INTRODUCTION
There’s no question that Mother Nature makes the best teeth. Despite advances in dental implant surgery and in the implants and abutments themselves, they cannot replicate the sensory perception that the periodontal ligament of a natural tooth provides. What’s more, a natural tooth can better cope with lateral biomechanical forces. That’s one of the reasons why, as a periodontist, I strive to save a patient’s natural dentition whenever appropriate and when I am confident that my surgical and nonsurgical periodontal disease treatment will be successful.
The question, “Should I treat and preserve or should I extract and place an implant?” is best answered via evidence-based assessment and treatment planning, which begins with gauging the expectations and commitment level of your patient.
For example, if a patient comes in and says, “I want to do anything possible to save my natural teeth,” chances are you will get a high level of compliance for long-term periodontal treatment, at-home oral care, and continued periodontal maintenance.
Equally important is a patient’s willingness to undergo, and ability to afford maintenance therapy every 90 days. This is critical to achieving positive patient outcomes, because the maturation of bacterial plaque occurs within 90 days and the patient becomes disease-active again.1
But when your patient makes statements such as “I hate going to the dentist,” or “I’ll never do that again,” it’s a definite red flag. If they say, “My insurance only pays for 2 cleanings a year,” that’s another warning sign. The bottom line is this: you can be a superstar in intricate periodontal procedures and grow bone in places where no other dentist can, but if you keep getting long-term treatment and insurance coverage objections, your success is unlikely.
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| Figure 1. Extraction versus conservation.3 |
Unfortunately, many specialists and general practice dentists alike are becoming “quick to extract.” Part of this is due to a 2-pronged campaign by the implant manufacturers. On one front, they wine and dine dentists and provide free training and continuing education credits. On the second front, they blitz the consumer media with the promise of “teeth in a day.”
The consumer marketing is prompting more and more patients to request implants rather than long-term therapy. What they don’t realize is that dental implants are not a “set it and forget it” solution; peri-implantitis has a prevalence rate ranging from 11.3% to 47.1% of implant patients.2
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| Figure 2a. Preoperative radiograph of tooth No. 19. | Figure 2b. A residual pocket depth of 7 mm existed on the distal of tooth No. 19. |
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| Figure 3a. Implant tooth No. 30. | Figure 3b. Implant crown. |
These are the major factors influencing clinicians and patients alike in opting for extraction and implants rather than preserving natural dentition. But even if a patient is ready, willing, and able to do whatever it takes and whatever it costs to save his or her teeth, further evidence-based analysis must be conducted to determine which course of treatment is truly best for the patient.
It takes a lot of patient education to offset the “teeth in a day” hype, and this is best achieved by forging strong relationships between general dentists and periodontists, who, in turn, need to maintain a united front in explaining treatment options to their comanaged patient in an objective manner, and work together toward the common end result of a positive patient outcome.
In my practice, I refer to the “Extraction Versus Conservation Decision Chart” developed by Avila et al3 to assess the patient’s condition and predict whether or not long-term periodontal therapy will be successful, or, in the patient’s eyes, an uncomfortable waste of time and money (Figure 1).
The decision chart contains 6 levels of detailed analysis for the following principal areas of assessment:
- Initial assessment
- Periodontal disease severity
- Furcation involvement
- Etiologic factors
- Restorative factors
- Other determinants.
As you can see, each of these principal areas contains several subcategories of analysis that are weighted and averaged to help the clinician determine 3 main evidence-based conclusions:
- Long-term survival: unfavorable
- Proceed with caution: recommended
- Long-term maintenance: favorable.
Decision chart analysis leading to conclusion No. 1 would strongly suggest extraction. No. 2 indicates that treatment is feasible; but if it fails, extraction is advised. Conclusion No. 3, although alluding to a positive outcome, may default to No. 1 if the patient rejects the treatment plan for financial or other reasons.
This decision tree chart was used to evaluate the patient and ultimately plan and perform the following case scenario.
