Osteoporosis, Bisphosphonates and Dental Implants

I have heard a lot of questions asked by dental professionals as well as patients regarding these topics lately.  The underlying question usually was: Do they mix?

Osteoporosis is a common disease characterized by decreased bone mass, increased bone turnover, and increased susceptibility to fracture.  In general, Osteoporosis itself is NOT a contraindication to having dental implants done.  Studies have shown that patients with osteoporosis enjoy the same kind of success rates with dental implants as patients without osteoporosis do.  What CAN present itself as a potential risk factor to dental implant surgery (and any kind of oral surgery for that matter), however, is the administration of Bisphosphonates (such as FOSAMAX®), which are designed to counteract the effects of osteoporosis.

Bisphosphonates belong to a class of drugs which inhibit osteoclast action and thus the resorption of bone.  This works well for maintaining good bone density (since the resorption cycle is being interrupted), however it can have disastrous consequences following bone surgery.  Bone will undergo a very structured healing response after surgery, which includes remodelling and turnover.  Osteoclasts play a very important part in this remodelling cycle of the healing phase.  If the osteoclast action is interrupted, osteonecrosis (bone cell death) may be a consequence.

Now not every regiment of bisphosphonates is a significant risk factor for post surgical osteonecrosis.  Up until very recently we have only haphazardly determined that injectable regiments of bisphosphonates or regiments of oral bisphosphonates for over three years present a definite contraindication to dental implant surgery.  Recently however, a test became available, which gives us a much more accurate way of determining the risk factor:  The CTx Test.

The CTx test, also known as the serum C-terminal telopeptide test, is a medical blood test that is used to assess the risk of bisphosphonate-induced osteonecrosis of the jaws.  C-terminal telopeptide is a marker used to measure bone metabolism. It is a by-product of normal bone metabolism or bone turnover.  If the CTx test shows a low value of CTx, then the implication could be that the bone turnover is low, thus the bone is less likely to recover from trauma, such as a tooth extraction or implant placement.  According to Marx ( J Oral Maxillofac Surg. 2007 Dec;65(12):2397-410.): “A stratification of relative risk was seen as CTX values less than 100 pg/mL representing high risk, CTX values between 100 pg/mL and 150 pg/mL representing moderate risk, and CTX values above 150 pg/mL representing minimal risk. The CTX values were noted to increase between 25.9 pg/mL to 26.4 pg/mL for each month of a drug holiday indicating a recovery of bone remodeling and a guideline as to when oral surgical procedures can be accomplished with the least risk.”   The latter portion of Marx’s statement implicates that any kind of Oral Surgery (including dental implant placement) could be an option, if a patient is taken off the regiment (under careful observation of his or her physician, of course) for about 3 months and a CTx re-test is taken for verification of new values.

If necessary, your dental professional or physician can order this test for you.  This test should be taken after 12 hours of fasting.

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A little bit on bone grafting…

The topic of bone grafting seems to be one of the more confusing areas in implant dentistry.  When do I need it, why do I need it and why is it so darn expensive?  Generally a bone grafting procedure is needed whenever there is insufficient bone available to place a dental implant of proper dimension.  Bone will resorb over time in the areas where teeth are missing.  I still don’t believe that patients always get the best explanation as to what the graft options are and what the pros and cons are – well, hopefully this little blog will shed some light on this topic.

For starters, let’s just quickly review the different classifications of bone grafts.  All bone graft materials can essentially be classified into the following classes:

  1. Autografts
  2. Allografts
  3. Alloplasts
  4. Xenografts
  5. Growth Factor Enhanced Grafts

Now, all of these five classes can have either or both of the following properties:

  • Osteoconductive – the ability to “guide” bone cells
  • Osteoinductive – the ability to accelerate bone regeneration

    A typical autograft from the chin

    A typical autograft from the chin

Autografts are bone grafts, which come from your own body.  This type of graft is still considered the “gold standard” by many surgeons.  It offers the best of both worlds; it has very good osteoconductivity and also great osteoinductivity due to its high content of resident growth factors.  The disadvantage is the higher morbidity.  It is always necessary to conduct a secondary surgical access in a remote location of the body in order to harvest the bone.  Depending on the quantity of bone needed, this can be the hip (for larger quantities) all the way down to an intra-oral site, such as the chin or the back of the jaw.  Autogenous bone grafts have shown to be some of the most predictable grafts in surgery.

