Bridge vs. Implant
December 28, 2011
Over the past few weeks I have had numerous new and existing patients who have had the need to replace single and multiple teeth. Based on the conversations I have had with these patients, there seems to be some common misconceptions about replacing teeth. I would like to share my thought process that I communicate with patients when they are forced to decide between different treatment rationales.
Let me start by using an example of a new patient I had in yesterday. The patient presented with the chief complaint of pain. The diagnosis was an infection of a previously root canal treated tooth which was deemed non-restorable. The only treatment was extraction. The teeth adjacent to this tooth are in good condition. There are four treatment options: extract and leave the space, extract and replace missing tooth with a removable appliance (partial denture), extract and do a fixed, cemented bridge (non-removable), extract and replace missing tooth with a dental implant.
Extracting the bad tooth and leaving the space is always an option. There are, of course, esthetic concerns as well as concerns about other teeth moving and loss of function. Replacing the missing tooth with a removable partial denture is an option but is not one that most people choose due to the fact that they have to wear something in their mouth. That leaves the last two options that most people contemplate: a bridge vs. a dental implant.
Fifteen years ago, when I started practice, the standard of care was to replace the missing tooth with a bridge. A bridge is a laboratory fabricated restoration where the teeth on either side of the missing tooth (abutments) are prepared for crowns. An impression is taken of the prepared teeth and the final product, a one-piece “3-tooth” porcelain bridge, is cemented onto the two teeth that were prepared. The advantages of this are: typically can done quicker than an implant and if the abutment teeth need crowns anyway, all is accomplished with that one procedure. One major disadvantage is that if you get decay on one of the abutment teeth, the entire bridge is typically lost. So, if you are prone to decay (especially if you do not visit the dentist on a regular basis), a bridge is probably not the best solution. Another disadvantage is that if the abutment teeth do not “need” crowns, a bridge requires perfectly good teeth to be ground-down. Because the bridge is one piece, flossing requires a special tool to thread the floss under the bridge.
Today, I would consider a dental implant to be the standard of care. A dental implant is a titanium “post” that replaces the root of the missing tooth. A single crown is then placed on that “post”. The procedure is typically less invasive than removal of a tooth. You cannot get decay on a dental implant. If something goes wrong with one of the teeth on either side of the dental implant, you only have to deal with the one tooth and not three teeth as in the example of the bridge. The teeth are all separate so flossing is normal. The cost of a single dental implant vs. a 3-unit bridge is about the same.
Although there are other things to consider, I am out of space this week. I encourage your questions.
Interdisciplinary Dentistry
December 21, 2011
Last week I was invited to attend the annual North Eastern Society of Orthodontists (NESO) meeting in Boston. You may ask why I attended an orthodontic meeting when I am not an orthodontist? The reason I was invited was because of the strong interdisciplinary component of the meeting. What is interdisciplinary dentistry?
I’ll use the example of a 38 year old woman I saw just yesterday as a new patient. She had not been to a dentist in a couple of years and wanted to have her teeth cleaned. She saw one of my hygienists, had her teeth cleaned, and then saw me for an examination. My examination of new patients usually includes a set of photographs of the teeth. Over the years, this has proven to be invaluable for me to be able to discuss a patient’s dental status. It is much easier to show and explain than just explain.
I evaluate 4 areas in every patient. Those areas are the biology, esthetics, function and structure of the teeth. The biology is the health of the gums and bone that support the teeth. This is important because this is the foundation of good health. I always evaluate the esthetics of the teeth because the smile is the most prominent feature of the face. The function of the teeth is an evaluation of how the muscles, joints and teeth are working together – does the patient have any muscles or joint (TMJ) issues and do the teeth show any signs of wear? Lastly, the structure of the teeth is the condition of the teeth themselves – what is the patient’s dental history and what is the condition of the existing restorative dentistry in the patient’s mouth?
As I was taking this new patient on a “tour” of her mouth, I simply described what I saw. As often happens, my patient started asking a lot of questions. The bottom line is that she always wondered why she had repeated dental problems and had a list of things she did not like about her teeth. Her dentists in the past had never looked this deep into her dental issues, so she was never given the opportunity to do anything about it. In the past, if there was a problem, the problem would get the quick fix, a crown or a filling, and life would go on until failure occurred again.
This patient, who came in just to have her teeth cleaned, announced that she was ready to fix her teeth correctly. As her dentist, I need to be able to deliver the level of care she expects. This is only possible with effective collaboration between a group of dentists. Her treatment will probably be phased over the course of a few years. It will require collaboration between me, an orthodontist, a periodontist and an oral surgeon. This is interdisciplinary dentistry.
Much of the NESO meeting was about treatment like this. The dentist must have the educational background of the many different disciplines of dentistry and be able to communicate their findings in simple terms that patients can understand. Doing a complete exam and reporting findings is the obligation of the dentist to the patient. This at least gives the patient the opportunity to choose the level of health that is right for them as an individual.
When it comes to actually doing the dentistry, it is essential that the general dentist, the quarterback of the team, has the right players assembled to make the entire treatment a homerun.
