Extracting too many teeth and replacing them with implants?

I'll be the first to state what I think is the obvious......no?! I think it's the natural progression of dentistry. Why do an apico on a tooth that has a poor prognosis and which has a 50/50 chance of long term success? Or watch a chronic perio case progressively lose bone over 4 or 5 years, giving the patient a bunch of "ifs" when you can look them squarely in the eye and give them a definitive and confident treatment plan for an implant? I find most patients are willing to spend more money up front for a much more predictable procedure rather than risk spending good money after bad on a less than ideal procedure.

The simple answer to a complicated question is "yes"; far too many salvageable teeth are being extracted and replaced with dental implants. One reason, among many, may be a lack of appreciation of the advances made in periodontal regeneration in the last 10-15 years. Speaking from the perspective of 32 years limiting my practice to periodontology and dental implantology I see far fewer hopeless teeth today than I did a decade ago. And that is not because patients are being referred earlier in the course of their disease; in fact the opposite is true. The techniques and technologies available today provide better and more predictable regenerative outcomes than ever before. Also, patients want to keep their teeth. The almost universal response to my initial question "What can I do for you, Ms. Jones?" is "I want you to help me keep my teeth". If you need an update on what is available in the arena of regenerative periodontics why not reach out to a periodontist in your area? If they are like my wife and I are they will be happy to talk about what is seriously cool stuff! And you might discover someone ready and eager to help you fulfill Ms. Jones' wishes.

Implants are more "predictable"?? I find this statement confusing to say the least in view of the startling high percentage of implants that develop peri implantitis within a few years of placement (some reports have this number approaching 50%). In addition, we still are fumbling around to find a predictable clinical protocol to maintain implants. And lastly, there is no protocol that even approaches predictability in treating peri implantitis. With natural teeth, we already have clinical protocols that research has demonstrated can successfully maintain them for years; and we have multiple surgical technics that have been shown both clinically and histologically to successfully regenerate bone around natural teeth with periodontitis. I do agree that there comes a time when it is prudent to remove a tooth and replace it with an implant. However, I think this judgment is being exercised much too soon in many instances, perhaps largely for financial reasons.

I think that the trend is to remove teeth and replace them with implants, which have their own set of problems (in particular peri-implantitis, which is generally more difficult to treat than is peri-odontitis). Before condemning a tooth to extraction and replacement with implants, look at what Dr. Danny Melker has done for 30 plus years to predictably maintain teeth. Periodontists working closely with like-minded restorative dentists can maintain teeth in comfort and function for decades. Implants will continue to be a very important part of dentistry, as should maintaining natural teeth.

I find that dentists new to implants tend to suggest extraction of natural teeth and implant placement more than dentist that have placed implants for many years. I feel the reason is that the latter group have had more experience with implant failures. As well, the older group typically has more experience and fluency with procedures that can extend the life of a natural tooth. Yes I love dental implants and know they have revolutionized dentistry but I have seen cases of natural teeth that could have been saved without major heroics removed in favour of implants. Some say why prolong the innevitable? (loss of tooth) with attempts to maintain teeth. At times it can be a very subjective diagosis, other times not. Patient evaluation and explantation (objective informed consent) and selection are critical. Nothing is guaranteed. I think over the next 10 to 20 years we will see a large wave of dental implant "inevitable failures" that will place some of this into persective. My hope is that by then we will also have innovative (and predictable) solutions to help with these cases.

