefits and risks
and to communicate their preferences. Thus, within the context in
which patients views about treatment options are valued (40), the individuals innate preference toward tooth retention via RCT could be
considered the most appropriate for that individual.
1540

Azarpazhooh et al.

Conclusion
Within the limitations of this survey study, the responses of participants reflected a higher value for retention of an anterior than a posterior tooth affected by AP. The high preference for retaining a tooth in
general was moderated by the specific consideration of RCT to retain
the tooth. All participants who preferred extraction to retention of an
anterior tooth also preferred replacement, primarily by ISC, whereas
only 39% preferred replacement of a posterior tooth. One enabling
factor (higher annual income), several need factors (previous RCT,
functional dentition, and good/excellent self-rated oral health), and
one dental health behavior factor (regular dental visits) were associated
with higher preferences for tooth retention in response to different
questions, but none of the predisposing factors appeared to have
such impact. When RCT and extraction are viable options, patients
should be advised about the treatment options in an impartial manner
and encouraged to communicate their preferences.

Acknowledgments
The authors deny any conflicts of interest related to this study.

References
1. Figdor D. Apical periodontitis: a very prevalent problem. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2002;94:6512.
2. Salinas TJ, Eckert SE. In patients requiring single-tooth replacement, what are the
outcomes of implant- as compared to tooth-supported restorations? Int J Oral Maxillofac Implants 2007;22(Suppl):7195.
3. Naert I, Koutsikakis G, Quirynen M, et al. Biologic outcome of implant-supported
restorations in the treatment of partial edentulism: part 2a longitudinal radiographic study. Clin Oral Implants Res 2002;13:3905.
4. Ruskin JD, Morton D, Karayazgan B, Amir J. Failed root canals: the case for extraction and immediate implant placement. J Oral Maxillofac Surg 2005;63:82931.
5. Thomas MV, Beagle JR. Evidence-based decision-making: implants versus natural
teeth. Dent Clin North Am 2006;50:45161, viii.
6. Di Fiore PM, Tam L, Thai HT, et al. Retention of teeth versus extraction and implant
placement: treatment preferences of dental faculty and dental students. J Dent Educ
2008;72:3528.
7. Azarpazhooh A, Dao T, Figueiredo R, et al. A survey of dentists preferences for the
treatment of teeth with apical periodontitis. J Endod (in press).
8. Bigras BR, Johnson BR, BeGole EA, Wenckus CS. Differences in clinical decision
making: a comparison between specialists and general dentists. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2008;106:13944.
9. Ozar DT, Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical
Applications, 2nd ed. Washington, DC: Georgetown University Press; 2002:343.
10. Dugas NN, Lawrence HP, Teplitsky P, Friedman S. Quality of life and satisfaction
outcomes of endodontic treatment. J Endod 2002;28:81927.
11. Statistics Canada. Physical Health Measures Division, Canadian Health Measures
Survey (CHMS). Ottawa, ON, Canada: Statistics Canada, Health Statistics Division;
2010.
12. United Kingdom Office of National Statistics. Adult Dental Health Survey: Oral
Health in the United Kingdom 1998. London: Office of National Statistics; 2000.
13. American Association of Endodontists. Patients information: endodontic procedures, 2010. Available at: http://www.aae.org/patients/patientinfo/faqs/. Accessed
June 15, 2010.
14. American Academy of Periodontology. Dental implant placement options: replacing
a single tooth, 2009. Available at: http://www.perio.org/consumer/2mb.htm - 1.
Accessed June 15, 2010.
15. American College of Prosthodontists. Prosthodontic procedures: bridges, crowns,
dentures, dental implants and more, 2010. Available at: http://www.prost
hodontics.org/patients/procedures.asp. Accessed June 15, 2010.
16. Gelberg L, Andersen RM, Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health
Serv Res 2000;34:1273302.
17. Andersen RM. Revisiting the behavioral model and access to medical care: does it
matter? J Health Soc Behav 1995;36:110.
18. Gilbert GH, Duncan RP, Kulley AM. Validity of self-reported tooth counts during
a telephone screening interview. J Public Health Dent 1997;57:17680.
19. World Health Organization. Recent Advances in Oral Health. Geneva, Switzerland:
WHO; 1992.

JOE Volume 39, Number 12, December 2013

Clinical Research
20. Armstrong JS, Overton TS. Estimating nonresponse bias in mail surveys. J Mark Res
1977;14:396402.
21. Pak JG, Fayazi S, White SN. Prevalence of periapical radiolucency and root canal
treatment: a systematic review of cross-sectional studies. J Endod 2012;38:11706.
22. Slade GD, Nuttall N, Sanders AE, et al. Impacts of oral disorders in the United
Kingdom and Australia. Br Dent J 2005;198:48993, discussion 483.
23. Koneru A, Sigal MJ. Access to dental care for persons with developmental disabilities
in Ontario. J Can Dent Assoc 2009;75:121.
24. Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Use of mouthguards among
12- to 14-year-old Ontario schoolchildren. J Can Dent Assoc 2007;73:505.
25. Slade GD. Derivation and validation of a short-form oral health impact profile.
Community Dent Oral Epidemiol 1997;25:28490.
26. Oosterhaven SP, Westert GP, Schaub RMH. Perception and significance of dental appearance: the case of missing teeth. Community Dent Oral Epidemiol 1989;17:1236.
27. Nassani MZ, Kay EJ. Tooth loss: an assessment of dental health state utility values.
Community Dent Oral Epidemiol 2011;39:5360.
28. Nassani MZ, Locker D, Elmesallati AA, et al. Dental health state utility values associated with tooth loss in two contrasting cultures. J Oral Rehabil 2009;36:6019.
29. Torabinejad M, Anderson P, Bader J, et al. Outcomes of root canal treatment and
restoration, implant-supported single crowns, fixed partial dentures, and extraction
without replacement: a systematic review. J Prosthet Dent 2007;98:285311.
30. Peretz B. Dental anxiety among patients undergoing endodontic treatment. J Endod
1998;24:4357.

JOE Volume 39, Number 12, December 2013

31. Winters RB. Id rather have a baby than root canal, or how to treat the fearful patient.
J N J Dent Assoc 1995;66:658.
32. Rousseau WH, Clark SJ, Newcomb BE, et al. A comparison of pain levels
during pulpectomy, extractions, and restorative procedures. J Endod 2002;
28:10810.
33. Watkins CA, Logan HL, Kirchner HL. Anticipated and experienced pain associated
with endodontic therapy. J Am Dent Assoc 2002;133:4554.
34. Bhatti T, Rana Z, Grootendorst P. Dental insurance, income and the use of dental
care in Canada. J Can Dent Assoc 2007;73:57.
35. Millar WJ, Locker D. Dental insurance and use of dental services. Health Rep 1999;
11:5567 (Eng), 5972(Fre).
36. Wong M, Lytle WR. A comparison of anxiety levels associated with root canal therapy
and oral surgery treatment. J Endod 1991;17:4615.
37. Lobb WK, Zakariasen KL, McGrath PJ. Endodontic treatment outcomes: do patients
perceive problems? J Am Dent Assoc 1996;127:597600.
38. Muirhead VE, Quinonez C, Figueiredo R, Locker D. Predictors of dental care utilization among working poor Canadians. Community Dent Oral Epidemiol 2009;37:
199208.
39. Foster KH, Harrison E. Effect of presentation bias on selection of treatment option
for failed endodontic therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2008;106:e369.
40. Elwyn G, Edwards A, Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract 1999;49:47782.

Patients Treatment Preferences for AP

1541