Dental Implants: Marketing vs. Reality

Dental implants are now, the standard of care for tooth replacement, improving dental health of million of people with missing teeth. Implants have also greatly impacted dental economics with increasing number of dental practices and companies offering their services and products. To gain market share, many dental practices advertise dental implants in the newspaper, with mailers, or on the Internet, offering incentives to attract potential patients to their offices. Here are common advertisements:

"Implant for $1,095; Abutment & Crown for $950; We Guarantee Successful Placement!"
"Implants Starting at $995"
"Teeth-in-A-Day"
"One-Hour Dental Implants"
"No Pain, No Bleeding, No Sutures”
“Free implant with purchase of crown”

If these offers sound too good to be true, they usually are. Here is what you need to know before getting burned by misleading advertising.

"Implant for $1,095; Abutment & Crown for $950; We Guarantee Successful Placement!"

This is a very common advertising ploy. It does not tell you the whole story. An implant refers to the post placed in the bone. The abutment is the extension attached to the implant, supporting the crown. Such “special” fees do not correlate with cost of labor and materials for a level of precision and quality that implant supported crowns require. Here is the typical range costs to surgeon and restorative dentists to replace a single missing tooth:

Implant placement related costs to the dentist:

• Dental Implant (reputable companies with well researched implants): $400 to $450
• Healing abutment (a temporary extension that sits on the implant): $40 to $50
• Surgical guide (a stent guiding accurate implant placement): $50 to $150
• Drills (series of drills in various diameters necessary to prepare the bone for implant placement): $50-$100

Prosthetic (actual tooth) related costs to the dentist:

• Impression post (to take impression of implant): $40 to $50
• Implant analog (An implant duplicate used for models): $25-$35
• Permanent abutment (supports the crown): Customized by lab: $225 to $450; Stock type: $100 to $150
• Permanent abutment screw (holds abutment on implant): $50 to $65
• Permanent Crown (made by a quality lab): $250 to $600

And for teeth replacement in the upper front area (smile zone) add:

• Temporary Abutment (Necessary for support of temporary crown): $125-$175
• Temporary Crown (Necessary for implants in the smile zone): $125-$175

As you can see, these costs to the dentist automatically add to $1,360 to $1,1950 just for the cost of materials. This does not include the impression materials, accessory materials, and personnel and administrative costs.

It is nearly impossible to offer such fees as $1,095 for an implant and $950 for a quality abutment and crown, and cover expenses for materials, labs, office, staff, marketing, and a leave marginal profit for the dentist. Here is the catch: Dentists employ common “cutting corner” strategies to offer a low fee and still make profit on this procedure.

Cutting Corner Strategies:

• Placing “no-frill” implants: Implants are titanium posts that are placed into the bone and act as root support for the abutment and crown. There are some generic implants in the market that may cost $95 to $150. The catch: Important characteristics such as titanium composition, machinery, surface type, design, and sterility of these “copy” implants are not well documented. They also have not undergone evidence-based testing or trials. There is little or no literature on their success and healing. Complications such as infections, fractures, non-bony healing, and bone loss may be at increased risk.
• Use of stock (generic) abutments: The abutment is the extension that is attached to the implant and supports the crown. Stock abutments are manufactured by the implant companies and are available in several standard sizes. These are cheaper than the recommended custom abutments. The catch: Stock abutments do not provide proper form and contour of a natural tooth. The cosmetic results are unpredictable and hygiene may be difficult. Custom abutments have clear advantages and are recommended by every experienced prosthodontist, dentist, surgeon, and laboratory technician.
• Re-using implant drills that are used to prepare the bone where the implant is placed. Drill’s sharpness, sequence, and surgical technique are crucial to achieve a stable implant with healthy bone and proper healing. To save money, some dentists reuse old drills that have become too dull. This can result in heat damage to the bone, poor healing, and implant failure.
• Use of inexpensive lower quality labs: It is commonly accepted that work performed by the lab is just as crucial as the work by the surgeon and the restorative dentist for long term success. Laboratory cost can be significant for quality prosthetic work, whether it's a crown, bridge, veneer, or denture. Some labs offer special fees to the dentists for doing the work, like a “$95 monthly special” for the crown. Here is the catch: Quality laboratory work requires careful attention to details, communication with dentist, precision fit, accurate margins, custom angulation and form of the abutment, and artistic porcelain work for a crown that looks good and functions well. All of this takes time and expertise, which is why a quality laboratory charges $225 to $350 just for the abutment and another $250 to $500 for the crown fabrication. The longevity and success of implant supported crowns depends on accurate and high quality work. Non-fitting components and poor quality materials will cause crowns or implants to fail.
• Not using a surgical guide that is mandatory during placement of an implant for accurate positioning and angle. This requires custom impressions of a patient’s teeth. Next, study models are poured in stone and a guide is fabricated in the laboratory or by restoring dentist or surgeon. Many do not do this because it takes extra time, materials, and lab fees. The catch: While it saves time and money, it frequently results in poor implant placement that can be too close to other teeth, tilted outward or inward, or set too deep. The result is an abnormal looking crown that may be difficult to clean, cause potential gum recession and bone loss, and increase the risk of implant failure.
• Same dentist placing the implant and the crown: Sounds convenient and nice, but here is the catch: Implant placement and fabrication of a crown are separate disciplines, and it is nearly impossible for any dentist to master both. It takes years of training and experience to place a dental implant. Similarly, in-depth knowledge and skills are required for the prosthetic part of the procedure. Implant dentistry is predictable, but not easy.

