Implants part 2. Prepare yourselves....

Part 2 Implant overview.

Hope you made it through the last without falling asleep/questioning why the hell you would read such a thing. This week’s post is going to detail a little more about the procedure of placing implants, long term care and general post implant placement information.

How long does the whole process take/what do I have to go through.

When answering this question there are various things to be considered, the main being whether or not the implants are placed and restored (i.e. placing of the crown or bridge or denture on top of the implant) in stages vs in one go.

I’m sure you will have all come across those adverts in the newspaper/the back of certain magazines that offer the operation to place the implant and then restoration of the implant in a day.

This is incredibly misleading, as it is virtually impossible to make a denture, crown or bridge to fit on an implant within a day, unless you have some sort of miracle lab and even then various impressions (moulds) need to be taken of your implants in order to get the best fit and appearance. If the dentist is just relying on one impression taken straight after the implants are placed when there is bleeding, swelling etc then it is highly unlikely that the crown/bridge/denture is going to fit, look good and work well. Thus if you went to a decent cowboy dentist they would require at least a couple of visits.

Now this only takes into consideration how it is going to look immediately. There is some debate within the implant community (a bunch of very cool people) about the length of time and number of stages that should occur for the best result.

ADI summarise this nicely.

“For routine cases, from the time of implant placement to the time of placing the first teeth, treatment times can vary between 6 weeks and 6 months. The availability of better bone can be used to decrease treatment time, whilst more time and care must be taken with poorer bone, which can therefore extend treatment times beyond six months”

They would class routine cases as simple tooth loss situations i.e. not following cancer treatment or illness, in patients with suitable bone.

When assessing all patients who are considering implants there is a basic structure of appointments etc that should be followed if you want to get the best out of the implants and not destroy your mouth.

Handy subtitle time…

Summary of stages for routine dental implants

Stage	Eh?	Other info – if you’re still with me
Diagnosis	Your current dentist may be the one who is offering to provide implants, in which case, they should be familiar with your mouth and hopefully should have been responsible for doing the groundwork for the time that you have been seeing them i.e. any fillings, treating gum disease etc. However different dentists will of course have different opinions and so if you are going to see an “implant specialist” in another practice, they may request that your own dentist carries out any dental repairs, filling replacements or extra courses of gum treatment. Hopefully they wont be pointing out anything too new and if they do i.e. “good GOD has a bomb gone off in your mouth”/ “you have RAGING gum disease” then you should perhaps consider finding a new general dentist.
Treatment planning	Treatment planning involves determination of where the implants are going to go. Certain things have to be considered at this point: a.    Whether there is enough bone to support an implant b.    Whether there is enough room to place an implant and its restoration (e.g. bridge, crown, denture) c.    Whether placing an implant is going to affect any important things in the mouth i.e. the sinuses/nerves. See some pictures below for this.	a + b The amount of bone and the amount of space have to be considered in various different dimensions. There are also different considerations for each area of the mouth due to the force that teeth take depending on their position in the jaw. The best way to explain this is with pictures. See below.

 1)    Vertical dimension: think of it as height of bone/space between the teeth or space between the jaws

· 

Now the above situation is only for front teeth which generally take a lot less force. Yes you use your natural teeth to bite into apples etc which technically you can do with implants but with the amount they cost per piece you’ll probably want to be cutting your apples up into pieces from now on.

So, for crowns towards the back of the mouth we need more space because the restorations have to be much stronger as the back teeth take significant grinding forces. For this reason we need at least 3-4mm space between the implant abutment and the opposing teeth.

In the picture below you can see that the space between the abutment on the implant and the top teeth is only just 4 mm. In this case this simply is not enough to make a decent white crown. The reason for this is that the white bit of the crown – the ceramic – has to be a certain thickness to a) look good and b) be strong enough. At less than an ideal than an ideal thickness will look like a grey blob and/or break and fracture as soon as you try and eat something. So for the picture below, the only option would be to place a full metal crown which can be made much thinner due to the increased strength of metal over porcelain.

