Ten-year survival rates of teeth adjacent to treated and untreated posterior

bounded edentulous spaces

Steven A. Aquilino, DDS, MS,a Daniel A. Shugars, DDS, PhD, MPH,b James D. Bader, DDS, MPH,c
and B. Alexander White, DDS, MS, DrPHd
College of Dentistry, The University of Iowa, Iowa City, Iowa; School of Dentistry, The University of
North Carolina, Chapel Hill, N.C.; and Kaiser Permanente Center for Health Research, Portland, Ore.
Statement of problem. Failure to replace a single missing posterior tooth may lead to a variety of den-
tal problems, which may ultimately result in tooth loss. However, little is known about the fate of the
adjacent teeth if a missing posterior tooth is not replaced.
Purpose. This retrospective study evaluated the survival of teeth adjacent to treated and untreated pos-
terior bounded edentulous spaces.
Material and methods. Data were obtained from electronic treatment records from the Kaiser
Permanente Dental Care Program, Portland, Ore. A final sample of 317 patients who met the study
inclusion criteria was identified. Each bounded edentulous space was placed in 1 of 3 treatment cate-
gories: untreated, restored with a fixed partial denture, or restored with a removable partial denture.
Subsequent treatment and the status of the teeth adjacent to the bounded edentulous space were fol-
lowed through December 1999. Ten-year Kaplan-Meier survival estimates were generated for each
treatment group, and differences in survival were evaluated with the log-rank chi-square test (α=.05).
Results. There was a significant difference in survival among the 3 treatment categories (P=.005).
Spaces restored with a fixed partial denture had longer 10-year survival estimates (92%) than those that
remained untreated (81%). Spaces restored with a removable partial denture had the poorest 10-year sur-
vival rate (56%).
Conclusion. Under the conditions and selection bias associated with this retrospective study, the sur-
vival of teeth adjacent to a single posterior edentulous space was negatively associated with removable
partial denture placement compared with no treatment or the use of a fixed partial denture. (J Prosthet
Dent 2001;85:455-60.)

CLINICAL IMPLICATIONS
The 10-year survival of teeth adjacent to a posterior-bounded edentulous space restored
with a fixed partial denture was 11% longer than spaces left untreated and 36% longer
than those restored with a removable partial denture. Additional outcomes measures,
longer observation periods, and treatment options such as single-tooth implants must
be evaluated if the profession is to provide patients with the evidence necessary to make
truly informed decisions regarding the replacement of a single posterior missing tooth.

I ncreasingly, patients want more detailed informa-

tion about the advantages, disadvantages, and expected
information leads to varied responses throughout the
dental profession as to whether to treat a given condi-
outcomes of various treatment options before deciding tion and, if treated, which procedure to use.1 Most
on a course of therapy. However, dentistry lacks much treatment decisions are based on “expert” opinion, not
of the evidence necessary to make truly informed deci- necessarily on valid scientific evidence. In general, den-
sions about treatment for many conditions. This lack of tists’ treatment recommendations are based on what
they have learned in dental school and continuing edu-
Supported by NIDR grant 5-R01-DE11878. cation courses, their personal observations, and practice
aProfessor, Department of Prosthodontics, University of Iowa.
experiences.2,3 The practitioner’s ability to apply objec-
bProfessor, Department of Operative Dentistry, University of North
tive, valid information is limited by the lack of formal
Carolina.
cProfessor, Department of Operative Dentistry and Sheps Center for outcome assessments for even the most common den-
Health Services Research, University of North Carolina. tal treatments.4
dSenior Investigator, Kaiser Permanente Center for Health Even the need to replace a single missing posterior
Research. tooth has been based on the time-honored assumption