"Implants Starting at $995!"

This is the “a-la-cart” approach. Sounds cheap, but here is the catch: Frequently, every aspect of the treatment, component, materials, and services are itemized. This means, you'll probably pay for the consultation, every X-ray, every screw, every part, and material used. And this does not include the crown or abutment. In addition, if something happens and an implant has to be replaced, you'll end up paying for it again. Add this to the money-saving strategies discussed, above and you'll see how it’s offered at low cost.

“Teeth-in-A-Day”

This has become a new craze, and yes, I believe, it’s largely a marketing fad. Teeth-in-A-Day means you have your teeth removed, implants placed, and receive crowns, bridges, or dentures all in one day. Here is the catch: While promising, the current science, knowledge, literature, research, and expertise is not sufficient to achieve predictable results in every individual. The approach may be successful, but only in very few candidates who present with no infection around their teeth, have great amount of bone, and all conditions are ideal. If conditions were this perfect, why would they need to have their teeth extracted to begin with? Many commercial “implant centers” do a hard sell to fit a patient into a treatment plan. Healthy natural teeth end up being extracted in order to place multiple implants and connect them with an immediate prosthesis on the same day! There are some evidence-based studies on this approach, but there are too many variables not yet thoroughly understood. While successful in some, use of this approach in poor candidates results in high rates of failure and implant loss.

"One-Hour Dental Implants"

This is a frequent advertisement and it means absolutely nothing. Every patient is different with varying needs, different complexities, and treatment approach. Even in the most ideal conditions, procedure can take 15 minutes to several hours based on the treatment which can and should vary from patient to patient. Even Domino's pizza no longer guarantees delivery of a pie in 30 minutes or less.

“No Pain, No Bleeding, No Sutures”

Yes, this is possible, but a few things need to occur! First of all, there is always some discomfort with an implant placement, although mild in most cases. A surgery without bleeding or sutures means that a dental implant was placed without an incision and gum tissue flap. This is absolutely possible. But here’s the catch: The team must use a CT-scan for 3-D work-up, and fabrication of a special guide to aid the surgeon for precise implant positioning. I have used this technique many times with great success. It does add to the cost, though, often by as much as $750 to $1000. It is well worth the extra cost if there are multiple implants, compromised bone anatomy, and a need for great accuracy in difficult cases. To have no bleeding or suture, without use of this technology, requires a “blind” implant placement that is difficult and challenging, even in the hands of most skillful surgeons. Even if there is bleeding, it usually stops in a few hours and sutures fall out in few days. I don’t recommend compromising implant positioning and accuracy to avoid slight bleeding and sutures.

“Free implant (with purchase of crown)”

This offer suggests that patients get a free dental implant when they pay for their crown. The '”free” offer is a common marketing tactic designed to hook a consumer into trying a product. This may be all right for marketing a new facial moisturizer, but not for dental implants. Here’s the catch: First it implies that implant placement and the crown are being done by a single ‘super-dentist,’ and as already discussed it is practically impossible for one person to have mastered both disciplines. Also, it suggests possible use of no-frills implants and itemizing all other aspects of treatment to make up for the ‘free’ implant cost. This means you'll pay for every X-Ray, part, piece, visit, replacements, etc. In most instances, you will end up paying more for the ‘free’ implant.

The reality is that implants work. While it’s a highly successful and predictable procedure, it’s not simple, requiring the skills of a trained specialist and restorative dentist working as a team. Implants have a more than 98 percent success rate when performed by the right team of dentists that use quality implants, customized components, and reputable labs. This saves patients money by preventing complications and re-dos, and improving longevity.

The old rule “If it's too good to be true, it probably is” applies to dentistry too. When looking for tooth replacement options, do not fall victim to misleading marketing tactics. Do your research, ask the right questions, and know what you are getting. It’s a lifetime investment and shouldn’t be taken lightly.

In part 2 of this report, we will discuss the right questions patients should ask when searching for implant treatment providers.


Please send all correspondence to:

DC Alliance for Dental Implant Awareness
4825 Bethesda Avenue, #310
Bethesda, MD 20814

hrkazemi@mac.com

Denture Wearers Seek Better Options

Mrs. S. was a 65 year old female who had been wearing a denture for about 10 years. She lost a number of her teeth due to gum disease and decay at early age and was given a full dentures. She talked about a time when she first got the dentures: "big, clonky pieces of plastic which was really tough to get used to! It caused me to gag a lot and best I could eat was mash potato and puree apple. It never really fit well so I started getting sore spots all the time. My dentist tried to reline them a few times, but it would only remain comfortable for a short time. Over the next several years, I had to get more relines as the dentures seemed to have less hold on my jaw bone. Just slipping all the time. It was not till recently that I realized my jaw bone was gradually being lost due to the denture. I tried using denture glues, but did not really work well and I was spending a lot of money on them. The denture is so loose now that I can not keep it in even during normal talking. It's really embarrassing. I like to go out a lot and spend time with family and friends. And like to also eat. But just can't! It's just horrible......."

