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Chasing the crown

William Hathaway Hartford Courant

People with dental implants eat better and seem to be healthier and enjoy life more than people who have a mouth filled with dentures, studies show. Even people with dentures eat more healthful meals if they have just two implants, said Dr. Jocelyne S. Feine, professor of dentistry at McGill University in Montreal, who has studied the health benefits and costs of dental implants. “Their reactions are phenomenal,” Feine said. “It makes such a difference in their lives.”

While technology is making implants easier to perform and the crowns that they support better-looking, their high cost keeps them out of the mouths of people who might benefit the most from them — the poor elderly on fixed incomes, Feine said.

She believes that implants — titanium screws inserted in the jaw to provide secure support for dental crowns — should become the standard of care in the United States and Canada.

“We have to find ways to provide the service at an affordable cost,” Feine said. “It is good for the patients and good for the public.”

Feine has an uphill fight. Most insurance policies will not pay for dental implants. Medicare also does not cover any dental costs. That means the patients must pay out of pocket. Although the prices of dental implants and crowns vary greatly from region to region, from dental office to dental office and from procedure by procedure, they aren’t inexpensive anywhere.

In some areas of the country, a single rudimentary implant and crown can run as low as $1,500. In other markets, the cost can be $5,000 or more per tooth for more complicated procedures. Those costs do not include periodontal work or bone grafts that sometimes are needed before an implant. Connecticut dentists interviewed for this article quoted costs for a single, standard implant ranging between $2,500 and $4,000.

The high costs of implants drive patients to seek other options. If they lose a tooth, a few patients decide to simply do nothing to replace it. But adjacent teeth can drift into the gap on the gum, which can lead to other dental problems.

Sometimes insurance will partially cover the costs of a fixed bridge — in which crowns replace the teeth on each side of the missing tooth, and a replacement tooth is suspended between the two crowns. Bridges are slightly less expensive than implants, although dentists say they are less desirable because they often need to be repaired. “There are some people without dental plans who say they can’t afford a dental restoration and simply find somebody to take all their teeth out,” said Dr. Thomas Taylor, head of the Department of Oral Rehabilitation, Biomaterials and Skeletal Development at the University of Connecticut Health Center. “It happens all the time.”

Dentures may be the least expensive option, but they fall far short of matching the chewing efficiency of natural teeth or implants, Taylor said.

“There are very good studies that show one or two implants can lead to dramatic improvements in self-image, quality of life and nutrition,” Feine said, adding that blood tests of elderly subjects who have received two implants indicate an improved diet.

Dentists need to do more to educate people about the value of their teeth, said dentist Dr. Joel Rosenlicht.

“The value people associate with their teeth is something that dentists have neglected,” Rosenlicht said. “Patients really don’t appreciate the value of their teeth until they are gone.”

Economic considerations, not those about health, often dictate what patients ultimately decide to do, he said.

“It’s become like buying a car,” Taylor said. “You have to decide whether you want a Chevy or a Cadillac.”

That’s why patients need to shop for implants as they would for a car, he said.

“People would be fools not to get another evaluation,” he said.

When they go shopping, dental patients today are likely to get a much better quality implant than they would have just five years ago, dentists say.

New materials have made crowns sturdier and more natural-looking. Imaging scans of the mouth have improved the precision with which incisions for implants are placed in the jaw, making for a better fit. And dental engineers have changed the shape and surface texture of titanium screws, which helps promotes rapid bone growth and healing around the implant, Taylor said.

Implant technology has improved so much that new procedures allow dentists to insert a complete set of implants in the upper or lower jaw in about an hour.

But at about $18,000 for one row of teeth, such procedures will benefit only the wealthiest, who are also the group least likely to need implants, Feine said.

The poor elderly are much more likely to lose their teeth, and if Feine is right, pay for it dearly with poorer nutrition and a shorter lifespan. In the United States, one out of every three people over 65 has lost all his or her teeth, she said. The percentage ranges from a high of 47 percent in West Virginia to a low of 13 percent in Hawaii, she said.

Feine recognizes that it is unlikely government health care programs will subsidize complete dental implants, but she said the cost of implants is only slightly more than the cost of dentures over the long run, when maintenance costs are included.

Even if the government doesn’t step in, some experts say that the same technology that has improved the quality of implants might also help eventually drive down costs.

“Just like the cost of computers has come down, implants will probably become more affordable,” dentist Sheldon Natkin predicted.

Others hope the market will help drive prices down, as more dentists join periodontists and oral surgeons in offering implants.

“As implants become accepted as the standard of care, hopefully the fee for service will come down accordingly,” Taylor said.

However, others aren’t so sure that prices will come down.

“I don’t think so, if you want an honest answer,” said Howard Mark, clinical professor of dentistry at the University of Connecticut and president of the Connecticut Oral Health Initiative, which seeks to improve access to dental services for low-income people. “(Dental implants) are big money-makers for both implant companies and dentists.”

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