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Received: 19 May 2019    Accepted: 21 May 2019

DOI: 10.1111/edt.12492

COMPREHENSIVE REVIEW

In the dental implant era, why do we still bother saving teeth?

Danielle Clark | Liran Levin

Division of Periodontology, Faculty of
Medicine and Dentistry, University of
Alberta, Edmonton, AB, Canada
Correspondence
Liran Levin, School of Dentistry, Faculty
of Medicine and Dentistry, University of
Alberta, 5‐468 Edmonton Clinic Health
Academy, 11405‐87 Avenue NW, 5th Floor,
Edmonton, AB T6G 1C9, Canada.
Email: liran@ualberta.ca
Abstract
Teeth are vital sensory organs that contribute to our daily activities of living.
Unfortunately, teeth can be lost for several reasons including trauma, caries, and
periodontal disease. Although dental trauma injuries and caries are more frequently
encountered in a younger population, tooth loss because of periodontal disease oc‐
curs in the older population. In the dental implant era, the trend sometimes seems to
be to extract compromised teeth and replace them with dental implants. However,
the long‐term prognosis of teeth might not be comparable with the prognosis of
dental implants. Complications, failures, and diseases such as peri‐implantitis are not
uncommon, and, despite popular belief, implants are not 99% successful. Other treat‐
ment options that aim to save compromised or diseased teeth such as endodontic
treatment, periodontal treatment, intentional replantation, and autotransplantation
should be considered on an individual basis. These treatments have competing suc‐
cess rates to dental implants but, more importantly, retain the natural tooth in the
dentition for a longer period of time. These options are important to discuss in detail
during treatment planning with patients in order to clarify any misconceptions about
teeth and dental implants. In the event a tooth does have to be extracted, procedures
such as decoronation and orthodontic extrusion might be useful to preserve hard and
soft tissues for future dental implant placement. Regardless of the treatment modal‐
ity, it is critical that strict maintenance and follow‐up protocols are implemented and
that treatment planning is ethically responsible and evidence based.

KEYWORDS
plaque, prevention, trauma

1 |  I NTRO D U C TI O N
Teeth are sensory organs that function in several different aspects
of everyday life. Mastication is an important role that teeth serve,
and the ability to chew food is associated with an individual's quality
1
of life. Other daily activities such as speech, and even smiling, are
done with one's teeth. As a result, teeth are important organs that
are associated with quality of life because of their role with esthet‐
ics, chewing, and speech. 2 When other organs in the body become
compromised, much energy is spent on preventing further damage
or even trying to reverse the damage. However, surprisingly, when
it comes to our teeth, patients and, sometimes, dental professionals
do not seem to value the preservation of them nearly as much. This
is a negative phenomenon because the more teeth a person has, the
more likely they are to have a higher quality of life.3 Unfortunately,
these vital organs are not invincible and can be lost because of several
reasons during one's lifetime. Periodontal disease, caries, and dental
trauma can all result in tooth loss across all ages.4,5 Furthermore, the
treatments provided to patients for periodontal disease, caries, and
trauma can also lead to tooth loss or poor prognosis.
In today's dental implant era, there are several treatment options
available to either save teeth or replace missing teeth. Periodontal

This article is being published concurrently in Journal of Endodontics. The articles are identical. Either citation can be used when citing this article.