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THE JOURNAL OF PROSTHETIC DENTISTRY AQUILINO ET AL

that failure to restore this edentulous space will lead to of teeth adjacent to restored and unrestored bounded
a variety of dental problems.5 These adverse conse- edentulous spaces (BESs).9 That study defined a BES
quences include the supra eruption of the opposing as “the condition that exists after a tooth is extracted
tooth or teeth, tilting or drifting of the adjacent teeth, and the adjacent teeth remain.” Teeth adjacent to 569
and loss of proximal contacts, which negatively impact treated and untreated BESs were retrospectively evalu-
the health of the supporting structures and the occlu- ated. Data were obtained from 3 sources: the Veterans
sion.6 These adverse consequences may ultimately Affairs Dental Longitudinal Study, the Kaiser
result in the loss of 1 or more of the teeth adjacent to Permanente Dental Care Program, and the Truman
the edentulous space. To avoid these problems, den- Medical Center–East. The results indicated that at
tists have been taught to replace the missing tooth least for the short term (≤8 years), the survival of teeth
with a fixed partial denture (FPD), a removable partial adjacent to a BES was not dependent on the restora-
denture (RPD), or more recently, a single-tooth tion of the missing tooth. There was no difference in
implant.6,7 the survival of unrestored BESs and those restored
The importance of this issue is underscored by the with an RPD; only a small but statistically significant
prevalence of missing teeth and the cost of replacing increase was shown for the survival of adjacent teeth
them. Although there has been a steady decline in the restored with an FPD.
prevalence of tooth loss in the United States, the This investigation is an extension of the previously
1988-1991 National Health and Nutrition mentioned study. Treatment records from the Kaiser
Examination Survey (NHANES III) indicated that Permanente Dental Care Program were evaluated for
overall, only 30% of the adult population was com- an additional 3 years (for a maximum of 10 years vs 7
pletely dentate (had 28 teeth). The percentage of years in the original study). As in the original study,
completely dentate persons declined with increasing the primary purpose of this retrospective cohort study
age, from 67% of the 18- to 24-year-old group to only was to evaluate the survival of teeth adjacent to treat-
2% of the 75 and older age group. Among dentate ed and untreated BESs. In addition, other variables
adults, the overall mean number of teeth present also that may be associated with tooth loss were evaluated.
declined with increasing age, ranging from 27 teeth in These included the association between the number of
the 18- to 24-year-old group to 16 teeth in the 75 and restorative procedures and endodontic treatment on
older group. Therefore, nearly one third of young the adjacent teeth as well as the overall periodontal
adults (18-24) had lost at least 1 tooth (other than treatment on survival of the teeth adjacent to the BES.
third molars); by middle age (50-54), approximately 6
MATERIAL AND METHODS
teeth had been lost; and after the age of 75, the aver-
age person had lost approximately 11 teeth.8 This The data source for this investigation was treatment
prevalence of tooth loss translates into increased costs records from a large group-model dental health main-
for dental treatment. Estimates, which used insurance tenance organization (HMO) in Portland, Ore.9 The
claims data, indicate that almost 7% of annual dental initial sample included all patients enrolled in the plan
care expenditures (roughly $3.2 billion) are related to during the years 1988 and 1989 (n = 106,629). From
the treatment of single missing posterior teeth.9 electronic treatment records and enrollment files,
For almost 50 years, prosthodontists have attempt- 1,212 adults (≥18 years of age) were identified who
ed to support their treatment decisions on the premise had either a first molar or second premolar extracted in
that the treatment provided should preserve the denti- either 1988 or 1989 and who maintained enrollment
tion that remains, not necessarily replace teeth that through 1999. Dental charts were audited to identify
have been lost.10 However, little is known about the patients who met the following selection criteria: (1)
fate of the remaining dentition if a missing tooth is not documented extraction of a first molar or second pre-
replaced. For example, most of the dental literature on molar (target tooth) with adjacent teeth remaining
tooth replacement with an FPD primarily reports pros- during 1988-1989, and (2) fewer than 5 other missing
thesis survival data.11-14 Although this information is teeth (with the exception of third molars and first pre-
of value, it does not answer the fundamental question molars removed for orthodontics) at the time of target
of whether the proposed treatment will result in an tooth extraction.
increased likelihood of patients retaining their teeth After applying these criteria, a final sample of 317
longer than if no treatment was provided. Although patients was identified. The mean age of these partici-
abutment tooth loss may appear to be a somewhat pants at the time of target tooth extraction was 45.5
crude outcome, it may represent a more meaningful years; 51% were women. Each BES was placed in 1 of
outcome to patients, especially those whose primary 3 treatment categories: untreated (UNTX), restored
treatment goal is retaining their teeth. with an FPD, or restored with an RPD. With the use
With the use of tooth survival as the ultimate out- of electronic records of dental treatment, the exact
come of interest, a recent study examined the survival dates of extraction were obtained. Subsequent treat-

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Table I. Five- and 10-year survival estimates for the 3 treatment categories
Treatment category n Number failed 5-y survival estimates (SE) 10-y survival estimates (SE)

Untreated 239 45 0.89 (0.02) 0.81 (0.03)