A typical allograft from a bone bank

A typical allograft from a bone bank

Allografts are a close relative of the autograft, in that it is of human origin, usually cadaver bone from a bone bank.  This always sets off a red flag with people with respect to disease transmission, however with the tight screening protocol and advanced processing technology this is virtually unheard of in the United States.  Allografts have the big advantage that they do not require a secondary surgical access site, however, they also have predominantly osteoconductive properties and very little if any osteoinductive properties.  Graft assimilation and maturation takes therefore longer than with the autografts.  Grafting success rates have also favored the autografts by a slight margin, depending on the individual application.

A typical xenograft of bovine origin

A typical xenograft of bovine origin

Xenografts are bone graft substitute from a different species all together, usually from bovine origin.  These grafts have usually only osteoconductive properties, since the organic portion has been completely removed (so no, there is no chance to contract BSE a.k.a. Mad Cow Disease).  The advantage of a xenograft is that there is a large quantity of bone available for the screening process for an exact micro architecture that is needed.  Their osteoconductive properties are therefore very good.  It can be distributed in particular form or as blocks.  Xenografts have shown to generate astonishing results, especially in sinus lift surgeries, which are often necessary for the placement of dental implants into the back areas of the upper jaw.

An example of recombinant human growth factor

An example of recombinant human growth factor

Growth Factor Enhanced Grafts are very new on the market.  These grafts capitalize on the regenerative powers of human growth factors such as Platelet Derived Growth Factors or Bone Morphogenic Proteins, both of which are generated by our own body during a bone repair and remodeling cycle, however these grafts are manufactured with recombinant DNA technology and are very concentrated.  These growth factor formulations are usually in liquid form that need to be combined with a “carrier”, such as collagen or a calcified matrix.  These grafts offer very good success rates, but their caveat is that they are VERY expensive.  This is an important point to consider, because more often than not, they just accelerate the graft assimilation and maturation time.  Research has yet to show whether the bone quality differs between all these different graft materials after a year or two.

Well, I hope this was informative for you.  I will be available for questions and comments, so don’t hesitate to post.

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So what can surgical lasers be used for in dentistry?

Surgical lasers are currently undergoing a tremendous evolution in dentistry.  Much of it has to do with the ability of manufacturers to scale their size down dramatically, and to make them more user friendly.  Additionally, new wavelength are constantly being added to the repertoire, which in turn broadens the

A periodontal procedure performed by a laser

A periodontal procedure performed by a laser

application field.  Dental or surgical lasers are defined by their lasing medium (the substance inside the laser, which creates the laser light), which in turn defines the wavelength of the emitted laser beam.

The following are the most common lasers used in dentistry:

  • Nd:YAG laser
  • Diode laser
  • ER:YAG laser & Er,Cr:YSGG laser
  • Carbon Dioxide laser

Each laser has its own unique application, based on the type of tissue interaction it offers.  Some lasers have their greatest energy absorption in soft tissue, others in bone tissue and yet others in hemoglobin or melanin.  the applications for lasers is basically chosen by their absorption spectrum in human tissue.

One of the main applications today in dentistry is soft tissue surgery.  Lasers are often used in periodontal disease cases, to complement traditional scaling and rootplaning procedures.  Lasers do not cause the kind of discomfort that traditional periodontal procedures cause.  That being said, not all periodontal procedures can be replaced by lasers either.

Another application which is gaining ground is photosterilization of compromised teeth or dental implants.

Photosterilization of a compromized dental implant

Photosterilization of a compromised dental implant

Often times we try to save compromised teeth and dental implants with a grafting procedure, however, a pre-requisite is that the surface of such a tooth or implant is meticulously cleaned and sterilized, or new bone will not form against it.

Laser bone surgery is just in its infancy in dentistry, but new powerful lasers make this possible already.  The advantage of laser bone surgery (in contrast to rotary instruments or piezo-electric instruments) is the cleaner and more sterile surgical field as well as the reduced post-operative inflammation and discomfort.