| The Single Implant Crown |
Tom M. Limoli Jr
The observations of Dr. Masters are right on the money. When both patient and case selection are dependent on insurance benefits, success in any form is most unlikely. All too often offices hide behind the word “estimate” and have the patients hoodwinked into accepting a treatment plan they can neither afford nor appropriately care for. Never should a patient be presented with a “singular” financial treatment plan whereby insurance benefits are calculated into the overall cost of care. The patient must see and acknowledge “both” dollar amounts reflecting with and without insurance participation. The most common of all dental implant procedures is by far the endosteal. According to CDT, procedure code D6010 includes the surgical placement of the implant body, the second stage surgery, and the placement of the healing cap. The global aspects of this procedure code encompass all 3 completed subcomponents. In other words—D6010 is not completed until the implant is stable and ready to be loaded. Of question with procedure code D6010 is the concept of the second stage (or pre-abutment placement) surgery. It is at this point where the doctor surgically exposes the implant head so as to test and confirm the integration of the bone to the implant. At this visit, the original surgeon who placed the implant body may (or may not) place either a healing collar or tissue contouring provisional abutment. This is the area of confusion because procedure code D6010 is not yet complete until the tissue surrounding the implant is structurally as well as aesthetically ready for the actual abutment that will retain the prosthesis. Depending upon your desired endosteal implant system of choice, the second surgery may or may not be necessary. Confused yet? With confirmation that the implant body has sufficiently bonded with the bone, the abutment (if necessary) is now ready to be placed in anticipation of the final prosthesis. The analog transfer process of selecting and/or modifying the abutments intended path of prosthetic insertion is all part of either procedure code D6056 (prefabricated) or D6057 (custom). Also, the direct cost of any post surgical custom impression trays as well as soft-tissue models; along with any other miscellaneous assortment of screws, nuts, bolts, washers, gaskets or socket wrenches; are all encompassed within your singular fee that you charge for either the prefabricated or customized abutment. Remember, it’s one code or the other and never both. This leaves us now with coding, billing, and reimbursem*nt for the final prosthesis. If the abutment, retainer and/or implant are supporting a single-unit crown, that crown will have the same fee as any other more traditionally placed crown. The same can be said for multiple units of a fixed partial denture or bridge. The fee is the same provided you have charged appropriately for either D6056 or D6057. | Table 1 | | Code | Description | Low | Medium | High | Average | RV | | D6010 | Surgical placement of implant body—endosteal implant | $1,532 | $1,755 | $2,435 | $2,012 | 40.24 | | D6056 | Prefabricated abutment—includes placement | $389 | $645 | $780 | $623 | 12.46 | | D6057 | Custom abutment—includes placement | $601 | $872 | $1,172 | $889 | 17.78 | | D6059 | Abutment supported PFM crown (high-noble metal) | $908 | $1,125 | $1,921 | $1,407 | 28.14 | | D7140 | Extraction, erupted tooth, or exposed roots | $110 | $180 | $363 | $159 | 3.18 |
CDT-2011/2012 copyright American Dental Association. All rights reserved. Fee data copyright Limoli and Associates/Atlanta Dental Consultants. This data represents 100% of the 90th percentile. The relative value is based upon the national average and not the individual columns of broad-based data. The abbreviated code numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for your individual office is available for a charge from Limoli and Associates/Atlanta Dental Consultants at (800) 344-2633 or limoli.com. |
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EVIDENCE-BASED CASE REPORT
Diagnosis and Treatment Planning
The patient, a 53-year-old white female, presented to my office requesting a comprehensive care program so that she could get re-established in a periodontal cleaning regimen. Her medical history was noncontributory. She takes no medications, some vitamins, and has no drug allergies. Her social history is negative for smoking, and she consumes 3 to 4 alcoholic beverages per week.
Her previous dental history includeed periodontal surgery in the lower quadrants, and nonsurgical therapy in the upper quadrants. Bone grafts were placed in a few areas in the lower molar areas. She has had no maintenance therapy in more than one year. Her initial periodontal exam revealed heavy subgingival calculus ,especially in the posterior areas.
Radiographs indicated that there was generalized horizontal bone loss in the maxillary arch ranging from 10% to 30%, and an isolated vertical defect on the distal of tooth No. 19. Tooth No. 19 had been grafted about 3 years prior to my examination. A residual pocket depth of 7 mm existed on the distal of No. 19 (Figures 2a and 2b).
Tooth No. 30 had been extracted almost 2 years ago, after being deemed hopeless by her previous periodontist. The patient reported that the tooth was not doing well periodontally, and her dentist thought it was also cracked, which was confirmed after extraction. The patient knew that she needed additional periodontal therapy, and also agreed to have tooth No. 30 replaced with a dental implant and PFM crown.
Treatment Protocol
Conventional periodontal osseous surgery was performed in the upper arch, scaling and root planing was administered with hand and ultrasonic instruments with the addition of local delivery antibiotics in No. 19 (Arestin) and a dental implant (Straumann Tissue Level SLActive) was placed in the position of tooth No. 30 (Figures 3a and 3b).
