Some teeth have more life: Options do exist

Absolutely! Good dentistry. I have s it who has one that is in excess of 30 years old.

Sadly, there are some in our noble profession who have put profit before the patient. I can't tell you how many patients I have seen for implant consultations who were wise enough to seek a second opinion, who were told by both specialists and certain "implant centers" that they should remove most or all of their teeth and receive an all-on-4 restoration. Many had mild to moderate periodontitis or were never told that they could pursue a removable prosthesis. I tell my students that implants are just another option, but like any elective treatment, it is none of our business to push or withhold this option from our patients. While much of my practice is related to implants, I offer all of my patients reasonable treatment alternatives that may or may not include implants, according to their needs and wants. Having attended law school during my 18 year of practice, it is my opinion that this trend towards sacrificing teeth as the first or only option is going to result in a wave of litigation at some point in the near future.

When there is a slight chance to save all or part of a natural tooth...this should be the first option...….your patients will appreciate you for this

I recently talked to a friend of mine who has been a practicing periodontist for 40 years and never placed an implant. He has lectured at 12 different grad perio programs over the past couple of years and presented many of his beautifully done perio/restorative cases. During his presentations he would ask the residents to present their treatment options. At 11 of the 12 programs implants were the only option, per the residents. Of course he would continue to show 20+ year follow ups on the successful restoration utilizing compromised natural teeth. Unfortunately institutions are teaching perhaps too much titanium. I have only been practicing 18 years and unfortunately I have been guilty of this titanium first mentality at times as well. Since reeling myself in I have found the practice of perio to be much more enjoyable and oddly enough I still place about 400 implants per year as there are a lot of missing teeth or truly non restorable ones without rushing to the conclusion.

Try and fail rather than fail to try. Up to a point. You will do ok by most folks that way

So glad in this new era of Implant dentistry we haven’t totally forgotten go old fashion restorative dentistry.! It’s an art and science and does work, if you know how to do it, and it does work!

I am not surprised by the very poor response to this important scenario. clearly, it is because many on this forum are titanium dentists and not true periodontists / restorative dentists? Please don't stop posting / replying / commenting to this important discussion initiated by our colleague and do continue presenting own cases pictures / x-ray images (before and after) to see if really we are not too much titanium dentists.

This is a wonderful discussion and exemplifies the point I have been making over some time. Implants are only one option and in many cases where teeth exist, implants are likely to be the second option. Implants are a fantastic alternative to dentures and bridges where teeth are missing. They have massively expanded our treatment options and allow us to be much more conservative and provide treatment options which can potentially support remaining teeth and increase their longevity because of reduced occlusal stress and providing a more manageable situation. The option of using implants has also been massively increased with modern grafting materials and exciting techniques. Thus implants are definitely a standard of care at present BUT not at the expense of natural teeth if there is a possibility of them being salvaged. Only 55% to 65% of implants are considered truly successful (and 5% fail) according to a variety of studies. So as a profession we need to be aware that implants are not always the best solution especially when remaining teeth can be saved. If for no other reason, saving a tooth may present a medium to long term option before an implant is forced upon us as an option – albeit that many times the teeth will survive a life time. We all know that it is not always possible to create good function, good aesthetics and emergence profiles with implants. As well, in many cases it is very hard to design prostheses that are easily maintained. Further, it is becoming evident that if periodontal disease is (or has been) present then peri-implantitis is a very likely consequence with implants. When high speed hand pieces first became available, the professions suddenly decided to massively increase the restoration cavity size because it was so easy. The logic was that amalgam would not decay so it was better to replace good tooth structure with amalgam. The consequence of this was that there was 10-20 years of dentists sacrificing tooth structure only to eventually find that it massively reduced longevity of teeth. Thankfully (especially with new resins) common sense has prevailed and minimal tooth reduction has now returned to dental practice. However I fear the profession is now at the point that because implants are easier to use, there is a swing to extraction dentistry. In the early 1900s the improvement to acrylic dentures made them more palatable (forgive the pun). As a consequence many patients were rendered edentulous very early in their lives because if they had no teeth all their problems would be solved and they would never have problems with their teeth again. 30-50 years later we all know the consequential problems this philosophy created. All on 4 allows a great option for edentulous patients to be able to function again, although only in some cases. However all on 4 should not be an excuse for the profession to wholesale render patients edentulous and to remove excessive amounts of bone. Above all else we should do no harm. I am yet to be convinced that in many cases, full clearances to allow all on 4 applies this mantra. As a profession we have a responsibility to do the best for our patients. We should also learn from the previous mistaken changes in philosophy that I explained above when new options become available. The tragedy is that the professions is gradually losing the ability to be restorative dentists; firstly because some techniques are no longer being taught and secondly because many dentists see an easy and more rewarding option by using implants. This discussion group happily seems to understand this and it would be prudent for us all spread the word of not being too hasty to extract teeth in preference for implants.

