“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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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.

My first post (hopefully not my last!)

And......deep breath......

Welcome to my blog, named in honour of my Dad who always wanted me to get a "proper" job in a dental practice which would have the pun-tastic name "Smiles Better". Unfortunately this is about as close as he's going to get to me owning something so here goes.

My name is Michelle. I am a 24 year old dentist/tooth worker.

After completing my training at Leeds University encountering my fair amount of "oh you're studying dentistry, do you want to be a dental nurse then" I went on to complete a year in general practice working away under the NHS contract with a bit of private tooth stuff thrown in and I am currently on a rotation (called DF2) working in the hospital setting. So whilst I am still a (very) junior member of the dental team I have seen the industry from various different angles and am keen to keep up with new innovations and ideas.

After being asked by several family members and friends to interpret charts given to them by their own dentists or to explain why they need certain treatments, along with a fair amount of "polite tellings off" of other special people in my life who perhaps decide that each mouthful of food should be washed down with Diet Coke ("It's diet, it can't be bad can it?") I thought it might be an idea to start some sort of online resource for other people in the same situation.

I therefore welcome anyone to comment with dental questions, queries, things they would like clarifying and I will do my best to ease your minds as well as throwing in the odd rant about issues close to my heart now and then.

Unfortunately now I have to add a subtle note...

DISCLAIMER
Any comments made on this blog are solely my opinion unless I reference otherwise. If I cannot provide objective answers on my own knowledge alone I will do my utmost to find reputable sources to do so. While I hope these comments do not cause offence I apologise if anything I say upsets anyone reading. I am not sponsored by anything dental and so any product recommendations are purely down to literature research or my personal trial and error. 

Now back to the post.

I have no idea whether anyone will read this, if anyone reads it how helpful it will be or whether this is my first and only post but I do hope that I can at least provide some comfort to at least one person who understands their mouth a bit better after reading.