“What about them implant things?”

Today’s blog post is going to be an overview of dental implants. I won’t go too much into specifics of types, the science etc because it’s a bit irrelevant, many boffins in many Scandinavian labs have done all the work for us and also, I  have no idea what half of the publications related to said science are on about.

I will split the topic into 2, what they are and what they can be used fo and in whom, then will do a part 2 explaining what is involved in their placement, aftercare, lifespan etc so stay tuned for that!

Shall we begin? Good.

What are they?

The Association of Dental Implantology UK (ADI) define implants as “a substitute for a natural root and commonly it is screw or cylinder shaped”. The actual object called the "dental implant" refers to the bit that is in the bone. Other components can be added/ attached to make the implant functional, for example, something called an abutment can be screwed on top, which passes through the gum and allows prosthetic (fake) teeth to be attached. See helpful pictures below.

Why would you need them?

So, you find yourself in the situation where you are either already missing, or are about to lose either 1 tooth e.g. you got caught in a drunken brawl, you ate too many sweets or in fact several teeth, for instance due to dental disease or following trauma (often horse related) or after removal of tumours etc. 

Placement of implants after cancer surgery is much more involved because not only are the teeth often missing, but the disgusting thing takes most of either one or both jaw bones with it and so extensive rebuilding is necessary before implants can be placed therefore making it much more complicated and beyond my limited realm of knowledge and so we shall stick to the “I haven’t brushed my teeth for 20 years and would now like you to fix it for me” causes of tooth loss.

How do they work and what can they be used for?

This seems a fairly obvious question however there is a lot of confusion of what implants can do. They are the closest thing to a natural tooth that can be provided by a dentist however they have several limitations. They can be used to replace individual lost teeth, in the majority of cases this is front teeth.

There is a lot of panic about losing and replacing of back teeth. Obviously if you have one of those smiles that shows every single tooth in your mouth and beyond, or have one of those laughs where you can see your epiglottis then the concern about missing a tooth is understandable. Fortunately most people don’t have this problem and so if you lose a molar tooth, there is actually no need to replace it. Especially with something that costs a minimum of 2 grand.

***As a side note if you come across one of those adverts promising 15 implants for the cost of a Mars bar, I would stay well away. I would consider dental implants in the same way you would think about other implants – hip replacements, breast implants etc and if you wouldn’t go to a rat infested converted house to have those done on the cheap, then you shouldn’t have your teeth done in the same situation. I think because they’re teeth people believe that the same standards are care aren’t necessary, only takes 5 years to be a dentist and that, surely my beautician could do it? The answer is no. Obviously. Mainly because if something goes wrong, its’ your jaw and your head. There is limited bone and so any infection caused by dodgy placement (bearing in mind there is a risk of infection even under pristine surgical conditions and a skilled operator) means that you are at risk of losing significant portions of your jaw bone and at this point, we can’t fix it. Mini rant over. Let’s continue

The only feasible reason for replacing a missing back tooth is to stop over-eruption of the opposing tooth, that is to say when the tooth that is biting against the one that is lost grows out of the gum and into the space. It is a very rare case that a tooth in the mouth ONLY comes into contact with 1 other tooth when biting, usually they touch 2 or 3 depending how you bite and for this reason usually over-eruption won’t occur.

Let’s see if a picture helps…

 Over-eruption means that the bit of the tooth that usually sits under the gum line is now exposed to the mouth. In terms of potential consequences this can look a bit unsightly, but again it would depend on your smile and what is shown. If you only see it in the mirror when you’re looking at a demented angle whilst stretching out your cheek then it really won’t affect your life. The other potential problem is that the bit of tooth under the gum line doesn’t have the protective enamel layer and so can be sensitive but again this can be dealt with in other ways that doesn’t involve damaging any teeth by placing bridges or burning a hole in your wallet.

Implants can also be used to replace multiple teeth either as a way of acting as an anchor for a bridge, which thus will replace 2 teeth, or to have several implants to more effectively hold in a denture.

Implants are NOT used to replace every tooth in the mouth. If you have no teeth left, then you need a denture. End of. The stabilisation of a denture CAN be improved by implants.

I emphasise word can for the following reasons. Fortunately some clever people have done some research so I can insert that now…

Assunção et al found that “Although the stability of the mandibular (lower) implant-retained denture was enhanced compared to a conventional denture, the quality of life and satisfaction levels were similar for both the groups.” i.e. the groups of people with and without implants felt equally happy (or in fact unhappy) with their dentures.

Allen et al found that “Subjects who received implants that replaced conventional complete dentures reported significant improvement after treatment, as did subjects who requested conventional replacement dentures” i.e. simply having some sort of denture was more important/life changing than having implants to hold a denture in.

Basically, implants are not the be all and end all of tooth replacement.

