Preservation Instinct by Dr. Brian S. Gurinsky

While dental implants have become common, should we really be aiming to preserve natural tooth instead?

by Dr. Brian S. Gurinsky

• Chewing and digestion. Teeth play a vital role in the chewing process, breaking food down into smaller pieces for easier digestion. Losing teeth can make it difficult to chew properly, leading to digestive issues and potentially affecting overall nutrition.
• Speech. Teeth also contribute to clear speech. It can take a period of adjustment to learn to use proper diction without natural teeth.
• Preserving jawbone density. Teeth stimulate the jawbone when you chew, helping to maintain bone density. When a tooth is lost and not replaced, the underlying jawbone can deteriorate over time, leading to changes in facial structure and potential problems with denture fittings.
• Preventing tooth misalignment. When a tooth is lost, neighboring teeth may start to shift or tilt into the empty space, causing misalignment. This can lead to bite problems, jaw pain and an increased risk of developing dental issues such as cavities and gum disease.
• Maintaining aesthetics. It can be much more challenging to attain ideal aesthetics with implants.
• Preserving oral health. Saving teeth helps maintain the natural balance of the mouth, reducing the risk of oral health issues such as gum disease, decay and infections.
• Cost-effectiveness. Restoring or saving a tooth through procedures such as fillings, root canals or crowns can be more cost-effective in the long run compared with tooth replacement options such as dental implants or bridges.
• Functional benefits. Preserving natural teeth allows for better biting force and chewing efficiency compared with artificial replacements.
• Psychological well-being. Having a healthy, complete smile can positively affect a person’s mental well-being, boosting self-esteem and overall quality of life.

• Natural appearance. Dental implants are designed to look and feel like natural teeth, providing a more aesthetically pleasing result compared with other tooth replacement options.
• Durability. Implants are durable and can last for many years—possibly a lifetime, with proper care. They are made from biocompatible materials such as titanium that integrate with the jawbone, providing stability and strength.
• Improved speech and chewing. Unlike removable dentures, implants allow for better speech and chewing function because they’re securely anchored in the jawbone.
• Preservation of jawbone. Implants stimulate the jawbone just like natural teeth, helping to prevent bone loss and maintain facial structure.
• No damage to adjacent teeth. Unlike dental bridges, which require the preparation and alteration of adjacent teeth, implants don’t affect neighboring teeth, preserving their natural structure.
• Easy maintenance. Implants are cared for just like natural teeth, with regular brushing, flossing and dental check-ups. There’s no need for special cleaning solutions or adhesives.
• High success rate. When placed by a skilled dental professional and with proper postoperative care, implants have a high success rate, typically exceeding 95%.

• Cost. Dental implants can be more expensive up front, compared with other tooth replacement options such as dentures or bridges. However, they’re often considered a long-term investment because of their durability and longevity.
• Surgical procedure. Implant placement requires oral surgery, which may involve some discomfort, swelling and a recovery period. Patients should be in good overall health to undergo the procedure.
• Healing time. The process of osseointegration, where the implant fuses with the jawbone, can take several months. During this time, temporary restorations may be needed before the permanent crown or prosthesis is attached.
• Potential complications. While rare, complications such as infection, implant failure, nerve damage or sinus problems can occur. These risks are minimized with proper treatment planning, adherence to postoperative instructions and regular follow-ups.
• Not suitable for everyone. Some individuals may not be suitable candidates for dental implants because of insufficient jawbone density, certain medical conditions or lifestyle factors.
• Require good oral hygiene. Maintaining good oral hygiene is crucial for the long-term success of implants. Poor oral hygiene can lead to complications such as periimplantitis (inflammation around the implant that has led to bone loss) or perimucositis (inflammation around the implant that affects only the soft tissue).