The final set of considerations in terms of measurements is for dentures.  There should be 10–12 mm of vertical space between the implants placed in either the top or bottom jaw (or in fact both) in order to place good sized teeth  

If a bar is used for the denture to clip onto – as opposed to simply clipping into the top of the abutments, then this measurement must allow for a space of 2mm between the gums and the bar so that it can be effectively cleaned under.

 

The next measurement to consider is width of the bone, i.e. between the cheeks/lips and the tongue/palate. Obviously these measurements all depend on the size of implants the specialist is intending to use. 3.25 mm diameter implants are the smallest available, according to dentalcare.com, 6mm width of bone is the minimal thickness into which 3.25 and 4 mm diameter implants can be placed.  Larger diameter implants (5 and 6 mm) require at least 7-8mm. Although these measurements are large enough to accommodate an implant, it means that the implant can only be placed in one direction as there is limited bone either side of the implant. .

So, miles back, I also mentioned the importance of checking for vital structures.

1)    The sinuses.

These are the bits in your face that get really painful when you have a cold.

2)    Nerves

 

 Once all the above nonsense has been assessed, and any bone grafts or sinus lifts have been performed (which the specialist can explain in far greater detail using your own xrays/scans and fun models etc) then we can get down to the good stuff and actually put the damn implants in.

Stage	Eh?	Other info – if you’re still with me
Implant Placement	Drilling the implant into the bone and the gum There are 2 different schools of thought as to how exactly this should go. Of course, the screw part of the implant goes into the bone, but there is some debate as to whether this screw should then be covered back over and allowed to heal completely hidden below the gum, OR whether an extra bit (an abutment) should be placed on top which pokes through into the mouth, and allow the gum to heal around this. Time for some more pictures	Implant placement is usually followed by a period of healing lasting from 6 weeks to 6 months. Stitches are normally removed 7 to 10 days after the implant placement.

 Generally, the process goes a little like this.

1)    Tooth extracted

a.    At this point if you had/have a whopping infection like an abscess then the area will be allowed to heal for a while as placing an implant into infection is like building a house in sand (and we all know how that song goes)

b.    After this healing, a space for the implant to go in will need to be made, unlike if the tooth is just removed and there is a nice space there from where the tooth was sitting

c.    If the tooth is just being taken out because of trauma/decay/gum disease then an implant can be placed into the socket straight away

2)    A hole for the implant to sit in is made in the bone. Generally there is already a “hole” from where the tooth was removed but this isn’t a standardised shape and so the area is shaped to fit the implant perfectly. 

 3)   It is at this point that the debate starts.

a.    Sometimes the implant screw is placed and then covered over and the gum is “sealed” with stitches

b.    Other times a “healing abutment” is placed on top of the screw which pokes through the gum. It looks like a small silver button on the gum in the mouth – lots of fun to scare children with.

                                          i.    After either a or b there is a period of osseointegration a.k.a integration of the implant with the bone of the jaw before any sort of crown, bridge or denture is placed on them. This allows for the implant to become more “part” of the jaw than a false object before you start expecting it to carry the weight of biting force.

                                         ii.    This process of osseointegration takes between 3 and 6 months depending what you read.

                                        iii.    During this time you will of course have a space where the tooth was. If you had coped fine with this space before seeking an implant then you can carry on with a space, however if you have had the tooth taken out or it has been knocked out in fact then you may not fancy walking around with a gap. The only realistic option is a temporary denture which will replace this missing tooth. Sadly it is a reality that if there is any period of time of healing then you will need a temporary option to fill the space and you just have to accept this I’m afraid.

c.    The implant, abutment and temporary version of whatever the final restoration is planned to be is placed straight away. The temporary version is not in the bite, i.e. there is a gap between the teeth so that biting forces are not applied to the implant while it heals. This of course means that you have a nicer option than a temporary standard denture but it will not be the final object and you will have to go back in a few months to have this done.

d.    Of course the above point is irrelevant if the decision is made to place the implant, abutment and final restoration i.e. crown/bridge/denture immediately. Of course this sounds like the ideal option. Minimal time spent, it’s what they use on those 10 years younger programmes so it must be good etc however it does not allow any time for this “osseointegration” before you are expecting a false titanium screw to stand up to the forces you apply when chewing through an overcooked steak. Imagine trying to walk on a hip replacement within hours of it being placed. You just wouldn’t and the same usually applies with dental implants but as with everything there are differing schools of thought.

