Sonntag, 29. Dezember 2013

Direct pulp capping in a dental trauma case

Limits of restorative dentistry

Endodontics and Implantology - enemies or allies

The true cost of a dental implant (part 2)

Externalities in dental implantology


Commune cost efficiency analysis performed within the decision making process today in clinical dental practice do not consider the so called “external costs”.

What are external costs?

External costs occur within the production process of a good and are usually imposed on third parties (human society , nature, etc.). These costs are social costs and have to be added to the purchasing costs of a good.

Where do external costs come from?

The vast majority of dental implants available on the market are manufactured out of titanium alloy. Titanium is found to a number of different mineral deposits. Processing titanium is  very costly.

“The relatively high market value of titanium is mainly due to its processing, which sacrifices another expensive metal, magnesium”.[1] Manufacturing process is made using very high temperatures (high energy consumption) as well as involving further rare and difficult to manufacture chemicals (example: chlorine, which is very rare on earth). Due to its costly manufacturing process titanium is today priced 35 times more expensive than conventional iron manufacturing.

Dental implants are cut of titanium bars using expensive and sophisticated CNC machining technology generating titanium waste. A very demanding individual packing, sterilization and labeling protocol follows which after the utilization of the dental implant adds hard to recycle waste.

The manufacturing process of dental implants can be considered to generate very high external costs imposed upon nature and human society.

Only an ecological responsible implementation of dental implants within offered treatment solutions can justify the very high external costs.

[1] Barksdale, Jelks (1968). "Titanium". In Clifford A. Hampel (editor). The Encyclopedia of the Chemical Elements. New York: Reinhold Book Corporation. pp. 732–738.

Mittwoch, 25. Dezember 2013

The true cost of a dental implant

The true costs of dental implants (part 1)
Liviu Steier
A variety of different dentate and edentate clinical situations will require today consideration towards  treatment options of including a dental implant.
Among the non-arguable clinical indications where dental implants are to be primarily considered, are fully edentate patients with reduced bonny support and a high muscle insertion – here more often affected - the lower jaw, followed by the partially edentate patient with special emphasize on the well-known Kennedy classification (Glossary of Prosthetic Terms 2013)[1]:
Class I: Bilateral edentulous areas located posterior to the remaining natural teeth      
Class II: Unilateral edentulous areas located posterior the remaining natural teeth.
Class III: Unilateral edentulous area located both anterior and posterior to it.  
Class IV: A single bilateral (crossing the midline) edentulous area located anterior to the remaining natural teeth.       
More and more, dental implants are advised and placed today to replace diseased but savable teeth due to insufficient endodontic, periodontal and restorative education, knowledge, skills, expertise and technological availabilities under exposure and pressure to non-medical contributing factors. 
Cost efficiency analysis                is very often performed by dental practitioners to facilitate the decision making process with patients.[2]  Any cost efficiency analysis performed to critically appraise root canal treatment indication is doomed to fail by non-pecuniary reasons according to White et al. (2006)[3]       :
1.       Endodontics versus implant studies
Endodontic studies
Implant studies
“…few high-level studies have been published in the past 4 decades related to the success and failure of nonsurgical root canal therapy. Likewise, most studies of endodontic surgical outcomes are of low.”
“…evidence supporting dental implant therapy is generally derived from case series studies rather than from higher level cohort or controlled clinical trials.”
2.       Endodontic versus Implant success criteria
Endodontic success criteria
Implant success criteria
“Most endodontic studies report data in terms of success, not simply of tooth survival.”
“…implant studies classify outcomes in a 2-category outcome system (success/failure); whereas many endodontic studies use a 3-three category outcome system (eg, success/uncertain/failure), negating the ability to make direct comparisons of success rates.”
3.       Endodontic versus implant outcomes
Endodontic outcomes
Implant outcomes
“…a cumulative success rate of 83% for vital pulps and 79% for nonvital pulps.”
“…the available data weakly indicated that the … implants had a higher incidence of early failure, which sharply decreased over time; that the … implant with rougher surfaces a lower incidence of early failure, but an increased rate of failure over time; and that the … implants, with immediate loading, had a higher prevalence of late failures which was attributed to perimplantitis.”
4.       Complications
Endodontic complications
Implant complications
“…post and core prostheses had a substantially lower rate of complications than either fixed partial dentures or implant prostheses…”
“…there appears to be a greater number of clinical complications associated with implant prostheses than other types of prostheses.”
5.       Clinician Expertise, Experience, and Technical Quality
“Limited evidence suggests that operator experience or training and technical quality as measured by radiographs, has an influence on endodontic outcomes.”
“Some evidence suggests that general dentists can achieve results similar to those of specialists in single tooth replacement cases.”
6.       “Convenience”
      “…there are no data demonstrating that implants are broadly superior to natural teeth.”
7.       Costs
“…although the endodontic, restorative, and periodontic cost of retention was generally less than the cost of replacement by an implant-supported prosthesis, the costs could be close, and that the treatment plan should be based upon the prognosis of each tooth being considered. Certainly, more resources and time are needed for implant therapy than for endodontics and routine restorative procedures.”
Conclusions by White et al. (2006)
1. ”At this time, choices between implant and endodontic therapies cannot be solely based on outcomes measurement evidence. The existing evidence is inadequate and not amenable to direct comparison. Few useful consensus statements and standardized protocols exist. We suggest that the dentist be guided by Hippocrates: “As to diseases, make a habit of two things: to help, or at least, to do no harm.”
2. Although outcome data is inconclusive and not suited to direct comparison, endodontic and implant therapies profoundly differ in other ways, including biological processes, diagnostic modalities, outcome measures, failure patterns, failure modes, consequences, resources needed, and in some specific health care implications.
3. Although rigorous and clearly defined outcome measures have been proposed for use in endodontic and implant outcomes studies, they are very rarely used. The use of simple survival measures and life table analyses in combination with defined treatment protocols might allow a clinically relevant data bank to be efficiently realized.
4. Long-term, large, clearly defined studies, with simple and clear outcome measures are needed to measure the clinical performance of endodontic and implant therapies.
5. Outcomes information alone is insufficient to derive treatment matrices and clinical treatment decisions. Risk factors need to be identified and quantified.”
The true cost of a dental implant will have to imply more than just the price paid by the dentist to the manufacturer and the price paid by the patient to the dentist. This is why any cost efficacy calculation to influence the decision making process: to save or to extract is to be considered biased.
…and not to forget that manufacturing dental implants has an ecologic impact on our planet same as treatment procedures correlated to dental implant placement, bone augmentation, maintenance, etc.
It can be concluded that the true cost of a dental implant is different to the amount priced in a treatment plan guesstimate.

