THE LEANING TOWER OF PISA AND THE DISEASED TOOTH: When to Save and When to Demolish !

The Leaning Tower of Pisa and the Diseased Tooth:

When to Save and When to Demolish….. Extract!

USING THE KAIFOO SWEAR CHART

Years ago, the Italians were horrified when the leaning tower of Pisa began to lean even more and as the local authorities scrambled to diagnose the cause and come out with a cure……. there was intense debate over whether it was worth saving and how long any attempt to save it would last and maybe…. just maybe it should just be demolished for the sake of public safety..... or could it… should it be uprighted. The wide ranging pros and cons from all over the world then given by all and sundry on saving or demolishing the tower mirrors the acrimonious global debate over the diseased tooth…… when to save and when to extract. Especially now with a ready solution of replacing with a dental implant.

With the advent of screw type titanium dental implants since the 1980s, dentists have been empowered with the ability to replace a tooth almost as good as new……… but never as good as the original. However, apart from the original, it is widely recognized today that an implant is the best way to replace a lost tooth….. until someone is able to grow a tooth in the mouth precisely, safely, reliably and rapidly.

The healthy natural tooth in the mouth is a marvelous piece of biological engineering that puts the most sophisticated human engineering to shame. The apparatus that connects the tooth to the bone have several types of sensors incorporated, as well as suspends the tooth in such a way that allows different types of food to be chewed efficiently in a controlled and comfortable manner. The suspension mechanism does not only consist of different types of fibres between the tooth and the bone but also within the periodontal space, a gel like intercellular substance that is thixotropic in nature. This means that under compressive stress it becomes more flowy and thickens back the moment stress is removed. The implant supported tooth compared to the natural tooth is not only crude but primitive! Like a private jet compared to a bullock cart. Both work but one does it in a far more comfortable and classy manner. The best luxury car suspension is zilch when compared to the suspension of a healthy natural tooth.

         

As a dentist who has regularly placed implants of different types for more than a decade, I have always wanted a more objective and reliable way to help the patient and the dentist to decide when to attempt to save a tooth and when to extract and replace with an implant. With the power in my hands to replace a lost tooth at will and almost as good as new, the temptation can be overwhelmingly in favour of extraction and implantation. This paper is an attempt to keep it in check and to be as objective as possible in making such a decision.

The method that will be outlined is based on a brief, limited review of some of the outstanding literature on the subject together with my personal experience. In sharing this, I am excruciatingly aware that I am sticking my neck out and that it is not the last word on it, but hopefully show a way forward that may be useful to my colleagues, and to which others can add.

Before we look at the method, it will be useful to be reminded of some of the statistics on the life expectancy of crown and bridgework on natural teeth, endodontically treated teeth and teeth adjacent to dental implants.

1. Fayed 1996 Journal of Oral Rehabilitation on 156 fixed partial dentures aka bridges: 35% failed within 10 years. The average life span of the failures were 6.1years. 46% of failures were from private practices. 15.4% were from dental schools.

2. Quinn 1996 Journal of the Irish Dental Society: The 10 year survival rate of crown and bridge restorations on natural teeth was 76.5%.

3. Napangangas 2002 Journal of Oral Rehabilitation: 16% failure rate in 10 years. Fixed bridges more than 5 units failed more than fixed bridges of 5 units and less. Dry mouth, high bacteria count, occlusion, oral hygiene and habits are important contributing factors to failure.

4. Torabinijad and Goodachre 2007 JADA Review of over 300 articles on endodontic success. 95% of teeth treated endodontically functioning 5 years post treatment. The 5 year radiographic success rate was 81.5%. The radiographic healed rate of endodontically treated teeth without pre-treatment apical periodontitis was 92%. The healed rate with a pre-treatment apical lesion was 74%.

5. Shimin Friedman 2002 Endodontic Topics: Contradindications for endodontic therapy are non-restorable teeth, periodontally guarded or hopeless teeth, patients with extensive dental problems and patients with limited socio-economic resources.

6. Yip Implant Dentistry: 5 year survival rate of a tooth treated with RCT and a post and core was 95%. Greenstein 2008 Compendium: Post failure is as high as 22% at 5 years.