Stories like this are not uncommon. People are living longer and healthier lives and dentures are simply not compatible with an active and healthy life style. Aside from social aspects, denture wearers may have problem getting proper nutrition affecting their overall health.

These patients are seeking better options!

For Mrs. S., two dental implants were placed, a 30 minute procedure under IV sedation and allowed to heal for 6 weeks before a new overdenture was made. She has been using the new prosthesis for about a year now and is extremely pleased and happy with it. She has become more social again and is enjoying her favorite foods much more than before.

Dental implants have transformed dentistry and oral health in ways we could have never imagined and they are certainly transforming lives of many denture wearers who are suffering as Mrs. S. did. The solution is amazingly simple and predictable: Placement of 2 or 4 implants to support an overdenture.

The simplest design is placement of two implants, one one on each side. After a 6-8 week healing, special attachments are placed allowing the dentures to 'snap' on to them. The implants provide great support of an overdenture allowing the patient to eat and speak comfortably. It also prevents further bone loss. It can also be easily removed for cleaning. No more relines, No more glues, No more slipping and sliding!

The second option is placement of 4 implants, two on each side. This give improved stability of the overdenture and therefore allowing patients even more freedom in their choice of diet and overall function. This is the most common design for patients with full denture.

Implants have 98%+ success rate and have extremely low complications when properly done. Patients report minimal pain after the surgery and recovery is remarkably fast. Sometimes the denture can be placed on the same day as the implant surgery or in 6-8 weeks once healed.

Patients of any age can have dental implants successfully, even with osteoporosis. There is no reason to have to live with limitations that regular denture bring; There are better options to help many live a better and more happy and active life.

Dr. H. Ryan Kazemi
www.facialart.com
(301) 654-7070

Fear of Nerve Damage with Wisdom Teeth Extractions!

Over the years, I have treated a number of patients for their wisdom teeth who were initially discouraged to have it done because as they were told: "their teeth is on top of the nerve!". The nerve spoken of is a sensory nerve that runs in the jaw bone just below the lower wisdom teeth and in very rare occasions may be in contact with the roots of the wisdom teeth. In all of these patients, the recommendations were made solely based on a panoramic x-ray or a small dental x-ray that appeared to show close proximity of the lower wisdom teeth to the canal that carries this sensory nerve. The concern during any wisdom teeth surgery is possible close relationship between the nerve and tooth, and the potential nerve irritation that may result in some degree of numbness over the lip and chin region.

The question is how valid is this concern and the recommendations given?

First, it is a known fact that in majority of patients there is a separation between the nerve and the wisdom tooth, even though it may appear otherwise on the x-ray! It's important to realize that a panorex or a small dental x-ray is a 2-dimensional image and overlapping structures on these images do not necessarily mean they are in contact.

As mentioned, there is often a separation between the nerve and roots of the wisdom teeth despite the x-ray appearance and therefore risk of nerve damage is extremely low. Even in rare instances where they are in contact, meticulous and careful techniques used by surgeon can minimize any chances of long term problems. Therefore, fear of nerve disturbance, although always possible, is largely unsupported and not removing the wisdom teeth carries much more real and significant complications in the long term. I have personally treated thousands of patients whose x-rays showed the typical 'tooth on top of the nerve' and yet the nerve was not encountered and surgery was successful with no sensory deficits.

Panorex has been considered the radiograph of choice for oral and maxillofacial surgeon when treating impacted third molars. There are 9 radiographic signs associated with an intimate anatomic relationship between the canal and the lower third molars: Radiolucent band , loss of cortex of canal, change in canal direction, canal narrowing, root deviation, bifid apex, superimposition, and contact of canal with roots of the mandibular molars. Without these positive signs, the risk of injury is considered miniscule, whereas the presence of 1 or more positive signs is not a good predictor of injury to the nerve.

Icat and three dimensional imaging is an alternative technique that can demonstrate anatomical relationships between teeth and nerve and improves diagnosis, however, there is an ongoing debate in the literature about the need for CT scans before third molar removal, even when 1 or more of the signs is noted on the panorex.

While there is no consensus or standard of care on this issue, it is felt that CT scans should be considered in selected cased, chiefly when 1 or more of the telltale signs are present on the panorex. It is also recommended to discuss it during informed consent; including potential risks and benefits of undertaking third molar removal using a CT scan compared to no CT scan. Patient should ultimately make the decision considering all the facts and involved cost.

For more information, contact Dr. H. Ryan Kazemi at hkazemi@facialart.com

Visit our site: www.facialart.com

Office Telephone: (301) 654-7070

Office location: Bethesda, MD

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

Choosing the Right Dentist For Your Needs

With rapid advances in dentistry, evolution of specialization, and marketing trends, choosing the right dentist for a specific need has become increasingly difficult for many people. Here is a simple guide in understanding various dental specialties and what they do best to help you ‘pick the right dentist for the job’:

General dentist: A general dentist has graduated from a 4-year dental school with no additional formal post-doctorate residency. Some may have completed a 1-year general practice residency program following dental school, providing them additional clinical experience and expertise. Some general dentists may have also taken extensive courses on specific disciplines, such as cosmetic dentistry, periodontal surgery, dental implants, endodontics, or orthodontics. Therefore they may perform these specialty procedures with great proficiency and can provide excellent treatment even in the most complex patients. As there are no specific regulations, It is best for patients to inquire about the proficiency and experience of a general dentist regarding complex procedures that are more often performed by specialists.

