Implantdentistry and related topics
created for education and demonstration purposes
Sonntag, 29. Dezember 2013
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
Endodontics
|
Implants
|
“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.
Part 2 to follow.
[1] http://www.academyofprosthodontics.org/_Library/ap_articles_download/GPT8.pdf
[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.
Montag, 2. Juli 2012
Freitag, 21. Oktober 2011
Dienstag, 2. August 2011
Mittwoch, 23. März 2011
An other case...
27 years yound female.
Medical history nil relevant.
Inserted in area 46 and 47
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.
Clinical picture showing butments in situ.
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.
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