So, that’s what they can be used for, how about what they actually are.

	For this reason, one of the risks of having implants placed is that if they fail, it is often due to damage to the bone surrounding the implant rather than the implant itself as the metal implant is far stronger than the bone it is encased in and in a fight, the weaker one loses. This is the same reason by post crowns fail – the post is stronger than the tooth it is stuck in, so rather than the post breaking, the tooth does instead. I will go into this more in the second part of this blog. Multiple implants to stabilise dentures work in a similar way but takes slightly more careful assessment as it is not a case of plonking an implant in where a tooth has come out. The position and placement of the implants in order to best retain a denture has to be worked out and will be different in every person.

  

As you can see from the above pictures, this particular patient has 4 implants. They can be left as the implants alone onto which the denture clips. Or the implants can be connected with a bar and the denture clips onto this. Sometimes fewer implants will be placed etc etc and this will all be decided by the implant-surgeon.

Below you can see how denture clips into the implants. This particular case does not have a bar whereas the one above does.

In the final bit of this blog post I will quickly go over who is not suitable for implants. Of course you will most likely be able to track down someone somewhere who will place the implants without asking questions. As I said earlier, if you like taking risks with your health and in fact life, go ahead. If not, go to someone who actually knows what they’re doing who will tell you the following.

Contraindication	Why
Smoking	Smoking reduces blood circulation in the mouth and suppresses the immune response in the mouth, what this means is that healing in smokers is crap. As healing is necessary for implants to work (as the bone needs to fuse around the implants) it is highly reduced in smokers. Thus infections and fusing of the implants is highly reduced. You may also experience more pain from the procedure and this pain could last for longer. It is also possible that the implant will never heal and this could leave you in constant pain, resulting in the removal of the implant. Finally, long-term smoking affects how dense the bone is meaning that finding suitable strong enough jaw bone is more difficult.
High alcohol use	Alcohol, like smoking, seriously affects healing and thus can lead to implant failure.
Gum disease	Number one, gum disease can destroy bone. No bone = no implants. Simples. Even if enough bone is found to put an implant in the first place, gum disease will inevitably lead to its failure through the same bone destruction.
Clenching and Grinding teeth	As briefly mentioned above, the implants are not natural shock absorbers like teeth are and so any excess force, like clenching and grinding of the teeth, can damage the crown on top of the implant and potentially the base of the implant as well just as clenching and grinding can damage natural roots.
Weakened Immune System	Implant placement requires an operation. While it is a relatively minor operation, any reduction to the immune system normal responses can lead to infection. Weakened immunity can occur naturally with age, due to chemotherapy, AIDs, cancer, steroid therapy, medication following transplants, Diabetes etc. Of course this will be discussed during consultation and whilst having these conditions/taking those meds does not completely rule you out from having implants, certain modifications to treatment might have to be made
Bisphosphonate Medication	Bisphosphonates are a type of medication taken mostly for osteoporosis, but also for conditions such as Paget’s disease, bone cancers, metastatic cancers. They basically alter the way that bone heals and for that reason, anything that “damages” the bone in patients taking these medications can lead to devastating infection.
Unsuitable bone	For example very thin bone. While it is possible to bone graft, move the sinus to create more space etc this is far more extensive treatment. This is particularly irritating when people come in, you tell them they need a denture, or that we cannot fix their dentures to make them like normal teeth. The automatic response of the patient being “what about them implants?”. If you have enough teeth missing to need a denture, you need a denture. If your dentures drop out because you have no bone left, you can’t have implants without a whole tonne of extra surgery.

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So that’s all for today folks!!!

Feel free to ask any questions and remember to check back in a couple of weeks for details of exactly what is involved in implant placement and sadly, things that can go wrong!!

References and that..

Allen, McMillan, Walshaw,  A patient-based assessment of implant-stabilized and conventional complete dentures The Journal of Prosthetic Dentistr Volume 85, Issue 2, February 2001, Pages 141–147

Assunção WG, Zardo GG, Delben JA, Barão VA. Comparing the efficacy of mandibular implant-retained overdentures and conventional dentures among elderly edentulous patients: satisfaction and quality of life. Gerodontology. 2007 Dec;24(4):235-8.

Chee & Jivraj  Failures in implant dentistry British Dental Journal 202, 123 - 129 (2007) 

http://www.adi.org.uk/public/implant/whatis.htm

http://www.clydedental.com/dental-implants-glasgow.html

http://www.philipfriel.com/implant-retained-dentures-gallery.html

http://kumarandentalclinic.com/Missing%20Tooth.htm
http://www.philipfriel.com/implant-retained-dentures-gallery.html

http://en.wikipedia.org/wiki/Dental_implant

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Oral How-giene

This may sound like a very broad and very obvious topic. Sadly over my relatively minimal tenure in the dental profession I have come across many abominations of the aforementioned topic.

