Recently I had an elderly patient who came to me in hysterics.  She was told by a dentist that she had to have all of her upper teeth extracted and implants placed.  She forwarded her recent X-Rays, and I examined them. Except for decay on a few teeth, she had a sound periodontal foundation. Clearly she did not require such invasive treatment to restore her mouth.  I could easily save her teeth with conventional crown and bridgework. What is truly upsetting is that this is not the first time I have encountered this scenario.

I cannot help but wonder what kind of doctor could propose such invasive and unnecessary treatment to a human being. It is appalling to think some doctors do not stop to consider the Hippocratic Oath: “First, do no harm.” These practitioners view patients as if they are cash dispensing mannequins. They reflect negatively on all the conscientious doctors striving to provide the best care—care that they would want for themselves if they had the same issue.

There are several reasons for the absolute epidemic of tooth extraction and implant placement taking place in the nation’s dental offices:

1.    Dentists do not have confidence in their crown and bridge techniques.  The techniques that are taught in every dental institution are incorrect and did not come from Dentistry’s roots. These techniques are responsible for the problems that dentists are having with crown and bridgework: recurrent decay and loss of retention. These problems were solved in the 1930s! The approach that originally came from Dentistry’s roots has more than a 70-year track record.

2.    Dentists are inundated with courses in implant therapy. By contrast, there are much fewer courses in full coverage restorations for natural tooth abutments. Implant courses are quite popular and seem to be preferred by most of the academic meeting planners. Their goal is to fill seats, not to present balanced curricula. In addition, implant continuing education courses are often financially supported by implant manufacturing companies whose primary goal is to sell implants to dentists. Albert Einstein understood the pitfalls of capitulating to popularity. He once remarked that, “what is right is not always popular, and what is popular is not always right.”

3.    Dentists do not understand that crown and bridgework is corrective and can compensate for dental problems in a way that implants cannot. Dentists have been erroneously conditioned to believe that crowns and bridges are nothing more than “tooth coverings” that are likely to fail.

4.    Dentists lack treatment planning skills.  Many dentists only have implant therapy in their treatment armamentaria, so implant therapy has become their “go-to” treatment option. As “one-trick ponies,” these practitioners see restorative problems from only one point of view. The famous psychologist Abraham Maslow pointed out in his book Psychology of Science, that “if all you have is a hammer, everything looks like a nail¹.” 

5.    Dentists are excessively burdened with financial pressures.  Many students graduate from dental school with debts in excess of $700,000! At a time when they should concentrate on building knowledge and skills, they are forced to think about how they will pay back these loans. Once they adopt bad habits, it is likely that they will never develop excellence in skills, restorative diagnosis and treatment planning. Many dental practitioners view implant therapy as the most lucrative method of increasing cash flow. The truth is that crown and bridgework can be just as lucrative as implant dentistry.

While implants can be a godsend for many patients, they are not the answer to every restorative problem.  Consider what researchers Giannobile and Lang have to say about implants:

 “The long-term prognosis for implants has been shown to be far less promising than that for natural teeth, even when they are compromised by periodontal disease or endodontic problems.  Often practitioners recommend implants even when teeth are only modestly compromised by caries, the need for endodontic therapy or periodontal disease to provide the patient with a quick solution to the problem.  Less trained individuals often recommend tooth extraction rather than retention.  This condemns many teeth that could be treated and returned to good function.   Even those teeth that are compromised have a much greater life span than the average implant².”

Most practitioners today follow a piecemeal approach to dental care—one that only considers filling a hole or a space. This approach does not require critical thinking. The piecemeal approach is heavily supported by insurance companies, which really do not care about the patient’s overall dental health; and by implant companies that care only about selling implants.

By contrast, an overall approach to oral health care considers the whole mouth with the idea of eradicating and preventing disease. 

The poster child for piecemeal dentistry is the single-tooth implant. A single-tooth implant only fills a space and does nothing for the adjacent teeth. In a perfect mouth the single tooth implant is the perfect treatment option. However, in almost every case presented in lectures and dental magazine articles, the teeth surrounding the implant site are rarely virginal. They almost always have periodontal bone loss, large fillings and crowns; or they will need crowns in the future. With a piecemeal approach to dental care, the patient’s problems are never actually solved. The implant fills the space and does nothing for the adjacent teeth that continue to require care. Patients end up with a hodgepodge of treatments that do not relate to each other or provide the best restorative architecture.

By contrast, crown and bridgework is corrective and can solve multiple problems in an entire quadrant. Corrective dentistry is possible because of Wolff’s Law, which states that bone is deposited and resorbed in accordance with the forces placed upon it. By minimizing destructive forces and compensating for periodontal bone loss, teeth solidify in their sockets and further periodontal bone loss is prevented.

It should be noted that periodontal disease is a multifactorial disease, and bacterial infection is only one factor. The most common factor is faulty dentitional and occlusal architecture that subjects the dentition to destructive forces. Thomas Forde, in his book The Principles and Practice of Oral Dynamics called this phenomenon “force-induced degeneration” in 1964³. He stated emphatically that “Forced-induced degeneration problems must be treated with scientifically proven engineering principles.”

 These principles include the following: 

·       Correcting muscle-occlusal imbalances

·       Restoring the integrity of the dental arch

·       Creating an Ideal Plane of Occlusion

·       Correcting faulty dentitional architecture

·       Applying mechanical stress breakers such as splinting and precision attachments.

Practitioners today tend to focus solely on implant therapy, and they generally don’t strive to save teeth. Often the patient’s teeth are salvageable, but few dentists today know how to save them. Dental practitioners should always remember that patients go to dentists to SAVE their teeth, not to have extractions and implants. Patients also want choices, and they want their doctors to excel at both saving teeth and at providing implant therapy. 

Many people might think from this article that I am against the use of implants, but nothing could be further from the truth.⁴ I have done many implant cases since implants arrived on the scene in the early ‘80s. What I am against is the overuse and inappropriate use of implants. I am also against pushing patients into overly invasive treatments without offering them alternatives.

What am I for? I am for treatment armamentaria that includes great techniques for both implant therapy and crown and bridgework for natural teeth. I am for treating patients with kindness according to the “golden rule.” I am for choosing the option that is best for each patient after considering all of the factors involved. And I am for raising the standards and level of education so that more patients can have access to the highest quality care.

If you would like to learn full coverage restorative dentistry techniques that have a real track record, visit www.theONWARDprogram.com. The website has more than 35 courses on full coverage restorative dentistry, a documents library and a monthly blog. Dr. Feinberg is a recognized author of 3 books (one on Crown and Bridgework that will be printed later this year) and lecturer.

¹Wikipedia, “Law of the Instrument,” https://en.wikipedia.org/wiki/Law_of_the_instrument.

²Dental Abstracts Vol 61, Issue 4; 2016; p.173; Keep the Ones Youve Got; Giannobile, WV, Lang NP:  Are dental implants a panacea or should we better strive to save teeth?  J Dent Res 95:5-6, 2016.

³Forde, Thomas; The Principles and Practice of Oral Dynamics; Exposition Press, New York; 1964.

⁴Feinberg, Edward; “Concepts for Successful Implant Therapy;”  The ONWARD program Documents Library: https://theonwardprogram.com/wp-content/uploads/2024/10/Feinberg-Concepts-for-Successful-Implant-Therapy-2024-1.pdf; 2024.