The patient and I discussed the importance of a 3-month maintenance interval to control her inflammatory response. Tooth No. 19 will continue in maintenance therapy that will include scaling and root planing and may require additional surgical therapy depending on whether probing depths increase, there is persistent bleeding upon probing, or radiographic evidence of decreased bone mass levels.
Closing Comments
The patient is enthusiastic about keeping her remaining teeth, even with the potential for additional surgical therapy.
This brief case report article provides an example of how treatment decisions are made in a periodontally compromised dentition. We should always refer back to the evidence in the existing literature, and perform regular thorough examination of our periodontitis patients.4
References
- Cohen RE; Research, Science and Therapy Committee, American Academy of Periodontology. Position paper: periodontal maintenance. J Periodontol. 2003;74:1395-1401.
- Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss. J Periodontol. 2010;81:231-238.
- Avila G, Galindo-Moreno P, Soehren S, et al. A novel decision-making process for tooth retention or extraction. J Periodontol. 2009;80:476-491.
- American Academy of Periodontology. Comprehensive periodontal therapy: a statement by the American Academy of Periodontology. J Periodontol. 2011;82:943-949.
Dr. Masters earned her dental degree from The University of Texas Health Science Center at San Antonio (UTHSCSA) and continued her education at the dental school with a 3-year specialty program in periodontics. She is a board-certified periodontist whose expertise is in the diagnosis and treatment of all types of gum diseases and performing both aspects of surgical and nonsurgical therapy. She is certified to use several types of sedation to alleviate anxiety in patients concerned about their surgical therapy. Dr. Masters is a member of the American Academy of Periodontology, the International Congress of Oral Implantologists, the American Dental Association, Southwest Society of Periodontists, and the Texas Society of Periodontists. She is also a clinical associate professor at the UTHSCSA Dental School. She can be reached at mastersdds@mdgteam.com.
Disclosure: Dr. Masters reports no disclosures.
FAQs
What Is Evidence Based Dentistry? EBD involves using clinical experience and research as the foundation of your practice and combining evidence with patient preferences and values to achieve shared decision-making. Many national dental councils promote EBD as the gold standard of treatment.
What is dental Code D6057? ›
D6057: Custom fabricated abutment — includes placement.
What is dental Code D6010? ›
CDT Code. Description. D6010. Surgical placement of implant body: endosteal implant.
Are teeth superior to implants a mapping review? ›
Conclusions: Based on this mapping review, teeth are superior to implants in their ability to resist biologic challenges, but implants are superior to teeth in managing higher compressive loads without prompting bone resorption.
What is dental Code D6240? ›
D6240 Pontic, porcelain fused to precious/high noble metal. (bridge units)
What is dental Code D8090? ›
D8090—Comprehensive orthodontic treatment of the adult dentition. This code is commonly used for adults who are undergoing occlusion and alignment corrections.
What is dental Code D2750? ›
D2750. CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL.
What is dental code D4263? ›
Diagnosis: Severe periodontal bone loss Treatment: D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site.
What is dental code D7280? ›
D7280 – Surgical access of an unerupted tooth
This procedure includes an incision, the reflection of tissue, and the removal of bone as necessary to expose the crown of an impacted tooth not intended to be extracted.
What is dental code D6205? ›
CDT Code. Description. D6205. Pontic – indirect resin-based composite.
The 9 Best Countries for Dental Implants
- Turkey. It's no surprise that Turkey is consistently ranked as one of the top countries for dental implants. ...
- Hungary. Hungary is well known for being one of the best countries for dental implants. ...
- Croatia. ...
- Czech Republic. ...
- Mexico. ...
- Germany. ...
- Thailand. ...
- United Kingdom.
Proficient and highly skilled in dental surgeries, even as recent graduates, an oral surgeon is the most qualified dentist to place dental implants. Additionally, they have both dental and medical training, so an oral surgeon is the best choice for anyone with compromising medical conditions or highly complex cases.
What are the 3 components of EBP decisions? ›
All three elements are equally important.
- Best Available Evidence. ...
- Clinician's Knowledge and Skills. ...
- Patient's Wants and Needs.
Key components of EBPH include: making decisions based on the best available scientific evidence, using data and information systems systematically, applying program planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating what is learned.
What are the four main elements of EBP? ›
Advocates for evidence-based medicine (EBM), the parent discipline of EBP, state that EBP has three, and possibly four, components: best research evidence, clinical expertise, and patient preferences and wants. Person-centered physicians also advocate for the person of the practitioner as a fourth component.