Dental Traumatology. 2019;00:1–8. © 2019 John Wiley & Sons A/S and |  1
wileyonlinelibrary.com/journal/edt  
American Association of Endodontists
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2       CLARK and LEVIN
treatment, guided bone regeneration, supportive periodontal therapy,
endodontic treatment, and dental implants are all available. However,
before determining the treatment plan, the proper diagnosis must be
made, and, then, an unbiased assessment of the prognosis needs to
be performed.6 When evaluating prognosis, one should examine the
patient to assess the long‐term prognosis of the different treatment
options and determine which one will best serve the specific patient
in the long run. For instance, when assessing a diseased tooth, there
is a need to evaluate if taking the required steps to save the tooth will
lead to a better prognosis than extracting it and placing an implant.
In order to properly assess and evaluate treatment options for
patients, unbiased and evidence‐based understanding of the many
factors that contribute to the prognosis for teeth and implants is re‐
quired. Assessing the true prognosis of all options and considering
the best available evidence to support each and every decision is
crucial before proposing the options to the patient.
2 |  TO OTH LOS S A N D M I S S I N G TE E TH
Several studies have explored the epidemiology of missing teeth
related to dental trauma, periodontal disease, and caries. These
studies have limitations because of the difficulty in gathering a large
amount of data collected with different indices. However, several
studies are available to provide an overarching view regarding the
reasons for tooth loss.
In the United States, over 6 million people over the age of 50
were edentulous between 2009 and 2014.7,8 The average number
of missing teeth because of caries ranges widely; however, there are
reports that caries accounts for 8.35 of missing teeth (the M com‐
ponent of decayed missing filled teeth) in 20‐ to 64‐year olds. 5 The
same study reported that only 15.7% of the study population did
not have a tooth extracted.5 The reasons for extraction included
pain (34.6%), a large cavity (5.6%), periodontal problems (6.0%), and
endodontic problems (3.2%).5 Another study reporting on missing
teeth in 14‐ to 89‐year olds found caries accounted for 86.2% of
extractions, periodontal disease accounted for 6.6% of extractions,
and trauma for 3.9% of extractions.9 The younger population
(5‐12 years old) seemed to experience extractions mostly because
4
of caries (64.3%) and dental trauma (43.0%). European and US
studies estimate periodontitis to affect 31%‐76% of individuals.10‒13
This is significant because tooth loss because of periodontal disease
14‒16
averages 0.04 to 0.08 patient/year. When tooth loss is studied
according to age, 80% of extractions because of caries are experi‐
enced in people under the age of 40 years, and 70% of periodontal
17
extractions are experienced in people over the age of 40 years.
3 |  LO N G ‐TE R M PRO G N OS I S O F TE E TH
A N D I M PL A NT S
Despite the excitement and the promising results with dental im‐
plants, there are some misconceptions regarding the real longevity
Significance
Dental implants are a popular treatment option for pa‐
tients who are missing teeth. Nonetheless, several less
extensive and invasive treatment options that involve sav‐
ing the natural tooth are available and have good prognosis
and success rates. If these options are used first, the op‐
tion to place a dental implant is still available. If the dental
implant fails, we no longer have the option of restoring the
natural tooth.
of this treatment option. WebMD, a popular medical site, states
that dental implants have success rates of 98%.18 Other seemingly
credible sites also report success rates between 95% and 98%.19,20
However, what these sites are often reporting are the survival rates
of dental implants, not necessarily success, and for a very short
follow‐up time. A dental implant is considered “survived” if it is
still in the mouth, which means that this includes dental implants
with peri‐implant mucositis, peri‐implantitis, severe bone loss, and
sleeping implants. Nevertheless, research has shown that after 5 to
10 years 80% of implants presented with peri‐implant mucositis, and
12%‐66% had peri‐implantitis. 21‒24 A dental implant with disease can
hardly be called successful; however, patients do not receive this in‐
formation sometimes. Thus, it is extremely difficult for patients to
make an informed decision. Unfortunately, even having the dental
implant as an option can, unintentionally, bias treatment planning.
Therefore, it is the responsibility of the clinician to educate the pa‐
tient using the current evidence on dental implants and not opinions
or beliefs. 25
Dental implants often become a treatment option when a tooth
is either missing or has a hopeless prognosis because of caries,
periodontal disease, or trauma. However, a study in patients with
aggressive periodontal disease showed that teeth labeled as ques‐
tionable or even hopeless could be retained in the mouth for as long
as 15 years. 26 The available tools for establishing prognosis can
sometimes be pessimistic, can lack predictability, and may result in
clinicians extracting teeth too soon. 27‒29 Furthermore, the relative
novelty of dental implants means that there is a lack of long‐term
data on their success, and this is an important consideration before
an extraction followed by implant placement is planned.30
When patients are presented with an option of saving a diseased
or traumatized tooth, the comparison treatment option should not
be the ideal, healthy implant. Instead, it needs to be compared with
