Wednesday, May 25, 2011

Saving Teeth vs Placing Implants

Hey all,

I don't have much time today because I have to go to a funeral. One of my patients died in his sleep on Sunday. His wife, a nurse practitioner, was sleeping right next to him. 67 years old. You never know guys. You never know.

Anyway, we were talking on Friday about me going to the Seattle Study Club for the first time. A local prosthodontist presented a case; we were supposed to get together in groups and try to figure out the best way to treat this patient. The patient was 63 and money was not going to be a problem. He was a full-mouth rehab and everyone knew that. But how would you rehab him?

He had some compromised teeth on the bottom, but they were savable. There was some erosion that had happened, but he claims he has no gastric reflux. He was going to need some root canals and some perio surgery, and then crowns on each tooth. Well, to make a long story short, everyone had a different opinion. And of course they were all different than the way that this dentist did it.

I will cut to the chase. The dentist had all his lower teeth out. He did five implants and an immediate screw-retained denture. After 4 months, he began the fabrication of his lower fixed perio-prosthesis. That is basically a porcelain denture that is "screw-mented" is what he said. Two of the implants got cemented with temporary cement and the other three are screw-retained (with no reason to take them off). The lower bridge is concave, so the patient just flosses (with yarn, of all things) and water picks under there. Easy.

Needless to say, I was blown away. I have learned (and am now thoroughly brainwashed) to save teeth at all costs. From school to the L.D Pankey Institute, it has always been save, save, save.

And that was being conservative! This guy is telling me that taking all the teeth out and dropping implants in is conservative. I had heard of this before this study club and scoffed at it. "Come on," I said. Now seeing this in slides, talking to other "conservative" dentists, I am blown away. My mind has been spinning since the meeting.

I think I am a changed man. BUT not totally changed. My eyes have been opened up to another mode of conservative treatment.

Let's talk about this a second. After the study club on Wednesday, I came back to work and on Thursday I had two tough patients. Guys in their late 60s. Guys that are medically compromised whose teeth are failing faster than I can fix them. You know the type: they have less saliva and more plaque, AND they don't have the dexterity or the motivation to brush and floss as well.

I have done more than $4000 worth of work for both of these guys that is now failing, less than 2 years later. (Yes, they both are on a three month recall, they both have fluoride trays and SOMA.)

So I told them both that taking out the teeth was an option. Meaning an implant-supported denture is now one of my options. Why spend $10,000 before you make the decision to take them out? And it is better to try to get them to do this now when they are in their 60s than when they are in their late 70s.

So taking all the teeth out (say, 12 teeth) and then doing 4 implants, then putting a screw-retained denture is going to run, off the top of my head, about $11 to $12k.
Damn, that is expensive. But then they can enjoy them. They will never have decay again. Most likely, they will never have a failure. All those other things are not going to haunt them (and YOU) for the rest of their lives.

I want to save teeth. I am sure of that. But I can tell you that I have had sleepless nights not knowing what to do with some people in my practice. Now I know.

Hope you are having a great Wednesday,

P.S. I talked to my implant surgeon, and he reassured me that he still does NOT do immediate load. You all know the success rate decreases, right? What would the number have to be for you to not do immediate load?

If the success rate was 10% less, would you do it? What if it was 7%? That is, implants are 97% successful. Would you do it if that was lowered to 90%, know one out of ten is going to fail?

I wouldn't and neither would he. That is why I say my mind hasn't been changed totally. We will talk about that on Friday.


Jess said...


You should look up the All-on-4 concept. I have seen and heard of great things with this system. It's pretty incredible, going from crappy teeth to an immediate load implant system in a day at a lower cost. The zygomatic implants for when there isn't enough bone just blew me away.

The thing to remember is that 'normal' implants have a success rate of approximately 96-98% anyway depending on which articles you read (this is off the top of my head from a lot of reading I did last year on implants vs RCT so forgive me if my numbers are incorrect). From what I hear and have read (but I have not researched this thoroughly) the success rate of the All-on-4 concept is approximately 2% lower, if at all. Seems pretty reasonable to me! I personally know of surgeons doing this and the success rates don't vary much, if at all, from 'normal' implant rehab.

Conservative? I'm still not convinced 100% but it's definitely an option (and things like the upper partial denture I saw today which was hanging on to an upper right premolar and first premolar, one of which is now going to now be extracted and added on to the denture, make me wonder quite seriously why they weren't both extracted in the first place so a full upper denture with better retention could be made, is making me inclined towards the 'less conservative' path!)

gatordmd said...


We sound a lot alike.

Thanks for reading,

Anonymous said...

It is simply you gaining perspective as time goes on. Once you see your work fail no matter what you do, you are more receptive to the fact that you cannot fix everything. Only time and experience can teach you that. Sometimes the patient just need to cut there losses and run.

Anonymous said...

Wow. I can't imagine the terror of getting your all your lower teeth 'harvested' in a day. I wish I was that brave!lol I could survive two but anything more than that and I'd be hiding under the dental chair! Anyway, good thing I have a patient dentist, Dr. Wolpo of

Anonymous said...

Now when you mentioned study clubs; I am just an ignorant patient who happens to prefer cast gold restorations.

I am curious to know what you guys think of the R.V. Tucker study clubs?


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