The Decision Between Tooth Retention or Replacement with Implants: A Continuing Dilemma

The global adoption of dental implants has significantly reshaped modern dental practices, with the market projected to reach USD 16 billion by 2029. However, despite high success rates, dental implants can still be prone to complications, particularly when underlying causes of tooth loss, such as periodontal disease and bone loss, are not addressed. This paper explores the biological and mechanical considerations in the decision-making process between preserving a tooth through periodontal therapy or opting for extraction and implant placement. It also highlights the importance of a holistic approach that includes assessing the patient’s oral health, periodontal status, and the biomechanical factors influencing tooth retention. Periodontal therapy has been proven to be highly effective, with both non-surgical and surgical therapies showing long-term efficacy in preserving natural teeth, especially in the presence of furcation involvement. Studies show that proper periodontal management, including regular maintenance therapy after the active therapy, significantly enhances tooth survival, even in cases of severe periodontitis. In contrast, dental implants, while effective, are not free of complications, mainly inflammatory peri-implant diseases, but also mechanical complications, which can compromise long-term outcomes. The paper reviews clinical studies on implant survival, demonstrating that periodontal therapy can sometimes offer a more cost-effective and biologically sound alternative to implant therapy, especially for teeth with severe attachment loss or furcation involvement. In conclusion, treatment decisions should be based on a comprehensive evaluation of clinical, biological, and patient-specific factors. By integrating regenerative therapies even in more compromised teeth and addressing the root causes of tooth loss, implant rehabilitation can be postponed for many years and offer a cost-effective and successful long-term treatment plan. This approach underscores the importance of individualized care in the evolving landscape of restorative dentistry and implantology.