Because tooth-loss so often creates long-lasting and generally negative effects for personal health and, not infrequently, appearance – the entire array of tooth replacement options has long been an important subject in the dental field. Dentists not infrequently discuss which options are best for their patients, given different circumstances. And if there is any debate in the profession at all, you can be sure the public will also question which options make the most sense for them.
The truth is there is no one right answer. Each person’s circumstances differ – whether the reasons are anatomic, functional, emotional, or financial.
But the question is still an important one to ask, because patients face new realities when they lose even one tooth. These changes include (but are not limited to):
And, then there are the secondary effects:
Poor health resulting from a changing diet
An inability to wear dentures
Financial challenges created by the need to address these problems
It is this last point that I want to touch upon here, because I have observed a good deal of confusion surrounding dental implants. As a dentist, I am obligated to review all options with an individual when discussing their tooth replacement options – regardless of affordability. I can’t, and don’t, pre-judge anyone financially when discussing their choices.
Commonly, though, when I raise the subject of dental implants, I get an immediate reaction along the lines: “Oh, forget it. I could never afford that. How about a bridge?”
Now, I’m not going to try to convince you that implants are cheap. Restore a full mouth with dental implants and it is likely to be costly. Nevertheless, cheap is relative. For some of my patients, even a small filling can be perceived as expensive. For my wealthy patients, they might be prepared to spend any price for what they perceive will serve them best. Lucky them. Right?
What I hope to do here, however, is to show you when an implant may make the most sense for a person. And — at least, when when it comes to replacing a single tooth — a dental implant may just be the way to go.
But first, permit me to remind you again – there is no one right answer for everybody. Your choices may be very different depending upon whether you are 25 or 85 years old, for example.
I’m sure you can fill-in still other reasons that affect your decision-making process. But for now, let’s consider the following scenario:
A patient loses one tooth.
For the sake of argument, we’ll call it a lower right first molar. Suddenly, the patient realizes this is annoying. Their bite is changing; their gums are sore. They feel the need to do something. Now.
Here are a few options. I’m just going to list the main ones, but there are sub-sets to some of these:
Do nothing anyway.
A removable denture.
A non-removable bridge,
A dental implant.
For the purposes of this discussion, the patient has already decided that doing nothing isn’t working for them.
So, the next option is a removable denture. I usually get “the face” on this one.
And with good reason. Food gets caught around partial dentures every time you eat. You will have to remove the appliance after EVERY meal and clean it separately from your own teeth. Certain foods will also cause it to dislodge as you eat, allowing some of the food to get caught between the denture and your gums. The cost – depending upon what kind of partial you have made – will typically range between $750 and $1,500.† The recommended replacement time: every 5 to 7 years. The reality – people replace them roughly every 15 years. Sometimes more. The longer they put off the replacement though, the more issues they may face with the replacement.
Bottom line: Removable dentures are potentially uncomfortable. Average lifetime replacement cost if you are 25 years old, (based on an average life expectancy of about 79 years, and an average 10-year replacement rate – not adjusting for inflation) is going to be nearly $7,000.
Next, we’ll take up considering a “bridge.” It’s called a bridge because it spans a gap (like a bridge spans a body of water) with a fake tooth, or teeth, in between the ones that are still there. The trouble is that you must shave down the supporting teeth to little stubs so that the result will look natural and be strong enough to take the force of daily chewing. For the most part, bridges look, and can often feel like, your natural teeth; but you do have to floss under the fake tooth after every meal. Food will get caught under there, whether you perceive it or not. If you don’t clean it regularly, the life expectancy of your bridge will be shorter.
Now, the cost on this option can really be widely variable, because some teeth need to have fillings replaced before they can be used as supports for the bridge. In other cases, the teeth may end up with root canals if the process of shaving them down results in lingering sensitivity. This doesn’t always happen, but it is a risk. If the tooth needs that additional treatment it will cost you more.
The average cost to replace a single tooth with a bridge is about $3,500. Again, that can be a little more, or less, depending upon what part of the country – or even what part of a city, you live in.
If, on the other hand, you also need to place or replace fillings on the teeth being used as supports, and you need to do root canals as well, it could be as much as $7,000.
