That was the title to the 3 hour implant lecture I presented at the Michigan Dental Association Winter Scientific Session on Saturday, January 21, 2012. There were approximately 85 dentists in the audience and from a show of hands, about 15% of those in attendance currently place implants in their private practice. Another 15% indicated that implants were not a routine method of tooth replacement in their practices. The rest of the audience indicated they routinely diagnose and restore implants for their patients.
The lecture reviewed the basic concepts of dental implant placement and the treatment planning aspects that can effect the success of treatment. Aspects of implant prosthetic techniques including impressions using abutment and implant level impression copings as well as the differences betweeen anterior and posterior implant abutment designs were covered. Clinical cases from my practice were then presented stimulating some excellent questions from the audience. Next we reviewed the options available for generalists to pursue additional implant education and credentials. Implant CE requirements as well as case documentation and testing involved with credentialling were reviewed.
The afternoon session covered the All-On-4 treatment option for the edentulous patient and the prosthetic steps involved in restoring these cases. Typical lab costs for restoring these cases as well as comparison to the 2-4 implant overdenture option was presented.
My reasons for presenting these materials were to reinforce the following concepts:
1. the scientifically documented superiority of dental implants compared to toothborne prosthetics for functional restoration
2. the treatment planning concepts needed for success to aid both those placing and those only restoring implants
3.the necessity of offering an implant treatment option for restoring the edentulous jaw
4. the training necessary for generalists to start placing implants and the risk management aspects involved with doing this in the general practice
I believe the program was successful in achieving these goals and I look forward to presenting on this topic again at the Michigan Dental Association Annual Meeting in 2013. If you are interested in scheduling a similar presentation for your study group or society, please feel free to contact me!
Dr. Panek
Click here to see the MDA Course listing
The past few months have been quite busy with international travel as well as finishing up another successful practice year. My chief professional accomplishment over the past year was achieving recertification (for the second time in my career) by the American Board of Oral & Maxillofacial Surgery. The ABOMS issues time limited certificates and to maintain certification, I had to complete 90 hours of continuing education in 3 years as well as pass a written recertification examination. With that done, I'm good for another 10 years.
The next challenge is fine tuning my lectures that will be presented at the Michigan Dental Association Winter Scientific Session January 21st at Crystal Mountain Resort. The morning session is a 3 hour lecture entitled: "Principles of Implant Placement: An Introduction for the Generalist- Do I Really Want to Do This?". My afternoon topic will be a 2 hour presentation entitled: "Simplified Fixed Implant Treatment for the Edentulous Patient".
After that is done, Advanced Cardiac Life Support (ACLS) recertification follows. Other changes and improvements in the practice include the introduction of an electronic anesthesia module for paperless recording of our anesthetic record as well as recruiting another Surgeon to join the practice.
It is an exciting time in dentistry and we look forward to the continued positive changes/improvements in our practice.
Wishing you a successful and healthy New Year!
Dr. Panek
The introduction of graftless solutions for implant therapy has called into question the need for grafting in certain implant cases. Immediate implant placement at the time of tooth extraction often will require grafting to support gum tissues in the anterior area or, to build up lost bone in the single rooted tooth extraction socket. Clinical experience confirms that grafting during the replacement of single rooted teeth is necessary when there is lack of adequate hard tissue (bone) to support the implant, as well as the overlying gum tissue.
