Saving teeth versus placing implants: A cost analysis

Figure 1: CBCT image of tooth no. 7 with advanced bone loss and no buccal or palatal plate — **Figure 1:** CBCT image of tooth no. 7 with advanced bone loss and no buccal or palatal plate

Figure 2: Radiograph of tooth nos. 6–8 showing all teeth with severe bone loss — **Figure 2:** Radiograph of tooth nos. 6–8 showing all teeth with severe bone loss

The long-term survival rate of dental implants has been well-documented in the literature¹ and is a treatment method widely implemented in general dental offices. Similarly, retention of teeth with moderate to advanced bone loss via various periodontal treatment methods has enjoyed similar-to-higher long-term success rates.² The practitioner often relies on clinical experience and therapeutic

Figure 3: Clinical photo of tooth nos. 6–8 after surgical debridement and showing a large bony defect — **Figure 3:** Clinical photo of tooth nos. 6–8 after surgical debridement and showing a large bony defect

familiarity when deciding whether to extract periodontally involved teeth and replace them with dental implants or save the natural dentition with regenerative therapy. Part of this decision matrix of save versus extract should be based on patient desire and long-term cost-effectiveness for the patient.Retention of periodontally compromised teeth with initial, surgical,

Figure 4: Bio-Oss Collagen bone graft placed to regenerate tooth nos. 6–8 — **Figure 4:** Bio-Oss Collagen bone graft placed to regenerate tooth nos. 6–8

and supportive therapy has been shown to have high long-term success rates in the literature.^3,4 Typical periodontal treatment for patients presenting to the dental office with moderate to advanced disease can consist of nonsurgical scaling and root planing, osseous surgery

Figure 5: Surgical re-entry of the area one year later showing bone repair — **Figure 5:** Surgical re-entry of the area one year later showing bone repair

with or without regenerative therapy (figures 1–6), and supportive periodontal maintenance at different time intervals according to patient need. Estimated totals for this type of treatment range from $2,400 to $3,300 depending on geographic location (table 1). This

Figure 6: Radiograph two years after surgery showing complete bone fill in teeth that were planned for extraction — **Figure 6:** Radiograph two years after surgery showing complete bone fill in teeth that were planned for extraction

treatment, if maintained by the patient with diligent home care, has proven to be effective in terms of preventing further periodontal progression and tooth retention over a long-term period.⁵

When analyzing the patient’s cost to maintain this treatment over a long period of time with hygiene intervals three to four times a year, dollar amounts range from $700 to $1,100 per year, again dependent upon geographic location. In a small subset of the population (less than 5% of patients with disease), refractory periodontal disease can still exist even with treatment. In such cases, treatment will have to be rendered continually to slow disease progression, increasing the overall costs of this type of therapy.⁶

Figure 7: Radiograph of multiple implant-supported bridges affected by severe peri-implantitis seven years after placement — **Figure 7:** Radiograph of multiple implant-supported bridges affected by severe peri-implantitis seven years after placement

Although implants have typically enjoyed high long-term survival rates,⁷ their initial and long-term financial impact to the patient can be much higher than that of saving the natural dentition.^8,9 Conservative valuations place initial costs for implant treatment around two to three times higher than saving natural dentition via periodontal therapy (table 2). In addition, implants are not without complications. Both biologic and/or mechanical complications can be associated with additional treatment costs to the patient. The literature is replete with discussion of biologic complications in the form of peri-implant disease.¹⁰ Studies show that the prevalence of peri-implant disease can range from 12% to 80% of implants in function.¹¹ Initial treatment involves nonsurgical debridement with implant-friendly armamentarium using systemic and/or local antibiotic placement.¹²

Figure 8: Clinical photo after surgical debridement of implant with severe bone loss — **Figure 8:** Clinical photo after surgical debridement of implant with severe bone loss

The need for advanced treatment of peri-implant disease is often determined by severity. Moderate to severe peri-implant disease often includes flap surgery, bone grafts, membranes, growth factors, and/or soft-tissue grafts¹³ (figures 7–9). The overall financial impact on the patient for this type of treatment can be quite high, considering that the patient was already subjected to costs for initial implant placement and restorative fees (table 3). Additionally, maintenance intervals after implant therapy should be equal to, if not more stringent than, those of natural teeth.

