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Posted: December 2, 2018
As with most things in dentistry, the thing that is better for you as a patient is what fits your goals and needs and desires. It isn’t up to the dentist to say that you should have this or do that… The dentist’s role should be to act as a guide or consultant and to provide you with the information necessary to make the decision that is best for you. With some things, that’s quite simple. If you have decay (a bacterial infection in the tooth) or gum disease (bacterial infection in the gums and bone) and you want to keep the tooth or teeth, then a filling or onlay or gum therapy may not only be your best answer, but also the one that intuitively makes most sense to you as the patient. Among the things that we do know for sure though, is that dentures are a very poor solution and you want to do anything you can to not have to wear them. There is a markedly higher incidence of GI problems and higher prescription medication use among denture wearers and the number of people who are happy with these ‘dental wigs’ is exceedingly small when compared with natural teeth.
If the problem is a failing tooth, the ‘right’ choice isn’t always as simple or straightforward. There are so many options and all of them are expensive so it’s hard to know which one is the best for you. It should start with keeping your long-term goals clearly in the front of your mind. Whether you have insurance to assist with the costs or not, one important consideration is the long run. Which approach creates the best result and causes the least issues down the road? The answer is usually that it depends, but in the case of the single tooth problem, there’s a clear-cut winner.
The reality is that you only have about four options when you are missing a tooth. Starting with the simplest and quickest and cheapest, you could simply do nothing. Leave the space there and just use the other teeth. If this is your third molar or wisdom tooth, you probably won’t notice any long-term problems and do just fine. However, if there is a tooth behind that space, it will potentially lead to a number of problems!
The most common tooth to be missing is the first molar, and since that’s in the back, it isn’t really an aesthetic issue. On the other hand, it is a big functional issue. That tooth is responsible for more than half of the chewing on that side and without that first molar, the other teeth are all overloaded. Missing a single tooth makes you about 50% more likely to lose a second tooth, and often there are gum tissue and bite problems along the way. Additionally, since the bone is only supported when it is used, you will lose bone in that tooth space on a pretty predictable timeline. This is one of those times where even though you could leave the space, the question really is whether or not you should. If your goals include being as healthy as possible for as long as possible, then you will most likely want to consider the other options.
The second option would be to fabricate a removable prosthesis that is generally called a partial or a partial denture. This pops in and out and uses metal or acrylic clasps to grab the teeth and hold it stable. These are a little better than doing nothing and less expensive than the other two options so they seem like a good idea, but they aren’t without compromise!
The number of them that get used for 5 years is exceedingly low! They will cost several thousand dollars and will require drilling on the teeth and be uncomfortable at first and hard to talk with and eat with. If you get used to wearing them and can actually function on them, then you will probably wear them for a little while, but eventually most people don’t. The number being used at 4 years is only 6 out of 10 and at 10 years, only 3! They also are pretty damaging to the teeth that they are clamped to. Those teeth need to have dental work done about 60% of the time by five years and 80% of the time at 10 years, so they end up having thousands of dollars of hidden costs for repairs and often the partial will need to be remade at that point too!
Almost half the teeth partials clamp onto are extracted by 10 years and the bone where the teeth used to be is lost at an even faster rate because of the partial! While they are pretty simple and seem like a good solution, for most people, partial dentures are an expensive thing to put in the junk drawer in the bathroom…
In the case of a bridge, there are several great benefits. While they are a bigger investment than a partial, they don’t come in and out and support a more stable bite over time. They are also easier to take care of than a partial. They only take a few weeks to a month to finish and look a lot like teeth when you are done. There is a lot to like about a bridge as an option and they have been used successfully for decades. Unfortunately, there is also a lot lacking in them as an ideal solution.
When looking at the reports in the literature, the numbers are alarming! In terms of expense, a three-tooth bridge generally is a little less expensive than an implant and a single crown. Over time, they become dramatically more expensive because of the additional work the bridges generally require. When building a bridge, the teeth on both sides of the space are prepared for a crown and are responsible for the load of the missing tooth as well.
The bridge will have decay at a much higher rate as a single crown only has decay about 1% of the time in five years versus a bridge which has been shown to decay between 22-27% of the time in those same five years! About 15% of bridge abutments will need to have a root canal procedure because of the additional stress on the tooth, and those root canals will fail more than 10% of the time. The teeth that hold the bridge in place will be lost about 10% of the time by 10 years and 30% of the time at 14 years and an alarming 50% of the time at 15 years! At the 10 year mark, about half of the bridges will need to be replaced and really it is more a question of whether you will need to remove additional teeth and make a larger bridge next time! As if that wasn’t bad enough, in the space where that bone has no stimulation from the root, the bone will continue to melt away. If you are planning to live more than 10 -15 more years, odds are you will be investing a lot more money in fixing the bridge work.
The first documented dental implant was around 600AD in the Mayan civilization and the implants were made out of seashells. Today’s solutions are much better researched and more effective! The success rates in dental implants today are in the high 90th percentile! As there is no work required on the adjacent teeth, there is much less reason for the adjacent teeth to require additional work like replacing failing fillings and crowns or root canals. They are much easier to clean because you can actually get floss around the teeth. Single tooth implants look and function much more like natural teeth and they help to maintain the bone because it has something to do!
Although the implant initially requires more time and money to be invested, over the long run it is a clear winner in terms of the overall amount of cost in terms of both time and money! Since the implant will never have decay issues and the long list of problems a bridge causes are all about the abutment teeth, the implants are much more stable and successful and significantly cheaper over the long term. The critical thing to address with implants is the health of the gum tissues, but if that’s maintained and the bite is right in the first place, you can expect the implant solution to last a long, long time!
One of the biggest concerns people have about dental implants is they seem like they would be a miserable thing to go through when having them placed, but it turns out they aren’t! Of course, nothing in a dental office is fun, but the reality is the process of taking the tooth out is generally much more uncomfortable than placing the implant and attaching your new tooth to it. Almost everyone comments to us that they are surprised that it really wasn’t a big deal at all!
Another amazing advantage of implants is that they are also flexible. If you happen to lose other teeth, the implant itself can often be refitted and transitioned from a single tooth implant to part of a bridge or to support a screwed-in denture. In a future blog, we will discuss some of the full-arch options you have with dental implants. It is frightening that wearing a denture will cause a dramatic loss of function, dropping from 200+ psi down to about 6 psi and making it hard to eat anything that isn’t mushy and almost none of the things you enjoy. It is more like a ‘dental wig’ that floats around in your mouth and, in fact, some people actually eat better with their dentures out and then just put them back in for social reasons! It is exciting to know that supporting those dentures with implants will allow you to regain about 85% of your bite force over time and once again feel like you are able to eat with your own teeth!
If you are concerned about options in case some or all of your teeth ultimately need to be removed, stay tuned. We’ll be sharing some of the amazing things implants can be used to restore you to ‘like-new’ again! It’s a powerful thing to be able to smile and talk and laugh and eat with confidence!!