Sir, I was very interested to read the views of Dr D. Howarth expressed in the letter Implants and dementia in the BDJ 2013; 214: 47. Dr Howarth's experiences are evidence of the increasing problems that lie ahead for some patients with implants and those who care for them. He confirms what many of us have feared, that implants are indeed a ticking time bomb.

Managing the consent process with a patient who has a compromised tooth isn't simple. There are costs and drawbacks to any solution. In an age where the implant companies market themselves with great force and allure, I suspect that endodontic treatment and re-treatment are occasionally overlooked as options.

The literature on the survival of implant supported restorations compared to restored endodontically treated teeth is pretty unequivocal. Whilst they both have the same survival rates,1 there are some overlooked facts to consider. When treatment planning for restored endodontically treated teeth it must be stated that once treatment is completed to a high standard no further intervention is necessary. Implant supported restorations on the other hand need continued intervention throughout the life of the patient such as prosthetic repairs, loose screws, lost implants and more.2 This is is not very desirable for an ageing and sick population. Furthermore, patients who have had endodontics completed to a high standard report an improved quality of life after treatment.3

It was my concern to encourage patients to understand more about their choices when they have a decayed or infected tooth that inspired the saving teeth awareness campaign (www.savingteeth.co.uk).

I enjoyed Dr Howarth's decision to retain his premolar gaps. When I'm on the London Underground, I often think that the 'mind the gap' mantra could translate well into the dental world, a reminder that the advanced solution today could become a problem for those of advanced age tomorrow.