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What to Say When a Patient Doesn’t Want to Replace a Tooth

I wrote a series of posts called Case Presentation for Implants, the first of which can be found here.  The first article in the series discussed strategies for choosing the right words and phrases to help our patients better understand their situation.

We are fortunate to have such a wonderful education!  Part of our job as health care providers is to adequately explain the principles of biology, chemistry, and physics to our patients so that they can make an informed decision about their treatment.

In this post I’d like to address one of the common barriers to tooth replacement.  There are many patients who don’t see a problem with extracting a tooth and leaving a space.  This is rarely a problem for an anterior tooth, of course.  But a crucial posterior molar or even a bicuspid may be viewed as being expendable.  During a consultation, too many of us get lost in the details and end up overwhelming the patients instead of informing them.

First I break the news to the patient that they are about going to lose the tooth.  I try to do that with compassion and smile.

“Mr. Elfman, I afraid this tooth is going to go to tooth heaven.  It has lived a good life, but it will be a waste of time and money to try to save it.  Fortunately, we have a few options to replace it after it is gone.”

Next I begin to discuss those options.  A fixed partial denture (bridge) and an implant are the two most likely candidates.  If the patient is resistant to extracting the tooth, we must try to help him/her understand that this a bad idea.  For more information on dealing with patients that don’t want to address decay and infections, check out this post entitled: “But It Doesn’t Hurt!”

But what if the patient agrees to an extraction but wants to just leave the space unrestored?  They understand that leaving disease in their body would be bad, but they don’t see the harm in not replacing a tooth.  As we all know, missing teeth lead to a host of problems: shifting and supra-eruption of other teeth, periodontal disease, and so on.

Since this destruction occurs at such a slow pace, the patient doesn’t appreciate or understand what is actually happening.  Imagine if tooth shifting occurred in days rather than years!  We would have very few problems convincing patients of the damage incurred by missing teeth.

So we must choose words that convey this sense of damage and destruction.  I’m not trying to scare them.  But we have all seen the damage done to other patients who never replaced their missing teeth.  We need to make sure the patient about to lose a tooth understands this.

Maxillary molars have erupted to fill the space left by missing teeth. Also note severe mandibular ridge bone loss of height and thickness.

“Not replacing the tooth will cause a host of problems for you down the road.  Teeth keep other teeth in place.  When we remove a tooth, the other teeth around it collapse into the space.  The tooth’s biting partner will even erupt into the space!  Now we have a few problems: (1) replacing the missing tooth in the future becomes harder since other teeth are in the way, and (2) the collapsing teeth are being used in ways for which they weren’t designed.  We bite on their sides, their sensitive areas become exposed to the elements, and so on.”

It helps to have some clinical photos and radiographs of other patients available.  Show them what a bite collapse looks like.  As the expression goes, a picture is worth a thousand words.  I like to have a few patient photos and radiographs on hand in the consultation room (removing the patient names, of course) for just this purpose.

If the patient still refuses to replace the missing tooth, you may choose to have them sign a waiver that lists all of the potential complications.


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