Why you SHOULD wait?	Why you SHOULDN’T.
A study by Adell et al. 1981 conclude that loading i.e. allowing the implant to take biting forces straight away after placement can interfere with healing. Ideally, we want bone to form all the way around the implant so that it becomes almost part of the jaw. If biting forces are applied to the implant too soon, the implant moves within the jaw (only minimal amounts like vibrations) meaning that instead of bone forming around the implant, soft squishy stuff forms instead –like when you pick off a scab too early and this inevitably will lead the implant to fail.	Studies have found that immediate implant loading achieved similar success rates as those reported in the delayed 2-stage approach therefore, who cares about all the theory.
Covering over the most important bit of the dental implant – the actual implant bit, allows for safe healing and protection of it from all the bacteria in the saliva.	If the implants are to be placed in the lower jaw, then there is more chance of success with immediate placing of the final crown/bridge/denture
	Some research suggests that GENTLE loading of the implant right after placement actually helps the strength of bone healing around the implant, a bit like gentle exercise after any operation will help with healing.

Stage	Eh?	Other info – if you’re still with me
Healing	As mentioned above, this takes around 3-6 months	During this time you will probably be going backwards and forwards to see whoever placed the implant(s) to  check healing, check how the gum is forming around the implant and to make any adjustments to temporary dentures etc
Restoration	This is the placing of the final crown, bridge or denture on top of the implant.
Looking after the damn things	It is important to again reiterate that dental implants are not natural teeth. They don’t act in the same way, they don’t fail in the same way. It is also worth noting that when an implant fails, it is really bad. If a tooth breaks or has to be taken out, then usually its just the tooth that’s the problem. According to Carl Misch, DDS, MDS (lots of letters after his name so he must be important) “when the implant fails, it also destroys the bone around the implant” often to the point where the whole plate of bone in front of the implant (the bit that you can feel under you gum) is completely lost Similarly,  “if that implant happens to have been placed on a bone graft, this means that this particular implant failure could result in insufficient bone to re-implant” i.e. there’s sod all that can be done if it fails.	It is worth mentioning at this point that dental implants don’t last forever. They have a life span just as hip replacements, boob jobs etc do. If you look after them well i.e. keep them clean, have regularly checks with your dentist and hygienist visits, don’t smoke, have ideal medical fitness then you could be looking at 20 years. HOWEVER during this time you will likely have to have the crown/bridge/denture on top of the implant modified as they will get worn or damaged by eating and so on.

.

 So, in summary,

1)    Don’t smoke

2)    If you have gum disease, don’t even think about asking for an implant

3)    If you want a quick fix, implants are not for you. Similarly if the thought of having a scalpel/bone drill coming at you makes you feel sick/dizzy then implants are not for you

4)    If the thought of having a denture puts the fear into you, then again, implants are not for you. In 99% of cases you wear a short term denture while the area of infection after taking the tooth out heals, or while the implant heals

5)    If you have no bone, you can’t have an implant unless you are suitable for bone grafting which takes time, effort, money and could potentially also fail.

6)     Go and see a specialist who knows what they're doing and can fix problems if/when they arise

I realise this was probably very hard going on the reading front, and admittedly it was probably written more for my benefit of learning through researching but maybe it will help someone!

As always, if you have any questions please feel free to ask. Finally, apologies for the varying fonts used on the pictures, I think I may have been losing the plot as I neared the end. 