Amesbury Nixes Fluoride
December 5, 2011
Last week, Amesbury residents voted in a relatively narrow margin against the re-introduction of adding fluoride to the public water supply. Fluoride has been added to many public drinking water supplies all over the country for decades in an attempt to combat dental decay. The theory is that ingested systemic fluoride strengthens the developing teeth and makes them less susceptible to decay.
I would bet you would think that I am a proponent of public water fluoridation given my profession. I am not. In fact, I think it is unethical, unnecessary, ineffective, unsafe, inefficient, and unscientifically promoted. Although there is not enough space in this column to go into this in depth, let me give you an example of each.
Public water fluoridation is unethical because it violates an individual’s right to informed consent to mass medication. It is okay to put substances in the public water to make it safe, but not to medicate, and especially not a heavy metal that accumulates in the body. Public water fluoridation is also unnecessary because people, including children, can have healthy teeth without being exposed to systemic fluoride. This is different than topical fluoride which I will touch on later in this column.
Public water fluoridation is ineffective as research has shown that fluoride’s benefits are primarily topical and not systemic. Countries that have halted water fluoridation generally do not see increases in decay. It is unsafe as systemic fluoride accumulates in the pineal gland and in bones, making them more brittle. Also, where the fluoride comes from is an interesting topic of discussion. Many municipalities get their fluoride from China.
Public water fluoridation is inefficient for many reasons, one being that more and more people drink bottled water (which is loosely regulated) and most of the public water ends up washing dishes, in the shower or watering the lawn. If ingestion of fluoride did make sense there are better ways to make it available to people who want it. But, is it really necessary?
Lastly, public water fluoridation is unscientifically promoted. As stated by the US Centers for Disease Control, “Laboratory and epidemiologic research suggests that fluoride prevents dental caries predominately after eruption of the tooth into the mouth, and its actions primarily are topical for both adults and children”. I am a proponent of topical fluoride such as the fluoride found in toothpaste. And, as we age, the decay rate often increases due to exposure of more root surfaces of the teeth which are more susceptible to decay.
Research continues on the effect that fluoride has on teeth, both systemically and topically. The research also continues on the effects that ingested fluoride has on the rest of the body. There is also mounding research on products other than fluoride that show promise in combating dental decay.
I have a fair number of patients on prescription level topical fluoride that I feel are more susceptible to decay. My protocol may be changing soon due to pending research. However, one thing is certain, those with a good diet, impeccable homecare, and who visit a dentist at least twice per year, are much less susceptible to decay no matter what they brush their teeth with.
Dental Insurance Benefits Expiring
December 1, 2011
I don’t know how you feel but I think this year is just flying by. I guess I feel like that every year. Only one more month left in 2011. For those of you with dental insurance, only one more month to use your dental benefits before they disappear and go toward the bonuses for the insurance executives. That is kind of a joke and it is kind of not.
As you know, if you have dental insurance, you have a yearly maximum amount of money that can be used for dental care. Although that yearly maximum (typically $1000-1500 per year) has not changed for 40 years in most situations, if you don’t use the money the insurance company keeps it. That’s right, if your insurance company doesn’t write a check out for your dental care, they keep whatever you don’t use.
On that note, if you have dental work that needs to be done, now is the time to do it. The only catch is that because many patients wait until the end of the year to use their dental insurance benefits, it is often difficult to get an appointment. Therefore, those reading this column will be one step ahead of everyone else. The big rush generally occurs in the next couple of weeks so book your appointments now.
This is especially true for patients who need multiple things done. Let me use a specific example. Let’s say your dentist has told you that you need a crown on a tooth but the tooth will need work done by a periodontist or even the dreaded root canal prior to doing the crown. Getting the “pre-crown” work done at the end of this year will allow you to finish the crown in the beginning of next year and maximize your insurance benefits.
It has always seemed crazy to me that we have to play these games with dental insurance, but that’s the way it works. If you have been told that you needed some work done and haven’t done it, call your dental office or insurance carrier to see how remaining benefits you have.
Just for clarification, as this is an area that patients sometimes get confused on, your yearly maximum is yours and not your spouse’s. If you and your spouse have dental insurance and a $1000 yearly benefit, you get to use $1000 and your spouse gets to use $1000. If you go over your maximum you cannot use any of your spouse’s benefits.
For those without dental insurance – you are not missing out on too much. Yes, dental insurance is nice to have, especially if your employer is paying most or all of the premiums. However, people tend to get into the frame of mind that if they do not have dental insurance they can’t go to the dentist.
I had a patient in just yesterday that had not been in for 5 years because he said he did not have insurance. Five years later the patient needs more work done than the insurance benefits will cover. It’s not worth it.
One thing is for certain, regardless of whether you have insurance or not, regular visits to a dentist is the key. If your goal is health you can’t do it alone. If the cost, or the fact you don’t have dental insurance is what is holding you back, talk with an office that offers financial arrangements that work for you. The longer you stay away the more difficult it is to catch-up.
