Effect of presentation bias on selection of treatment option for

failed endodontic therapy

Keith H. Foster, DMDa and Ershal Harrison, DMD, RPHb, Kentucky
UNIVERSITY OF KENTUCKY COLLEGE OF DENTISTRY

Objective. The purpose of the study was to determine if treatment option presentation bias affects decision making by
patients when they have failed endodontic therapy.
Study design. First-year dental students simulated the role of patients. All students were given the same scenario of a
symptomatic tooth with failed endodontic therapy and asked to select from between 2 treatment options: nonsurgical
endodontic retreatment or extraction and implant placement. One half of the students had characterizations of the
treatment options biased toward nonsurgical retreatment, and the other half had characterizations of the treatment
options biased toward extraction and implant selection. Statistical analysis was performed with chi-squared test.
Results. Biased presentations significantly influenced the treatment selection by the students (P .0006).
Conclusion. If treatment options are presented in a biased manner to favor one option, the patient is more likely to
select that treatment option. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e36-e39)

Treatment options for failed endodontic therapy include nonsurgical or surgical endodontic retreatment
and extraction with or without replacement of the
tooth.1-3 General dentists, oral maxillofacial surgeons,
endodontists, residents, and dental students have been
shown to differ in their decision making and treatment
planning recommendations for teeth with failed endodontic therapy.4-7 Their recommendations may be influenced by their level of experience, training, and
familiarity with different treatment procedures. For example, endodontists were more likely to recommend
endodontic retreatment than oral maxillofacial surgeons, who were more likely to recommend extraction.4 Alternatively, fourth-year dental students recommended extraction and implants rather than endodontic
retreatment at a higher rate than their general dentistry
faculty.7
Patients with failed endodontic therapy, usually in
conjunction with their general dentists, make decisions
regarding treatment from among more than 1 reasonable treatment option. Treatment options should be
clearly and objectively communicated to the patient for
the patient to make the best informed decision. Patient
autonomy in decision making is desired,8 but if the
information presented by the dentist or dental specialist
is biased, it could influence the patient toward one
a

Assistant Professor, Division of Endodontics.

Assistant Professor, Clinical Team Leader, Oral Health Practice.
Received for publication Apr 14, 2008; returned for revision Jun 23,
2008; accepted for publication Jun 23, 2008.
1079-2104/$ - see front matter
2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2008.06.018

e36

treatment option over another. Bias can be transmitted

to patients by way of the selection of information
presented and the characterization of information presented to the patient. No study has yet been done that
demonstrates differences in patient decision making
regarding choice between endodontic retreatment or
extraction and implant placement when the information
provided to the patient is biased. The purpose of the
present study was to determine the effect of presentation bias on the selection of treatment option for failed
endodontic therapy.
MATERIALS AND METHODS
The study protocol was reviewed and approved by
the University of Kentucky Institutional Review Board.
Study participants were preclinical first-year students
present for a scheduled oral radiology class session.
The study authors were not instructors in the oral radiology course. At the beginning of the class, the students
were presented with a cover letter consent form and
given an opportunity to ask questions regarding the
study by one of the investigators (E.H.), who was a
general dentist. Students were not informed that the
study was about bias. Each student was given a 1-page
form with a scenario, radiographic image, and instructions to select between 2 described treatment options:
endodontic retreatment or extraction and implant. No
further information or verbal instructions were given to
the students. The students had not had any course
contact with either author before the study, although the
students may have known the authors by name, face,
and position within the dental school. Therefore, the
endodontist involved in the study (K.H.F.) chose not to
be present during distribution of the consent form and

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Foster and Harrison e37

Table I. Selection option results

Fig. 1. Radiogram of tooth #21.

study form to the students, to eliminate any chance of

biasing responses toward endodontic retreatment.
The following directions and scenario were given to
all students:
Directions. Read the following scenario and select
either option 1 or option 2.
Please do not discuss this with your fellow students.
Base your decision only on the information given.
There is no right or wrong answer.
Scenario. Which of the 2 treatment options below
would you prefer in your mouth to take care of this
chronically sore tooth which recently caused an episode
of acute swelling and pain? The tooth in question is
tooth #21; it has already had root canal treatment.
A radiographic image, Fig. 1, was embedded in the
study form. Although each student received this same
scenario, one half of the students received treatment
option descriptions biased toward endodontic retreatment selection and the other half option descriptions
biased toward extraction and implant selection.
Options biased to endodontic retreatment selectionOption 1 You can have the tooth removed, wait 3
months for the extraction site to heal, and then have a
metal implant placed surgically into the jaw bone. A
crown can then be anchored to your implant once the
implant has successfully fused with the bone. You can
wear a temporary partial denture with a fake acrylic