a realistic dental implant that might have complications such as peri‐
implant mucositis or peri‐implantitis. 21‒24 This is supported by evi‐
dence that shows implant survival rates are lower than teeth, even
when they are compromised but properly treated and maintained.30
A systematic review reported long‐term tooth loss rates to range
from 3.6%‐13.4%, whereas the rate of dental implant loss ranged
from 0%‐33%.31 Another review compared the survival of dental im‐
plants with endodontically treated teeth. The survival rates of dental
CLARK and LEVIN
implants ranged from 73%‐95.5%, whereas the survival rates of end‐
32
odontically treated teeth ranged from 89.7%‐98.1%.
The high survival rates of compromised teeth that were properly
treated and maintained were shown to surpass the survival rates of
dental implants in a long‐term follow‐up. It is also noteworthy that
extracting a tooth is an irreversible decision, and it cannot be un‐
done if a dental implant fails. Thus, the decision to extract a tooth
needs to be assessed thoughtfully.32
4 | K E E P TH E TO OTH
When it comes to a compromised tooth caused because of trauma,
caries, or periodontal disease, there are 2 main options: keep the
tooth or extract it. Keeping the tooth may not be an easy treatment
option. However, it is important to recognize that extracting a tooth
and placing a dental implant may include complicated procedures,
such as bone augmentation and soft tissue management. If the de‐
cision to keep the tooth is made, the following treatments may be
necessary to ensure better long‐term results.
4.1 | Endodontic treatment
Deep caries lesions as well as traumatic dental injuries such as extru‐
sion, lateral luxation, and intrusion can eventually lead to pulp necro‐
33,34
sis. In those cases, patients may require endodontic treatment in
order to save the tooth. In some severe cases, extraction might be
considered as an alternative treatment option. When these options
are provided to the patient, it is important to detail the pros and cons
of either case. A 2007 systematic review reported success rates of
primary root canal treatment ranging from 68%‐85%.35 A 10‐year
follow‐up of molars with endodontic treatment had a 89.2% success
rate, whereas another 10‐year follow‐up showed an 84.1% success
rate and a 93% survival rate.36,37 Other studies in adults have found
that survival rates after root canal therapy can reach 95% at 4 years
of follow‐up after primary or secondary (ie, retreatment) treatment,
whereas the success rates can range from 83% for primary treat‐
38,39
ment and 80% with secondary treatment. A detailed compari‐
son of endodontically treated teeth and dental implants by Setzer
32
and Kim showed that dental implants have a higher loss rate than
endodontically treated teeth. Based on the existing evidence, if a
F I G U R E 1   A patient with stabilized
periodontal condition on a significantly
reduced periodontium under supportive
periodontal therapy. The teeth are not
mobile, and there are no periodontal
pockets or active disease
|
      3
root canal treatment is possible, it may be a better option than dental
implants.32
4.2 | Periodontal treatment
When teeth are periodontally compromised, their prognosis is es‐
tablished, and again 2 main treatments are available: periodontal
therapy to retain the tooth and extraction. However, when it comes
to establishing prognosis for periodontally compromised teeth,
there is a lack of an ideal tool available to do this accurately. 29,31,40
Therefore, focusing on saving the compromised teeth is a treatment
option worth merit.
Periodontal treatment can encompass different surgeries, bone
augmentations, and supportive periodontal therapy. Supportive
periodontal therapy involves strict follow‐up, frequent scaling and
root planning, and, most importantly, oral hygiene education and in‐
struction. Periodontal treatment followed by proper supportive peri‐
odontal therapy showed great success in the literature and seems
to be dependent on patient compliance (Figure 1).41,42 If patients’
compliance is good, there is an increased chance of survival of the
compromised teeth.41,42 The survival of periodontally compromised
teeth that were properly treated and regularly maintained ranged
from 92%‐93%.30 Furthermore, even rates of survival of hopeless
and questionable teeth in patients diagnosed with grade C periodon‐
tal disease (formerly known as aggressive periodontitis) vary from
60%‐88%, respectively. 26 Thus, instead of extracting teeth because
it seems to be a less complicated treatment option, using periodon‐
tal treatment followed by proper supportive periodontal therapy to
retain periodontally compromised teeth should be prioritized.31 In
the event that this therapy is not successful and the tooth needs to
be extracted, there is still the option of a dental implant because a
backup will have 10‐year survival rates of 82%‐94%.30
4.3 | Intentional replantation
Even if a periodontally or endodontically compromised tooth is
not salvageable, a dental implant may not be the next treatment
in line. Intentional replantation involves purposefully extracting
a compromised tooth and replanting the tooth into its socket.43
Although intentional replantation is considered as a last resort
treatment option, the treatment was reported to have a 90%
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4       CLARK and LEVIN
success rates in the first 6 months.43 Between 6 and 12 months,
the survival rate decreased from 85% to 80%, and after 48 months,
the survival rate of replanted teeth stabilized.43‒45 A meta‐analysis
of 6 studies also showed a high success rate of 89.1% of intention‐
ally replanted teeth.46 The success of this procedure is influenced
