May 042015

Short Answer: No, it’s not.

Long Answer: Dentists don’t bring up the topic of implants when discussing a missing tooth for many reasons. Many times, regrettably, it is because of financial considerations or simple ignorance.  One can assume the dentist has the best of intentions and simply thinks you cannot afford an implant or you cannot endure the procedure for some medical reason. These may be valid reasons, but they can be included in the conversation and in the final recommendations. But to omit the topic altogether is inappropriate. I don’t think there are any situations where at least the topic of implants shouldn’t come up when discussing a missing tooth. Some dentists are simply not comfortable with implants in general. They feel they are too complicated, time-consuming or they just don’t have a knack for them. That in itself is not a problem. I don’t like and am not necessary an expert at every possible procedure in dentistry; however, that doesn’t excuse the omission of such a treatment option and a referral to a dentist who can complete that part of the treatment if the patient ultimately chooses to have an implant.

Some dentists don’t discuss implants because of their own financial considerations. It is usually advantageous for a dentist to do one of the other options before recommending an implant for several reasons: When a dentist recommends an implant, he typically first makes a referral to a specialist (like a periodontist or oral surgeon) to surgically place the implant. This may account for half of the total fee which is now being charged by someone else, that is, if the patient ever goes. It has been cited that over 35% of patients being referred to a surgeon for an implant never actually go [The Journal of Dentistry, 38, 173-181. Levin, R. (2004) Implant dentistry and patient financing.]. So there is already a good chance that more than a third of patients will never follow through and the dentist will never profit from any procedure. For those that do make an appointment and have an implant placed, there is usually a healing period of 3-6 months before the newly placed implant is suitable to get a new crown on it. This is yet another 3-6 months that the dentist has earned no money. Many things can happen in that time: the patient could move, run into financial trouble, have changing life circumstances, new medical issues, etcetera. Should any of these happen during the 3-6 months of waiting, once again the dentist will not see a penny of profit. Assuming everything falls into place and the patient has an implant placed and waits the 3-6 months, then the dentist’s profit is still not all it could have been. Although it depends on where the dentist is located, a typical fee for a crown and abutment (the part between the implant and the final tooth/crown) may be $2,200. From that, the dentist must pay a special laboratory to make everything, not to mention other parts, pieces and materials which could easily add up to about $700. All in all, the dentist may spend about 1 hour 30 minutes to do everything needed from start to finish. With a gross profit of about $1,500, this translates to $1,000/hour. Although it sounds like a lot, it is important to re-emphasize that this is gross profit, not what the dentist takes home. But in any case, there is more to be made with alternative procedures as is shown next.

Instead of an implant, the dentist could do a bridge (two crowns connecting a fake tooth between them which fills the gap). When a dentist does a bridge, the finances skew more in the dentist’s favor. A “3-unit” bridge for one missing tooth may cost the patient about $3,000. Unlike with an implant, the patient does not get referred anywhere else and the work can start immediately. Also, laboratory fees for a bridge are usually less than for an implant because the work does not need to be as precise and there are fewer specialty parts involved. But for the sake of comparison, let’s say the laboratory charged the same $700. In this case, the dentist made $2,300 and the money was collected immediately. In total, the dentist spent approximately 2 hours doing this procedure from start to finish. This translates to $1,150/hour (about 15% more than when doing an implant). So from purely a financial standpoint, what makes more sense for the dentist: Recommending a procedure that he may (if all the stars align) profit $1,500 from in 3-6 months or one where he will profit $2,300 from immediately? Bottom line: some dentists may see no financial reason to offer or even discuss implants in their practice. If you are missing a tooth and there is no mention of an implant, consider getting a second opinion.

Nov 272014

Short Answer: No

Long Answer: I’m not really sure why well-educated dentists still propagate this old-wives tale. The idea is that as the wisdom teeth erupt (or try to erupt), they will push your other teeth forward and cause them to crowd together. Some dentists use this as a reason to convince patients to have wisdom teeth removed. First let’s get the facts out of the way: This has been studied extensively and it is a myth – plain and simple.

Just one of many studies [J Am Dent Assoc. 1992 Aug;123(8):75-9]

OK, now let’s put the research away and just use some good judgement. Most people have 16 teeth on the top and 16 on the bottom. Four of those are wisdom teeth. Sometimes wisdom teeth don’t have enough room to grow out or they may be growing out at an angle (thereby getting stuck under the molars in front of them). Now how in the world can 2 teeth move 14 other teeth with long, well-establish vertical roots forward? That’s physically not possible. Imagine trying your hardest to push 14 burly rugby players huddled together all by yourself. Good luck. Also, if wisdom teeth really did push your other teeth forward, why then do the wisdom teeth stay stuck under the gums or at their obscure angle? One would think they should eventually get all those teeth out of the way and come out normally, but of course that does not happen. Lastly, many patients are shocked to notice their teeth getting crowded and they proclaim in an exasperated tone, “How come this is happening? I had my wisdom teeth taken out!”. In other words, crowding continues to happen even when there are no wisdom teeth present. This puts a big hole in the myth about wisdom teeth crowding other teeth. In fact, we see teeth crowding even when a patient has no back molars at all.

So what does cause teeth to crowd? There is a natural process that occurs every time you chew which compresses your teeth towards the front of your mouth. Teeth are naturally tipped slightly forward so every time you take a bite, they get a little shove forward. It is a very slow process but it happens a little more every day (to most people but not all). From an evolutionary standpoint, there were no dentists in ancient times. People lost teeth throughout their life. Chewing on a tooth here and tooth there is very inefficient while chewing on a grouping of teeth is much better. As long as teeth keep drifting forward, spaces between teeth were minimized as they clumped together. The end result was a happy well-fed Neanderthal.

There are very good reasons to have wisdom teeth removed and I will cover the subject in more depth in future posts. But removing them because they are crowding your teeth is not one of those reasons.