Stuff I looked at

http://www.adi.org.uk/

Gapski R, Wang H-L, Mascarenhas P, Lang NP. Critical review of immediate implant loading.  Clin. Oral Impl. Res, 14, 2003; 515–527

Adell, R., Lekholm, U., Rockler, B. & Bra˚nemark, P.I. (1981) A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. International Journal of Oral Surgery 10: 387–416

Bra˚nemark, P.I., Adell, R., Breine, U., Hansson, B.O., Lindstrom, J. & Ohlsson, A     1969 Intra osseous anchorage of dental prosthesis I: Experimental studies Scandinavian Journal of Plasticand Reconstructive Surgery 3: 81–100.

http://www.dentalaegis.com/id/2008/09/the-myths-and-realities-of-immediately-loaded-dental-implants

http://www.dentalcare.com/en-US/dental-education/continuing-education/ce203/ce203.aspx?ModuleName=coursecontent&PartID=1&SectionID=-1

http://www.denta.lv/?act=ipa&l=lat

http://cincinnati-oralsurgery.com/implantology_files/image018.jpg

http://www.intelligentdental.com/wp-content/uploads/2012/01/nerve-injury.png

http://www.mccullochlaw.net/images/nerve_injury/12_Panorex%20View.jpg

http://www.edgardelchaar.com/imagesadmin/services/12051703201088.jpg

http://www.drchetan.com/dentalpics/plog-content/images/dental-instruments/dental-implants/dental-implant-14.jpg

My current rant topic: E Cigarettes

Even the writing of the above “product” as a title offends me. For those who have managed to bypass the tsunami of people walking the streets/sitting on public transport/your favourite restaurant with what looks like a tiny musical flute sticking out of their mouth, e cigarettes are the new “cool” way to smoke.

They are advertised as being the best thing you can do for your health and from the sheer volume of marketing bumph surrounding them you would think they were some sort of miracle that purified even the finest mountain air.

In this blog post I will therefore attempt to work out

1)      What the hell they are

2)      What the hell is in them

3)      Why the hell people think it is acceptable to use them like a lollipop

The premise of the e cigarette is that it is supposedly a healthier alternative to regular cigarettes because they do not contain tobacco. This sounds all well and good as we know the damage that tobacco can cause – in particular reference to my area of “expertise” it can lead to a whole range of oral cancers which can involve not just the areas of your mouth visible when you yawn but a whole realm of other areas in the head and neck. Most brands of this device also claim that they do not contain tar. Another benefit of course unless of course you wish for your lungs to look like the surface of the M6.

They were primarily designed as an addition to the realms of nicotine replacement therapy (NRT) alongside patches, gum, medication like Champix etc and therefore used to cut down smoking.

All of this sounds very positive, so much so that one lady who switched to using a certain brand of the e cigarette to write the poem below:

No more cigarettes for me
What could I do, I liked the taste
Went to e-cigarette with much haste

Cigarettes without the bad bits
Made it easy to kick the habit
They come in lots of different flavours
For me to try and quickly savour

The prices are great
Delivery is never late
So give Smokers Angel a go
And try their range of Halo

Now that is quite a gushing testimonial. Similarly, the woman below appears extremely pleased with her e cigarette. It has even managed to get her a gentleman willing to photobomb her holiday snaps.  What could possibly be so bad.

 

On that note, let’s see if we can find any information at all about what is in them. Now trust me, I spent a good few hours trying to research this and the only thing I consistently came across was marketing BS. So I turned to the BMA (as I so often do)

What are they?

“E-cigarettes are battery-powered products designed to replicate smoking behaviour without the use of tobacco – some look like conventional cigarettes, while others appear more like an electronic device”  They consist of a cartridge containing liquid nicotine, an atomiser (heating element), a rechargeable battery, and electronics.

E-cigarettes have been marketed as cheap and healthier alternatives to cigarettes as well as to look and feel like cigarettes for use in places where smoking is not permitted since they do not produce  smoke. E-cigarettes are products operated by a single use or rechargeable battery that heats a liquid based solution (often containing nicotine) into a vapour. This is then inhaled by the user, simulating the effect of cigarette smoking.

