In recent years, the rise in elective extractions of healthy or restorable teeth for dental implants has drawn professional scrutiny. Media outlets have reported worrying cases of irreversible procedures driven by reasons other than strict clinical necessity. In response, organizations such as the American Association of Endodontists (AAE) have emphasized the ethical imperative to preserve natural dentition when feasible.1
This manuscript examines the basics for clinical decision-making, exploring the impacts of marketing, training variability, and financial incentives on treatment planning decisions. The underlying advocacy is for patient-centered care that prioritizes evidence-based, conservative options.
The implant boom and ethical crossroads
Implants (especially full-arch and zygomatic solutions) have become highly popular but rather expensive; single units costing thousands and full arches tens of thousands.2 Corporate strategies further drive this trend.3 Meanwhile, non-accredited training programs are not always sufficient to provide adequate preparation, often lacking sufficient oversight, and creating variability in clinical competence.
Social media has normalized implant treatment, sometimes portraying extraction as a lifestyle upgrade. However, responsible treatment planning must be grounded in preserving the patient’s health and long-term function.
Why tooth preservation matters
Natural teeth offer advantages implants cannot replicate, including proprioception, periodontal ligament function, and immune defense.4,5 Implants lack these biological properties and only restore about 80% of bite force.6 Ambiguous marketing may lead patients to overlook these limitations.
Read related article: Understanding Procedure Codes: A Practical Look at Risks and Ethics
Ethical gray zones
Some patients are advised to extract or treat healthy teeth for prosthetic convenience or aesthetics. These decisions can be acceptable if driven by patient preference and supported by thorough informed consent.7 Some cases, however, present the consequences when preservation is not adequately considered.2
Clinical and ethical evaluation framework
Evaluating restorability involves assessing periodontal, restorative, endodontic, and strategic value:
Periodontal: Teeth with severe bone loss or persistent disease may be non-salvageable.8
Restorative: At least 1.5–2 mm of ferrule improves stability of restored teeth.9
Endodontic: Complex anatomy, vertical fractures, or unresolved infection may warrant extraction.10
Strategic value: Anterior teeth can support aesthetics and self-esteem, whereas molars provide occlusal and prosthetic stability.11
Risks of unwarranted extraction
Implants carry risks, such as peri-implantitis, bone loss, and failure, often leading to costly revisions.12 Emotional and financial burdens follow, particularly problematic when patients were not fully informed. Thus, professional care demands transparent discussion of these risks.
Restoring ethical balance
To restore integrity in dental care delivery:
Educate patients: Mention viable less invasive options.
Encourage second opinions: Especially when extractions (full clearance) are advised.1
Enhance training opportunities: Ensure that vetted instructional programs are available to the profession.
Limit financial concerns: Involve insurance and 3d party payers in the process.3
Conclusion
The extraction of healthy or restorable teeth solely to facilitate implant placement contradicts the fundamental conservative principles of dentistry. The preservation of natural dentition should be promoted, supporting evidence-based, patient-centered practices that respect the long-term health of the patient. General dental clinicians have a critical role in maintaining these standards by evaluating tooth restorability comprehensively, prioritizing transparent communication, and fostering trust in the patient-dentist relationship. Upholding these principles is essential for sustaining the integrity of the profession and ensuring that patients receive care that genuinely serves their best interests.
Oral Health welcomes this original article.
References
- dKelman B, Werner A. Dentists are pulling healthy and treatable teeth to profit from implants, experts warn. KFF Health News. 2024. Available from: KFF Health News
- Butkovic S. Dentists are pulling healthy teeth, pushing implants for profit, report finds. DentistryIQ. 2024. Available from: DentistryIQ
- AAE. Statement from the American Association of Endodontists. AAE. 2024.
- Afrashtehfar KI, Assery NM, Alblooshi KAK, Schmidlin PR. Maintaining periodontally compromised teeth seems more cost-effective than replacing them with dental implants. Evid Based Dent. 2024;25(3):129–30. doi:10.1038/s41432-024-01050-2.
- Afrashtehfar KI, Kazma JM, Yahia I, Jaber AA. Dental implants significantly increase adjacent tooth loss risk due to root fracture. Evid Based Dent. 2024;25(3):123–4. doi:10.1038/s41432-024-01052-0.
- Afrashtehfar KI, Jurado CA, Abu Fanas SH, Del Fabbro M. Short-term data suggests cognitive benefits in the elderly with single-implant overdentures. Evid Based Dent. 2024;25(2):71–2. doi:10.1038/s41432-024-00999-4.
- Guzman-Perez G, Jurado CA, Alshahib A, Afrashtehfar KI. An immediate implant approach to replace failing maxillary anterior dentition due to orthodontically induced severe root resorption. Int J Oral Implantol (Berl). 2023;16(4):339–48.
- Newman MG, Takei HH, Carranza FA. Carranza’s Clinical Periodontology. 10th ed. St. Louis: Saunders Elsevier; 2006.
- Juloski J, Radovic I, Goracci C, Vulicevic ZR, Ferrari M. Ferrule effect: A literature review. J Endod. 2012;38(1):11–9. doi:10.1016/j.joen.2011.09.024.
- Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498–504. doi:10.1016/S0099-2399(07)80180-4.
- Yeng T, Messer HH, Parashos P. Treatment planning the endodontic case. Aust Dent J. 2007;52(1 Suppl):S64–7. doi:10.1111/j.1834-7819.2007.tb00523.x.
- Afrashtehfar KI, Desai VB, Afrashtehfar CDM. Preoperative administration of amoxicillin is not recommended in healthy patients undergoing implant surgery. Evid Based Dent. 2022;23(2):78–80. doi:10.1038/s41432-022-0266-7.
About the author
Dr. Afrashtehfar is a Canadian board-certified prosthodontist with subspecialty dental implant training from the Universität Bern. Ranked in the top 2% of scientists globally, he holds advanced degrees from McGill, UBC, and Bern. He serves as adjunct faculty in Dubai and Switzerland, lectures internationally, and focuses his practice on advanced implant and full-mouth rehabilitation.
Dr. Freedman is a founder and past president, American Academy of Cosmetic Dentistry, a co-founder, Canadian Academy for Esthetic Dentistry, Regent and Fellow, International Academy for Dental Facial Esthetics, and a Diplomate and Chair of the American Board of Aesthetic Dentistry. Adjunct Professor of Dental Medicine, Western University, Pomona, California. Author of 14 textbooks and > 1000 dental articles.