Improvements in the macrogeometry of dental implants allowing greater stability is now making it possible to place immediate implants in molar extraction sites. If the apex of the dental implant can be stabilized in 3 to 5mm of bone in or below the socket, immediate placement is possible. This still is an indication for simultaneous hard tissue grafting in most instances, and often the implant cannot be provisionalized or must be submerged. Recent studies have documented the success rate of immediate molar implant placement.1
Another indication for molar implant placement and simultaneous grafting has historically been in the posterior maxilla. Often the maxillary sinus is expanded and sinus lift bone grafting was thought to be necessary to regenerate bone in the sinus for added implant support. A recent animal study shows that placing a hard tissue graft is not necessary and may in fact inhibit the regeneration of bone in the maxillary sinus. Bilateral sinus lift procedures were performed in rabbits with placement of Bio-Oss grafting material on one side and no graft on the other. The nongrafted side was treated with placement of a minisrew to support the sinus membrane in the elevated position. Immunochemical assay showed that faster and greater new bone formation was observed in sites that received no grafting material.2
A 5 year follow up study of 80 patients shows the clinical application of this concept. In this study, patients had open sinus lift procedures with simultaneous implant placement. The membrane was elevated and supported only by the implants that were placed in bone ranging from 3.5-6.5mm in height. No grafting of the sinus was performed. Conebeam radiographic study showed a 5.4-9mm gain in bone height and 100% success at 5 years.3
The use of tilted posterior implants, as in the All-on-4 technique, avoids the need to perform sinus grafting and is necessary if immediate loading is planned. For single teeth or short-span implant bridges that will undergo late loading, sinus lifting is indicated, but now it appears that the expense and infection risk associated with placing grafting material can be avoided.
We are always looking for ways to simplify implant treatment and improve predictability while at the same time reducing dental implant costs for our patients. Immediate molar implants can save patients 3-4 months of time by allowing implant placement and extraction socket healing to occur simultaneously. Graftless sinus lift implant placement avoids the use of expensive grafting materials and the infection risks associated with allograft placement. Obviously, treatment options must be tailored for individual patients and not all patients may be candidates for these simpified procedures. For more information, contact us to discuss patient referral or to schedule an appointment.
1 Immediate,Early and Late Implant Placement in 1st Molar Sites, Annibali et al, Int J Oral Maxillofac Implants 2011:1108-1122
2 Comparison of New Bone Formation in the Maxillary sinus with and Without Bone Grafts: Immunochemical Rabbit Study, Dong-Seok-Sohn et al, Int J Oral Maxillofac Implants 2011:1033-1042
3 A 5 Year Follow-up of 80 Implants in 44 Patients Placed immediately After the Lateral Trap-door Window Procedure to A complish Maxillary Sinus Elevation Without Bone Grafting, I-Ching Lin et al. Int J Oral Maxillofac Implants 2011;26:1079-1086
In a previous blog, current advances in evaluation and treatment of patients needing in office sedation was discussed. Many patients needing oral surgery or dental implant placement need or request IV sedation for a variety of reasons. Anxiety regarding the procedure, as well as the fact that many of these procedures are impossible to perform comfortably with local anesthesia alone, are indications for sedation.
Increasingly, nonspecialist dentists have been promoting use of sedation in the office for dental or oral surgical procedures. The public must be assured that the care in the dental office has the same level of safety as an anesthetic provided in a hospital or accredited ambulatory surgery center. Since the 1970's, members of the American Association of Oral and Maxillofacial Surgeons (AAOMS) have used the Office Anesthesia Evaluation (OAE) as a way of certifying that the standards established for anesthesia care are met. AAOMS members in the state of Michigan undergo the OAE every 5 years. Unfortunately, the state has no similar organized mechanism to evaluate non-oral surgeon dentists and their offices in the same manner.
Anesthesia standard of care changes were a main topic of the Anesthesia symposia at the recent AAOMS annual meeting and scientific session in Philadelphia last month. Some of the changes in office surgery have to do with changes mandated by the federal government through the Centers of Medicare/Medicaid Services (CMS). The Joint Commission, which is responsible for accrediting hospitals and healthcare centers, uses CMS critera in it's evaluation of healthcare providers. CMS and now the Joint Commission are placing restrictions on the practice of operator anesthetists in the hospital setting. Examples of this practice would be a physician administering an intravenous sedative as part of an endoscopic exam or minor surgical procedure. Oral surgeons are also classified as operator anesthetists however, they provide the service generally outside of the hospital setting and are currently not regulated in this way.