by several factors including the extent of periodontal disease and
the presence of root fracture. Nonetheless, it is a rather simple
procedure that is less costly than dental implants and has minimal
morbidity for the patient.46,47 Although the survival rates of re‐
planted teeth do not compete with those of the classic periodontal
treatment and endodontic treatment, the survival is notably high
and is a conservative option that may be viable for some patients.
4.4 | Autotransplantation
When a tooth is avulsed, extracted, or congenitally missing, replac‐
ing the missing tooth with an implant is a treatment option. However,
another available option may be replacing the missing tooth with an‐
other tooth. Autotransplantation involves moving a donor tooth to a
receptor site in the same patient (Figure 2).48 Success rates for this
procedure are as high as 96% and survival rates as high as 98% for
autotransplanted teeth.49‒52 Reported complications of autotrans‐
plantation include pulp necrosis, root resorption, and hypermobility.53
Not only is autotransplantation a good option because of high success
rates, it is also a good option for growing patients who cannot have
dental implants placed. The placement of dental implants is not ad‐
54,55
vised until patients are no longer growing. This can mean spending
a long period of time without a tooth if it is lost to trauma, caries, and
so on at a younger age. Autotransplantation provides adolescents and
growing patients a treatment option to replace a missing tooth.56 If the
autotransplantation is not successful, the patient still has the option of
a dental implant. However, if the implant is placed first and fails, the
second and third rounds of dental implant treatment are not as suc‐
57,58
cessful as the first round.
5 |  E X TR AC T TH E TO OTH — PR E S E RV E TH E
TI S S U E S
If the decision to extract a compromised tooth is made, the long‐
term outcomes must be carefully thought through and, most im‐
portantly, explained in detail to the patient. The media surrounding
dental implants can not only mislead patients but also mislead
clinicians. It is very hard to accurately compare prognosis when
we assess the outcomes of a compromised tooth with the ideal,
fully osseointegrated dental implant. Instead, the potential com‐
plications of placing a dental implant need to be considered and
discussed starting with the surgical process itself. If there is insuf‐
ficient bone volume, it may be necessary to treat the patient with
bone augmentation surgery first. After the healing time for this
procedure, the implant can be placed. However, a common miscon‐
ception among patients is that the implant is the entire tooth, with
the crown included. Because this is not the case, the healing of the
implant needs to occur before the restorative treatment. Not only
can the implant placement be a timely process, these surgeries can
also come with complications such as sinus penetration, nerve dam‐
age, bleeding, and perforations of the bone plate. 59 Furthermore,
dental implants are not invincible and can be even more susceptible
to oral bacteria and require proper follow‐up and maintenance.60
Complications such as peri‐implant mucositis and peri‐implantitis
are prevalent; the prevalence of implants with peri‐implant mucosi‐
tis is around 80%, whereas peri‐implantitis affects approximately
12%‐66%. 21‒24,61 Despite the notion that dental implants are 99%
successful, it is important to understand the current evidence and
apply that information during the treatment planning process. Other
options for dealing with a missing tooth or teeth include no treat‐
ment, a fixed or removable partial denture, or orthodontic move‐
ment to close the gap and not necessarily place dental implants.62
Furthermore, when a tooth is deemed hopeless, there might still
be an option to use it for preservation of soft and hard tissues for
future implantation.63
5.1 | Preservation of hard and soft tissue
In the event the tooth is truly hopeless after all prognostic factors are
considered, extracting the tooth still may not be the ideal treatment
option, at least not immediately. Sometimes patients may delay the
placement of a dental implant for several reasons, such as anxiety, cost,
or early age.64,65 However, if the tooth is removed, the alveolar bone
can resorb.66 During this process, both the hard and soft tissues might
change, and it will be more challenging to completely restore those
tissues when the patient is ready for implant placement. In order to
achieve the proper esthetics, the preservation of hard and soft tissue
needs to be considered before extracting a tooth.66 Using procedures
F I G U R E 2   Autotransplantation of
a maxillary premolar to an incisor area
(missing because of dental trauma) in a
13‐year‐old boy. Immediate postoperative
clinical and radiologic view
CLARK and LEVIN
such as decoronation or orthodontic extrusion have been proven use‐
ful in preserving or augmenting hard and soft tissues.
5.1.1 | Decoronation
Dental trauma that results in an avulsed tooth being replanted into
the socket can eventually lead to ankylosis.67 In children and ado‐
lescents, this can also cause infrapositioning of the tooth and cause
adverse events during orthodontic therapy.68 The recommended
treatment in some cases is to surgically extract the ankylotic tooth,
which itself is a traumatic procedure.67 Another option is decorona‐
tion (Figure 3).69 This treatment involves removing the crown of the
tooth and leaving only the root inside the bone. Often, the tooth
has been previously treated endodontically. Before covering the
root, the endodontic filling must be removed, allowing the canal to
68
fill with blood. The purpose of this procedure is for the root even‐
