If I have one serious regret about my age, it’s that my permanent teeth grew before New York, my hometown, got fluoridated water. I first lost a permanent molar to decay in my early 20s, and the resulting bridge had to be replaced several times over the next several decades, eventually as a four-piece appliance.
Now that has to go too. Because I couldn’t floss and clean properly under the bridge and between the abutment crowns, I developed a severe periodontal infection.
Dr. Michael Zidile, the young periodontist I consulted, took one look at my mouth and said, “That’s not how we do restorations these days. A bridge is not a permanent solution and makes it very difficult for most people to keep their gums and underlying bones healthy. Now we do implants and individual crowns where needed.”
More out of curiosity than disbelief—and before investing thousands of dollars and countless hours into new teeth—I did my homework and got a second opinion. Dr. Zidile, I learned, is right. In the vast majority of cases, implants to replace missing teeth are by far the best long-term solution to maintaining a healthy mouth. Also, because they rarely need to be replaced, they are more economical in the long run than bridges.
A drop down option
Implants to replace missing teeth have come a long way in the 25 years since I last wrote about them in this column. Better materials, procedures and professional experience result in far fewer problems than occurred in the early years of implants.
Critical to their success, however, is the right selection of both patients and doctors — and, after implantation, a commitment to good oral hygiene. Dental implants should be treated like natural teeth: kept clean and free of plaque with proper brushing, flossing and periodic professional cleanings.
“Bridges are no longer the standard of care,” said Dr. Lawrence J. Kessler, periodontist and associate professor of surgery at University of Miami School of Medicine, he told me in an interview. “For most people who are missing teeth, implants are the treatment of choice.”
Implants do not wear out and adjacent healthy teeth do not need crowns to support them. And because it’s easy to clean and floss between implants, the gum tissue and underlying bone are more likely to stay healthy.
With a bridge, if one of the supporting crowned teeth breaks or develops decay or nerve damage, the bridge and its three or more crowns must be removed and replaced.
Implants can replace single missing teeth or multiple teeth in a row. For those who have lost most of their teeth, implants can be used to anchor a full or partial denture. About half a million implants are placed every year in this country.
On average, the total cost of an implant to replace a single tooth is $3,500 to $4,000 (more if other procedures are required), or about one-third more than the cost of a bridge. But while bridges have an average lifespan of 10 years, an implant can last a lifetime.
Many insurance companies now cover implants, but most people do not have dental insurance and have to pay out of pocket. If cost is an issue, consider treatment at a dental college, where implants may be available at discounted prices as part of the tuition.
It is not a quick process
The basic technique involves surgically inserting a titanium screw – the implant – into the supporting bone, which can be done under local anesthesia in less than an hour, and placing a small false tooth called an abutment, followed by a crown. The resulting tooth looks and feels natural.
The process is long. Unlike a bridge, which can be completed in two weeks, implants typically take about eight weeks for the screw to be firmly attached to the bone before the final crown is placed. “A patient’s health, not age, determines eligibility for an implant,” Dr. Kessler said. “I just did implants on a 93-year-old man who needed them to fit a partial denture. I put two implants in a man when he was 85 and five more at 88 with no problems either time.
“If the cases are chosen correctly, the implants are very successful — 96 to 97 percent successful. And they rarely fail on the road.”
A more important consideration is having enough bone in the jaw to support the implant, although in some cases bone cells removed during the drilling for the implant or taken from elsewhere in the mouth can be used to fill gaps.
“If someone has diabetes or is a smoker,” Dr. Kessler said, “the chances of success decrease because a poorer blood supply reduces the fusion of bone cells with the implant.”
Also important is healthy gum tissue, without periodontal disease. Before I could undergo an implant procedure, I had to have periodontal treatment to get rid of plaque, calculus and infection in the roots of the teeth and in the gum tissue around the bridge and crowns.
In some cases where a tooth needs to be extracted, an implant can be placed immediately after the extraction, with the advantage of limiting bone loss in the area. When bone is not stimulated, it tends to break. I consider myself fortunate that despite having this troublesome bridge for many decades, my underlying bone remained healthy enough to support an implant.
Choice of doctor
Just as any doctor can legally perform surgery, any dentist can legally perform implants. Be sure to choose someone well trained in the technique. Attending implantology classes on the weekend is rarely sufficient. There are risks involved in placing implants, including damage to a nerve or the sinus cavity, which are magnified when the practitioner lacks adequate training.
Implants were once done primarily by oral and maxillofacial surgeons, most of whom operated independently of dentists. Now at least as many implants are placed by periodontists who are trained in the technique and coordinate their work closely with the patient’s dentist. Ideally, the periodontist should be board certified.
Just as you might ask for referrals for a future nanny or house cleaner, consider asking to speak with the doctor’s other patients before deciding to go ahead with an implant. Although every case is different, at least you can determine how well you are likely to be taken care of.