Figure 9: Clinical photo of implant grafted with Bio-Oss Collagen to attempt to save the implant bridge — **Figure 9:** Clinical photo of implant grafted with Bio-Oss Collagen to attempt to save the implant bridge

The periodontal attachment to a natural tooth is different from attachment to an implant and is less likely to breakdown. Much more attention is needed to maintain dental implants and keep them free from bacterial adherence and breakdown.¹⁴ Because of the anatomical differences, a large disparity in percentages can be seen when comparing the prevalence of reoccurring periodontal disease after treatment to the percentage of implants that will demonstrate complications after insertion of the prosthesis.¹⁵ With that said, studies show that periodontal therapy has proven to be cost-effective when compared to other types of tooth replacement therapy over a 15-year evaluation.¹⁶

Tables 1–3 present actual treatment cost differences between the patient who opts to “save” the natural tooth (treatment plan A) and the one who chooses to “remove” the tooth via extraction and placement of an implant (treatment plan B). These fees vary according to geographic location and represent insurance codes from New York City, Los Angeles, Chicago, and Dallas.

This information was presented to an actual patient in a private practice setting along with long-term survival rate percentages of each of the treatment modalities. After reviewing both the survival rates and the financial costs related to each treatment plan, the patient accepted treatment plan A, citing the following reasons: desire to keep her own teeth, lower cost, and quicker time to completion.

Another scenario that took place in a private practice with actual dollar amounts can be seen in treatment plan C. This patient had already paid for treatment plan B in the $5,000–$7,000 range and subsequently presented to the practice with moderate peri-implantitis. In addition to the money the patient had already invested, she would now be responsible for the financial costs of treatment plan C.

After reviewing the additional costs and lengthy healing time involved with surgery to correct the ailing implant, the overall costs associated with treatment were in the $8,000–$10,000 range, with more than three years of treatment time invested. Of important note is that most insurance companies limit the amount of reimbursement for implant-related services. When dealing with insurance companies, accurate ADA coding and claims submission are critical to facilitate services and expedite reimbursement.

In conclusion, there are many factors to consider when deciding between saving the natural dentition and extracting and placing implants. All parties must consider the long-term economic impact on the patient as well as the long-term success rates of the treatment. Both implants and periodontal therapy to save natural teeth have high initial success rates, with implants usually incurring initial costs. However, when looking at long-term retention rates, natural teeth often demonstrate fewer complications and have a smaller financial impact when correction is needed.¹⁷

Author’s note: All photos courtesy of Scott Froum, DDS

Editor's note: Join us for the not-to-miss Perio-Implant Advisory Symposium on October 23, 2020. In this important virtual meeting, you’ll learn the newest skills it takes to save patients’ natural dentition. Bring your team and transform your practice. Conference schedule and special rates available at this link. Presented by Geistlich Biomaterials.

References

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2. Levin L, Halperin-Sternfeld M. Tooth preservation or implant placement: a systematic review of long-term tooth and implant survival rates. J Am Dent Assoc. 2013;144(10):1119-1133. doi:10.14219/jada.archive.2013.0030

3. Setzer F, Kim S. Preserving the natural tooth versus extraction and implant placement: an evidence-based approach. Rosen E, Nemcovsky CE, Tsesis I, eds. In: Evidence-Based Decision Making in Dentistry. Springer International; 2017:73-95. https://doi.org/10.1007/978-3-319-45733-8

4. Axelsson P, Lindhe J, Nyström B. On the prevention of caries and periodontal disease. Results of a 15-year longitudinal study in adults. J Clin Periodontol. 1991;18(3):182-189. doi:10.1111/j.1600-051x.1991.tb01131.x

5. Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol. 1978;4(5):225-237. doi:10.1902/jop.1978.49.5.225

6. Magnusson I, Walker CB. Refractory periodontitis or recurrence of disease. J Clin Periodontol. 1996;23(3):289-292. doi:10.1111/j.1600-051x.1996.tb02091.x

7. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: A 10-16-year follow-up of non-submerged dental implants. Clin Oral Implants Res. 2010;21(7):772-777. doi:10.1111/j.1600-0501.2010.01912.x