You will benefit from a general dentist if you have the following needs:

• General restorative needs (fillings, crowns, bridges, dentures, etc.)
• Routine periodontal care (Cleaning, management of early or moderate periodontal disease)
• Cosmetic procedures (bleaching, bonding, veneers, etc)

If a general dentist has additional training and experience, they may provide:

• Simple extractions, root canals, orthodontics, periodontal procedures, and some pediatric dentistry.
• Complex restorative, cosmetic, and surgical procedures per their experience, proficiency, and personal comfort.

** Most general dentists choose to refer all or most of the specialty or complex procedures to specialists **

Specialties Recognized by the American Dental Association

Prosthodontics: A prosthodontist has received three additional years of post-doctoral training in dentistry gaining advanced skills in both cosmetic and restorative procedures. Some may also perform common periodontal or oral surgery procedures, but most focus on treatment of patients with complex cosmetic and restorative needs. In a patient with multi-disciplinary needs (e.g a patient who needs crowns, implants, root canal treatment, and gum surgery), a prosthodontist will act as both the restorative dentist and the coordinator of the overall treatment and other team dentists.

You will benefit from a prosthodontist if you have the following needs:

• Both simple and complex restorative needs (crowns, bridges, veneers, etc.)
• Dental implants and reconstructive dentistry
• Rehabilitation of patients with partial or complete missing teeth
• Advanced cosmetic procedures (bleaching, veneers, tooth reshaping, bonding)
• Multi-disciplinary complex dental needs

Oral and Maxillofacial Surgery: Oral surgeons receive 4-6 years (6 years for combined DDS / MD programs) of post-doctoral training in accredited residency programs. They receive hospital-based training in oral and facial surgical procedures and anesthesia, in addition to extensive medical training to care for the medically compromised patients. Most are board certified as necessary for obtaining hospital privileges. Oral surgeons are limited to performing surgical procedures and anesthesia and offer key role in the overall care of dental patients.

You will benefit from an oral surgeon if you have the following needs:

• Extraction of teeth (wisdom teeth and others)
• Dental implant placement (surgical aspect)
• Minor and major bone grafting procedures to create site for implants
• Oral biopsies
• Corrective Jaw surgery (orthognathic surgery)
• Oral and facial infections
• Oral and facial trauma
• TMJ related treatments
• IV sedation / Anesthesia
• Procedures requiring hospitalization
• Surgical treatments in pediatric patients

Endodontics: Endodontists are root canal treatment specialists. They receive 2-3 years of post-graduate training on treatment of conditions affecting tooth’s root canal system. Endodontists have advanced surgical and non-surgical skills that make them uniquely qualified to treat routine as well as complex cases. The root canal contains the blood supply and nerve tissue vital to a healthy tooth. Insults such as decay, trauma, or other infections can compromise its health, therefore requiring root canal treatments. Current techniques, instrumentations, and technology (such as microscopes) allow endodontists achieve high treatment success.

You will benefit from an endodontist if you have the following needs:

• Saving a non-vital or irreversibly inflamed tooth and avoid extraction
• Root canal treatment for teeth that exhibit temperature sensitivity or pain due to decay or trauma
• Teeth with abscess due to necrotic root or other types of pathology (such as cysts) compromising its health

Orthodontics: Orthodontists receive 2-3 years of post-graduate training, specializing in straightening teeth and management of jaw relations in both children and adults. Crooked and crowded teeth are prone to decay, periodontal disease, and possible loss. Misalignment of the teeth and jaws can lead to premature wear, further damage and chronic facial and joint pain. Through use of braces or other techniques such as invisalign, orthodontists can align teeth for improved function and aesthetics. Orthodontic related treatments may start in patients in as early as 8 years old or adult patients.

You will benefit from an orthodontist if you have the following needs:

• Straighten and align teeth for improved bite and aesthetics
• Correction of misaligned or asymmetrical jaws
• Retainers or night guards
• Treatment of TMJ and facial muscles related pain

Periodontics: Periodontists receive 2-3 years of post-graduate training for treatment of gum disease, various gingival procedures (functional and cosmetic), and dental implants for teeth replacement. Periodontists often work along with general dentists or prosthodontists for long term periodontal care of patients (bone and gum tissue surrounding teeth). They provide both preventive periodontal care as well as both surgical and non-surgical management of periodontal disease. While some procedures are performed by both periodontists and oral surgeons, they often work in collaboration on patients with complex needs requiring both expertise.

You will benefit from a periodontist if you have the following needs:

• Surgical and non-surgical treatment of gum disease
• Preventive periodontal procedures
• Treatment of gum recession via grafting procedures
• Cosmetic gingival procedures
• Minor bone grafting procedures for implants
• Dental implants placement

Pediatric Dentistry: Pediatric dentists receive 2-3 years of specialized training after dental school, and are dedicated to the oral health of children from infancy through the teenage years. The very young, pre-teens, and teenagers all need different approaches in dealing with their behavior, guiding their dental growth and development, and helping them avoid future dental problems. Some may provide oral sedation for increased patient comfort. Pediatric dentists may work in collaboration with orthodontists to treat growth related teeth or jaw misalignment.