The average lifetime replacement cost with the same parameters given above (25 years old with an average life expectancy of 79 years and a 10-year average replacement rate) is going to be: $31,500. And that assumes that the underlying teeth will be strong enough to survive that many replacements.
That brings us to dental implants.
Here is the breakdown: The average implant cost in many metropolitan areas is around $1,800 – $2,200. If you end up needing a bone graft before the implant can be placed, though, add another $550. (Basically, a graft is adding bone to your jaw when you don’t have enough for the implant.) So far, these costs are just for the implant. It doesn’t include the cost of the crown. Add about another $2,100 for the parts needed to make up what supports the crown above the gumline, and the crown itself. If your tooth is short, and there isn’t enough tooth height to which your crown can be easily cemented, you might need something called a UCLA abutment — it lets your dentist screw down the crown instead of cementing it. That could cost you more. How much depends upon the lab your dentist uses, but $500 more wouldn’t be unusual.
On the low end, one implant may cost $3,900. On the high end, let’s round up to $4,900.
So, what about the average lifetime cost?
That’s less than either partial dentures or bridges!
Because, unless you bite into a rock, grind your teeth uncontrollably, or have some serious illness that causes you to lose bone around the implant – any of which can happen to you with the other options as well – you will probably have your implant for life. Still, no one can guarantee this because, sometimes, plain ol’ dumb luck will factor into any equation.
But, you can’t get a cavity on an implant. On the other hand, you still can get a cavity on the teeth that support your partial denture, or bridge (and crowns, for that matter).
So, do the math. Look at your circumstances, and decide what is right for you. But when your dentist starts talking to you about dental implants, hear them out. It just might be more cost effective than you realize.
† [Note: The prices mentioned here are just averages in US Dollars at the time of this writing. Actual costs could be more, or less, depending upon where you live.]
I haven’t written anything to the blog for some time now. Like so many people I know, I have been busy with other projects. Every now and then, though, something will come up and I find I tell myself, “I need to write about that”. Recently, an exchange with a patient prompted me to write on the subject of how much time a patient might expect from a crown or a bridge.
What I found interesting was this patient’s viewpoint about something that was happening with her relative. It seems that this relative was experiencing a problem that required she/he have a crown re-made. My patient, made an off-hand comment to me along the lines that her relative’s dentist might not have been so great because the crown was having to be redone.
I’m thinking: Oh, it must have just been placed recently.
She’s thinking: After about twenty years.
Granted. My patient has not (yet) had to replace any of her dental work and she has been with me nearly twenty-five years.
But here’s the thing: as a dentist when I hear that a crown lasted twenty years, I think – “Sounds like that dentist did a pretty good job.” It seemed to me, my patient had an entirely different impression.
I asked her: “Did you realize that the average life for a crown or bridge is only between 5 and 15 years?” My patient seemed a little alarmed by that, but acknowledged she did not realize it.
There are so many factors that can go into how long a crown or bridge may last, that this can be really difficult to predict. The five- to fifteen-year figure often cited by dentists is based upon university studies and insurance company estimates of how frequently they need to be replaced. Most insurance companies will pay for a new crown after five years, although, a number of them have recently extended that replacement date to 7 or even 8 years.
In all fairness, sometimes crowns can fail due to manufacturing errors. But the reality is that this is very seldom the case. More often it is the patient that fails the crown.
How so? There are two main reasons: decay under a poorly maintained crown and tooth clenching and grinding.
But here are a few other ways a crown can break –
Removing bottle caps
Cracking crab claws
Holding roofing nails
Tearing open cellophane packages
Inappropriate use can cause porcelain that is veneered onto a metal base to break off. Using common sense is important.
Provided a crown is manufactured to high standards, after choosing the right material for you, and having it fitted correctly to your bite it has the potential to last a lifetime.
Home care has something to do with it too.
