Firstly, be aware that I write this article from a position of bias. I make my living from trying to save teeth and this will always be my first priority.
I accept that there will be times when a tooth will no longer be saveable and it will be better to extract it and possibly replace it with an implant, but this article intends to inform that options are often available, and these should be weighed up carefully before making any final decision.
Over 20 years ago dentists would extract a tooth because they did not have the ability to save it. Now, with better technology and success rates for root canal treatment quoted in high quality research papers of between 68% – 98% (1,2), it is reported in the newspapers that some dentists extract teeth because it is relatively easier to replace them with implants. Consider this extract from The Times in 2010:
Some dentistry experts believe that many general dentists lack the expertise or inclination to save teeth through complicated procedures such as root canal work. Traditional family dental care is at a turning point. Dr Julian Webber, a former president of the British Endodontic Society, believes that a growing number of high street dentists — private and NHS — are incapable of high-quality root canal work and are more interested in removing teeth, then replacing them with gleaming white artificial replacements.
Good old-fashioned dentistry standards seem to be disappearing, with some dentists removing teeth that could be root treated and rebuilt,” says Webber. “Preserving a tooth is technical and demanding. The alternatives, such as putting in an implant, can also be tricky, but some dentists prefer them because they are more lucrative. Why should we have our teeth removed unless absolutely necessary? If you go to hospital with a broken leg, would you expect to come out with a wooden one?”
The Times. June 1, 2010
With implants now universally accepted as being dependable, long-lasting replacements for teeth and causing the least possible damage to the surrounding teeth and bone, the decision to simply remove a broken down tooth and place an implant is particularly attractive. However, I feel that the argument is much more complex and to a degree the advantages of maintaining one’s own teeth for as long as possible are no longer being recognised.
God has provided us with a unique and brilliant set of tools with which to chew our food, so that we can survive and thrive. With multi-layered tissues designed to dissipate high forces, complex root shapes and a hydraulic ligament designed to spread the load through the jaw bone, innervations and pressure transducers designed to stop breakage, and its chemical production plant designed to inhibit noxious bacteria and decay; a tooth, like any part of our anatomy, is truly a thing of beauty. Compare the intricate complexities of a fully formed tooth with an implant. A cylindrical piece of metal machined out of titanium, drilled and screwed straight into the jaw-bone. There is no elegance in design, it is nothing more than a rawplug. There is no comparison.
Without the protective mechanisms in place, patients with implants generate huge forces in chewing cycles and these will inevitably cause damage somewhere. Breakage of the metal screws supporting the tooth crown are becoming common. I have noted a significant increase in vertical crown fractures in teeth adjacent to implants, as the feedback pressure mechanisms are blunted by the presence of a metal screw in the jaw.
However, my argument to save teeth whenever and wherever possible is one that I propose with pragmatism. Just because I have the expertise and technology to save a tooth, does not always mean that I have to save a tooth. There are times when trying to save a tooth is the wrong choice, whether for health or for financial reasons. It is important to consider all the elements of the presenting problem and to rationally decide the very best way to proceed based on all of the facts. A tooth must be restorable and this will depend on there being enough tooth substance/dentine left. Rebuilding teeth is only practical and viable if there is at least 1-2mm of dentine above gum level. Metal and carbon fibre posts have historically been used to support the crowns of teeth in endodontically treated roots – but these have a high failure rate, particularly when there is little tooth substance left and the tooth is needed to support a bridge or partial denture. In those cases, serious consideration must be given to the implant option.
I do though include my philosophy of dentistry into these calculations, and that is to try and hold on to natural teeth for as long as they can remain healthy and functional. Some times we might only be talking 5, 10 or 15 years, but these are years that will delay the next stage of treatment.
Remember, every treatment will have a finite life to it, and that includes implants. Do not believe any dentist that tells you that that his filling/veneer/bleaching/ root treatment/crown/bridge/implant will last a life time. Everything will fail; it is only a matter of when.
The final word should always rest with high quality research, so that our decision making is evidence based. Systematic reviews enumerate and statistically collate all the research available on a selected topic, providing a definitive answer to a clinical issue. A recent systematic review was carried out to compare the outcomes, benefits, and harms of root canal treatment and a crown, an extraction followed by an implant and crown, extraction and replacement with a denture and extraction without replacement. Although the researchers found limitations with the data, the following conclusions were drawn (3):
Based on available evidence it appears that initial endodontic treatment has high long-term survival rate for periodontally sound teeth that have pulpal and/or periapical pathosis. Equivalent long-term survival rates have been also reported for extraction and replacement of the missing tooth with an implant-supported restoration. Substantially lower long-term survival rates have been reported for extraction and replacement of the missing tooth with fixed partial dentures… For patients with periodontally sound teeth that have pulpal and/or periradicular pathosis, implant, endodontic, and fixed prosthodontic treatments had superior psychosocial outcomes, primarily with respect to patient self-image, compared to extraction without replacement or with replacement using a fixed partial denture.
From that I would conclude that without very good reason, natural teeth should always be saved wherever possible. With good quality root canal treatment they are likely to be effective and healthy teeth in the medium to long term, and avoid the consequential trauma of tooth extraction and implant placement, along with possible cosmetic issues of producing aesthetic gum contours.
1. Y.-L. Ng et al., Outcome of primary root canal treatment: systematic review of the literature – Part 1. Effects of study characteristics on probability of success. International Endodontic Journal 40 921–939, December 2007
2. Alley et. al., A comparison of survival of teeth following endodontic treatment performed by general dentists or by specialists. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. Vol. 98, No. 1. July 2004
3. Torabinejad et al., Outcomes of root canal treatment and restoration, implant-supported single crowns, fixed partial dentures, and extraction without replacement: a systematic review. J Prosthet Dent 2007; 98:285–283
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