You will benefit from a pediatric dentist if you have the following needs:

• Any dental related procedures in patients from infancy to early teen-age years
• Fillings, crowns, and root canal procedures on primary teeth
• Knocked out or fractured primary teeth (may require an oral surgeon)
• Treatment of minor trauma to primary teeth
• Routine cleaning and preventive dental procedures

The ‘DDS’ vs. ‘DMD’ Question

A common question is what is the difference between a dentist who is a DDS vs. one who is a DMD!

DDS: doctor of dental surgery DMD: doctor of dental medicine

DDS or DMD Indicates the degree awarded upon graduation from dental school to become a general dentist. There is no difference between the two degrees; dentists who have a DMD or DDS have the same education. Universities have the prerogative to determine what degree is awarded. Both degrees use the same curriculum requirements set by the American Dental Association's Commission on Dental Accreditation. Generally, three or more years of undergraduate education plus four years of dental school is required to graduate and become a general dentist. State licensing boards accept either degree as equivalent, and both degrees allow licensed individuals to practice the same scope of general dentistry. Additional post-graduate training is required to become a dental specialist, such as an orthodontist, periodontist or oral and maxillofacial surgeon.


Choosing the right dentist for a specific problem or need is an important part of our oral health. Everyone deserves the best treatment dentistry can offer and making engaged decisions is an integral part of this process.

For more information, contact Dr. H. Ryan Kazemi at hkazemi@facialart.com

Visit our site: www.facialart.com

Office Telephone: (301) 654-7070

Office location: Bethesda, MD

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

Who is best for Placing Dental Implants? A Guide for Patients to Make Better & More Engaged Decisions About Their Oral Health

There are three things in life that we protect more than anything else: our family, money, and health. We carefully protect them with every resource we have to avoid irreversible loss. And we follow some innate behaviors: We don't hire a stranger to babysit our kids no more than trusting our attorney who took some accounting courses with managing our hard earned money. But somehow we have lost the grip on protecting our health. We blindly accept doctors' recommendations regardless of whether it's their area of expertise or not. We select a doctor because they accept our insurance and pay little attention to how good they are and what their training and qualifications are. It makes no sense any more than trusting our tv repairman to fix our computer logic board or have our internist do a bypass surgery! The reason behind this inconsistent behavior may be because for years people did not have a better option. Medical and dental knowledge and technology even up to two decades ago was a fraction of what is known now. Physicians and dentists managed to learn a lot and do a lot and it worked. And frankly it was not easy for people to access information, so they had to go with what their doctors told them.

But times have changed. We live in a specialized world, with an immense amount of knowledge in each field which continues to grow at a rapid rate. In-fact, there is so much information and knowledge that it is practically impossible for any one person to master any more than one or two disciplines in their lifetime. It's time to come to grip with reality and take more responsibility for our health and make decisions that make sense, protecting our health like we protect our families and money.

Dental implants have revolutionized dentistry and the way we as dentists can help millions of patients with missing teeth regain their confidence, function, aesthetics, and overall oral health. The science and knowledge of dental implants has evolved greatly since they were first introduced by the father of implant dentistry, professor Branemark almost 50 years ago. It has now become one of the most successful procedures that we perform, approaching 98% plus success rate. This is mainly related to highly skilled implant surgeons trained in accredited residencies, continued advancement in technology and techniques, and better understanding of its biology and healing. But this knowledge is not achieved easily. Some clinicians spend their lifetime doing and learning about dental implants, performing hundreds and thousands of procedures, attending many conferences, and reading endless numbers of related literature each year........to reach what I call a "Level of Mastery". Our great success is a reflection of this dedication and mastership by these clinicians.

Here is the problem and a potential disaster in the making: In the past few years, there has been increasing trend for dental implant companies and some study groups to sponsor "weekend" courses targeting the general practitioners to buy their products and perform these highly technical and demanding procedures on their own patients. There is huge profit for these companies to do so as the general dentists make up the majority of the dental practitioners and therefore potential sales.

The current state of economy has amplified this problem. For number of dentists patient flow and treatment acceptance has declined. With decrease in production, many decide to perform such procedures themselves where they would have previously referred them to specialists.

And we are starting to see the results of this: Failed implants, increased infection, poorly positioned implants that can not be restored, nerve damages, loss of jaw bone, etc. This is very concerning, because the industry has worked so hard and so long to bring this unique service to patients transforming their lives with such great predictability and success.

Weekend courses clearly do not cover appropriate areas of study to meet the legal standard of care for implant placement. Most expert clinicians attest, "implant surgery is never simple". In response to this alarming trend, the Institute for Dental Implant Awareness (IDIA) recently released new training guidelines for basic implant placement. It is hoped that implant companies and organizers of these "weekend" courses comply and change their protocols. But this will take time and will certainly not be an easy battle.