They are primarily used (apparently) as a means to quit smoking and therefore the major studies conducted on e-cigarettes have analysed nicotine content, as addiction to this apparently why people cannot quit smoking. “An analysis of the total level of nicotine generated by e-cigarettes which vaporise nicotine effectively found that the amount inhaled from 15 puffs was lower compared with smoking a conventional cigarette”. Please note the extremely vague wording used by the usually extremely un-vague British Medical Association. Another study analysed sixteen e-cigarette brands and found the total level of nicotine in vapour generated by 20 series of 15 puffs varied from 0.5 to 15.4 mg. Again, there is no regulation, nor any standard or reproducible results that can be produced from e cigarette testing.

In 2009, the United States Food and Drug Administration (FDA) released results of an analysis of some e-cigarette product, it showed that the tested e-cigarette cartridges contained carcinogens and toxic chemicals. Analysis of two leading brands by the FDA also revealed:

• • diethylene glycol (a toxic chemical) in one cartridge at approximately 1%
• • tobacco-specific nitrosamines (which are human carcinogens) in half of the samples
•  tobacco-specific impurities suspected of being harmful to humans (anabasine, myosmine, and ßnicotyrine) in a majority of the samples

The tests also suggested that quality control was inconsistent or non-existent:

• • cartridges with the same label emitted a markedly different amount of nicotine with each puff
• • one high-nicotine cartridge delivered twice the amount of nicotine compared to a nicotine inhalation product approved by the FDA.

 i.e. the biggest food and drug regulatory body in the world cannot conclusively say that is in the products or what they give out.

See next subheading.

E cigarettes – the new enemy?

Whilst I absolutely cannot deny that any improvement on smoking normal cigarettes is beneficial to health in general and therefore oral health, e cigarettes are a dangerous realm to enter into.

The reason they are cheaper is because they are not taxed in the same way as regular cigarettes. Hurray, I hear you shout. Sadly, these taxes pay my wages in the NHS, they also put people off smoking because it makes it so darn expensive. Without this deterent what is to stop people continuing to pump dangerous chemicals into their bodies. Similarly, they are not regulated in the same way as normal cigarettes. For cigarettes to be sold they have to go through rigorous quality control, the same does not apply for e cigarettes. Due to this, we have absolutely no clue what is in them.

All that can be said is that they are not licensed as a medicine in the UK, and there is no peer-reviewed evidence that they are safe or effective for the purpose of helping to cut down smoking, as a “healthier” alternative to smoking or in fact any other reason except making you look like you’re smoking a marker pen.

The World Health Organisation document (which is 50 pages long I might add); WHO STUDY GROUP ON TOBACCO PRODUCT REGULATION raises further concern about the use of these products as nicotine replacement therapy. “Delivery of nicotine to the lung raises concern about safety and addiction that go beyond that related to currently approved NRT, concern…is associated with the probable exposure of the lung to repeated dosing, perhaps hundreds of times a day for many months, if these products are used as a smoking cessation aid, or for years, for smokers who use them as long-term cigarette substitutes”. That is to say, the delivery of nicotine directly to the lungs has never before been studied, and whilst manufacturers get away with using certain chemicals in e-cigarettes because they approved for human consumption, we have no idea of the effect they have when inhaled.

Most people who purchase and use e-cigarettes claim they do so as a means to cut down on smoking i.e. smoking cessation, instead of things like patches, gum and so on. Sadly, the World Health Organisation(WHO) who govern most of what we do in terms of medication, health choices, prevention etc state that “as of July 2013, the efficacy in using electronic cigarettes to aid in smoking cessation has not been demonstrated scientifically”. They tend to err on the side of caution as they are such a huge body of people of differing backgrounds and motivations that having a strong unified opinion on something is a difficult task. However, so unified was their opinion in this case that they recommend "consumers should be strongly advised not to use" electronic cigarettes until a reputable national regulatory body has found them safe and effective”. Nuff said.

The British Medical Association have also been forced to offer up an opinion on the damn things and their summary is not much more positive than the WHO. They state that “four out of five e-cigarette users continue smoking, and use e-cigarettes primarily as a substitute where smoking is not allowed” thus completely defeating the object of switching to e-cigarettes for a smoking cessation purpose. Again, the BMA agree, expressing their concern that e-cigarettes may undermine smoking prevention and cessation, as their use is likely to reinforce the normalcy of the smoking behaviour”.

