Dental Treatment Options
Last updated in May 2015
Despite substantial progress in the prevention of caries and gum disease, most Americans’ mouths still bear witness to their ravages. Although the incidence of dental caries has fallen dramatically, about 70 percent of adults aged 35 to 44 have lost at least one permanent tooth, and about 30 percent of adults over age 65 are missing all their teeth. The usual procedures for repairing and replacing teeth have not changed in many years: drilling cavities and restoring with composite (tooth-colored) or amalgam (“silver”) filling, root canal therapy, placement of crowns, insertion of fixed bridges or partial dentures, and use of complete dentures. But progress continues on most fronts.
Below is a brief discussion of several repair and replacement procedures.
Dental implantation is a common restorative procedure in which a dentist inserts an “artificial tooth root,” usually made of titanium, into the jawbone. This artificial root can serve as the support for a crown or a bridge. If performed properly, the bone will heal directly to the implant material, and gum tissue will form a biological seal around the posts that protrude through the gums.
Implants aim to overcome some of the disadvantages of removable dentures. Because dentures are not permanently fixed in place, they can move when you speak, eat, or yawn. Dentures can also cause discomfort to gums when chewing or when food particles get lodged between dentures and gums. In addition, the bone that supports the dentures may shrink, resulting in a progressively looser fit and difficulty wearing the dentures.
The most common type of implant is a root-form implant. The below-gum portion of a root-form implant is inserted into a hole made in the bone. A post secured to this piece can then be used to secure a prosthetic device, such as a crown or a bridge, above the gum. The process involves inserting the implant and allowing the bone to attach to it over a period of three to six months before attaching the bridge.
While implants can have substantial benefits, the procedure is expensive—usually more than $3,000 for a single implant and more than $15,000 for multiple implants plus a complete set of artificial teeth for the lower jaw.
If you pursue the implant option, carefully select the dentist or dentists to do the work. Implants have increased dramatically in popularity and now represent a lucrative opportunity for dentists whose incomes are suffering from stiff competition and reduced demand for cavity treatment. As a result, some of the thousands of dentists who have begun performing implants may not be adequately trained. Oral surgeons and periodontists who do implants at least have extensive experience in the surgical aspects of the process, dealing with gums and bones. But problems of implant rejection, effects of stress from the attached appliance, and other issues require specific knowledge and experience.
We recommend that you solicit more than one opinion as to whether you are a good candidate for an implant and the specific implant approach that is best for you. It is a good idea to have the implant placed by a periodontist certified by the American Board of Periodontology or an oral surgeon certified by the American Board of Oral and Maxillofacial Surgery. Then have a prosthodontist (a specialist in dentures and other restorations) certified by the American Board of Prosthodontics prepare and mount the artificial teeth. Ask any dentist you are considering how many implants he or she has done, and obtain references. Discuss the particular implant technique the dentist plans to use—and ask whether it has been approved by the ADA based on clinical trials.
Bonding and Veneers
The process used to place sealants on the chewing surfaces of teeth to prevent cavities can also restore discolored, damaged, or missing teeth. When used in restorations, the process is called bonding.
The bonding procedure consists of roughening (or etching) the surface of the targeted teeth by dabbing acid, and then applying a plastic, or resin, to the roughened surface.
Bonding is used to place veneers on cracked, chipped, or stained front teeth. One technique is to mold soft composite resin onto the surface of the tooth, and then contour the hardened resin to the exact shape desired. Another technique is to bond a thin plastic or porcelain veneer, much like a false fingernail, to the front of a natural tooth.
The virtue of bonding, as compared to traditional capping procedures, is that it doesn’t significantly alter the natural tooth. By contrast, placing a traditional crown requires the dentist to grind away at least a portion—and sometimes most—of the natural tooth to secure the crown.
Bonding generally costs about one-third less than getting a conventional crown, and the bonding process is also quicker. For example, four front teeth can be treated with the bonding technique in a single office visit, while several office visits are required for a crown.
The use of bonding techniques has been restrained by several concerns. Because, until recently, the materials used in bonding procedures have been weaker than conventional crowns, they have been considered appropriate only for front teeth, which are exposed to less stress than molars. Indeed, patients with bonded coverings on their front teeth are often advised to avoid using these teeth to bite apples, carrots, and other hard foods. Also, bonded material has been susceptible to staining by tobacco, coffee, tea, and some foods, and bonded restorations have been less durable than traditional crowns. In addition, it has been difficult to match bonded materials to the precise color of a patient’s natural tooth enamel. But new processes and materials, including ceramics and composites, have gone a long way toward solving these problems.
If you are interested in having bonding work done, ask your dentist about his or her training and experience. To decide if you like the dentist’s sense of style, ask to see photographs of past work. Bear in mind that in poor bonding jobs the bonded material may come into contact with and irritate the gum.
In addition to providing a veneer for teeth, bonding can also secure fixed bridgework. The traditional approach for holding a false tooth in the gap between two natural teeth is to file down the natural teeth and cover them with a one-piece device that has the replacement tooth built into the middle. The bonding alternative is to extend “wings” on each side of a false tooth and bond the wings to the surrounding natural teeth—no grinding of natural teeth required. Unfortunately, this works only with adjacent teeth that have not been severely weakened by cavities.
Bonding can also secure orthodontic appliances to teeth. Performing bonding instead of wrapping bands around the teeth makes braces less conspicuous. In fact, braces can in some cases be constructed so that all wires are behind the teeth and not visible.
Root Canal Therapy
If the nerve or pulp of a tooth is diseased or injured, root canal therapy may be necessary to save the tooth. A small opening is made in the tooth, and the tooth’s nerve tissue is removed. The dentist will then clean out the tooth and reshape the canals inside the tooth roots. Each tooth may have anywhere from one to four root canals. The root system of the tooth is then sealed with a rubber-like material that allows the cells of the jawbone to maintain the tooth root without further infection or discomfort.
Root canal success rates are very high, and new techniques—particularly in imaging, instruments, and anesthesia—have made the procedure faster, safer, and less painful.
Don’t agree to a tooth extraction if you can possibly avoid it. Extraction is generally only one of several remedies—and usually the least desirable. Although pulling a tooth may seem more economical than, say, a root canal treatment, the long-term effects can be grave. For example, other teeth may shift in the direction of the space and place undue stress on the remaining teeth. On the other hand, retaining teeth with severe infection or bone loss can put adjacent teeth at risk and cause the loss of multiple teeth loss and other complications down the road.