So what should you do as a patient if you are planning to get dental implants? Here are some key questions to ask your dentist to help you make an engaged decision about your treatment and ultimately your oral health:

1) What is your specialty? Oral surgeons and periodontists receive formal implant surgery training in accredited residency programs; some prosthodontists and general dentists may also have advanced surgical training. Caution: An "Implantologist" is not a recognized and accredited specialty nor does it indicate proper training.

2) What is the extent of your training in implant surgery? Ask specifically the names of the courses, dates, durations, and who sponsored them. Search these courses and see if they are legitimate programs endorsed or supported by professional associations.

3) How many dental implants have you placed? A specialist or any skilled clinician has placed hundreds if not thousands of implants. They do these procedures day-in and day-out. However there are some clinicians who are also excellent and skilled through indepth training who may not have yet placed significant number of implants.

4) Do you work with any specialists? Even if a dentist places some dental implants, they almost always work with specialists in their area; Ask if it's OK for you to speak with them and get a different perspective. It's your right

5) Ask to speak to other patients about their experience. Personal testimonials are very valuable and meaningful.

6) Ask the assistants and receptionists about dental implants (how they work, how long it takes, what are the steps, etc); If they can not answer your questions or defer you constantly to the dentist, then they most likely do not perform many of them!

7) Ask for brochures, supporting articles, before & after photos, and other detailed information. A practice with focus on dental implants will have all of these readily available.

Such engaged questions can also be asked of other highly specialized procedures such as extractions, grafting procedures, wisdom teeth, root canal procedures, orthodontics, etc.

As dentists, we have the responsibility to provide the finest care that we can to serve the best interest of our patients and we must remain committed to this oath. But it is also the responsibility of every patient to get involved and make engaged decisions about their health.

Dr. H. Ryan Kazemi


To reach Dr. Kazemi for this story and others:

Email: Hkazemi@facialart.com
Tel: (301) 654-7070

web: www.facialart.com

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

Risk of jaw bone necrosis with patients on Fosamax or other bisphosphonate drugs

Bisphosphonate-induced osteonecrosis of the jaw adversely affects the quality of life. American association of oral and maxillofacial surgery recently published a position paper on this condition. Majority of patients are on the oral form such as Fosamax, but some are receiving IV therapy which have more serious consequences. It is important that we continue to educate our patients with this condition and its implications, and current knowledge on management strategies. This quick reference guide reviews important facts for every patient on bisphosphonate therapy and their treating dentist.

What is it? Bisphosphonates are used for treatment of osteoporosis, hypercalcemia of malignancy, Pagets disease of bone, multiple myeloma, and metastatic bone disease in a number of cancers

What are the various forms of this drug? Intravenous forms: Zometa and Aredia (for management of cancer related conditions) and more recently, Reclast (for osteoporosis). Oral forms: Fosamax, Actonel, Boniva (for treatment of osteoporosis and osteopenia); Boniva is available in oral & IV

What are the reported effects on jaws? The primary concern is osteonecrosis of the jaws characterized by poor healing of the bone following common oral surgery procedures (i.e. extractions, implants, periodontal surgery, etc.)

How do I know I have osteonecrosis of the jaws? When all the following are present: 1) current or previous treatment with a bisphosphonate, 2) Exposed bone in the oral region for more than 8 weeks, 3) No history of radiation therapy to the jaws

What are the risks for developing bisphosphonate-induced osteonecrosis of the jaws (BIONJ)? Increased risk with use of IV forms, duration of therapy more than 3 years, over areas where there is thin gum tissue, and patients using steroids at the same time. There is 7-fold increase risk in cancer patients exposed to IV form with history of dental disease. It occurs more commonly in the lower jaw.

How can it be prevented? Before treatment with IV bisphosphonate, patients should have complete oral evaluation and treatment to avoid surgical procedures later. In patients on oral form of the drug, if possible, may discontinue oral bisphosphonate for 3-months before and 3-months after elective invasive dental surgery to lower the risk.

What are the treatment strategies?

Asymptomatic patients on IV bisphosphonate: Maintain proper hygiene and dental care, Avoid surgery if possible
Patients on oral bisphosphonate less than 3 years: Elective surgery is safe. There is always a small risk however and informed consent should be discussed for any elective surgery.
Patients on oral bisphosphonate less than 3 years along with steroids: Consider discontinuation of oral bisphosphonate for at least 3 months before surgery; restart drugs once healed.
Patients on oral bisphosphonate more than 3 years: Consider discontinuation of oral bisphosphonate for at least 3 months before surgery; restart drugs once the surgery site has healed.


Dr. H. Ryan Kazemi is a board certified oral and maxillofacial surgeon in Bethesda, Maryland. He is a clinician and lecturer on the topic of dental implants, bone grafting, and other oral surgery procedures. He also produces video podcasts on dental implants and oral surgery to educate dentists and patients for making better and more engaged decisions about their oral health.

To reach Dr. Kazemi for this story and others:

Email: Hkazemi@facialart.com
Tel: (301) 654-7070

web: www.facialart.com

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

Teeth Extractions- What Patients Should Know...

Extraction of a tooth is is an emotionally traumatic experience, but the actual procedure does not have to be. If performed by an experienced oral surgeon, the procedure can be done easily and quickly with minimal complications and optimal comfort. IV sedation is a marvelous anesthesia option making the experience great.