This normalcy was nicely illustrated just last week when I walked past a patient sitting IN THE DENTAL HOSPITAL WAITING ROOM smoking one of these devices, regarding me with confusion at my anger with her behaviour. Similarly, the fact that the e cigarettes are generally quite aesthetically pleasing and gadgetty-looking means that people are far more likely to openly smoke them, and thus consume more nicotine than they would should they smoke their normal cigarettes, thus negating the intended purpose of switching.

Our Australian cousins also echo this. “Other unintended consequences of e-cigarette use include the potential to induce nicotine addiction in non- smokers or maintain addiction in current smokers who might otherwise quit. Furthermore, concerns have been raised that e-cigarettes may undermine the comprehensive indoor  smoking restrictions and smokefree air policies” and making it generally acceptable for people to be seen smoking after years of hard work aiming to make them feel as embarrassed about smoking in public as public urination – people still do it but its few and far between, although maybe I grace the wrong areas of town at the wrong time of night.

The National Institute for Health Care and Excellence (NICE) recently published new public health guidance backing the use of licensed nicotine products to help people cut down as well as stop smoking. However, these guidelines did not cover e-cigarettes. Again, without having to say it, I imagine several suited men sitting round a table and laughing at the concept of e-cigarettes even being considered in this category of something that they would advise or recommend as something of health benefit.

Now of course, I cannot complete an analysis of the use of this product without referring to the superpowers of the USA – namely the Food and Drug Administration department (FDA). They basically regulate everything that is consumed, injected or applied by our friend across the pond and thus you could argue, have probably become fairly used to seeing products come and go, and are unlikely to have any emotional response related to items they are asked to assess. So strongly therefore did the FDA feel about e cigarettes that way back in 2010 long before the e cigarette phenomenon reached our shores, they issued warning letters to a grand total of 5 electronic cigarette distributors for various violations of the Federal Food, Drug, and Cosmetic Act (FDCA) including unsubstantiated claims and poor manufacturing practices. What is more worrying is that the FDA only regulates products intended for therapeutic use i.e. as a nicotine replacement therapy, and therefore, if a company decides to purely register their e cigarette product as recreational, or a hobby based item, then it completely negates all regulation by any drug agencies. Still fancy puffing away on one of them?

Dental Impact

What most people don’t consider is the effect that smoking has on their mouth. Whilst smoking e cigarettes should technically reduce risk of oral cancer, the presence of carcinogens in most of the leading brand’s e cigarettes negates this benefit. Similarly, the main causative factor of smoking related gum disease is nicotine. As the e cigarettes are rammed with the stuff, they offer no benefit in terms of “the leading cause of tooth loss” (thanks Corsodyl). That is to say, puffing away on your e-cigarette is just as harmful to your gums as smoking regular cigarettes and so your path on the road to dentures is just as speedy. In fact the WHO state that 90% of the nicotine that people smoking e-cigarettes are so desperate to get into their lungs, is actually deposited in the mouth.

In Summary.

The Medicines and Healthcare Products Regulatory Agency in the United Kingdom reported that it planned to regulate e-cigarettes as medicines from 2016 when new European tobacco laws come into force so until then, it remains that we have no idea what e-cigarettes are. In my mind, used as a nicotine replacement therapy, i.e. to smoke less and less over a set period until smoking has been stopped, completely, is fine, so long as they smoke it miles away from me, not around children, and that the whole thing stops being glamorised.

What I trawled through in order to write this blog:

BMA, E-cigarettes in public places and workplaces A briefing from the BMA Occupational Medicine Committee and the Board of Science, March 2012

BMA calls for stronger regulation of e-cigarettes

March 2012 (updated January 2013) A briefing from the Board of Science and the Occupational Medicine Committee

http://www.cancerwa.asn.au/resources/2013-11-13-ecigarettes-position-statement.pdf

http://www.ecigarettedirect.co.uk/

http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm

http://whqlibdoc.who.int/publications/2009/9789241209557_eng.pdf

WHO "Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS)". World Health Organization. 9 July 2013.