Fixed partial denture 65 4 0.97 (0.02) 0.92 (0.04)
Removable partial denture 13 6 0.77 (0.12) 0.56 (0.15)

ment and the status of the teeth adjacent to the BES

were followed through December 1999.
The primary outcome evaluated was “time to fail-
ure,” with failure defined as the extraction of at least 1
of the adjacent teeth. Follow-up began on the date of
the target tooth extraction for the UNTX group and
on the date of prosthesis delivery for the FPD and RPD
groups. For failed situations, follow-up ended on the
date of extraction of the adjacent tooth. For all other
patients, follow-up ended on December 31, 1999.
Other variables that may be associated with tooth
survival were also evaluated. The variables selected
were based on their availability from the electronic
treatment records and their possible associations with
tooth loss. These included the total number of restora-
tive procedures (amalgam or resin composite
restorations) completed on the adjacent teeth, repre-
senting the caries rate for these teeth. The total Fig. 1. Kaplan-Meier survival curve for 3 treatment cate-
number of endodontic procedures completed on the gories.
adjacent teeth was also evaluated because pulpless
teeth have been associated with poorer success rates
than teeth with vital pulps.15,16 Finally, the overall
periodontal status of the patient was evaluated by treatments or retreatment on the adjacent teeth). A
means of the amount of periodontal treatment proxy for periodontal health was developed from the
received since the time of target tooth extraction. number of periodontal procedures recorded in the
electronic patient treatment records. Patients were
ANALYSIS
defined as having less-than-optimal periodontal health
Kaplan-Meier survival estimates were generated for if they received 2 or more periodontal procedures (for
each treatment group with Proc Lifetest in SAS version example, scaling and root planing, periodontal
6.12 for windows (SAS, Cary, N.C.). These survival surgery) within 1 calendar year for 3 or more years
estimates represented the distribution of probabilities after the extraction of the target tooth.
of both bounding teeth surviving for various lengths The relatively small sample size and small number of
of time. Differences in survival among the 3 treatment failures prevented the use of multivariate analyses to
groups were evaluated with the log-rank chi-square evaluate the relationship between restorative, endodon-
test (α=.05). tic, and periodontal procedures and each of the main
Additional variables were also evaluated for their treatment categories.
bivariate relationship with survival (chi-square,
RESULTS
α=.05). For this analysis, the number of restorative
procedures was dichotomized as 2 or fewer (repre- Table I displays the Kaplan-Meier 5- and 10-year
senting the expected amount of restorative treatment survival estimates and Figure 1 graphically depicts the
on the adjacent teeth for the observation period) or 3 survival curves for each of the 3 treatment categories.
or more (representing a greater-than-expected amount There was a significant difference in survival among all
of restorative treatment and the probability of a high- 3 treatment categories (log-rank chi-square=10.43,
er caries rate in these persons). The number of P=.005). However, because of the small number of
endodontic procedures was also dichotomized as 0 subjects (n = 13) in the RPD treatment category, the
(representing those with no endodontic treatment on analysis was repeated for just the UNTX and FPD
the adjacent teeth during the follow-up time) or 1 or groups. With the RPD group removed, the difference
more (representing those with 1 or more endodontic in survival between the FPD group (92%) and the

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THE JOURNAL OF PROSTHETIC DENTISTRY AQUILINO ET AL

Table II. Proportion of cases receiving higher levels of restorative endodontic and periodontal treatment on teeth adjacent
to the bounded edentulous space
n Restorative* Endodontics† Periodontics‡

n % n % n %

All cases 317 69 21.8 50 15.8 53 16.7

Survivors 262 48 18.3 36 13.7 39 14.9
Failures 55 21 38.2 14 25.5 14 25.5
Chi-square value§ 10.53 4.70 3.65
P value .001 .030 .056
*Number of cases receiving ≥3 restorative procedures during the observation period.
†Number of cases receiving ≥1 endodontic procedure during the observation period.
‡Number of cases receiving ≥2 periodontal procedures for ≥3 years during the observation period.
§Chi-square evaluating significance (α=.05) between survivors and failures for each type of treatment.