Teeth require extractions for several reasons. These include:

• Severe caries (decay)
• Significant periodontal disease
• Significant pain due to infection / inflammation of the pulp (nerve of the tooth)
• Non-restorable due to position or significant caries
• Non-responsive to endodontic therapy (root canal procedure)

With modern day techniques and skills, teeth extractions can be done with minimal invasiveness and time. In fact, surgical removal of teeth takes only 5-10 minutes in most situations. The initial healing takes place in 48-72 hours and typically stable in 5-7 days. Complete healing of any extraction site takes about 6 weeks. Dental implant replacement can be done in 6-8 weeks after an extraction. It is crucial that at the time of extraction the supporting bone is inspected for any defects. The bone undergoes significant resorption and loss following a tooth extraction resulting in defects that are unsightly and difficult to maintain proper hygiene. Also, they create a poor site for implant placement later.

Therefore a site preservation grafting is recommended in the following situations:

• Augmentation of bone loss due to periodontal disease or abscess
• Enhancement of the tissue architecture in the upper front area (Aesthetic zone) to optimize aesthetics and smile line
• Preservation / Augmentation of bone necessary to allow placement of dental implants or other prosthesis at a later time

A transitional prosthesis may be fabricated and placed in the extracted site on the same day.

So here are the key information to remember about a tooth extraction:

1) Best performed by experienced oral surgeons

2) IV sedation is the preferred anesthesia option

3) Always replace the missing tooth with an implant to maintain oral health and condition of other teeth

4) Consider grafting procedures to preserve your jaw bone and maximize on function and aesthetics once restored

For more information, contact Dr. H. Ryan Kazemi at hkazemi@facialart.com

Visit our website: www.facialart.com

Office Telephone: (301) 654-7070

Office location: Bethesda, MD

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

Computer-Assisted Planning For Placement of Dental Implants

Dental implants have become the optimal treatment option for replacement of missing teeth. They have 98% + success rate and have allowed many patients achieve normal eating and smile without the irreversible damaging effect of other alternatives such as bridges or dentures.

To achieve optimal functional and aesthetic results with dental implants, it is crucial that the patient has adequate bone and gum tissues and the implants are positioned properly in all dimensions. Utilizing readily available office CT scans, it is now possible to obtain cost effective cross sectional images of the patient's jaws that can then be converted to 3-dimensional images. These images reveal accurately the dimensions of the existing bone as well as the vital anatomical structures in proximity, such as nerves and sinuses. Often, the dentist first makes a special prosthesis (embedded with barium sulfate) that takes into account the final bite and teeth positions. Patient then wears this prosthesis during the CT scan creating radiological marks on those images. These marks represent the future sites of the crowns and the proposed positions of the dental implants, a critical tool in initial diagnosis and planning.

Utilizing a special software, we then convert the obtained CT scan into 3-dimensional computer images that give us a 360 degree view of the patient's jaw, available bone, its anatomy, and the surrounding vital structures. Next we place virtual dental implants in their previously determined and planned positions guided by the marked sites on the CT. The result is a computer model demonstrating the the existing bone anatomy, vital structures, and accurately positioned dental implants that will eventually support the patient's teeth.

This 3-dimensional computer model is then used to fabricate a surgical guide or stent that translates the implant positions in the computer to a working jig that will be used by the oral surgeon during placement of the implants. These custom made gigs are extremely well fitting allowing the surgeon to easily and accurately place the implants in their appropriate positions. Once healed, the implants can easily be restored by the patient's dentist knowing the foundations (i.e. dental implants) are in the right place and orientation.

We are utilizing this cutting edge technology on many patients allowing us better diagnosis, less complications, more accurate implant positioning, shorter and less invasive surgeries, and enhanced results that meets the patients' goals.

Dr. H. Ryan Kazemi is a board certified oral and maxillofacial surgeon in Bethesda, Maryland. He is a clinician and lecturer on the topic of dental implants, bone grafting, and other oral surgery procedures. He also produces video podcasts on dental implants and oral surgery to educate dentists and patients for making better and more engaged decisions about their oral health.

To reach Dr. Kazemi for this story and others:

Email: Hkazemi@facialart.com
Tel: (301) 654-7070

web: www.facialart.com

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

Dental Implants in the Smile Zone- Keys for Success

Loss of a front tooth, whether due to an accident or decay, can be a very traumatic experience for a person. Dental implant is a great treatment option for replacement. However the front teeth and the surrounding smile zone present unique challenges that make therapy in this area amongst the most difficult to do. It requires the most expertise in both diagnostic and technical protocols. Here are the 5 key principles every patient should know, on how to achieve great results with Dental Implants in the Smile Zone.

Historically, patients had either a bridge or denture to replace their missing teeth. While a bridge offered satisfactory aesthetic results, it was too invasive and damaging to adjacent teeth due to the required preparation or ‘cutting down’. And a denture was aesthetically unpleasing, and difficult to wear and chew with; and often resulted in further damages to other teeth and supporting bone.

Dental implants have 98% + success rate, and are now the mainstay in teeth replacement therapy. But the aesthetic zone in the upper front area presents unique challenges which must be carefully addressed by the clinicians for optimal results.