Lastly there is the new field of biostimualtion, which has actually nothing to do with surgery, but can help dramatically in the healing process.  Biostimualtion was already discussed in a previous post underCold Lasers.

For more information on lasers in dentistry, please visit my website at: http://www.robertgougaloff.com.

Why are dental implants not covered by dental insurances?

Dental implants have a very poor history with dental insurances. In fact, as of today I have yet to hear from a dental insurance that covers dental implants.

Now before I dwell on this too much, lets look at an example of a dental insurance here in California: Delta Dental – a reputable insurance company. When it first opened its doors in the 1960s, it gave its members on the average a $1,000 yearly limit. Now, mind you this was in the ’60s. At that time you could have had pretty much your full mouth redone for $1000, considering that the average crown price was about $60 back then. Now guess what the average yearly limit is today, over 40 years later? If you guessed $1,500, you were right. And the average crown price?? Well it ranges on the average here in California between $600 and $1,200. Can we all see the discrepancy here?

Now the average single tooth implant (which includes the surgical placement of the implant, the abutment and the final crown) is between $3000 and $4,500 on the average (go my website to find definitions and images for these components). As you can see, the economical challenges would be immense for an insurance company to overcome.

If insurance companies actually did cover dental implants, like they cover other dental work, they would eventually force doctors to accept a much lower payout for their implant work. That is very difficult to do, because implants and all the associated surgical and prosthetic hardware are very expensive to manufacture and purchase. Accepting a lower fee for implant services will lead some practices to “cut corners” in order to protect their profit margins and that is exactly what you don’t want to do with dental implants. They are very technique sensitive devices, and success rates could be dramatically reduced, if inferior products are being used.

I therefore take the position that dental insurances and dental implants are dangerous mix that should not be attempted. Many patients have found other creative way to finance such expensive work, like Care Credit or flexible spending accounts.

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Can a crown be fitted immediately after the placement of a dental implant?

One of the most asked question that I get is whether an implant can be placed and fitted with a crown immediately (or at least a temporary crown). This is especially important to patients, which have lost a tooth in the esthetic zone or the visible smile line.

A very legit question, although most of you probably get a very vague answer on this question. Well, truth be told, there is no simple “yes or no” answer to this. The first question that needs to be answered is whether this is to be done immediately after an extraction (i.e. extract the original broken tooth, place a dental implant and then connect a crown to the implant right away), or at a delayed stage, when the extraction site is already healed up.

In the delayed scenario, the chances are usually much better for that, because we can usually achieve good initial stabilization of the implant due to the better quantity and quality of bone (this usually pertains to teeth in the esthetic or visible smile zone anyways).

In the immediate scenario, the chances are often reduced, due to discrepancies between the geometry of the implant and the remaining tooth socket, the need for grafting and poor implant stability. Unfortunately this is the scenario, where we need to take advantage of this treatment modality the most, because it would facilitate the bone and gum tissue maintenance.

So, in summary, if the implant is stable enough at the time of placement, whether it is right after the extraction of the original tooth or not, and the patient does not have excessive clenching and grinding habits, an immediate crown or temporary crown can usually be placed. To see a series of images of an immediate temporary placed on a dental implant which was placed at the same time, follow the following link: Placement of a dental implant and immediate temporary crown.
or for the PDF version in form of a slide presentation, go to the PDF file: Placement of a dental implant and immediate temporary crown. (This is a 40Mb download, however).

Lastly, you can also connect to my website Robert Gougaloff and go to the “Slide and Photo Center” page to get the PowerPoint presentations.

How many doctors does it take to get an implant done?!?!

Oh boy! We can certainly open up a can of worms with this question – so let’s get started!

I think this question needs to start with a preliminary question – and that is whether Implant Dentistry is actually its own specialty or not. Well, the official word (at least according to the American Dental Association and pretty much all state boards) is a resounding NO! This might seem strange, since there is more research pouring in to this field than any other specialty in dentistry and since there are over 50 journals world wide dedicated to this field. There are full-time two-to-three-year residencies at universities, which specialize and teach only Implant Dentistry, just like there are time two-to-three-year residencies teaching Periodontics, or Orthodontics, and still, their graduates cannot officially call themselves specialists in this field (although they can limit their practices to this field only)! So what’s going on??