7. Dr. Priest 1999 International Journal of Oral and Maxillofacial Implant : Dental implants to be 97.4% successful. 196 teeth adjacent to implants were followed. In 10 years, only one tooth required a replacement restoration and one tooth was extracted. The success rate of teeth adjacent to dental implants was 98.8%.

With these in mind, a tooth can be accessed to save, wait, extract or refer by filling up the chart with a tick and then adding up the percentages. The column with the most percentage indicates strongly which direction to take the tooth. “A Novel Decision-Making Process for Tooth Retention or Extraction” by Gustavo Avila et al which includes one of the doyens of implant dentistry Carl E. Misch is one of the most comprehensive study and write-ups on the subject and a very thorough chart was presented, that covered almost every conceivable scenario and may detract it from being very useful to the average dentist. In coming out with the SAVE WAIT EXTRACT REFER CHART aka SWEAR CHART, I have attempted to make the very complex process practical, and reasonably simple.  I hope it will be of help to similarly simplicity-obsessed persons like me. I will be grateful for all helpful feedback. Have fun!!

References:

1. A Novel Decision-Making Process for Tooth Retention or Extraction Gustavo Avila, Pablo Galindo-Moreno, Stephen Soehren, Carl E. Misch, Thiago Morelli, Hom-Lay Wang jop2009.080454

2. Teeth and Dental Implants: When to save, and when to extract Link: http://www.jerseycoastdentalforum.com/lecture-notes/documents/TeethAndDentalImplants.pdf

3. Teeth Versus Implants in Periodontal Patients Kapoor S, Kapoor V, Pathak A, Tiwari M,
Sikka G Journal of Advanced Medical Science 2013; 1(2) : 78-82

4. Dental Implants vs Real Teeth Dr Richard S Kahan Endodontist Endodontic Specialist Harley Street London.htm

SAVE WAIT EXTRACT REFER CHART

KAIFOO SWEAR CHART TO DETERMINE THE FATE OF A TOOTH

TO HELP YOU DECIDE ON THE FATE OF A TOOTH: FILL UP ALL THE COLUMNS AND THEN ADD UP THE PERCENTAGE

TOOTH/TEETH INVOLVED: __________________________________

 REMARKS:-________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Answer the question: Based on the patient’s opinion…….. and so on, I will save/wait/extract/refer. Tick the column that you feel most appropriate or leave blank. Choose your first impression each time. Studies have shown that one’s first impression is usually accurate. Read “BLINK” by Malcolm Gladwell

FACTORS AND %TAGE	SAVE	WAIT	EXTRACT	REFER
PATIENT’S OPINION ……….30%
PATIENT’S BUDGET………….20%
PERIODONTAL STATUS……..5%
CARIES………………………………5%
CURRENT RESTORATION…..5%
FRACTURE…………………………5%
AESTHETICS………………………5%
ENDODONTICS………………….5%
MALOCCLUSION……………….5%
MEDICAL CONDITION……….5%
DENTIST’S EXPERTISE………..5%
MATERIALS AVAILABLE……..5%
TOTAL

The column with the most percentage indicates strongly which direction to take the tooth.

DECISION:__________________________Date:_____________

Created by Dr. Chow Kai Foo BDS; FDSRCS; AM(Mal); Cert. of Oral Implantology

DR. CHOW KAI FOO

ORAL SURGEON AND ORAL IMPLANTOLOGIST

BDS SINGAPORE FDSRCS ENGLAND

CERT. of ORAL IMPLANTOLOGY UNIVERSITY OF FRANKFURT GERMANY

FICD ACADEMY OF MEDICINE MALAYSIA

NATIONAL SPECIALIST REGISTER

Website: smalldentalimplants.blogspot.com

Email: doktorkfchow@yahoo.com

Mobile: 0123661987

Please feel free to give me your comments and feedback.

NOTE: Please Google "kaifoo swear chart" and go to MDA NEWS 

to get the pdf copy of the complete article with pictures.

BELOW IS AN EXAMPLE OF HOW THE 

KAIFOO SWEAR CHART

IS USED.