In my twenty-five years of practice, I have seen this repeatedly. For me, two cases have illustrated it best:
Earlier in my career, I had a patient who needed a lot of dental work. He already had quite a bit done, but much of it was pretty old and, frankly, it didn’t look very good. It’s actually uncommon for me to see work that I believe wasn’t done carefully, but if any situation fit that bill, this was it. His crowns fit like “socks on a goose.” I don’t know where he had it done and, at this point, it really isn’t the moral of this story. The important thing is that this work was, apparently, what he could afford at the time. What amazed me was that these crowns were still functioning after more than twenty years. There was no reason they should have. They fit that badly. So, why were they working? This patient’s home care was excellent. He brushed and flossed after every meal. He knew that getting new dental work was going to be costly for him, so Mr. Flosser he made sure that what he had lasted him. I was impressed.
Not too many years thereafter, I saw a different patient for a new patient exam. This man had bridgework from ear to ear. Honestly, it looked great. Pretty much everything about his crown and bridge work was technically correct. The bite was good, they were esthetic, and when I took his diagnostic x-rays, I noticed that the critical areas fit perfectly. Someone obviously took a great deal of care to make sure that they delivered a great product to this patient. I would have gone to that dentist.
But another thing that I observed when I reviewed the films was that there was decay all over the place. So much, in fact, that the only way to correct it would have been to remove the bridges, clean out the decay and replace everything.
The likelihood that his dentist would have left behind that much decay is nearly zero. No one who took that much care into crafting his work would have allowed it. But the real reason I know that is this: during the course of my exam, I observed that this patient has so much plaque and garbage in his mouth, I doubt he ever brushed his teeth. It looked like he had just finished eating cottage cheese before he came in. The plaque was that heavy.
This man’s dental work was only between two and three years old. He probably paid a small fortune for it. It was that extensive.
Now, I had the unpleasant task of telling him my findings. To make a long story short, I never saw him again. Mr. Cottage Cheese probably thought I was trying to put one over on him. Nothing bothered him (yet!), and it was most likely inconceivable to him that he should have anything wrong in so short a time. And yet, it was not a promising scenario.
Today, however, an equally common cause of crown or bridge failure is tooth clenching and grinding. I have written about this epidemic elsewhere. But, if you grind or clench your teeth, things are just going to wear out a lot faster. It’s just common sense. If you had a choice of parking your car in the middle of a golf driving range or outside of the driving range, under which conditions is your car likely to end up with the better paint job?
Some people can place amazing forces on their teeth. When they do, if a tooth was in really bad shape before it was restored, the crown probably won’t survive the weak tooth. You need something of a substrate to support and retain the crown. The cement can’t be relied upon to do the entire job.
Also, to put things into perspective, the average force on a back tooth is typically around 75 pounds per square inch. When we chew, that goes up a little – maybe, to 80 or 90 pounds per square inch. Remarkably, some people have been recorded as having applied as much as 3,000 pounds per square inch on their teeth while sleeping. That can crack a virgin tooth, let alone one that has had any work done to it.
In the end, there really isn’t a simple answer as to how long a crown should last. It can vary. With all other factors being equal, I would hope for no less than seven years and consider anything beyond fifteen years “good.”
Many of my patients who are still with the practice after 25 years and that I still have the opportunity to examine, continue to have their original crown and bridge-work. But some have moved to other states, and others have passed away in their older years. Yet, much of what I can see looks pretty good. Some old crowns and bridges could use a face-lift. That usually means replacing it.
Every now and then, I wonder about those two patients I mentioned above: Mr. Flosser and Mr. Cottage Cheese.
Mr. Flosser may still be running around with those old crowns. Mr. Cottage Cheese is probably wearing dentures by now. . . .
OK. So let’s say it has been decided: you are a candidate for an implant.
You may have heard that getting an implant can take a long time. By contrast, you can have a bridge to replace your missing tooth in about two weeks or less. Isn’t that better?
Not so fast. It all depends.
Let’s look at a couple of scenarios. If you are replacing only one tooth and have two adjacent teeth here is what you should consider:
In order to place a bridge, you have to shave down those teeth so that they will support the bridge. This limits their longevity and may open the door to the need for additional work, such as root canal therapy in the future.
You should also understand that bridges don’t last forever. The national average, according to university studies and insurance company estimates, is only five to fifteen years. If, you are in your twenties, a bridge can turn out to be much more costly over your lifetime.
