Periodontally Questionable Teeth: Retention vs. Extraction and Implants
With the advent of widespread utilization of implants among general dentists as well as specialists, the issue of retention of periodontally questionable teeth assumes a new dimension. Prior to the ubiquitous use of implants, many periodontally diseased teeth were retained through frequent recalls and heroic treatment efforts. Removable and fixed periodontal prostheses were taught in dental schools and post-graduate programs. Should we now be revising our traditional approach to the retention of questionable or marginal teeth and leaning more toward extraction and replacement with implants? Or have we already leaned too far in that direction and extracted too many periodontally questionable or marginal teeth when we could have maintained them? What should we be teaching dental schools and what should be our current philosophy.
15 Comments on Periodontally Questionable Teeth: Retention vs. Extraction and Implants
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LANAP
1/23/2012
Yes we have leaned too far in that direction and extracted too many periodontally questionable or marginal teeth when we could have maintained them. We now have LANAP that can reverse periodontal disease. Even though it has been in the literature over 14 years and has FDA clearence to reverse the # 1 cause of tooth loss less than 1% of dentists in the USA offer this service.
Unfortunately, it is easier and more profitable to screw patients with titanium.
Dr Tony Collins
1/24/2012
What is LANAP? In Australia we have a draconian government body that restricts products from general use. To register a product for general use is a HUGELY expensive exercise that is only feasible for companies if there is wide demand from the profession. If LANAP is some wonder product, few, if any, know of it here in Australia. More information, please
LANAP
1/26/2012
Hello Dr Tony
LANAP is an FDA cleared laser procedure that reverses gum disease. You are welcome to visit my web site for more information. Click on my name and it should take you to LaserGumDentist .com
DrB
1/24/2012
Out of curiosity what is the recommended case few per quadrant, since we are comparing treatment options. Thanks
SG
1/24/2012
There is no question (at least in my mind) that many dentists are now of the mind set of removing periodontally involved teeth quite quickly and replacing them with implants. In addition to the fact that there are many time-proven treatment modalities to treat such teeth with moderate-advanced periodontal disease (LNAP is just one such alternative), we must also take into consideration the very high incidence of complications that we have been seeing with implants now that we have been able to follow them for a number of years (there are several references bearing this out, one of them being the relatively new text edited by Dr.Stuart Froum). Implants have most definitely added to and expanded the treatment possibilities that we can now offer to our patients. However, I think it still comes down to the most critical factor, namely ACCURATE, THOROUGH, DIAGNOSIS. Removing a tooth with moderate-advanced periodontal disease is often the easiest and quickest (and dare I say the most profitable) treatment option...however, this does not necessarily make it the preferred treatment for the patient.
Dr Nisha Mehta
1/24/2012
In my opinion removing and throwing slightly compromised periodontic/endodontic teeth and replacing them with implants is not a fair practice.
With proper diagnosis,treatment plan,patient education,post op maintenance and and recall regime,treatment of such teeth and salvaging them will benefit the patient functionally,psychologicaly and financilly.
Anand Bhalodi
2/17/2012
ya i totally agree with you....the reason more and more dentist persue extraction of periodontally compromised teeth as least in India is because is needs intervention by a prosthodontist to actually foresee whether that tooth is going to bear the functional loads....the concept of cross arch bridge is a valid option for treating generalized mobile teeth....
Dr SvKouris
1/25/2012
I am a periodontist and as such I routinely place implants. You can give to a patient, with the help of your prosthodontist function and aesthetics with a properly placed implant. But beauty is in the eye of the beholder. Nothing compares to a properly treated periodontally healthy dentition. Nothing gives me more satisfaction than saving compromised teeth. I firmly believe that these teeth can be maintained for a good number of years and serve the patient very well. Yes, there is a point where decisions about extraction or retention of compromised teeth have to be made. But there is no point in bringing this toward extraction and implant placement more and more. We were trained to save teeth not to extract them. Not to mention that due to the economic crisis it may be a more financially viable solution for the patient
DrB
1/25/2012
Sorry I mistyped above. What is case fee for LANAP per quad, in general. As the doctor pointed out above towards the end of his statement it is about what we can do to help our patient keep function in economically difficult times. So, both the patient and the doctor make a joint decision to save teeth or not. It comes down to how much will I have to spend as a patient over ten years to keep a quadrant of teeth vs extracting/ implanting and being done with it. Sometimes, and don't misunderstand this is case specific, but sometimes repeated dental care to keep sensitive teeth and bacterially infected tissue under control for ten years isn't worth it to the patient just based on the time and effort it will take. Even if it's slightly cheaper. Yeah, I was taught to save teeth too.