Absolutely agree with Dr. T !!! implants are finally showing their true colors and coming home to roost after a couple of decades of aggressive marketing by manufacturers and lecturers working for them. I have been placing iimplants since 1988, ie the days of IMZ and Corevents. Periimplantitis is literarely popping up on implants that were perfectly placed with great bone, oral hygiene and good occlusion. Manufacturers and their cronies would lead you to believe that it is YOUR fault that this is happening and/ or poor hygiene on the part of the patient. BS ! I have some patients that brux, barely use floss and their implants are doing fine after 15 years. On the other hand, I have other patients coming after only three years of placing implants in with great hygiene, nice occlusion but implants failing. We simply don't know enough yet about this disease , let alone how to treat it. Recommended treatments by " experts" are all over the place . The price we end up paying for these failed cases is exorbitant, considering that even one failure condemns a whole fixed hybrid that cost the patient over $30,000 in many cases. I am on pins and needles every day worried about a call from an all on 4 patient that may develop periimplantitis and I have many out there. I'm sure that call will be coming someday and I am NOT looking foreward to it. I have become VERY selective with placing implants and have actually been pushing fixed bridges instead in many cases where the adjacent teeth have restorations. Call me chicken conservative or whatever, I just think we still have a LONG ways to go in learning why these implants fail but until then, I am going to be WAAAY more selective than ever. So the answer is yes definitely save that tooth for as long as possible and don't promise yourself or the patient the perfect implant solution.

As an oral surgeon who makes a living removing helpless teeth I agree with the above comments. I see a lot of periodontist endodontists, implantologists, gps and OMS jumping the gun. I don't think that there is such a thing as a totally predictable implant. Each case is evaluated individually, implants are another tool in the bag. Each dental procedure has a finite lifespan but extractions are forever. I've been doing this since 1988 and have a great respect for implants when used prudently. I also save teeth with LANAP since I have a regeneratively based practice and use it to augment my OMS procedures. Implants are just as vulnerable to periodontal pathogens and have rules of placement,healing and prosthetics which must be respected. I feel it is the Wild West out there with a lot of boasting and bravado. A tooth and an implant are humbling experiences!

I think that one has to consider statistical success probabilities on a 5 yr plus basis. Myself instead off sending a patient to an Endodontist , or Periodontist for retreatment of a failure or re surgerizing a failed case for the 2nd or even 3rd time at a total cost of $3000-5000 or more,. and to loose the teeth within 5 years is just a bad choice and I've seen it done!!! That money could have been better spent on some implants and prosthodontics. We have a high profile "Implant Specialty Center" in the area run by a Prosthodontist and a couple of oral surgeons and their answer to everything is to just extract and replace with implants, when some more conservative treatment would have been more appropriate, less expensive, less traumatic for the patient, and have just as good success and patient satisfaction. So success probability and patients wishes and finances all have to be considered in decision making. I think there is also a problem with GP's too heavily reliant on certain "Specialists Opinions" who send patients to for example "a periodontist who sees the world from his own window" who then proceeds to soak the patient for every nickle he can get, to the point where the patient can no longer afford restorations!! I've seen this done more times than I care to remember!! I have been in practice for 34 yrs as a GP have a Certificate in Prosthodontics, Fellow of ICOI, Student of Carl Misch among others and at this point have seen and done a little........ So I guess that the bottom line is Good judgement and common sense must prevail!!

Dentists practicing oral rehabilitation should be well trained and understand all the disciplines that are involved in trying to preserve natural teeth. Having received my post graduate training in the department of Oral Rehabilitation at the Hebrew University in Jerusalem 1966-68, I am very familiar with all of those disciplines, and how we would salvage a single molar root in order to attach a fixed bridge so that the patient would not have to have a removable prosthesis.... and those hemisectioned roots provided good service for many years. Today, I look at compromised teeth as I do a car which requires extensive body work in order to remove the dents, rust, and questionable strength. No matter how much sanding was done, how much filler was used, how many coats of paint was applied......if the body was thoroughly rusted......... sooner or later it will come back to haunt you. If there is a good chance a tooth can be saved through conventional dental techniques, and periodontally it is sound....then by all means save it........no man made material can compete with what nature gave us.

All have made great comments. It depends on the patient and how they present. Complete and partial dentures and bridges are great solutions on occasion. As I told a consult today. Every solution present their own problems. Usually implants do improve a persons quality of life, but it is our duty to inform a patient, that usually lost teeth due to their lack of care, and that their level of responsibility will be elevated. Informing a patient of their level of responsibility does not always sink in. Some patients get it and are mature and some are immature or never accept responsibility for their actions. All in all there are enough frustrations in dentistry without going out looking for them. This may not of answered the question but is relevant.

