"The Consequences of Not Replacing a Missing Posterior Tooth" by Dr. Daniel Shugars and colleagues in September JADA allegedly tries to scientifically test the validity of a basic tenet in dentistry: "Failure to replace a missing posterior tooth is assumed to result in a host of adverse consequences, which include shifting of teeth and loss of alveolar bone support."
The article then dramatically immediately assures the reader that it has by and large succeeded in a landmark refutation by stating in the abstract’s Clinical Implications section, "These findings suggest that for the large majority of patients who experience a single-tooth posterior BES [bounded edentulous space], immediate treatment may not be critical to the maintenance of arch stability."
However, this sweeping statement is erroneous and potentially damaging if followed in all its implied instances since this "large majority" does not include persons who were in their pre-teens, teens and early twenties when they experienced the loss of a first molar. We only discover this vital age-qualifying limitation of this abstract’s alleged new truism far into the body of the article (if we are curious enough to read that far), where it casually mentions, "The mean age of these subjects at the time of extraction [of either a first molar or a second bicuspid] was 45.5 years (range, 24 to 90 years). ..."
This salient age qualifier is omitted from the Methods section of the abstract, which only mentions 111 patients, and the abstract’s Conclusions similarly only alludes to "this group of patients."
Only at the end of this seven-page article do we again have a brief chance to find the truth about this critical age-qualifying factor of this "large majority of patients" (if we have the time and energy to carefully re-read the article and ferret out the reference), "These findings suggest that for the large majority of patients in this age range who experience a posterior BES." This abstract’s clinical implications are thus potentially damaging to the nation’s health, and all the more so since this article appears in the JADA and, even worse, it was selected as a JADA Continuing Education article.
The lower first molar, the most frequently extracted tooth, is the "six year molar," and the greatest damage if not replaced soon—as advocated in the "prosthodontic textbooks, case reports and patient educational materials" that the authors deride—often begins when a patient is as young as eight or 10, or a teenager.
A typical case history presented in a letter to a dental editor (Dental Survey 1963; July:72) is similar to those I often have been faced with for over half a century: "A 23-year-old girl in excellent health reports that her lower first molars were extracted when she was 16. She is now becoming aware that her dental condition is not normal and would like to have it corrected, if possible, within the limits of her husband’s income (he is an Army sergeant). She was advised that the condition is easy to prevent but difficult to correct. Any assistance you can give to prevent eventual destruction of the patient’s arches will be appreciated. —R.E.J., Iowa."
First-molar extractions perpetrated on the young sometimes are often long-range time bombs; many decades are then required before the "adverse consequences" scenario causes problems severe enough for the victims to need and seek full-mouth rehabilitation.
This study is based largely on middle-aged subjects who have denser bone than the young. These subjects had kept all their teeth for a long time until disturbed by a single extraction not of periodontal disease etiology. They have demonstrated better periodontal resilience than the total population. And the study only measures a "median follow-up period [of] 6.9 years" after occurrence of the BES.
The profession does not need so much, as the authors conclude, "to work diligently toward identifying the factors that do predict adverse consequences" of an untreated posterior BES as to work toward being motivated to have the profession eliminate the BES. Endodontia plus tooth restoration is a 100 percent sure prevention of those "adverse consequences," is cheaper and better than any prosthesis and should be the normal standard.
