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Filling In the Gaps: Real Concerns About Dental Implants

Dental researchers say dental-implant systems have a success rate that’s as high as 98.7 percent, but experts disagree on what constitutes success. Furthermore, no independent studies track the long-term durability of dental-implant systems.

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Three million Americans receive a total of 5.5 million dental-implant systems every year, according to American Academy of Implant Dentistry (AAID), which is a trade association. AAID expects the number of patients in the United States who receive a dental-implant system to increase by 500,000 in 2015 and says the global market will grow to $6.4 billion in 2018.

We found three reasons for the growth of dental-implant systems, which are permanent artificial teeth for when you lose a tooth because of periodontal disease or injury. First, more general dentists than ever before place, or install, dental-implant systems instead of referring patients to a more expensive specialist. Second, advancements in technology now allow consumers to get a functional dental-implant system in a matter of days, instead of waiting 3 months as is typical with traditional dental-implant systems. Finally, the least expensive “one-day” dental-implant systems now cost $1,000–$2,500 per tooth, compared with $2,500–$5,000 per tooth for a conventional dental-implant system.

A dental-implant system has three components: a crown, which is the artificial tooth; an implant, which is the artificial root; and an abutment, which is the connector that joins the crown to the implant. At least 400 dental-implant systems of varying material and styles exist in the United States. A single implant crown now costs anywhere from hundreds to thousands of dollars, depending on whether it’s premade or custom-made and whether it’s made from plastic, metal or porcelain.

Unfortunately, no independent evidence proves that dental-implant systems are more durable than ever before. Dental-implant experts often say the procedures have a success rate of up to 98.7 percent. However, we found that the term “success rate” often is used to describe the process of simply placing a dental-implant system, not as a measure of how the dental-implant system holds up to years of biting and chewing.

“If a patient has half of their jawbone gone, and the implant is still integrated into the base of their jawbone, some experts call that success,” says Dr. Joan Otomo-Corgel, who is the president of American Academy of Periodontology (AAP) and has placed dental-implant systems since 1985. “Success to me is an implant that is healthy and easy to maintain.”

Unfortunately, almost all studies of dental-implant systems were conducted by manufacturers or by dentists who place dental-implant systems—two groups that benefit from reporting the highest possible success rate.

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Experts tell us that dental-implant systems can last up to 40 years depending on the procedure and follow-up maintenance, the type of dental-implant system, the quality of the bone in which the implants are anchored and the patient’s overall oral health. However, an April 2013 report by AAP found that up to 48 percent of all dental-implant systems likely will result in some complication. Most common are peri-implant mucositis, which is inflammation in the soft tissue around an implant without loss of bone; or peri-implantitis, which is inflammation with bone loss. In other words, no matter what type of dental-implant system that you get, no matter how much that you pay for the procedure and no matter how experienced that your dentist is in placing a dental-implant system, it’s critical that consumers maintain their oral health and consult with their dentist regularly after surgery to prevent complications.

COURSE OF TRAINING. General dentists typically are the first to tell you whether you have to have a dental-implant system. Ten years ago, most general dentists referred such patients to a specialist who has 3–5 years of training beyond dental school in oral surgery or periodontics (the study of structures, such as gums, that support teeth).

However, no mandatory standards exist in the United States for how much training is required before a dentist can place a dental-implant system. Any licensed dentist can perform any dental procedure legally.

The cost of such training decreased over the past decade, and now it’s less time-consuming for dentists to study surgical techniques for placing a dental-implant system. Two-year courses over weekends and even 1-to-3-day seminars typically are offered by the manufacturers of dental-implant systems. In 2014, 60 percent of dental-implant systems were placed by specialists, and 40 percent were placed by general dentists, according to Academy of Osseointegration (AO), which is an organization of dental-implant professionals. AO expects that 60 percent of dental-implant systems will be placed by general dentists by 2017.

OPEN UP. Experts tell us that dental-implant systems can last up to 40 years depending on the procedure, the dental-implant system, the bone in which the implants are anchored and the patient’s overall health.

OPEN UP. Experts tell us that dental-implant systems can last up to 40 years depending on the procedure, the dental-implant system, the bone in which the implants are anchored and the patient’s overall health.