Part 2 to follow.

[2] Pennington MW, Vernazza CR, Shackley P, Armstrong NT, Whitworth JM, Steele JG. Evaluation of the cost-effectiveness of root canal treatment using conventional approaches versus replacement with an implant. Int Endod J. 2009 Oct;42(10):874-83.
Kim SG, Solomon C. Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and single-tooth implant alternatives. J Endod. 2011 Mar;37(3):321-5.
[3] White SN, Miklus VG, Potter KS, Cho J, Ngan AY. Endodontics and implants, a catalog of therapeutic contrasts. J Evid Based Dent Pract. 2006 Mar;6(1):101-9.

Mittwoch, 23. März 2011

An other case...

27 years yound female.

Medical history nil relevant.

Preoperative x-ray
12 weeks after extraction
X – ray post surgery showing two BioHorizons 3,5mm x 12mm internal taper

Inserted in area 46 and 47

Picture showing the master model at delivery session – abutments attached to mounting guide.
Intraoral clinical picture showing the healthy and mature gum profile before prosthetic loading.
Intraoral clinical picture showing the fitted restoration.
Intraoral clinical picture showing the bite situation and the optimal hygiene access areas
X-ray to check the correct fit.

Implant supported prosthodontics

69 years old male.

Medical history nil relevant.

Tooth 36 lost about 18 years ago. Tooth 35 lost about 10 weeks prior to fixture installation.

Fixtures installation in local anesthesia, crestal incison, ful flap raised, use of conventional surgical guide, drill protocol according manufacturer, fixtures inserted by hand, excellent primary stability, bone B-w, vestibular graft (BioOss) covered by membrane (BioGide), wound lips tightly closed by suture.

Suture removal after 14 days.

II nd stage surgery after 3 months. Local anesthesia, full flap raised, healing caps, wound lips sutured around.

Suture removal after 14 days.

Temporary abutments and temporary crowns to modelate mergence profile.

6 weeks later impression and FGP registration.

2 weeks later prosthetic loading.

X-ray performed after fixture installation.
Proof of healthy gum surroundings and prosthetic loading.

Clinical picture showing butments in situ.

Restoration delivered from the lab, splinted crowns PFM – high precious metal – occlusal screw access open – abutment mounting guide.
Clinical picture to demonstrate perfect aesthetic and functional integration into remaing dentition and excellent hygiene accessabilty.