CMS has also promulgated new rules on monitoring of the patient during IV sedation or general anesthesia. End tidal capnography (exhaled CO2 monitoring) is now required for the assessment of ventilation of patients during IV sedation and general anesthesia. A time oriented anesthesia record is also part of the newly evolving standard as well. While oral surgeons are not directly regulated by CMS or the Joint Commission, the general consensus is that these elements of anesthesia monitoring will soon be the standard of care in dental/oral surgery offices as well. In our office we have been using end tidal capnography for over three years, and feel it is valuable in assessing patient ventilation during IV sedation.
Preoperative evaluation of patients was also a topic of interest at the annual meeting. The recent increase in the prevalence of younger overweight and obese patients requires a reassessment of risk for IV sedation in the office. Overweight and obesity have been positively linked to undiagnosed cardiovascular diseases as well as diabetes and pulmonary difficulties. The significantly overweight or obese patient has an increased risk of having sleep apnea which can increase the risk of anesthetic complications. Proper preanesthetic assessment for these conditions will allow a modification of the type of anesthetic available to the patient or, the option for anesthesia care by an anesthesiologist in a hospital setting if indicated.
If you wish to learn more about IV sedation options available in our office for a procedure call to schedule a consultation with one of our board certified oral & maxillofacial surgeons.
Many patients seeking oral surgical care or dental implant placement may be using or have used bisphosphonate (BP) drugs. Agents such as Zometa, Boniva or Actonel are useful in the control of osteoporosis in postmenopausal women. Intravenous forms of these drugs are also used to retard cancer metastasis in chemotherapy.
Since 2003, there have been numerous reports in the scientific literature of osteonecrosis of the jaws (ONJ) associated with BP treatment. ONJ is breakdown or decay of the jawbone that can lead to chronic pain and at times permanent disfigurement. The disease can occur spontaneously or be caused by a dental infection or dental procedure.
The incidence of ONJ was found to be 0.8% in a retrospective study of 4,000 cancer patients reported in 2006. Since that time, millions of patients have been also been placed on these drugs, not for cancer but for the treatment, and at times, the prevention of osteoporosis.
Osteoporosis can lead to significant disability later in life, and short term use of these drugs has been shown to stabilize this disease. Oral surgeons however are reporting ONJ in patients that have used BP's for osteoporosis. There is concern about risks of oral surgery or dental implants in patients on these drugs. The current opinion is that patients using oral BP's for 3 years or more, especially in combination with steroid medications like prednisone, are at some risk of ONJ.
Researchers have identified the incidence and risk factors for ONJ, but little is known about how BP's are related to or cause the disease. What is known is how BP's effect bone by slowing down or stopping the turnover or remodeling of bone. This is how osteoporotic bone can become stronger over time but also how it may not heal properly after surgery. BP's also are known to effect soft tissues by decreasing angiogenesis (growth of new blood vessels). This is useful in controlling or preventing cancer metastasis or spread. It is not known if prevention of angiogenesis is directly linked to ONJ.
Researchers at Columbia University in New York published the results of a laboratory study of the effects of BP's on oral cell wound healing in 2008. Mouse oral mucosal cell cultures were exposed to the BP pamidronate at a range of clinically relevant doses. The findings show that BP treatment inhibits cell growth and wound healing at these doses and that the inhibition is not due to cell death.
This research is important because little is known about the pathobiology of ONJ and how best to treat it. It is known that the risk of ONJ can be minimized by having excellent dental health before starting these drugs. This can be accomplished by having a comprehensive dental exam including full mouth xrays and carrying out a complete dental treatment plan to address tooth decay (dental caries) and gum (periodontal) disease.
Further research is necessary to identify the specific mechanism of injury by BP's and allow the development of rational treatment protocols for ONJ. If you have taken BP's and require oral surgery or dental implants, please contact us to schedule a consultation.