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A study that was published July 2014 in The Journal of the American Dental Association looked at 922 dental-implant procedures between 2010 and 2012 and found that general dentists were slightly less successful than specialists were in placing a dental-implant system in a patient’s jawbone. Study author Dr. John D. Da Silva, who is an associate professor at Harvard School of Dental Medicine, identified two factors as the biggest causes of failure for a dental-implant system: low-density bone and pre-existing chronic inflammation from advanced periodontitis or other causes. AO and Institute for Dental Implant Awareness (IDIA), which is a specialist association, say the risks that are involved in placing a dental-implant system—damage to a nerve or sinus cavity, incorrect placement of implants and misidentification of adequate bone mass—are magnified when the practitioner lacks hands-on training.

“Weekend” courses typically don’t provide the hands-on training that a residency-based program does, says Dr. Joseph Gian-Grasso, who is the president of AO and a periodontist. He says the quality of training in placing dental-implant systems has become “highly variable,” which can affect patient care.

AO recommends that dentists have at least 1 year of training from an academic institution before he/she places a dental-implant system. IDIA says dentists should have at least 60 hours of course curriculum in placing dental-implant systems. An abbreviated training course won’t provide enough time to address in depth how to determine whether a patient has the proper bone density for a dental-implant system and complications that can arise during the procedure, says Cynthia Bollinger, who is the director of IDIA.

Survey data from American Dental Association (ADA) show that dentists who train in specialty programs average 102 hours of training in placing dental-implant systems. Dental schools typically provide 31 hours of such training. Manufacturers of dental-implant systems typically provide 49 hours of training during their weekend courses, ADA’s survey shows. We asked ADA how much training that it would recommend, but it didn’t give us an answer.

We didn’t find any data that track the number of dentists whose training in placing dental-implant systems is limited to short seminars. However, we spoke with three dentists who conduct seminars about dental-implant systems, and they claim to have trained “thousands.”

After consulting with 12 experts, we believe that the best advice is that you should ask about your dentist’s background, experience and training before you go ahead with a dental-implant procedure. You should make sure that your dentist has at least 1 year of experience in placing dental-implant systems and has experience placing dental-implant systems in challenging situations, such as in patients who have jawbone deficiencies, a history of mild gum disease or a history of smoking.

 You also should make sure that your dentist and your hygienist will provide you “continuity of care” for at least 1 year after your dental-implant procedure. In other words, you want to make sure that the same professionals who placed your dental-implant system will perform your subsequent checkups. Continuity of care is particularly important for dental-implant systems, Otomo-Corgel says, because the dental-implant system has to be monitored closely for any signs of periodontic disease.

ONE-STOP IMPLANTS. Besides the fact that more dentists place dental-implant systems than ever before, more dental-implant centers opened in the past 5 years. According to ADA, the number of U.S. dental-implant centers increased to 2,500 in 2011 from 2,000 in 2009, which is the most recent data that are available.

One advantage of a dental-implant center is that you typically get an all-inclusive cost estimate. We found that a consumer might save up to $1,000 on a one-tooth dental-implant system at an all-inclusive center. If you pay for each element of a procedure separately, then you might get separate bills for the dental-implant system, your anesthesia, your CT scan and the surgery itself. A CT scan from outside of a dental-implant center can cost $250–$1,000.

Another advantage of dental-implant centers is that they typically provide 3-D CT imaging, which gives a dental surgeon a better picture of bone volume and facial anatomy than do X-rays, which might be all that’s available at a dentist’s office.

REPLACING A TOOTH. At least 400 dental-implant systems are available in the United States, and they typically cost $1,000–$5,000 per tooth. All systems include three components: the implant (artificial root), the crown (artificial tooth) and the abutment (connector that joins the crown to the implant).

REPLACING A TOOTH. At least 400 dental-implant systems are available in the United States, and they typically cost $1,000–$5,000 per tooth. All systems include three components: the implant (artificial root), the crown (artificial tooth) and the abutment (connector that joins the crown to the implant).

American Academy of Implant Dentistry

The staff at a dental-implant center typically has sufficient experience, Otomo-Corgel says. However, we also found that most dental-implant centers tend to overstate the speed of their implant procedures. ClearChoice, which is the largest chain of dental-implant centers in the United States, claims to deliver “new teeth in just one day.” We found that the ClearChoice process actually involves a minimum of five visits: an initial consultation, a preprocedure finalization of the treatment plan, the dental-implant-system surgery and placement of temporary crowns, a post-procedure checkup and the installation of the permanent crowns. This timeline assumes that you don’t have to have bone grafts, which is an additional procedure that can cost thousands of dollars and require at least 6 months for healing before a dental-implant system can be placed.