8. Schwendicke F, Graetz C, Stolpe M, Dörfer CE. Retaining or replacing molars with furcation involvement: a cost-effectiveness comparison of different strategies. J Clin Periodontol. 2014;41(11):1090-1097. doi:10.1111/jcpe.12315

9. Øystein F, Grytten J. A comparison of teeth and implants during maintenance therapy in terms of the number of disease‐free years and costs—an in vivo internal control study. J Clin Periodontol. 2013;40(6):645-651. doi:10.1111/jcpe.12101

10. Froum SJ, Froum SH, Rosen P. A regenerative approach to the successful treatment of peri-implantitis: a consecutive series of 170 implants in 100 patients with 2- to 10-year follow-up. Int J Periodontics Restorative Dent. 2015;35(6):857-863. doi:10.11607/prd.2571

11. Lindhe J, Meyle J, Group D of European Workshop on Periodontology. Peri-implant diseases: consensus report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(suppl 8):282-285. doi:10.1111/j.1600-051X.2008.01283.x

12. Salvi GE, Persson GR, Heitz-Mayfield LJA, Frei M, Lang NP. Adjunctive local antibiotic therapy in the treatment of peri-implantitis II: clinical and radiographic outcomes. Clin Oral Implants Res. 2007;18(3):281-285. doi:10.1111/j.1600-0501.2007.01377.x

13. Froum SJ, Froum SH, Rosen PS. Successful management of peri-implantitis with a regenerative approach: a consecutive series of 51 treated implants with a 3- to 7.5- year follow-up. Int J Periodontics Restorative Dent. 2012;32(1):11-20.

14. Froum S. Top 5 anatomical differences between dental implants and teeth that influence treatment outcomes. Perio-Implant Advisory. September 12, 2017. https://www.perioimplantadvisory.com/clinical-tips/periodontal-complications/article/16412223/top-5-anatomical-differences-between-dental-implants-and-teeth-that-influence-treatment-outcomes

15. Heitz‐Mayfield LJA, Salvi GE, Mombelli A, et al. Supportive peri‐implant therapy following anti‐infective surgical peri‐implantitis treatment: 5‐year survival and success. Clin Oral Implants Res. 2018;29(1):1-6. doi:10.1111/clr.12910

16. Pretzl B, Wiedemann D, Cosgarea R, et al. Effort and costs of tooth preservation in supportive periodontal treatment in a German population. J Clin Periodontol. 2009;36(8):669-676. doi:10.1111/j.1600-051X.2009.01409.x

17. Donos N, Laurell L, Mardas N. Hierarchical decisions on teeth vs. implants in the periodontitis‐susceptible patient: the modern dilemma. Periodontol 2000. 2012;59(1):89-110. doi:10.1111/j.1600-0757.2011.00433.x

Editor’s note: This article originally appeared in Perio-Implant Advisory, a newsletter for dentists and hygienists that focuses on periodontal- and implant-related issues. Perio-Implant Advisory is part of the Dental Economics and DentistryIQ network. To read more articles, visit perioimplantadvisory.com and subscribe at this link.

Scott Froum, DDS, a graduate of the State University of New York, Stony Brook School of Dental Medicine, is a periodontist in private practice at 1110 2nd Avenue, Suite 305, New York City, New York. He is the editorial director of Perio-Implant Advisory and serves on the editorial advisory board of Dental Economics. Dr. Froum, a diplomate of the American Board of Periodontology, is a clinical associate professor at SUNY Stony Brook School of Dental Medicine in the Department of Periodontology. He serves on the board of editorial consultants for the Academy of Osseointegration's Academy News. Contact him through his website at drscottfroum.com or (212) 751-8530.

Kyle Summerford is a leader in dental office management. Over the course of 18 years, he has established himself as a self-proclaimed financial guru. He is founder and president of Summerford Solutions Inc. and cofounder of elitedentalclaims.com, which is aimed at helping dental practices across the US overcome their challenges with navigating dental insurance plans. Summerford is a dynamic lecturer and author. He serves as editorial director of DentistryIQ’s Dental Office Manager Digest newsletter. His monthly column, Coding with Kyle, is a terrific source of information for dental professionals.