Let’s see how this plays out:
For the sake of argument, consider that a person has lost their first molar. The 2013 national average price for crowns (the individual units that make up a bridge) was about $1160. Since our hypothetical bridge has three units, that adds up to $3,480. If existing fillings need to be replaced due to decay, it could cost another $500. And if a root canal is needed because the filling is now closer to the nerve, this can cost as much as another $1,100 for a molar. Suddenly, the total bill can exceed $5,000 using our example.
In five to fifteen years the bridge may need replacement. Let’s be generous and say it lasts fifteen. Between the ages of 25 and 85, that’s four replacements – nearly an additional $14,000 – if nothing else is needed.
In the long run, replacing one tooth using a bridge can cost nearly $20,000 over your lifetime. And that’s assuming it is still in a condition that permits a new bridge.
What if instead we replace the tooth with an implant? At today’s rates, a traditional root form implant runs between $1,800 and $2,000 in my area. An abutment (that’s the part which ties the implant and the implant crown together) will range in price from an average of $850 to $1,200. Prices for implant crowns vary widely – though many dentists charge the same fee as they do for regular crowns. In this example, we’ll use the fee given above, so $1,160.
If we take the higher estimates here, we’re up to $4,360. That’s only $880 more than our bridge in the earlier example’s “best case” scenario.
The difference? That implant (barring situations like an accident causing physical injury to the implant) has a good chance of lasting a lifetime. That’s a lot less than $20,000 over time if you go the bridge route.
I have had patients react in various ways to this analysis. Some tell me “I really don’t want to wait three to nine months, while wearing a temporary partial, for the implants to be ready.” Others have said, “Well, if I’m going to have to replace a bridge down the road, or even end up with an implant later anyway – I might as well just do it now.”
Both arguments have their merits. But at least now you have some information that can help you make an informed choice.
We hope we will never lose a single tooth. Unfortunately, it happens sometimes. We can lose a tooth for many reasons. I won’t delve into them in this article. The purpose here is to help you to decide between a bridge and an implant, in the event that you have to make that choice.
Just so we are clear: No two situations are completely alike. I have neither seen nor evaluated your case and am simply discussing general principles. You should always consult a competent and licensed professional to assess your specific circumstance before making a decision that will affect both your health and finances. Nevertheless, here you are. Either a tooth has been compromised and is lost already, or it is about to be extracted. If the idea of dental implants has crossed your mind, your dentist first has to determine whether you are a good candidate for the implants. The criteria can be broken down into three broad categories:
Do you have any medical issues that may prevent successful placement of an implant?
Do you have sufficient bone?
Will your existing bite allow it?
So let’s get into it:
1. Medical Issues. Health conditions that could prevent an implant being placed may include, but are not limited to:
Recent heart attack or stroke
Active treatment of malignancy
Intravenous bisphosphonate use
You should disclose anything you think could be a matter of concern with your dentist. The success rate with dental implants is very high, but careful case selection is the key to success.
2. Sufficient Bone. Again, this needs to be determined by the implant surgeon. Your bone needs to be high enough and wide enough to accommodate the implant. If it isn’t, you may still qualify for a dental implant, but will likely require an additional procedure called bone grafting. Your dentist or implant specialist will determine your specific needs.
3. Your Bite. What does the bite have to do with anything? There was a tooth there to begin with, right? Both implants – and natural teeth – survive longer when your teeth and jaw are in harmony. If your bite has collapsed – meaning the upper jaw and lower jaws are now too close to each other – there may not be enough room to place an implant without orthodontic (braces), or surgical, intervention.
Starting to sound a bit complicated? Don’t worry, in most cases, the dentist can tell you pretty quickly if he feels implants will work for you. Sometimes, he needs additional screening tools to make the final call but, if he does, he’ll let you know that too.
Dr. Richard Walicki is a Philadelphia dentist practicing general and cosmetic dentistry. While we hope you find the information contained herein interesting and useful, this blog is for informational purposes and is not intended to diagnose any oral disease. Dental conditions should be evaluated by your dental health professional or a qualified specialist.