To Keep or Not To Keep Every Tooth, That is the Question
(When it is not a good idea to keep your own teeth)
As you may have discovered, dentistry today is practiced differently than even ten years ago. The profession has entered an era of research and technological advances, now evaluating oral care from the perspective of overall health. This perspective tries to address one’s physical discomfort as well as overall systemic compromises, plus their emotional attitude about their appearance and financial constraints. It’s about one’s quality of life.
Our office makes every attempt to save each and every tooth, but maintains a long-term focus in these decisions. We never remove a tooth because it is the easiest or least expensive option. Removal is only suggested when it provides the best option for long-term success. Our goal is to reduce the chance of future re-treatment or functional compromise while increasing your satisfaction when eating, speaking, and smiling – this affects your self esteem and daily activities.
Here’s a true story to prove this point:
In 1979, I saw a patient with 8 top teeth and 7 bottom teeth, instead of the 16 on each jaw that adults should have present. These teeth had periodontal disease which was ruining the bony foundation. Because dentistry functioned on the premise to keep all teeth, I made her
temporary partial dentures and sent her for surgery to get the periodontal disease under control. Her teeth stayed so temperature-sensitive after
this, something out of my control. She eventually had 14 root canals to remove the nerves, spending $10-12,000 in the process. Since teeth become brittle after root canal, I made expansive bridges to strengthen all
the teeth in each jaw. They lasted 3 years. At that point, I had to remove all her teeth and place 6 implants on the top and 6 on the bottom. She has been happy with them for 17 years. Because of the knowledge and experience that I now have, 25 years later, it is easy to see that trying to save her teeth was a bad decision. I should have placed implants at the onset because it would have been more cost-effective and yielded a more predictable outcome. By the way, the patient is my mother-in-law, and she still loves me!
Now, when I examine patients for the first time, I have no pre-conceived notions about their needs. I don’t make snap decisions. I just listen to their assessment of the problem and its impact on their daily lives. I’m then able to find the best solution for their problem. My objective is always the same. I look at the entire mouth to see what must be done to retain or restore healthy bone, create a better smile, and allow people to eat and speak comfortably. I often ask my patients if they want to save their teeth, have no recurring dental problems, and want to complete treatment in the fewest visits with maximum comfort. In every case, I
hear a resounding “yes” to each point from each patient. But then they balk when I explain that, to provide the level of care needed for long-term success, I need to remove a tooth that is in bad shape even though it doesn’t bother them. Due to patient neglect, lack of competent care, or resistance to following the past recommendation of a dentist, the foundation for dental work is inadequate. For example, a tooth that has been treated with a filling, then had a root canal, which was later crowned after it broke off, and now presents with inadequate bone support is not a good tooth to use in the future. It has a very limited prognosis, even though it has been treated with 10-12 appointments by various dental specialists over the course of many years.
Unfortunately, it’s not as easy as just removing a painful tooth, or one with a limited prognosis. When a tooth is extracted, it creates a domino-effect on the remaining teeth. They can tip rotate or drift so severely from their intended position that they cannot be used for subsequent treatment. Sometimes a drifted tooth may not even have fillings, yet it must be removed or have orthodontic correction to properly restore function to the mouth.
Understandably, patients are taken by surprise when dental Prosthodontic specialists recommend appropriate treatment that focuses on long-term improvement, or advise that teeth need to be remove when they are beyond hope. Because your total dental health and comfort is paramount, removal is the
best option to remove infection that threatens your jawbone and contributes to several systemic diseases (see pamphlet XXX). It’s not about losing teeth but, rather, about gaining long-term healthiness! Additional benefits include a natural-looking smile and improved chewing function for years to come. People often fear someone who deviates from the plan laid out by the general dentist whom they’ve trusted over the years. It’s difficult to trust someone new, especially if
they cannot perform a miracle, yet charge significant fees to improve the condition. Remember that this fee provides total treatment rather than fragmented fees for periodic service which could involve uncomfortable, compromised function during the course of treatment. General dentists are similar to general practice physicians, in that they know how to manage your health when it is routine. They try everything they know to treat your malady, but they can’t easily keep up with current developments in all nine of the different specialties.