Inhibition of Oral Mucosal Cell Wound Healing by Bisphosphonates, Landesberg et al, J Oral Maxillofac Surg 66:839-847, 2008
We will be attending the American Association of Oral & Maxillofacial Surgeons 93rd annual meeting in Philadelphia next week. One of the highlights will be sessions on updates in the delivery of anesthesia/sedation in the office environment. Oral surgeons have a long history of innovation and safety in the delivery of anesthesia in the dental office. We are unique in that Oral & Maxillofacial surgeons are the only medical/surgical specialists that undergo at least 6 months of fulltime hospital based anesthesia training. No other medical/surgical specialty that provides intravenous anesthesia along with surgical or invasive procedures (radiography,endoscopy etc.) has this extensive anesthesia training.
Oral & Maxillofacial surgeons in the State of Michigan are required to undergo an office anesthesia evaluation every 5 years. The evaluation includes an objective survey of facilities, resuscitative equipment and drugs necessary to provide office anesthesia services. Oral & Maxillofacial surgeons are also required to provide documention of certification in Basic Life Support (CPR) and Advanced Cardiac Life Support (Defibrillation and resuscitation of cardiac arrest including advanced airway techniques).
The topics to be covered in the Philadelphia meeting anesthesia sessions will include innovations in anesthetic drug delivery as well as risk assessment regarding treatment of medically compromised patients. With the rise in obesity and related diseases, more patients are are being seen that require modifications in anesthetic management. Often this means local anesthesia, minimal IV conscious sedation or, treatment in a hospital outpatient center.
Patients that have concerns about anesthetic management are advised to schedule a consultation before surgery to discuss their options. IV sedation is available in the office for the placement of dental implants or removal of wisdom teeth. Check out the patient anesthesia information on our website!
Want to find out the usual fee for a dental implant or wisdom tooth surgery in your area? A new healthcare fee clearinghouse is bringing this information to the web for consumers to access at no charge. FAIR Health is a nonprofit organization that maintains a database that healthcare insurers now use to determine reimbursement rates for care. The service was started after a settlement reached with the New York State's Attorney General investigation of Ingenix, a database previously used by insurers to establish healthcare reimbursement fees. The investigation disclosed fraud and conflict of interest in the way insurers used and helped maintain the Ingenix database.
FAIR Health's website, www.fairhealthconsumer.org, is a resource for consumers seeking fair, unbiased information regarding insurance company reimbursement for healthcare. The site provides an estimated charge, estimated reimbursement and out-of-pocket cost for any dental procedure simply by entering your zip code and description of service or CDT(Current Dental Terminology) code.
The fees in the database are derived from actual costs submitted by local dental providers and should be an accurate representation of the general fee for a particular service in your area. Keep in mind that service fees may vary for the same procedure between different providers. Also, your particular out-of-pocket expense for dental care is determined by deductibles, and yearly benefit maximums that your employer provides. Those without dental benefits will find the information useful in planning for anticipated dental expenses.
The FAIR website only provides information on dental services at this time. Medical reimbursement fees will become available in August of this year.
Many patients coming to our office ask if it is possible to place dental (tooth) implants at the same time teeth are removed. Dental research has shown this procedure to be very predictable.* Individual teeth or all of a patient's teeth can be replaced using modern dental implant techniques. Innovative implant designs from Nobel Biocare, Straumann and Biohorizons allow us to provide this service in a predictable manner.
The advantages of immediate dental implant placement are a decrease in the treatment time. In selected cases, there is the opportunity to also place a temporary tooth, implant bridge or set of teeth at the same time. Immediate replacement of front teeth with an implant and temporary crown makes it possible for a patient to be able to smile without the use of a removable partial denture. A full arch (whole jaw) replacement of teeth allows the patient to function without the need for messy denture adhesives.
We have many years of experience with immediate implant placement and would be happy to arrange this treatment for you if desired. An initial office consultation is often necessary to determine the best method of treatment for you. We are currently offering implant consultations free of charge. (Any necessary digital imaging is extra). The complimentary consultation includes a medical and dental history review and examination by one of our board certified doctors. Any neccessary correspondence/consultation with your general dentist is also included.