Play the percentages. Get as many years as possible with teeth first before going to implants We have been sold sold a bill of goods on implants. They also have a life span. Every year a conventional ( or unconventional) restoration remains adds to the life of a succeeding Implant. Patients need to be appraised of all options.

It is unfortunate that restoring badly compromised teeth is becoming a lost art. Every patient I have ever asked the question of, " if possible, would you prefer to keep your natural tooth/teeth "........ the answer has always been yes. I know some colleagues who have given up doing root canals and instead automatically extract every abscessed tooth in favor of implants. Whether this is good dentistry can be debated. A patient in comfort and in good function should be the end goal. We need to utilize all the tools in our toolbox and do what is in the best interest of the patient.

This is true dentistry!!! I've done a great many cases like these two above, and similar, and even worse off! Please read this story, I think you'll all enjoy it. I once had a case early in my practice when, during a apicoectomy which started out as routine on a #11 (upper left canine) I discovered that the whole distal HALF of the root was completely decayed the whole length of the root! This came as a shock because the x-rays (both the pan and the PA) only showed the apical lesion on the failed RCT on that #11! That #11 was only one of two abutments of an anterior canine-to-canine PFM bridge, and when I told the patient that she would have to lose the #11 and, therefore lose the bridge, she started crying badly, sobbing, and begging me to do anything --anything!-- to save the canine and her bridge. You see, the poor woman was poor, a 38-year old mother of 4 kids, and she had no other upper teeth. To her, this #6-11 PFM bridge was her whole life, and she was trying to hang on to it with all her might and all her soul. Such is the psychological power (and desperation) of poor people in her situation! Implants were nowhere near an option 30 years ago as they are today and, even if they had been, she would not have been able to afford even a 10th of the fee as a single mother, and quite poor, struggling to feed her kids. I remember her with tears in my eyes to this very day!!! What follows is a lesson in what happens when you care, really really really care! And when you demand, really demand of yourself the best that you can come up with, and even beyond. So... I took a break from the surgery, carefully replacing and covering the flap temporarily, allowed the patient to close her mouth to rest and left her with an assistant while I went to smoke a cigarette to ponder what to do. That's when it hit me! I went back in and rebuilt that whole distal half of the root (and I do mean the whole distal half, as if you had split the root vertically into two right down the middle) out of? ... are you ready for this?... amalgam! My reasoning on the spot, while smoking that cigarette, was simple: "Amalgam! If it's bio-compatible enough for a retrograde filling, why not to rebuild half a root?" That may sound like simplistic logic, but it worked! It wasn't easy, mind-you. I called up the help of two assistants to control the operative field well so I could have good and clean field of vision while I excavated all the decay, made the appropriate mechanical retentions the whole length of the root with a fine inverted cone, and condensed and built up the amalgam into the shape of the distal root. I must admit though that I did have some help from nature, in the form of an apical 1.5 mm of remaining sound dentin on that side of the root, which I used as a "roof" for the whole amalgam build-up. I saved that root and it was fine, and her bridge remained in place for another 5 years, when I lost her to follow up. But I have no reason to believe that, failing other drastic developments, that amalgam-restored root didn't last a whole lot longer. 5 years follow up x-rays looked fine, as all bone had properly filled in around that half-amalgam root! Restoring ANYTHING that can be restored is, and always will be, my first go-to option! Removables my last, titanium in the middle, and I always give the patient all options. As I'm sure you can tell from my "verbose" writing style, I spend an inordinate amount of time educating the patient and discussing all the pros and cons of every treatment option. Too often too many practitioners are too willing to sacrifice the best "implant" that nature has to offer for a titanium screw. Is it for a few bucks more? Is it because sometimes it's just easier to drill a hole in the bone and screw in an implant instead of finagling with the fine intricate details and technical difficulty in restoring difficult cases? Perhaps it's a combination of both. Sadly the mentality is changing, and not for the better -- certainly not always in the patients' best interests. I've already seen too many Dr's being all too willing to extract all teeth (some of which can still have a reasonable life-span) and go to an all-on-4. Immediate loading is becoming almost norm for some, even though it flies in the face of bone biology. Are we all becoming victims of that "I want this yesterday" mentality? And, have we become so lazy that we don't want to take the time to explain to patients that implant healing has its own tempo, imposed by the body itself, which we cannot -- indeed should not even try to -- change? Has the profession simply become too lazy, or perhaps not instructed enough, to contemplate (or even know) different restoring options, like the ones shown above? I admire guys who take the time to do these things, and guys like Timothy C Carter above, and I would love to see more Dr's doing things his way -- which is also my way! Like Joseph Kim, DDS, JD above said, all this titanium bonanza will all start to blow up in the face of the profession in a unprecedented wave of litigation in the not-too-distant future. In some ways it already has, in the case of some of the so-called "implant centers" (dubious commercial establishments, at best, peddling unrealistic "immediate" total reconstructions) being sued for gross failures in cases of failed all-on-4's. Not surprising at all!

