Many factors, from ethical considerations to the patient's overall health, must be considered in this important decision, according to Charles Goodacre, D.D.S., M.S.D., dean of the School of Dentistry at Loma Linda University.
"We have an obligation to provide the longest-lasting, most cost-effective treatment that addresses the chief complaint of the patient," he told a standing-room-only audience Friday at the ADA's 149th Annual Session. Dr. Goodacre added that patients should truly need and desire the treatments dentists provide. He gave an example of someone who had their teeth restored by 47 veneers when they only had one crooked tooth.
Thus, while implants are a wonderful option with a low failure rate -- ranging from 0% to 11% for implant single crowns to 2% to 13% for implant fixed partial dentures (FPDs) -- implants are not the only option for teeth with periapical pathology.
Endodontics continues to be the best option in many cases. After root canal therapy, 92% to 98% of teeth without periapical lesions remain disease-free. Even teeth with periapical lesions remain disease-free 74% to 86% of the time. Diffuse periapical lesions over the root usually indicate root fracture, and these teeth should be immediately extracted.
“The preservation and restoration of oral health should always be the primary focus of our profession.”
As a practicing prosthodontist, Dr. Goodacre was quick to add that FPDs have a survival rate of 94% after five years. However, FPDs can develop complications, including caries of the abutments, loss of retention, tooth fracture, prosthesis fracture, and pulpal pathology. To minimize these adverse events, practitioners must consider the span of the FPD, along with the alignment and vitality of the abutments among other things. Longer span bridges (over three units) fail more often, as do nonvital abutments, which also have a higher caries risk.
If careful diagnosis and treatment planning leads the doctor to conclude an implant is the best option, the doctor must obtain informed consent that includes alternatives such as periodontal or endodontic treatment.
Dr. Goodacre acknowledged that some insurance companies do not cover implant treatment. He sees that trend changing. "They're beginning to realize that their cost over the long-term will be less ... it's not because of their humanistic spirit," he joked, bringing chuckles from the group composed primarily of general dentists.
Some factors to consider when deciding whether to place implants:
- Survival rates. All implants are not equal. Twenty-five percent of implants placed after therapeutic maxillary radiation will fail. Eleven percent of implants in smokers fail, and 8% of implants placed in patients with controlled type 2 diabetes fail. Yet many dentists believe it is OK to place implants in patients with controlled diabetes, but not in patients who smoke.
- Adjunctive procedures. Sinus grafting, ridge augmentation ... may influence the outcome of the procedure, and they add to the cost for the patient.
- Prescription medication. An attendee asked, "Does Fosamax affect implant failure rate?" Dr. Goodacre explained that the use of bisphosphonates such as Fosamax raises concerns because of their link to osteonecrosis. Most adverse events are associated with IV use, but there is up to a 7% osteonecrosis risk with oral use. Steroid use also may lead to problems with implants. Patients must be informed about this risk.
- Complications. Hemorrhage, bone fracture, and implant failure are possible.
In addition, there are ethical issues to ponder. Treatment should be "based on scientific evidence" and doctors must "present alternatives with a balanced perspective. "The preservation and restoration of oral health should always be the primary focus of our profession," Dr. Goodacre said.
Despite the high success rate of dental implants, dental students and recent graduates are more likely than experienced dentists to treatment plan a single implant than root canal therapy, according to a 2008 article in the Journal of Dental Education.
Dr. Kim-Chi Do, a 2007 graduate of LSU School of Dentistry, said afterward that the course "reaffirmed and reconfirmed everything we learned." As for older grads, who comprised most of the audience, they were too busy asking Dr. Goodacre questions to comment on what they learned. Based on their interest and rapt attention during the presentation, the survey results will be very different a few years from now.
Monica "Dr. mOe" Anderson, D.D.S., is a general dentist, writer, and motivational speaker in Austin, TX.
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