By JANE E. BRODY, New York Times

November 16, 2009

If I have one serious regret about my age, it is that my permanent teeth developed before New York, my hometown, got fluoridated water. I first lost a permanent molar to decay in my early 20s, and the resulting bridge has had to be replaced several times in subsequent decades, ultimately as a four-part apparatus.

Now that has to go as well. Because I could not floss and clean properly under the bridge and between the supporting crowns, I developed a severe periodontal infection.

Dr. Michael Zidile, the young periodontist I consulted, took one look at my mouth and said: “This is not how we do restorations nowadays. A bridge is not a permanent solution and makes it too hard for most people to keep their gums and underlying bone healthy. Now we do implants and individual crowns where needed.”

More out of curiosity than distrust — and before I invested thousands of dollars and countless hours on new teeth — I did my own homework and got a second opinion. Dr. Zidile, I learned, is correct. In an overwhelming majority of cases, implants to replace lost teeth are by far the best long-term solution for maintaining a healthy mouth. Also, because they rarely need to be replaced, in the long run they are more economical than bridges.

A Growing Option

Implants for replacing lost teeth have come a long way in the 25 years since I last wrote about them in this column. Better materials, procedures and professional experience result in far fewer problems than occurred in the early years of implants.

Critical to their success, however, is proper selection of both patients and practitioners — and, after the implant, a commitment to good oral hygiene. Dental implants must be treated like natural teeth: kept clean and free of plaque through proper brushing, flossing and periodic professional cleanings.

“Bridges are not the standard of care anymore,” Dr. Lawrence J. Kessler, a periodontist and associate professor of surgery at the University of Miami School of Medicine, told me in an interview. “For most people who lose teeth, implants are the treatment of choice.”

Implants do not decay, and adjacent healthy teeth do not require crowns to support them. And because it is easy to clean and floss between implants, the gum tissue and underlying bone are more likely to remain healthy.

With a bridge, if one of the supporting crowned teeth breaks or develops decay or nerve damage, the bridge and its three or more crowns must be removed and replaced.

Implants can replace individual lost teeth or many teeth in a row. For those who have lost most of their teeth, implants can be used to anchor a full or partial denture. About half a million implants are placed each year in this country.

On average, the total cost of an implant to replace a single tooth is $3,500 to $4,000 (more if other procedures are required), or about one-third more than the cost of a bridge. But while bridges have an average life span of 10 years, an implant can last a lifetime.

Many insurance companies now cover implants, but most people do not have dental insurance and must pay out of pocket. If cost is an issue, consider treatment at a dental college, where implants may be available at reduced rates as part of the teaching process.

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Not a Quick Procedure

The basic technique involves surgically inserting a titanium screw — the implant — into the supporting bone, which can be done under local anesthesia in less than an hour, and attaching a small fake tooth called an abutment, followed by a crown. The resulting tooth looks and feels like a natural one.

The procedure is a lengthy one. Unlike a bridge, which can be completed in two weeks, implants usually take about eight weeks for the screw to become firmly attached to bone before the final crown can be placed. “A patient’s health, not age, determines suitability for an implant,” Dr. Kessler said. “I just did implants for a 93-year-old who needed them to fit a partial denture. I put two implants in a man when he was 85 and five more when he was 88, with no problems either time.

“If cases are chosen well, implants are very successful — 96 to 97 percent successful. And they rarely fail down the road.”

A most important element is having enough bone in the jaw to support the implant, although in some cases bone cells removed during drilling for the implant or taken from elsewhere in the mouth can be used to fill in gaps.

“If someone has diabetes or is a smoker,” Dr. Kessler said, “the chances of success are reduced because a poorer blood supply diminishes the fusion of bone cells to the implant.”

Also important is healthy gum tissue, free of periodontal disease. Before I could undergo an implant procedure, I had to have periodontal treatment to get rid of the plaque, tartar and infection on the tooth roots and gum tissue around my bridge and supporting crowns.

In some cases when a tooth must be pulled, an implant can be placed right after the extraction, with the advantage of limiting bone loss in the area. When bone is not being stimulated, it tends to break down. I consider myself lucky that although I’ve had this troublesome bridge for many decades, my underlying bone has remained healthy enough to support an implant.

Choosing a Doctor

Just as any physician can legally perform surgery, any dentist can legally do implants. Be sure to choose someone thoroughly trained in the technique. Taking a weekend course in implantology is rarely adequate. There are risks involved in placing implants, including damage to a nerve or sinus cavity, which are magnified when the practitioner lacks adequate training.

Implants were once done mainly by oral and maxillofacial surgeons, most of whom operated independently of dentists. Now at least as many implants are placed by periodontists who are schooled in the technique and who coordinate their work closely with the patient’s dentist. Ideally, the periodontist should be board-certified.

Just as you might ask for referrals for a prospective nanny or house cleaner, consider asking to speak with other patients of the practitioner before deciding to proceed with an implant. Though every case is different, at the least you can determine how well you are likely to be cared for.

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