Very nice comments are being posted. as said earlier please include pictures of cases before and after treatment if available.

True Altruism.

Excellent discussion and points (and clinical experience story). Like I have commented in another one of the posts, my intention first is always to save as many teeth as I can and then use the other modalities, i.e. partials/bridge/implants in order to help my patients achieve a full complement of teeth to allow proper function. All-on-4 which is the latest rage, is in some cases is too aggressive. Glad to hear that I am on the right path with other more experienced practitioners recommendations in this day an age where I see a new implant only practice popping up near me, every other day. I use implants as a last option to replace a tooth, not first. Also, with the contacts opening, (it really bothers me when I see it in my patients, and yes, I can always add more porcelain, but then my treatment is never fully complete), implants are an option with a new complication/limitation and thus not a good long term option. Thanks again for all your contribution to this site. I am enjoying learning from cases and discussions from our more experienced colleagues. Sincerely, Dr. Moe

Two very useful resources to know more about “when to save or remove a tooth” are: 1. Kendrick S, Wong D. When to restore or extract—a clinical guide. Inside Dentistry. 2011;7(1):42-50. 2. Bernstein SD, Horowitz AJ, Man M, et al. Outcomes of endodontic therapy in general practice: a study by the Practitioners Engaged in Applied Research and Learning Network. J Am Dent Assoc. 012;143(5):478-487

Please read an Argument Against Extraction as a Treatment Alternative for Restorable Teeth Vicente Telles, DDS; Mariana Bezamat, DDS; and Alexandre R. Vieira, DDS, PhD

A very good article read before concluding this well-discussed topic: An Argument Against Extraction as a Treatment Alternative for Restorable Teeth Vicente Telles, DDS; Mariana Bezamat, DDS; and Alexandre R. Vieira, DDS, PhD June 2019Issue - Expires June 30th, 2022 Compendium of Continuing Education in Dentistry