When multiple problems exist, such as several missing teeth, a collapsed bite or difficult dental reconstruction, it may be time to ask your dentist for a Prosthodontic consultation. This specialist, called a Prosthodontist, has spent a minimum of 2 additional years in dental school, studying total mouth reconstruction. That’s why they can provide implants, specialized partials and dentures, and sophisticated crowns or bridges that look natural and feel comfortable.
I have been a big part of shaping the discipline related to bone and implant research for the past 30 years and, as a result, contend that the integrity of the jawbone is a more important requirement than saving bad teeth. Remember that it’s the foundation for everything else! You would never rebuild a disaster-struck home on a faulty foundation, would you?
I have good news. Research now demonstrates that tooth removal, when accompanied by steps to remove diseased bone and augment growth of new bone, actually prepares the site for an implant or dentures that may provide a life-long option. And dental CAT scan technology can now verify these structures
before the work begins. You’ve probably heard that partial or full dentures are difficult to wear, but that’s because the bone that supports them was never prepared properly in the past. We’ve also perfected the design of implants so some dentures are held in place with permanent fixtures. Times are changing! I have even more good news. Technological advances now ensure that you will never go without teeth. Not for one second. If multiple teeth must be removed, you will more than likely leave our office with functioning teeth that allow you to talk, eat, and smile – not with some temporary fix that is annoying.
Research has also proven that some long-held beliefs in dentistry are no longer accurate. We’ve always known that teeth located behind an extracted tooth tend to fall like dominoes into the space, but now we realize that this compromises the function of half the mouth. We know that teeth don’t lose their ability to erupt and that certain teeth, once considered “cornerstones” with long roots, may be better off gone than mal-aligned. We also know that the more that teeth have been repaired, the less predictable their prognosis. And we know that infected teeth that remain in the jaw for a long time actually dissolve bone and pose a risk to your overall health. If the tooth is later fixed, you remain dentally handicapped. But with all this knowledge, we still would rather keep as many teeth as possible because it is emotionally satisfying. We just need to exercise realistic decision-making rather than short-changing a patient with compromised care in the futile
attempt to save a tooth for a couple of years until it re-surfaces as another problem.
Dentistry needs to do everything in its power to help patients maintain optimum dental and physical health, and predictable outcomes, using research and technology as valuable tools. We try very hard to save teeth. But if losing a tooth or teeth creates a more long-term, predictable solution, then the optimal approach is removal. It will be more cost-effective treatment in the long run while preserving your bone and overall health. Therein lies the answer to the “To Keep or Not to Keep” question.
What Can Be Done?
Resist the temptation to just react to differing opinions about dental care and recognize the value of the prosthodontist, a restorative specialist, when complex problems are present. Think in terms of long-term solutions that preserve the foundation of the teeth. Bone loss is not reversible, so do everything in your power to preserve it. Embrace the value of science and technology now available in dentistry, and benefit from it. A thorough diagnosis which supports your overall health is much wiser than addressing one problematic tooth at a time with patchwork repairs and repeated visits. Not to mention the continual drain to your nerves and checkbook over the long haul of uncomfortable, interim treatment. This may actually prove more expensive than upfront, total reconstruction.
It is in your best interest to insist on a total plan for restoration, including any surgery or post-operative care needed a year later, prior to proceeding into the initial treatment with anybody. I continue to be amazed by the quantity of patients who come to my dental practice having had surgery, but do not yet have any agreed-upon plan for restoring their mouth to proper function. That’s like pouring the foundation for a house, without a blueprint. Don’t let yourself get caught up in that!
© Dr. Anil K Agarwal; Winterset Dental Care