The problem usually begins with a simple question: “so, how often a day do you brush your teeth”. At the beginning of my studies I believe my emphasis was on “a day” assuming that most people would abide by the twice a day brushing rule. Sadly these people were in the minority.

 I then reassessed my questioning technique and modified to “how often do you brush your teeth”. I was met frequently with, “errr I’d say around twice a week”.

Just to put this into some sort of context a have created a week-to-view calendar of this patient’s oral hygiene habits.

Again, just to emphasise the point this would involve, going to bed, waking up, going to bed, waking up, going to bed, waking up, going to bed and waking up WITHOUT CLEANING YOUR TEETH.

Of course there are many combinations of the above diary and I have just highlighted one, of course said patient may have a special gathering on a Wednesday so they may rummage behind the sofa and whip out their brushing implement (I avoid using the word toothbrush for reasons described later) for this exceptional event upping their weekly mouth cleaning total to 3.

I realise sadly I am a special breed of person who struggles to have a glass of water without feeling like my teeth are covered in fur, but surely this must feel AWFUL. What is often shocking is these people are in attendance of their dental appointment with a partner. Someone who presumably gets within a close vicinity of said mal-brusher. I will leave your mind to fill in the rest.

After realising that the majority of people neither brush twice daily, nor use a toothbrush I have modified my questioning to “so, what is your cleaning routine for your teeth” which usually gets me the response I am after.

I have also encountered a realm of instruments and methods used for cleaning teeth. From sticks (“Jesus used a stick so must be good enough for me”) to brushes which only could have been designed for horses.

As I have mentioned before, I am not sponsored by anyone or anything (I can’t imagine why) and so my advice comes not from a monetary fuelled avenue. Whilst I enjoy a gadget and thus use a Sonicare toothbrush, this was given to me free are charge during University when our young student minds were easily swayed by freebies. You can pick up toothbrushes for 9p. Yes that’s right, 9p. I just checked. Look. http://www.tesco.com/groceries/Product/Details/?id=256420940. They do pretty much the same job. Strangely enough saying this, I have only encountered one person who used cost as an excuse for not brushing.

A few of my personal favourite excuses, alongside those I have borrowed from other colleagues’ horrific reports are recorded below.

“I used to have great teeth but they wouldn’t let me take my electric toothbrush to jail”

“My previous dentist told me brushing damaged the gums so I don’t bother anymore”

“My gums bleed when I brush” This excuse isn't so comical and I will cover later on in another post.

“My brother flushed my toothbrush down the toilet” (which warrants the question how powerful is your toilet flush!?)

“My toothbrush broke”

“I get up very early and the sound of my electric toothbrush wakes up the kids”

Apparently the excuses don’t stop at the brushing implement itself.

“I just don’t like the taste of toothpaste”

"My dad took the toothbrush to work so I couldn't use it"

“I’m allergic to fluoride”

"No one told me I was supposed to clean my teeth"

“I don’t have time” – this is often said by a woman wearing make-up so thick that could only be removed using a wallpaper stripper

There are some people who get away with not adequately cleaning their teeth. Sadly the majority of poor mouth-cleaners are those who also believe losing a filling and leaving it for 5 years won’t cause any detrimental effect. Please refer to previous blog post for my feelings on this. These people of less-than-socially-acceptable plaque carriage are also the ones who enjoy the following rant:

“I don’t understand why my teeth are so rubbish. They just aren’t formed right I don’t think. When I was pregnant they just crumbled/I fell off a bike when I was 37 and they’ve never been right since/they just fell apart. My sister/brother/dog has lovely teeth and I just don’t understand why I’m so unlucky”.

Post-rant actual advice

1. Brush twice a day. Yes. Brush. With a toothbrush. If you use the right technique which any dentist or hygienist will be able to show you it doesn’t really matter whether you use a manual or electric toothbrush

• I personally feel electric toothbrushes are easier to use. You can’t apply too much pressure and for people with manual dexterity problems or who suffer from laziness it does the work for you. At this point I could insert various studies and "clinical trials" showing results of manual vs electric toothbrush contests. Sadly 99% of these are sponsored, conducted, altered and generally biased by the dental trade. I.e. Oral B pay for studies to be done about Oral B. Same for Sonicare etc etc. Therefore it is not wise to read to much into this. As a general guide, it is what feels comfortable to you. Some people despise sonic toothbrushes, I personally very much enjoy mine.
• If however you are going to venture into the world of dental gagettery, then I would recommend the following. Invest. This does not mean spending a fortune. In fact Boots and the like have offers on the Oral B brushes all the time and do an extra special offer around Christmas time (generally knocking off 50p more than in all previous months). In saying this, I mean stay away from the toothbrushes that are basically a manual brush with batteries in. They will do nothing more than your normal brush but cost a lot, and the toothbrush heads also cost a lot more. 
• With the example of Oral B brushes, the Oral B 1000 does pretty much what the Oral B 5000 (and I've just noticed they have added the word "Triumph" to their latest brush name - fancy). The difference is a clock with a smiley face - something I'm sure a little home arts and crafts could conjure up, and a few "free" brush heads. Considering the difference in price is about 70 pounds, these free brush heads seem to have a significant mark up to the ones you can buy separately.