*The Immediate Placement of Dental Implants Into Extraction Sites..., Bell, Diehl et al, J Oral Maxillofac Surg 69:1623-1627,2011
Clinical Outcome of Immediately Loaded Maxillary Implants..., Boedeker, Dyer and Kraut, J Oral Maxillofac Surg 69:1335-1343, 2011
Immediate Loading of Implants and Fixed Complete Dentures..Boulos, General Dentistry, 406-409, Sept/Oct 2010
On April 27 through 30th , I was at the Biohorizons Global Symposium in Pheonix, Arizona. The weather was beautiful but I spent 21 hours indoors during these 3 days participating in continuing education courses as well as attending the main podium talks on advancements in biomaterials unique to the Biohorizons implant product line. Biohorizons has a complete product line of endosseous implants as well as biologicals for use in implant dentistry. It is the fastest growing implant company in the world and does business in over 50 countries.
The main focus of the meeting was how the unique properties of the product line increase the predicability of implant treatment in immediate placement, immediate function and esthetic reconstructive cases. The main podium speakers were international authorities in the field and included Drs. Carl and Craig Misch, Maurice Salama, Mike Pikos, Hom Lay Wang, Michael Ricci, Myron Nevins, Bach Le and Steven Gans. The following is a summary of key topics regarding current implant treatment.
The Biohorizons Laser Lok surface on the neck of their regular length and total body of their short implants has been shown to guide the migration of fibroblasts and osteoblasts providing a strong soft and hard tissue connection between the dental implant and recipient site. This has been found to provide a stabilizing effect to soft tissue and bone levels dramatically decreasing normally accepted physiologic bone loss found around other implants. In vitro and in vivo studies have shown the predictability of this effect which appears to be a "game changer" in the necessary design features of implants for optimal long-term health.
Current therapy for anterior implants in the esthetic zone indicates the necessity of bone and soft tissue grafting either at the time of tooth extraction or during implant placement. The consensus as recently as 5 years ago that immediate implant treatment in the esthetic zone was predictable, has not stood the test of time. Long term labial gingival migration of 1-2mm around these implants has shown the need to avoid immediate extraction implants in the esthetic zone if there is not an intact labial plate of bone greater than 2mm in thickness and a thick gingival biotype. This effectively eliminates up to 75-80% of patients as candidates for this procedure. Even if these conditions are present, it appears that grafting is still advantageous to avoid the long term complication of labial gingival recession.
Regarding implant designs, it appears that platform switching does not prevent these long term problems. It is more effective to use an implant engineered and research proven to preserve bone levels and soft tissue attachments as the Biohorizons implant line does. More information is available at biohorizons.com.
Dr. Panek
In a previous blog post I reviewed the recent findings of epidemiologic studies related to third molars (wisdom teeth) and health complications. Research has shown connections between inflammed third molar teeth and pregnancy, diabetes and arterial disease complications.
The American Association of Oral & Maxillofacial Surgeons (AAOMS) convened a multidisciplinary conference on Third Molar Science in Washington DC last October. The following report excerpt is from AAOMS TODAY.
"The invitation-only audience was composed of representatives from dental, governmental and third party organizations with the greatest stake in knowing the facts about third molar pathology and the systemic implications for patients. An expert panel presented the latest fiindings on third molar extraction, retention, surveillance and costs, including the incidence and experience of patients in Canada, Finland and the United Kingdom."
"Findings of the AAOMS Third Molar Clinical Trials continue to show...the local and systemic health implications of asymptomatic wisdom teeth are far broader than previously thought, which makes earlier and frequent surveillance of retained third molars more critical."
"Additional key findings include:
- 80 % of young adult subjects who retained previously healthy wisdom teeth had developed problems within seven years.
- Monitoring retained wisdom teeth over a lifetime may be more expensive than extraction.
- Most patients (60 %) with asymptomatic wisdom teeth prefer extraction to retention.
- Retaining wisdom teeth can increase the risk for broader conditions, including preterm birth and cardiiovascular disease."
An audio recording of the press conference highlighting the findings is available in the media section of the AAOMS website, aaoms.org.
Dr. Panek