LANAP
1/26/2012
Dr B
Each case of LANAP is unique though it is about the same cost for Traditional Osseous Periodontal Surgery. Though it can be less, considering Scaling and Root Planing does not need to be done prior to LANAP. That would save you about $1000 and four hours of work.
In our office a full mouth case it is around $6,000.
The health benefits are difficult to estimate though Aetna Medical and Columbia University did a study that showed a 16% reduction in health care related costs by having healthy gums.
If you consider the cost of one implant with bone grafting it is about the same. 32 to 1 not bad.
Or if you consider what it would cost to remove all the teeth and have dentures made it is about the same cost. Though you would keep the natural teeth. Also, consider 40,000 for upper and lower fixed implant supported bridges.
A famous philosopher once said "It is more blessed to give than to receive."
Happiness is a spiritual reality -it's a quality of the spirit- and it's found more in giving than in receiving, whether in relationships or other ways.
In spite of the crass materialism of our culture - in spite of the countless messages that assure us every day that happiness is to be found in having more - many people are aware at some level that all the SUV's, second homes, electronic gadgets, stylish clothes and large bank accounts, etc. can never buy them happiness, because happiness is elsewhere.
In my opinion LANAP is in essence giving more than we receive for the service.
I believe that only the dental benefits of one quadrant of LANAP should be worth more than $10,000. Full mouth its a steal at $40K.
Even though I feel the value of LANAP is worth more than $40K I have not charged more than $6,000 for a case.
BTW this does not include the Medical benefits.
LANAP
2/2/2012
I went to a lecture by Nobel where they recommended charging the patient $25,000 for all on 4, for one arch. With LANAP $6K is not bad for two arches that would be about a $44,000 savings and they get to keep their teeth ;-)
Prof.Samir
1/25/2012
REPLACE A PERIODONTALLY affected with a healthy tooth is a great line of treatment
SG
1/25/2012
And what do you do when the "new" healthy tooth/implant develops problems??
FoundThisOnline
1/27/2012
Sounds like everyone is parrotting what we've been taught in school. "Save as many teeth as possible." But its very subjective and needs to be individualized to the specific patient. I have many patients with 50% bone loss generalized throughout the mouth. On the average patient, I would probably say extract and make complete dentures. If the patient comes to me asking for complete dentures, and/or is in chronic pain, then its a no-brainer.
But if there is no mobility, decent hygiene, no change in bone loss over several years, and/or no pain, then keep the real teeth.
Nothing functions like a good, healthy, well-maintained tooth. A good, well-maintained implant is a close second, but still second best. And even a stabile, well-maintained "less-than-ideal" tooth is better than a denture.
A denture is not an alternative to teeth, its an alternative to being WITHOUT teeth.
The same should be said for implants.
ImplantsRUs
1/27/2012
It all comes down to what is best for the patient.
If they lost the tooth due to perio, then they'll lose the implant to perio. Period. They aren't going to suddenly start Sonicaring, flossing, rinsing, and everything else it takes to keep the mouth healthy.
If they lost the tooth to decay, yeah, maybe an implant is an OK replacement.
If they lost the tooth to trauma, then until the trauma subsudes, an implant isn't an option.
If they lost the tooth to a root canal failure, then what was the cause of the original root canal need?
As far as the original question, FoundThisOnline is correct. Its very subjective and needs to be individualized to the specific patient, based on your professional education, experience, and morality/ethos.
How long will that slightly unhealthy, periodontally compromised tooth last (or be expected to last). We're not omnipotent. We can't predict the future, but like Meteorologists, we can make valid assumptions based on evidence, history, and patient attitude.
Just be honest with the patient, and yourself, and don't do it for the quick $$$.