2. Use a toothpaste with fluoride. At least 1450ppm. It will say this on the side of the box - usually as something fluoride (the something usually being sodium or potassium). Even the really inexpensive toothpastes pretty much all have a good level of fluoride in. (N.B this is the recommended level for adults, children are a different matter. We can also prescribe much higher levels of fluoride if we think you are at a higher risk of getting tooth deca

3. DO NOT RINSE AFTER BRUSHING. The reason we recommend a fluoride toothpaste is because fluoride helps stop bacteria in its tracks. It also hardens the tooth structure. If you wash this off, you pretty much counteract using a toothpaste and so might as well just use a brush and water. Or a stick in fact

4. Mouth wash. This is a tricky one. I like to view mouthwash as a personal preference type thing. Unless we recommend mouthwash as an aid in fighting gum disease (in which case chlorhexidine is the only thing with any proven efficacy), for dry mouth (something I will happily write about if anyone wants advice) or for orthodontic patients (who require more meticulous oral hygiene because they have blobs of metal and Hanibal Lecter type head gear) there is no particular reason for using mouthwash other than to freshen breath.

• We would always recommend an alcohol free mouthwash purely because the less alcohol you can expose your delicate mouth to the better (due to its cancer inducing properties – I’ve put this in brackets so it hopefully makes the “cancer” word less terrifying)
•  If you’re going to use it, wait at least 30-60 mins after brushing for the same reason we say don’t rinse. Ideal would be to rinse at a completely different time of the day so that your teeth are getting another hit of fluoride. Its a bit like applying moisturiser straight after you've already put some on. Its not going to do any harm and it will probably make your skin feel nice, but not as nice as if you wait a few hours and reapply. 
• If you have been recommended to use chlorhexidine this is slightly tricky. Certain ingredients in toothpaste – namely the ones that make it foam – in-activate the stuff in chlorhexidine that makes it work. Sadly it also doesn’t work if there is too much of a plaque layer on your teeth. Therefore pinpointing a time to rinse when it will be effective is tricky but I would say if you are within the 30-60 minute window I mentioned before you should be safe
• For the aforementioned orthodontic (brace wearing) people, or for those who are deemed "high risk" for dental decay - which your dentist can discuss with you - there are a plethora of fluoride mouthrinses. Whilst your dentist can prescribe some which will have a higher concentration of fluoride, you can also pick them up over the counter.

5. Tooth brushes DO NOT clean in between teeth. Gum disease is caused by a build-up of bacteria in between the teeth and below the gum line. The bristles of your brush (or splinters of your stick if you are so inclined) are far too big to get to this area. Therefore to effectively clean your teeth you need to be flossing or using interdental brushes like TePe’s. (I will be writing a separate post about gum disease to explain this in more detail but you get the jist)

I hope this makes sense and that you have picked up some pointers amidst my general annoyance at the general population for their lack of oral cleanliness. In all honesty I should be grateful as it keeps me employed however it would be nice not to feel the need to wear 3 masks and hold my breath to protect me from the halitosis I encounter on a daily basis from whichever dental chair I am leaning over. This is of course not an exhaustive list. There are many other things you can do to get optimum oral hygiene. There is also a lot more you can do to reduce your chances of getting tooth decay and I can of course cover this at a later date. This post is more of a baseline for improving your hygiene rather than the be all and end all of dental decay prevention!

As always, please feel free to ask any questions about toothpaste, toothbrushes, brushing techniques etc etc.

Dental Prevention Toolkit. 

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_102982.pdf 

This is a very long document aimed at toothworkers however if you have any confusion over what brand of toothpaste/mouthwash contains what ingredients then it is very helpful. 

Below I have provided a bit of a modified contents page of things that might be useful. 

Page number	What you’ll find there
20	Names of toothpaste brands with the amount of fluoride they contain
25	Diet related stuff to help reduce your risk of getting rotten teeth
29	Lists of sugar free medications – they usually say sugar free on the box and most good pharmacists will know which medicines don’t have nasty sugar in, but it is a helpful guide if you’re not sure
There is generally a lot of helpful information in this whole document but I’m hoping there will be very few of you that will rifle through all the jargon as it sort of invalidates the reasoning for me writing this blog so, for my sake, please continue to visit smiles—better!