Make no mistake: It’s a good idea to get a dental-implant system quickly after you lose a tooth. In the first year after you lose a tooth and its roots, 25 percent of the underlying bone’s density will decrease, experts say. If only a single tooth is missing, then the surrounding teeth will help to limit the amount of bone loss. However, if you’re missing at least two teeth and you wait for more than a year, bone grafts might be required to secure the dental-implant system to your jawbone. Acting quickly preserves bone, because implants typically are made from materials, such as titanium, that provide the most stable foundation for bone to grow, experts tell us.

A debate among dentists is when and whether it’s advisable to do immediate loading, which is the placement of a crown in occlusion—meaning that it touches the corresponding tooth on the opposite jaw and is subject to biting forces—within 24–48 hours of receiving a dental-implant system. Immediate loading is the key to the ultrafast “teeth in a day” concept at dental-implant centers. Almost all of the experts whom we interviewed tell us that immediate loading can be done safely as long as the dental-implant system immediately demonstrates “primary stability,” which means that no movement exists. However, patients who have thin bone structure aren’t candidates for immediate loading, because the bone has to grow to the surface of the implant to keep the dental-implant system stable.

All experts say the safest approach is the traditional process of delayed loading, in which an implant is given at least 3 months to osseointegrate in a lower jaw (mandible) and 6 months in the upper jaw (maxilla) before the crown can be attached and full bite force can be applied.

RANGE OF PRODUCTS. At least 400 dental-implant systems are on the market, compared with roughly 100 in 2000. In the ultrapremium range ($4,000–$5,000), the latest dental-implant systems are designed by computers for each patient with the help of 3-D printing. The market is so competitive and volatile that many manufacturers of dental-implant systems won’t exist in 5 years, Otomo-Corgel says.

If you have a problem with your dental-implant system and the manufacturer isn’t in business, then you might have a difficult time finding the necessary components to repair your dental-implant system, Otomo-Corgel says. Consequently, you should ask your dentist how long the manufacturer of the dental-implant system has been in business, how familiar your dentist is with the quality of the dental-implant system and what product support the company has in providing components to repair a dental-implant system.        

As part of the increase in the number of dental-implant systems, the number of less expensive “mini” dental-implant systems has increased in the past 5 years. We found that a mini dental-implant system generally costs half of the price of a standard dental-implant system, because no surgery is involved and the components of the system are less expensive. Standard dental-implant hardware typically costs between $1,800 and $2,500 per tooth, while mini dental-implant hardware ranges from $300 to $900.

The diameter of mini implants ranges from 3 mm (one-eighth of an inch) to as little as 1.8 mm, which is less than half of the size of those that are used for standard dental-implant systems. That means that mini dental-implant systems require less bone, which makes them an option for people who have little bone or can’t afford a bone-grafting procedure.

Experts say mini dental-implant systems are less invasive to place than standard dental-implant systems are, because the mini implants generally can be inserted directly through the gums and into the jaw. The procedure is less painful than conventional implantations are, and healing goes faster, according to Todd Ellis Shatkin, who founded International Academy of Mini Dental Implants, which is a trade organization. Almost all experts agree that a mini dental-implant system is a good solution for patients who can’t afford a conventional dental-implant system or don’t have the necessary bone density.

“I am convinced that [mini dental-implant] placement followed by placement of a well-made overdenture is a financially feasible, highly successful and much appreciated solution for these unfortunate patients,” says Dr. Gordon Christensen, who places dental-implant systems.

Six years ago, mini dental-implant systems were used as a means of securing a temporary bridge, crown or denture after a standard dental-implant system was placed, so the standard implant had enough time to integrate into the jawbone. Now, we found that most dentists will place a mini dental-implant system as a substitute for a conventional dental-implant system. However, almost all experts with whom we spoke agree that a mini dental-implant system has a substantially lower bite-force tolerance than a standard dental-implant system does, which might make the mini dental-implant system more likely to break or move out of alignment over time. Bollinger says mini implants are too small to “get the kind of stable foundation that patients need to be able to have normal biting and chewing forces.” However, she acknowledges that certain patients aren’t candidates for a conventional dental-implant system or can’t afford it.

Unfortunately, even though the expanded uses for mini dental-implant systems started 10 years ago, no independent evidence exists on the long-term viability of mini dental-implant systems. As with standard dental-implant systems, success rates measure how well that the mini dental-implant system was placed in the bone rather than how well that it stood up to long-term use.

Now, that’s something to chew on.

Tracie L. Thompson has covered health topics for 30 years. She has written for Cardio, Cleveland Clinic Magazine, Diagnostic Imaging and Health Measure.

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