UNTX group (81%) was not statistically significant of the teeth adjacent to the BES must have been favor-
(log-rank chi-square=3.64, P=.057) at the end of the able for the placement of an FPD. Thus, patients with
10-year follow-up. a better prognosis were likely to be overselected to the
The results of the bivariate analyses of the other FPD group, whereas those with a poorer prognosis
variables evaluated (Table II) indicate that failures had were either left untreated or restored with an RPD.
significantly greater numbers than survivors of restora- The results of this study appear to be consistent with
tive procedures and endodontic treatment on the the potential for bias toward the FPD group, in that
adjacent teeth during the observation period (P=.001 this group had the longest survival estimates.
and P=.030, respectively). Although not statistically As stated previously, teeth adjacent to BESs
significant (P=.056), failures were also more likely to restored with an RPD had the poorest survival esti-
have had periodontal treatment than patients in whom mates of any of the treatment groups in this study.
both adjacent teeth survived. The 56% 10-year survival estimate was similar to the
approximately 60% 8-year survival estimate for the
DISCUSSION
RPD group from the Kaiser Permanente Dental Care
Failure to replace a missing posterior tooth has been Program but substantially lower than the approximate-
believed to result in several adverse consequences. ly 75% 8-year survival estimate from the combined
These include the supra eruption of the opposing data of the previous study.9 Although statistically sig-
tooth or teeth, tilting or drifting of the adjacent teeth, nificant, the decreased survival estimates for the RPD
and loss of proximal contacts, which negatively impact group should be viewed with caution because of the
the health of the supporting structures and the occlu- very small sample size (n = 13) of this treatment group
sion.6 These adverse consequences may ultimately and the potential for selection bias. In addition to the
result in the loss of 1 or more of the teeth adjacent to potential bias noted previously, patients with more
the edentulous space. teeth missing than just the BES within an arch also
The results of this retrospective study indicate that may have had their treatment choice biased toward the
the difference in survival of teeth adjacent to a posterior RPD group; these patients may have had an increased
BES restored with an FPD versus those untreated was predilection for caries and periodontal disease.
11%. This large difference in survival estimates, 92% for We attempted to reduce this bias by restricting the
the FPD group versus 81% for the UNTX group, is like- sample to patients with fewer than 5 missing teeth
ly to be clinically significant even though the relatively (other than third molars and premolars extracted for
small sample size rendered the difference statistically orthodontics) at the time of target tooth extraction.
insignificant (P=.057). The 92% 10-year survival of This restriction was introduced to decrease the num-
teeth restored with an FPD is consistent with the 8-year ber of subjects with the poorest prognosis but
data from the previous study by Shugars et al9 and with probably did not eliminate them. Despite the poten-
other studies on FPD survival.11-13 A recent meta- tially poorer prognosis for abutment teeth restored
analysis also reported that FPD abutment tooth survival with an RPD, NHANES III data indicate that approx-
was approximately 96% at 10 years.14 imately 35.7 million Americans between the ages of 18
As with all retrospective studies, certain limitations and 74 wear some type of removable prosthesis.
apply. There was a lack of control over the assignment Therefore, dependence on removable prostheses is still
of treatment categories and therefore the likelihood a necessity for millions of Americans.17
that there was substantial bias in the treatment select- Caries is believed to be one of the leading causes of
ed for each patient. It is presumed that the prognosis tooth loss.16,18 The significant association of increased