• Poor bone quality or quantity. Sufficient bone density and volume are necessary for successful implant placement and osseointegration (fusion of the implant with the jawbone). If the patient lacks adequate bone support or has poor bone quality, the implant may not integrate properly, leading to failure.
• Infection. Infections can occur during or after implant surgery if proper sterilization protocols are not followed or if the surgical site becomes contaminated. Periimplantitis can compromise osseointegration and cause inflammation, bone loss and implant failure.
• Insuficient healing time. Osseointegration requires adequate healing time. If the implant is subjected to excessive force or pressure too soon after placement, it may fail to integrate properly.
• Smoking and tobacco use. Smoking and tobacco use can impair blood flow and hinder the body’s ability to heal, increasing the risk of implant failure. Nicotine and other chemicals in tobacco products can also contribute to gum disease, which is a common cause of implant complications.
• Medical conditions. Certain systemic conditions such as diabetes, autoimmune disorders, osteoporosis and uncontrolled periodontal disease can affect the body’s ability to heal and may increase the risk of implant failure. Studies have also shown a higher rate of implant failure from patients taking antidepressants (SSRIs), medications for GERD (proton pump inhibitors), high-cholesterol meds, antihypertensives, bisphosphanates for osteoporosis, autoimmune disease medications (Methotrexate), chronic usage of NSAIDs, some antibiotics (fluoroquinolones), and those who have a deficiency in Vitamin D.
• Poor oral hygiene. Inadequate oral hygiene can lead to plaque buildup around the implant, increasing the risk of periimplantitis and gum disease. Proper brushing, flossing and regular dental checkups are crucial for maintaining oral health and implant success.
• Overloading. Applying excessive pressure or force on the implant during the healing phase or after crown placement can strain the implant and surrounding bone, leading to failure. Patients should follow postoperative instructions and avoid habits such as chewing hard foods or using the implant as a tool.
• Improper placement. Incorrect placement of the implant in terms of depth, angle or position can compromise its stability and integration with the jawbone, increasing the risk of failure.
• Allergic reactions. Rarely, patients may experience allergic reactions to implant materials such as titanium or components used in the restoration. This can lead to inflammation, implant rejection or failure.
• Implant design or quality. Poorly designed implants or substandard implant materials may contribute to implant failure. Using high-quality, FDA-approved implants and components is essential for long-term success.

• Open-flap debridement, with or without bone grafting. The goal of this treatment is to retract the gingival tissue to expose the entire root surface and alveolar bone. This allows the clinician to have improved visibility and access, thus allowing more effective root debridement and defect debridement. When the bony defects are amenable to grafting (more on that later), the clinician has the opportunity to graft the bony defects (known as guided tissue regeneration). Flaps are often apically positioned in a further effort to reduce pocketing.
• Osseous surgery, with or without bone grafting. Similar to open-flap debridement but also involves recontouring the alveolar bone. The rationale for recontouring the bone is to reestablish the physiologic architecture of the bone, which would mimic the architecture in a healthy situation. When there are bony defects that are amenable to grafting, the clinician has the opportunity to graft the bony defects.
• Laser treatment. Essentially, this is surgery but does not require reflecting a flap. It is a less invasive and less painful treatment option for the patient, but patient selection is important and only a few lasers have been shown to have merit.
• Crown lengthening. While this is not a technically difficult procedure to perform, case selection is highly important. There is a limit to how much we can lengthen a crown before we start to compromise the supporting bone on adjacent teeth and before we start to create an unaesthetic result.
• Orthodontic eruption/forced eruption. In a nutshell, this is using orthodontics to move the tooth coronally to create more tooth structure to restore.

Dentaltown editorial advisory board member Dr. Brian S. Gurinsky was born in Dallas and attended college at the University of Texas at Austin. He continued his education at Baylor College of Dentistry in Dallas, where he obtained his Doctor of Dental Surgery. After graduation, Gurinsky began a three-year residency in periodontics and dental implants, and earned his certificate in periodontics from the University of Texas Health Science Center in San Antonio. He has private practices in Denver and Centennial, Colorado.