Because dental implants are so successful, there may be a question about when you should treat or remove questionable teeth and replace them with dental implants. Let’s consider some common circumstances using science and what is in the best interest of the patient’s health, and the finances of these decisions.  My preference, and science supports this, is to save teeth when appropriate and possible.  One reason for this preference is any time a tooth is extracted there will be some bone loss and possible gum changes in that area which may lead to some esthetic and homecare consequences. Here is what we know to be true: crowns, veneers and onlays, gum treatments and root canals are successful long-term treatments for teeth and are a healthy and cost effective way of addressing an oral health issue.  Usually, saving your tooth is less costly than implant replacement. Here are four scenarios and recommendations:

Example one:  most teeth and gums are healthy but one tooth has a minor problem (cavity, slight mobility, small fracture) and needs treatment.

• If the cavity or fracture is small and bonding a filling will resolve the issue, there should be no hesitation to save the tooth.  Bonded fillings are known to have excellent success.  Slight tooth mobility can usually be resolved with bite and gum evaluation and treatment. The finances and health of the patient are best served with saving and treating the tooth.

Example two:  most teeth and gums are healthy but one tooth has a major problem (very deep cavity, extensive fracture, abscess or advanced mobility) and needs treatment.

• Saving a tooth with a very deep cavity, abscess or extensive fracture may involve more extensive treatment, but in most cases retaining the natural tooth is better for the gum and bone health in that area and less costly than removing the tooth and replacing it with an implant.

• A change in scenario here is if the tooth has so much decay or bone loss that restoration, bite or gum treatment, has a questionable prognosis.  Now the discussion has to be is the patient willing to try to save the tooth knowing the prognosis is less favorable.  An implant replacement may be the best decision in this case.

Example three:  the patient has mostly very unhealthy teeth/gums. The question here is, when is it appropriate to remove all the teeth and consider replacement with implant supported restorations?  

• If all the teeth are hopeless the decision is easy, remove teeth and replace with implants.  

• However, sometimes not all teeth are hopeless.  If saving a few teeth and replacing only the hopeless teeth leads to a good final restoration then save the teeth and place implants where needed.

• If saving the few good teeth leads to a compromised final restoration then saving a few healthy teeth is not appropriate.   Here is where my general preference for saving healthy teeth is modified since the overall health of the patient is best served by removing a few healthy teeth.  This will allow for a better, longer lasting final result.

Example four:  teeth and gums are not hopeless but have some issues and the patient has some medical conditions that may impact long-term oral and medical health.

• Careful consultation with the patient’s physician is important as the science of the drugs used to treat the medical condition and/or maintain the patient’s health are changing.

• Patients starting bone density drugs, Sjogren’s patients, patients with advancing dementia and those with compromised immune systems are all at-risk patients.  Care has to be taken in making decisions on treating now or waiting.  Some medical conditions will worsen over time.  Maintaining and treating questionable teeth is more difficult and costly in later stages of disease and age progression.

In general, if teeth are treatable and restorable, the healthier approach would be to treat those teeth rather than remove them and replace them with dental implants.  However, as some of the possible scenarios demonstrated, teeth and gums in very poor, untreatable conditions, or certain medical conditions of the patient, require removal of teeth and replacement with implants to provide the patient with the healthiest and most cost friendly outcome.  If you are faced with the decision to treat or remove teeth, it’s always best to discuss the alternatives with your dentist..

Dr. Robert A. Gallegos is a Fellow in the Academy of General Dentistry, visiting faculty at Spear Education, alumnus of Pankey Institute, Qualified Invisalign provider, member of the American Academy of Cosmetic Dentistry, the American Academy of Dental Sleep Medicine and the American Dental Association.  Dr. Gallegos practices dentistry in Middleburg, VA.  www.MiddleburgSmiles.com

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