What is the process of evidence-based decision-making? ›
Evidence Based Decision-Making is a process for making decisions about a program, practice, or policy that is grounded in the best available research evidence and informed by experiential evidence from the field and relevant contextual evidence.
What are the 8 principles of evidence based practice? ›
- Eight Evidence-Based Principles for Effective Interventions.
- 1) Assess Actuarial Risk/Needs.
- 2) Enhance Intrinsic Motivation.
- 3) Target Interventions.
- a) Risk Principle.
- b) Criminogenic Need Principle.
- c) Responsivity Principle.
- e) Treatment Principle.
EBP is a process used to review, analyze, and translate the latest scientific evidence. The goal is to quickly incorporate the best available research, along with clinical experience and patient preference, into clinical practice, so nurses can make informed patient-care decisions (Dang et al., 2022).
What are the new dental codes for 2022? ›
- 2022 CDT Codes.
- Effective January 1, 2022.
- New. Description.
- D3911. intraorifice barrier. D3921. decoronation or submergence of an erupted tooth. ...
- Revised. Description.
- D0120. periodic oral evaluation – established patient. D0180. ...
- D4276. combined connective tissue and pedicle graft, per tooth. D5862.
Code 3 – Calculus and Plaque present under the gum margin and gingival pockets between 3.5 – 5.5mm. Code 4 – Calculus and Plaque present under the gum margin and gingival pockets over 5.5mm.
D3220. Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental. junction and application of medicament.
What is dental code D7111? ›
D7111 extraction, coronal remnants - deciduous tooth
Removal of soft tissue-retained coronal remnants.
What is dental code D1516? ›
D1516. Space maintainer – fixed – bilateral, maxillary.
What is dental code D8060? ›
• D8060 – interceptive orthodontic treatment of the transitional dentition.
What is dental code D5130? ›
□ D5130 Immediate Denture - Maxillary. $2,140. □ D5140 Immediate Denture - Mandibular.
What is dental code D2644? ›
D2644 Onlay - porcelain/ceramic - four or more surfaces.
What is dental code D2954? ›
A prefabricated post and core (D2954) is a standard (out-of-the-box) post, and it typically comes in various sizes. A standard post will be placed if the size and fit are perfect to stabilize the tooth without the need of a dental laboratory fabrication. Most dental practices will use this method.
What is dental code D2392? ›
D2392. Resin-based composite - two surfaces; posterior.
What is dental code D9222? ›
D9222. Deep sedation/general anesthesia – first 15 minutes.
What is dental code D7230? ›
D7230 removal of impacted tooth – partially bony
Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.
D5282. Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary.
What is dental code D5867? ›
Dental Insurance Codes
Describe the type of attachment used. D5867 - Replacement of replaceable part of semi-precision or precision attachment (male or female component)
What is dental code D3333? ›
D3330 Root canal-molar: Root canal: back tooth. D3331 Treatment of root canal obstruction: Removal of a separated instrument, finding a Ca+ canal. D3332 Incomplete root canal therapy: Inoperable or fractured tooth, root canal procedure not completed. D3333 Internal root repair: Repair of perforation defects.
What is dental Code D9947? ›
D9947 Custom sleep apnea appliance fabrication and placement.
What is dental Code d5899? ›
Immediate Partial or Complete Denture: A removable prosthesis that is specifically designed to replace a portion or all of the missing dentition in an arch, which is inserted immediately following extraction of teeth.
What is dental Code D9440? ›
D9440 Office visit - after regularly scheduled hours.
What is cost of full mouth dental implants in USA? ›
Full mouth dental implant procedure costs can range anywhere from roughly $7,000 to $68,000 overall. These types of implants have an average cost of around $25,000. Keep in mind that it can cost anywhere from $3,500 to $30,000 to get a top or bottom set of full mouth dental implants.
What country has the most affordable dental implants? ›
Costa Rica
If you're seeking low-cost dental implants, a trip to Costa Rica can help you save 50-70%. In Costa Rica, a dental implant costs around the US $750. This cost covers the implant, abutment, and surgical implantation of the implant in the jaw.
Who is the best dentist in the world? ›
The List of TOP 10 Richest Dentists in the World
| Rank | Doctor's Name | Net Worth (approx) |
|---|
| #1 | Dr. Dan Fisher | $ 1.1 Billion |
| #2 | Dr. Richard Malouf | $ 1 Billion |
| #3 | Dr. David Alameel | $ 900 Million |
| #4 | Dr. Clint Herzog | $ 100 Million |
6 more rows4 Jan 2017
It's estimated that about 5 to 10 percent of dental implants fail, either shortly after a procedure or months or years later. If you're scheduled to have dental implant surgery, or if you currently have an implant, here's what you need to know about implant failure and other potential complications.