As a prosthodontist I would say "yes" too many teeth are being extracted. With proper restorative treatment including all the mono-specialities such as endo, perio and ortho then a properly restored natural tooth will be "better" as you have maintained the periodontal ligament so have proprioceptive feedback. Anterior guidance on teeth is significantly better than on an implant. The studies show a restored dental implant has the same life expectancy as a tooth so that discussion although valid is not really of consequence. I think the conversation should be steered towards prevention of tooth loss - yes a wierd statement from a pros guy who restores teeth and implants!

Had a funny thought, once teeth are treated with restoration, enamel and tooth structure are slowly going down the path of loss with each subsequent treatment. With extractions and implants bone eventually goes down the path of loss, it never completely comes back even with the best grafting. I guess the answer is prevention but as dentists it is satisfying to help patients with the treatments and technology we have today however imperfect. The exception in my opinion is impacted third molars since that bone regenerates if the teeth are removed early, now I know I'm a dental nerd! You could also argue for ortho regerating bone. So I think we have to give ourselves a break here and lay some responsibility on our patients with home care and appreciate that poor effort in hygiene will cost them money in the restorations. But I think the point here is that implants are not perfect. I have seen so much change in dentistry most for the better!

Great thoughts by all. At the end of the day one realizes that there are no straight answers to Implants versus preservation of natural teeth. I am a OMS and had been placing implants from 1985. My experience is there are cases where the success is beyond expectations and there are cases where every thing was right and procedure failed. So what I want to say is first line of treatment should be the effort to save the natural teeth if the clinician feels it has a reasonable chance of survival with proper Pero, Endo or minor surgical procedure.

as Carl Misch himself refers to endo, "pre-implant therapy".

I Agree ,we need to think what if this was me or my wife . I work with an Endo specialist and every case referred gets another look to completely rule out saving the tooth . Sadly the rise and commercialism of All on 4 is a big problem here as no effort is made to save very restorable teeth as it interferes with the protocol ...... so 5 or 5 good teeth are removed along with a few mm s of healthy bone and teeth screwed in as "teeth in a day " . Patients are not told that the procedure will age them 20 years in a few minutes !!!! So yes we need to be a lot more regenerative in our plans new synthetic Bone graft materials are game changing as well as protocols .... Peter

Hmmm. Hard to debate whether "too many teeth' are being extracted---especially when the clinical decisions are made between one doctor and one patient. We all hear the mantra of "advances in periodontal therapy"--we have been hearing that stuff for decades, so not much is new. Fact is, we have now jumped from marginally effective procedures like "scaling, root planing, crown lengthening, and soft tissue architectural reconstruction, to much higher dollar "guided tissue regeneration" and other "state of the art" hoopla, with all its goops, salves, emollients, and membranes. Sadly, many patients still have bad breath, continued pain, and face repeat appointments undergoing these painful procedures when they should have considered other (often better) options like dental implants. Lets not forget that as long as the patient has the (hopeless) tooth/teeth, doc has a patient--and a potent revenue source.

I am not sure what the context of Dr. J's last comment was. "Lets not forget that as long as the patient has the (hopeless) tooth/teeth, doc has a patient–and a potent revenue source." I think that the vast majority of dentists provide treatment options with informed consent and their patients interest first and formost. I doubt that many dentists would simply think I will try and save this tooth for added future revenue. (I appologize if I got the context wrong). There is a phenmenon related to pharmaceuticals where sales of drugs are very high until the negative side effects of the drug become better known. With negative events and experiences, the use and prescriptions of the drugs becomes less with time. I think we are seeing this in the implant world.

