Decision making in implant dentistry: an evidence-based and decision-analysis approach.

Decision making is an essential part of oral healthcare. It involves diagnostic and therapeutic uncertainties, providers heuristics and biases, patients preferences and values, as well as cost considerations. A model for the factors influencing decisions in healthcare was described in 2000 by Chapman & Sonnenberg (10) and has been adapted here to discuss decision making in implant dentistry. The decision-making model describes two major components, the normative and the descriptive, which are involved in decision making (Fig. 1). The normative aspect of decision making relies on quantitative information derived from systematic reviews and predictive models on the probabilities and uncertainties of treatment outcomes. Clinical outcomes, such as survival or success of a tooth or a restoration, are assessed based on the utility they offer to the patient and their costs. Normative analyses allow quantitative comparisons of alternative therapies and can identify optimal treatments for multiple attributes. The descriptive aspect in decision making involves cognitive processes and biases of both providers and patients that translate the normative information into clinical action. Decision making in healthcare occurs at three broad levels: the level of lawmakers and governmental regulators; the level of insurance plans that determine coverage and reimbursement for healthcare; and the level of the provider and patient. This review will focus on the decision-making process at the provider–patient level regarding treatments aimed at retaining diseased teeth or extracting diseased teeth and replacing them with an implantsupported prosthesis. Although implant-supported prostheses have become the treatment of choice in an increasing number of patients (32), it remains controversial under which conditions retaining a tooth may be futile and replacing a tooth with an implant-supported prosthesis may be considered over-treatment. Owing to the complexity and variability in designs of removable dental prostheses, the discussion will be limited to fixed dental prostheses. The evidence-based approach and decision analysis constitute two major approaches in decision making in implant dentistry. Recently, a number of systematic reviews have been published regarding the success and survival rates of teeth following periodontal and endodontic treatments and of dental prostheses supported by teeth or implants. The present narrative review does not intend to replicate these systematic reviews; instead this review will attempt to build upon the compiled information, synthesize the provided data and apply them in a clinical context to assess which may offer greater benefits, namely removing natural teeth and replacing them with an implant-supported fixed dental prostheses or treating diseased teeth with the goal of retaining them.