There are three common types of dental implants that you can choose from Endosteal, subperiosteal, and zygomatic. Endosteal is the safest and most common, followed by subperiosteal, and then zygomatic being the last and most complex. It is rarely used.
What are the most durable dental implants? ›
Since the 1960s, implants made from titanium have become the standard and enjoy long-term success rates of about 95%. But zirconia implants are emerging as an alternative to conventional titanium implants due to their biocompatibility, soft-tissue response, and aesthetics.
Who should not get dental implants? ›
The Very Elderly (with some exceptions)
However, in general, implant dentists, oral surgeons, and periodontists will hesitate before recommending implants for patients over the age of 85. The very elderly tend to have more chronic illnesses that could interfere with the healing process.
How many teeth can you put on one implant? ›
An implant is rarely used to replace multiple teeth on its own, but it can be combined with another to replace up to six teeth. That means an implant on its own can support a max of three artificial teeth.
What is evidence-based practice in simple terms? ›
EBP is a process used to review, analyze, and translate the latest scientific evidence. The goal is to quickly incorporate the best available research, along with clinical experience and patient preference, into clinical practice, so nurses can make informed patient-care decisions (Dang et al., 2022).
What is evidence-based practice and give an example? ›
Through evidence-based practice, nurses have improved the care they deliver to patients. Key examples of evidence-based practice in nursing include: Giving oxygen to patients with COPD: Drawing on evidence to understand how to properly give oxygen to patients with chronic obstructive pulmonary disease (COPD).
What are the 3 components of evidence-based practice? ›
Components of Evidence-Based Practice
- Best Available Evidence. ...
- Clinician's Knowledge and Skills. ...
- Patient's Wants and Needs.
EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research”.
What are the 6 steps of evidence based practice? ›
Regardless of the setting or your level of expertise, EBP practitioners use the same steps to arrive at the best medical decision.
- Ask a question. ...
- Look for evidence. ...
- Analyze the evidence. ...
- Integrate your finding. ...
- Evaluate the outcome. ...
- Share the information.
Benefits
- EBP promotes the quality, efficacy and cost-effectiveness of psychotherapeutic interventions and reduces the likelihood of harm. ...
- EBP leads to the generation of new knowledge. ...
- By promoting knowledge translation, EBP facilitates the clinical decision-making process for practitioners.
Evidence-Based Practices & Programs
- The Guide to Community Preventive Services (The Community Guide): Task Force Findings. Centers for Disease Control and Prevention (CDC) ...
- U.S. Preventive Services Task Force (USPSTF) Recommendations. Agency for Healthcare Research and Quality (AHRQ) ...
- Bright Futures.
Systematic Reviews and Meta Analyses
Well done systematic reviews, with or without an included meta-analysis, are generally considered to provide the best evidence for all question types as they are based on the findings of multiple studies that were identified in comprehensive, systematic literature searches.
What are Evidence-based practice strategies? ›
Evidence-Based Practice: Skills, techniques, and strategies that have been proven to work through experimental research studies or large-scale research field studies.
What are the three domains of evidence-based dentistry? ›
Defining evidence-based dentistry
' Evidence-based dentistry is based on three important domains: the best available scientific evidence, dentist's clinical skills and judgment, and patient's needs and preferences.
What is evidence-based decision-making? ›
Evidence-Based Decision Making (EBDM) is a strategic and deliberate method of applying empirical knowledge and research-supported principles to justice system decisions made at the case, agency, and system level.
What are the 8 principles of evidence-based practice? ›
- Eight Evidence-Based Principles for Effective Interventions.
- 1) Assess Actuarial Risk/Needs.
- 2) Enhance Intrinsic Motivation.
- 3) Target Interventions.
- a) Risk Principle.
- b) Criminogenic Need Principle.
- c) Responsivity Principle.
- e) Treatment Principle.
How Does EBP Improve Quality of Care? EBP improves patient care quality when nurses "translate research findings into clinical practice" as explained in the six steps above. This ensures patients receive the most effective and safe care given the current body of nursing knowledge.
What is the main aim of evidence-based health care? ›
It is a decision making process that takes into consideration contextual factors and combines the health worker's expertise acquired through clinical practice and experience, current best evidence obtained from clinically relevant research, and patient values.
What is evidence-based decision-making in healthcare? ›
Evidence-based practice is the use of the best available evidence together with a clinician's expertise and a patient's values and preferences in making health care decisions.