Well, the problem is the amount of cross training which has been done by all members of the dental community: Periodontists, Oral Surgeons, General Dentists, Prosthodontists, and even some Endodontists. Now throw in that Implant Dentistry can be a very lucrative way of doing dentistry and you got yourself a potent mix of torqued legislature, lobbying power and opinion-wielding legal consultants controlling this issue.

So how many doctors does it take? Well, I say however many are necessary to get the job done properly. This can be one very well trained doctor, who has undergone rigorous training in this field, or many doctors each of which is a specialist in his or her own field. Bear in mind though that the more people are involved, the more things can go wrong too. Breakdown of communication is an often cited problem with the team approach, which can lead to a compromising result. On the other hand, a single doctor who is not well trained in this field can lead to the same compromising result.

Most patients prefer the convenience of having the whole procedure done in one office, rather than being shuttled from one office to another. The trend is definitely going towards dentists getting the extra surgical and prosthetic training done themselves and offering full-service Implant Dentistry in their offices. Implant supply companies also tailor their sales strategies towards this trend. For you as the patient or consumer, it is very important and imperative to make sure that your doctor(s) has/have the necessary training to do the Implant Dentistry for you. The best situation is if you have someone, who has dedicated a few years to a full-time residency at a post-graduate university level and has remained active in the field.

Comments are definitely welcome on this issue!!

So what’s up with these new Cold Lasers?

Cold Laser Application for TMJ Pain

Cold Laser Application for TMJ Pain

This is a post in response to a request I have received and some of the blog posts I have read on other sites.  I hope it is informative for you.  As always I welcome any kind of comments or questions.

First of all, “Cold Lasers” are not to be confused with “Cool Lasers”.  “Cool Lasers” are utilized in cosmetic medicine or dermatology to reduce acne scars or wrinkles.  “Cool Lasers” actually generate enough energy so that the water in your skin cells absorbs the laser light. The absorption in turn causes the instantaneous vaporization or destruction of the cell.  There is really nothing “cool” about this laser, in fact this is a thermal tissue reaction, however, the skin is kept “cool” via external cooling mechanisms.

“Cold Lasers” on the other hand are truly “cold” to the touch and their function is purely geared towards biostimulation and healing.  Nowadays, these lasers are often being referred to as “Biostimulatory Lasers”.  Cold Lasers do not create any heat, yet they are very powerful.  To give you an example, surgical lasers for dental surgery generally range between 2 Watts and 7 Watts in output power.  Cold Lasers on the other hand, can have actually 100 Watts or more output power at their tip, yet they will never cut tissue.  So what’s going on here you ask?!?

Well, the difference is the POWER DENSITY at their delivery end.  Surgical lasers have an emitter tip of a few hundred microns in diameter.  Therefore, a few watts of output power are concentrated into a very small diameter at the cutting tip, which yields a very high power density.  A high power density can have enough

Cold Laser Application for Rapid Orthodontics (Invis

Cold Laser Application for Rapid Orthodontics (Invisalign)

 energy to cut tissue.  Cold Lasers on the other hand have an emitter tip of several millimeters to centimeters in diameter.  So, despite their high output power, the power density at the delivery tip is very small and is therefore incapable of creating a thermal effect in tissues, let alone cut them.  In addition, Cold Lasers often “pulse” (they switch on and off) at very high frequencies.  Their power is usually given for the peak output at each of the pulses, so that the average power output is dramatically lower.

So what do Cold Lasers do for you?  Well, in the simplest sense they transfer photon energy into your cells.  Cells use this photon energy to produce their own energy source, which is a molecule called ATP.  Once cells load up on ATP, they have enough energy to regenerate themselves faster and better.  Research has also shown that Cold Laser therapy can reduce inflammation, by blocking the production of certain inflammatory molecules such as interleukins.

Cold Lasers present a growing treatment modality tool in Laser Dentistry.  Their advantage is that there is no danger of over-dosing, there are no adverse effects, and there is above all NO PAIN involved in the procedure.  New uses for Cold Lasers evolve constantly, but we use them currently in the dental field for improved healing after oral surgery procedures, periodontal surgery, faster implant integration for dental implants, TMJ pain, faster orthodontic movement of teeth and desensitization of teeth.