Group

Retreatment

Implant

Bias to retreatment
Bias to implant

17
4

10
21

tooth, something similar to wearing an orthodontic

retainer, to hide the spot with the missing tooth while
the bone heals. The total treatment would take between
4 and 6 visits. Option 2 You can predictably keep your
natural tooth by having the root canal treatment redone. You would not have to have surgery and the tooth
would feel more like your other natural teeth. The
treatment would take between 1 and 2 visits. In the
unlikely event that the retreatment is not successful, you
could then have the tooth extracted and have an implant placed.
Options biased to extraction and implant placement
selection-Option 1 You can have the previous root canal treatment redone with a 75% chance of healing
long term. You have a 25% chance that it wont heal. If
the root canalassociated disease heals, there is still a
risk of tooth loss. The tooth is still susceptible to recurrent decay, periodontal disease, or possible root
fracture, any of which could result in the need for
extraction in the future. Option 2 You can have the
tooth extracted now and have it replaced with an implant. The chance of successful treatment with an implant and crown replacement is approximately 95%.
The discomfort associated with the natural tooth will be
permanently eliminated. The implant and its crown will
never decay, and if there is any periodontal disease in
your mouth, the implant will be affected much less than
your own teeth. Statistical analysis was performed with
chi-squared test. Level of significance was established
at P .05.
RESULTS
The results are presented in Table I. Fifty-three students were present for the study, including 19 female
students, 2 students of Asian descent, 6 students of
African descent, and 1 student of Hispanic descent. One
unidentified student chose not to participate after reading the consent form and the study form with scenario.
There was a significant difference between the 2 bias
groups (P .0006). The majority of students in the bias
to retreatment group selected the retreatment option.
The majority of students in the bias to extraction and
implant group selected the implant option.
DISCUSSION
The results of the study showed that a biased presentation describing 2 reasonable treatment options for

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Foster and Harrison

failed endodontic therapy can influence the option selected by a patient. The predoctoral students were selected because of their perceived ability to read and
understand the scenario and treatment choices without
further explanation. These students had as yet had no
courses in restorative dentistry, prosthododontics, periodontics, endodontics, oral pathology, or oral surgery.
With their limited exposure to the dental school curriculum, it was unlikely that they had developed any
opinions regarding the merit of one treatment option
over another and would base their selection on the
information given. Participants were not asked whether
they had a personal dental history or family dental
history of previous endodontic or implant therapy
which could have influenced their decision depending
on whether there had been a favorable or unfavorable
outcome.
The descriptions of the treatment options were purposefully kept short; each was 4 sentences in length.
The endodontic retreatment option biased pair was
intended to be influenced by the qualitative descriptions
of the procedures in terms of number of appointments,
time to completion, and the need for surgical procedure
with implant placement. The implant option biased
pair was intended to be influenced primarily on the
basis of prognosis. The prognosis estimate of 75%
chance of healing with nonsurgical retreatment is a
reasonable estimate to present to patients based on
recent success-failure studies on endodontic nonsurgical retreatment of cases with periapical (PA) lesions.9-11 The prognosis estimate of 95% chance of
success with single tooth implant is also a reasonable
estimate to present to patients.12-14
Other treatment options for the study scenario could
have been included in the study. Treatment options for
endodontically treated teeth with asymptomatic PA lesions could include no treatment with follow-up, nonsurgical retreatment, surgical retreatment, or a combination of nonsurgical and surgical retreatment. The
scenario in the study described ongoing symptoms with
a recent acute episode of pain and infection. Although
no treatment is favored by general dentists more often
than by endodontists for asymptomatic teeth with PA
lesions after initial endodontic treatment,5,6 the scenario was meant to exclude the option of no treatment.
Surgical endodontic treatment could have been listed as
an alternative third option with an approximate equivalent prognosis to nonsurgical retreatment3,15 or a better prognosis than nonsurgical retreatment.16 However,
we wanted the participants to consider only 1 surgical
option, that of extraction and implant placement. With
#21 in the esthetic zone, virtually all patients would
prefer to have the tooth replaced if the tooth were
extracted. This particular case, with #20 serving as an

abutment for a fixed partial denture and #22 being

caries and restoration free, was intended to exclude a
fixed partial denture replacement option.
We chose not to include cost comparisons in the
treatment option descriptions. We wanted to primarily
assess the results based on presentation bias in prognosis and procedural description. If cost estimates were
included, the results would likely be skewed more to
the lower-cost option, particularly due to the assumed
financial constraints of the study population of firstyear dental students. Students at the University of Kentucky College of Dentistry are required to pay standard
patient fees for all treatment rendered; there are no
student fee discounts or waivers. In the study scenario,
the tooth may have only needed an access restoration
for the apparently serviceable crown after retreatment,
which would be much less expensive than the extraction and implant option. Even if the crown needed to be
replaced, a cost-benefit analysis study found that orthograde endodontic treatment, crown lengthening, and
crown was less expensive than the cost of implant
placement and restoration.17 Alternatively, implant advocates now state that the cost of extraction and implant
replacement for single teeth compares favorably, and
may be more advantageous over the long term compared with endodontic and restorative therapy.18
Standard considerations for implant placement not
described in the treatment options include surgical
complications, such as neurosensory disturbance and
the possible need for site enhancement with bone grafting, and mechanical complications, such as prosthesis
and implant fracture.19
Patients desire varying levels of autonomy when
making decisions regarding their treatment.8 Whether
patients desire a passive, collaborative, or active role
regarding their treatment, they will all rely to a certain
extent on the information provided by their dentist for
decision making. The patients dentist must objectively
and ethically provide information to the patient regarding treatment options, treatment considerations, risks
and benefits of the different options, and the expected
prognosis of the different options. The present study
shows that if treatment options are presented in a biased
manner toward one option, the patient is more likely to
select that treatment option.
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clinical study comparing surgical and nonsurgical procedures. J
Endod 1999;25:814-7.

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Reprint requests:
Keith H. Foster, DMD
Assistant Professor
Division of Endodontics
University of Kentucky College of Dentistry
Chandler Medical Center
D-444 Dental Science Building
Lexington, KY 40536-0297
kfost2@uky.edu