458 VOLUME 85 NUMBER 5

AQUILINO ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

numbers of restorative procedures with failures trolled clinical trial. However, randomized controlled
(P=.001) is understandable if one assumes that need clinical trials raise concerns about human participation,
for these restorative procedures was associated with a can be prohibitively expensive, and would not yield
higher caries rate. Furthermore, the increased number results for nearly 2 decades. Therefore, the profession
of restorative procedures in patients who had 1 of the must rely on retrospective studies, with an under-
bounded teeth extracted also occurred over a shorter standing of their limitations, to provide information
period. about important clinical issues. Retrospective studies
The significant association between endodontic also suggest areas in need of further research.
procedures and failures (P=.03) is also consistent with The results of this study show that the use of an
previous literature. Although only a few in vivo studies FPD to restore a BES may result in an increased pos-
specifically address the survival of endodontically treat- sibility of abutment tooth survival compared with no
ed teeth,19 poorer success rates for pulpless teeth have treatment. However, as stated previously, tooth loss is
been reported than for teeth with vital pulps.12,15,16,20 a somewhat crude outcome measure. Moreover, an
Finally, although not statistically significant FPD is placed for many reasons other than simply to
(P=.056), there was a trend for failures to have had a increase the survival of the adjacent teeth. Therefore,
higher proportion of periodontal treatment than sur- additional outcomes such as changes in adjacent and
vivors. This trend is consistent with the literature in opposing tooth position, periodontal pocket depth,
that, along with caries, periodontal disease is one of attachment loss, temporomandibular joint function,
the leading causes of tooth loss in the adult popula- pulpal status, patient satisfaction, chewing function,
tion.16,21 The lack of statistical significance may be, in and costs associated with various treatment options
part, due to the conservative way in which periodontal also must be evaluated. If for some reason the patient
status was evaluated (≥2 periodontal procedures with- desires to postpone treatment, risk factors need to be
in a calendar year for ≥3 years) from the data available identified that can be used to determine when inter-
in the electronic patient records. In addition, some vention may be required to prevent irreversible
patients may have had periodontal disease diagnosed changes. Finally, there is a need to conduct these stud-
but not treated. These patients therefore were not cat- ies over longer periods and to incorporate additional
egorized as having periodontal treatment, and this treatment options, such as single-tooth implants, into
may have biased the results. these types of analyses.
These additional variables may have been related to
CONCLUSIONS
the treatment provided and may have a greater associ-
ation with tooth survival than whether the BES was In this retrospective cohort study, there was a sig-
restored or remained untreated. However, the small nificant difference in survival of teeth adjacent to a
sample size did not provide the power necessary to posterior bounded edentulous space among the 3
conduct the multivariate analysis necessary to deter- treatment categories. Spaces restored with a fixed par-
mine whether there was a relationship between the tial denture had longer 10-year survival estimates
restorative, endodontic, and periodontal variables and (92%) than those that remained untreated (81%).
each of the main treatment groups. In a previous study Spaces restored with a removable partial denture had
that examined reasons for tooth loss among adult the poorest 10-year survival estimate (56%). An
Kaiser Permanente Dental Care patients, both caries increased proportion of restorative treatment and
and periodontal disease were identified as the main teeth that had endodontic treatment was also associat-
reasons for tooth extraction.22 ed with a higher rate of failure (loss of at least 1 of the
In addition to the limitations previously noted, teeth adjacent to the edentulous space).
other limitations of this retrospective study were the Because several potentially important variables were
lack of standardization of the treatment provided and not available and because comparison groups were not
the restricted data available from the electronic patient randomized to treatment, the improved survival
records. The validity of the data is based on the relia- observed among teeth adjacent to spaces restored with
bility and accuracy of the recorded entries, and certain a fixed partial denture cannot be attributed solely to
variables that may be related to the outcome of inter- the fixed prostheses.
est, such as the degree of bone loss and the patient’s
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The effect of glass fibre-reinforcement on the transverse

Noteworthy Abstracts strength, deflection and modulus of elasticity of repaired
of the acrylic resins
Current Literature Keyf F, Uzun G. Int Dent J 2000;50:93-7.

Purpose. This study evaluated the effects of glass fiber reinforcement on the transverse strength,
deflection, and modulus of elasticity of 4 types of polymethyl methacrylate (PMMA) joints
repaired with autopolymerizing acrylic resin.
Material and methods. Four types of heat-polymerized acrylic resin test specimens (each 60 ×
10 × 3 mm) were fabricated. The acrylic resins studied were Lucitone 199 (De Trey Division,
Dentsply Int, Weybridge, Surrey, UK); QC 20 (De Trey Division, Dentsply Int); Meliodent
(Beyer Dental, Newburg, Germany); and Impact (Dental Exports of London, Wodford, UK).
The bottom and sides of test specimens were placed in dental stone to form a repair template.
Lines were drawn 3.5 mm on each side of the center line. Forty-five degree bevel joint margins
were cut at these lines to simulate fracture, and the center section was discarded. A 1-mm gap was
created between the margins before repair with autopolymerizing acrylic resin with and without
glass reinforcement fibers. A 3-point loading test was used to measure transverse strength, deflec-
tion, and modulus of elasticity of the repaired acrylic resin joints. The data were subjected to
statistical analyses.
Results. There were significant differences between the fiber-reinforced and nonreinforced
repaired acrylic resins. Fiber reinforcement increased the transverse strength of the specimens test-
ed. It also raised the deflection values of all acrylic resins, except QC 20, and increased the
modulus of elasticity of Impact acrylic resin.
Conclusion. Glass fiber reinforcement significantly increased the resistance to deflection and the
modulus of elasticity of repaired acrylic resins. 30 References. —RP Renner

460 VOLUME 85 NUMBER 5