tually to be replaced with bone, in turn preserving the volume of
alveolar bone for both esthetics and future implant placement.70 As
opposed to the traumatic surgery of removing an ankylosed tooth,
which can have negative sequalae, decoronation is a more predict‐
able and conservative procedure. Furthermore, decoronation can
preserve both the height and the width of the alveolar ridge for fu‐
ture implant placement.71
F I G U R E 3   A decoronation procedure
performed to preserve bone for future
implant placement. Note the bone growth
coronal to the root in the follow‐up
radiograph (arrow). (Courtesy of Drs Yuli
Berlin‐Broner and Eyal Nuni)
|
      5
5.1.2 | Orthodontic extrusion
Another option, particularly for a growing patient, is orthodontic
extrusion of compromised teeth.72 Placing single tooth implants in
esthetic zones can be challenging because of factors such as a pa‐
tient's smile line and the morphology of the adjacent teeth and the
hard and soft tissues.73 This can become more challenging if a tooth
is extracted and bone resorption occurs, leading to altered hard and
soft tissues. However, if a tooth has a hopeless prognosis, extrac‐
tion is often the treatment. In order to avoid the bone resorption
caused by the extraction of compromised teeth, orthodontic extru‐
sion of the tooth may be a valid treatment option.73 This treatment
involves orthodontically extruding the root, leading to an increase
in the width of attached gingiva, and preserves the alveolar bone
for future implant placement.74‒76 Orthodontic extrusion becomes
an even more conservative option because the patient is more likely
to not need bone augmentation when a dental implant is placed.63
6 | M A I NTE N A N C E A N D FO LLOW‐ U P
Whether the decision is made to extract a tooth or not, mainte‐
nance and follow‐up are important and applicable throughout the
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6       CLARK and LEVIN
treatment. As part of the treatment process, it is imperative that the
mouth remains disease free, meaning no caries, infection, or active
periodontal disease. This translates into educating patients about
proper oral hygiene practices and ensuring that periodontal disease
is stable and there is a low risk for new caries or trauma. This includes
educating patients about the use of mouth guards and head protec‐
tion for patients who participate in high‐risk sports or activities.77,78
Also, a strict recall protocol must be implemented for professional
appointments. It is important that this recall protocol is based on the
specific needs of the patient.79 For different types of dental trauma,
the International Association for Dental Traumatology has published
guidelines for the suggested follow‐up frequency for different inju‐
ries.80‒82 If a compromised tooth is extracted and an implant is placed,
the same concept applies. With high rates of peri‐implant disease, it
is necessary to diagnose and treat peri‐implant mucositis at its earli‐
60
est stages to prevent it from progressing to bone loss. Overall, the
strict follow‐up allows the clinician to detect potential complications
early and help avoid further deterioration of the complications.
7 |  E TH I C A L CO N S I D E R ATI O N S
In general, clinicians try to assess the prognosis of compromised
teeth. However, the literature shows that this effort is not very
successful or accurate.31 With that in mind, clinicians need to think
carefully before extracting a traumatized tooth or one with signifi‐
cant disease or bone loss. Furthermore, dental trauma patients are
often young and still growing, so placing a dental implant comes with
a long‐term commitment. If a 20‐year‐old patient will need an im‐
plant, they will need that implant to be successful for 70 or 80 years.
Unfortunately, there are minimal data that show outcomes of dental
implants after 50 or 70 years. It should also be kept in mind that the
biology of the tissues surrounding teeth and implants are different,
and they provide better long‐term protection for natural teeth.83,84
Therefore, the procedures outlined previously are important and
can enable the patient to keep the tooth in the mouth longer or at
least preserve bone so that when a dental implant is placed, perhaps
the patient will need it for less time. In order to fulfill our ethical obli‐
gations as health care providers, clinicians need to be informed with
the current evidence and accurately present the pros and cons of all
of the available treatment options. 25
8 |  CO N C LU S I O N
Dental trauma, caries, and periodontal disease compromise teeth.
However, do we really need to extract a compromised tooth? Even
if treatments do not end up saving a tooth for a patient's lifetime, de‐
laying the placement of a dental implant may be important as well as
preserving the hard and soft tissues. The decision to extract based
on assessing prognosis is not always adequate because the literature
supports the success and survival of teeth treated with root canal
therapy, periodontal therapy, autotransplantation, and so on. Dental
implants, although seemingly successful, do not have long‐term data
(over 50 years) and are an irreversible treatment option. If an implant
fails, we may only place another implant. If a tooth fails, at least we still
have the option of placing a dental implant.
C O N FL I C T O F I N T E R E S T
The authors confirm that they have no conflict of interest.
ORCID
Liran Levin  https://orcid.org/0000-0002-8123-7936
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How to cite this article: Clark D, Levin L. In the dental
implant era, why do we still bother saving teeth? Dent
Traumatol. 2019;00:1–8. https​://doi.org/10.1111/edt.12492​