I agree that nowadays we pull the extraction trigger quiet often. We see implant as a reliable option for teeth with poor prognosis. Sometimes patient is not really confident with the explanation that you give to him, about preserving a teeth which has not a good mid term prognosis. It´s our responsibility to asses the patient and make the decision with the patient. The patient is now an active asset of the overall treatment plan.

I have been doing Root Canal Treatments since 1998. So far even for borderline cases, i like to retreat and possible crown lengthening before jumping to placing implant. I like to give my patients options of treatments but at the end it really is about them trusting our judgment to take care of our patients.

Implants are a very viable treatment when placed by knowing and experienced hands with good judgement vs making about the money. They have their limitations as any other treatment. It may not be about the implants but the market.

This is a very complex subject and unfortunately as this thread enforces most of us will go with our own biases and find the facts to support them. To bring extreme examples of severely compromised teeth and whether to extract them or save them is big picture a red herring. On this issue we can discuss until the cows come home but I think misses the point of whether we are extracting too many teeth and replacing them with implants. I have worked in Jerusalem for 25 years (qualified as a dentist 30 years ago) and treat many tourists and many people who are here for a temporary perio- UN, UNRRA, diplomats, journalists etc., which gives me a far broader perspective and overview than most dentists. As with many new technologies- users rush into them, over use them and then over time a balancing process takes place in which the new technology finds it's proper role/position within the market place. In many ways this has happened with implants as it also happened with dentures. The third set of teeth was seen as a panacea for a generation of patients ( no decay, no pain, cheaper,quicker etc.,) and over many years and after many people suffered horribly until dentures eventually found their rightful place within the dentist's treatment armamentarium. Bottom line- Implants are a wonderful replacement for missing teeth. They are not a wonderful replacement for natural teeth. Too many times dentist's have used their patients as guinea pigs and too often I hear at implant lectures re previous work...."if we knew then what we know now ..........." If for no other reason that should make us think several times before extracting teeth that are relatively straight forward to save. Too often IMO too many are too quick to extract. Worst case scenario the implant option is almost always available years down the line if the conventional treatment does not hold up as expected. We can't put back the natural teeth once extracted! Indeed although this is a tangent - i think in general we dentists are overly aggressive to treat. I continue to be amazed how often teeth will survive far longer than predicted in the majority of cases and even more so when a preventative regimen is involved- but that is a a whole other discussion.

Periodontal disease is not a disease of titanium deficiency! Teeth deserve as much, or more, respect as implants! Our goal, as periodontists should be to keep teeth in good health, function and aesthetics for the life of our patients, when possible. Kenny Levine

Hello Peter You stated "Patients are not told that the procedure will age them 20 years in a few minutes !!!!" When I examine a patient I check muscle function and facial esthetics as it relates to the dentition. When you show a patient how the loss of a few teeth affects their facial appearance as a result of bone and muscle atrophy they want to throw credit cards at your receptionist. I don't do all on 4 so can you tell me what you are seeing over time in these patients from a facial esthetics standpoint? Thanks Greg Steiner Steiner Biotechnology

Great thread... many good comments and some a bit harsh. As a general dentist or anyone who is restoring dental implants, you have a great respect for the dental implant. If not placed at the right time (too early) or in the wrong position, it can haunt the dentist that has to maintain the restoration (general dentist or prosthodontist). By too early, I mean the patient wasn't given enough of a chance to save the tooth prior to implant placement. If nothing goes wrong... it's no big deal. But if the dental implant procedure doesn't go as planned, you would like to be able to say, "we did everything we could to save the tooth prior to the implant procedure." Patients need to be aware of the risks and benefits. The other issue is improperly located implants placed by surgeons who have no restorative responsibility. As a restoring dentist that places implants, proper placement is critical because I am responsible for maintaining this restoration for life. I do feel some specialists could work a little harder at saving teeth - mainly periodontal issues that be treated. I've seen lots of osseous therapy hold up for years. I like to use the phrase, "nothing is better than your own teeth." At least that way when a patient gets a dental implant they don't have too high of expectations.