Here is the problem: Loss of a tooth results in significant shrinkage of bone and overlying gum tissue in the region of the front incisors and canines. Also there can be additional remodeling and shrinkage after implant placement or grafting procedures . All of this, if not addressed, will result in an uneven gum line, poor aesthetics, difficult cleansing, and even failure of the implant in the long run. So here are the 5 key principles in achieving a result that you will love:

1) ‘Fail to Plan’; ‘Plan to Fail’

During the Initial Diagnosis and Planning, both the surgeon and the restorative dentist must collaborate closely and evaluate the following: Bone and Gum tissue level and thickness; Periodontal health; Smile line; and the position of other teeth. This requires x-rays or other imaging techniques, detailed examination, and study models which are all vital to a proper diagnosis. Study models can further be used for simulation of the final crowns, fabrication of a temporary prosthesis for the patient and making a special guide aiding the surgeon during implant placement. The surgeon and the restorative dentist, each with expertise in their field, should then review the gathered information and design a collaborative detailed plan to achieve a patient’s realistic goals. This plan, along with impending challenges, possible solutions, and associated risk factors should be throughly be discussed with the patient. Team communication is vital to executing the plan and ultimate success.

2) Preserve the foundation

Extraction of a tooth consistently results in loss of bone and the overlying gum tissue . This can easily be prevented by making sure that the surgeon grafts the site at the time of the extraction. Preserving the bone also maintains the overlying gum tissue, therefore creating a healthy foundation for the implant and its crown. The graft materials most often used for this type of procedure are calcified granules supplied in individual containers and it is rarely necessary to obtain it from the patient in form of actual bone. These materials promote bone healing in an extraction socket and minimize its shrinkage. Another way to preserve the foundation is placement of the implant at time of the extraction. This is known as ‘immediate implant’ and can be done predictably in appropriate sites. Finally, the temporary prosthesis, whether removable like a flipper or fixed like a bonded temporary crown, needs to be carefully shaped to guide the gum tissue during its healing.

3)Precise positioning of the implant by surgeon

With a healthy foundation, the surgeon can now place the dental implant. But it is most crucial that the implant is positioned properly in all dimensions including Height, width, and depth, and angulation. A poorly positioned implant is grounds for disaster and results in poor aesthetics and function. A simple rule is “To Never Place an Implant in Wrong Position”. This is accomplished by using a surgical guide made on study models or by using Cat scan generated computer planning. While the actual placement of a dental implant is simple, safe positioning and handling of the supporting tissue can be complex and should be performed by an experienced and skilled clinician.

4) Shaping the gum tissue

During the implant healing, the gum tissue architecture is further designed by placement of a temporary crown on the implant. This is one of the most crucial steps and is often overlooked or rushed. It is the only way to create the desired gum tissue level and shape as well as providing a patient a ‘glance’ of what the final crown will look like. In some situations and if appropriate, an immediate temporary crown may be placed on the same day as the implant. Otherwise it maybe placed several weeks later. Either way, the temporary crown should be left in place for 3-4 months to ‘design’ the proper gum tissue architecture as well as give patient the opportunity to provide feedback on its appearance and comfort.

5) Final Crown

The temporary crown provides a lot information that can be used to make the final crown look more natural, comfortable, and pleasing to the patient. Depending on the smile line, gum tissue thickness, and its shape, the restorative dentist may decide to use metal or ceramic extensions to support the final crown. Known as abutments, these extensions must have proper contour to create a natural and healthy gum line and crown. In the smile zone, it is crucial to use customized abutments that are fabricated in a laboratory, and not use ‘off-the-shelf’ abutments which are reshaped chair side by the restorative dentist. It is the use of customized abutments that allow optimal gum tissue architecture, aesthetics, and crown fit. The final crown itself may be made of either porcelain with underlying metal or completely out of ceramic material. This decision must be made by the restorative dentist based on aesthetic requirements of that specific patient. Finally it is important to use a quality laboratory and technicians who understand the demands of implants in the aesthetic zone and can work closely with the restorative dentist to make high quality crowns.

Losing a front tooth is a devastating experience for most people altering their self image, confidence, and social interactions. Dental implants offer a great solution for replacement however must be performed carefully by clinicians who have in-depth understanding of its challenges, biology, and the strict protocols required for optimal success.

For the video podcast of this blog, go to itunes (search word dr. kazemi) or vimeo.com (Dr. Kazemi's oral surgery channel), or visit our website: www.facialart.com (To-The-Point Multimedia Platform- 10 minute updates)

DDSForums.com- A new site for dentists to collaborate

DDSForums.com is a new online site for dentists allowing them to learn through collective intelligence and experience sharing. The first city for the forum is Washington DC, but soon will be expanding to other cities. This will allow the dental practitioners to get to know each other and also do the following:
1) Share an experience, a question, or idea
2) Post photos and videos
3) Form their own groups and manage their members
4) Post events and inform all members
5) Post interesting articles or cases for discussion

Each member must be invited and approved to join.
Click here to watch the DDSForums.com introduction video

For more information or to request membership, contact Dr. Kazemi

Common Misconceptions and the Truth About Dental Implants

I am often asked by people if dental implants really work as they tell me their difficult stories or others' poor experiences. There seems to be a lot of misconception and misinformation out there. So What is the truth?

Tooth loss is a big problem in America. Approximately 100 million Americans are missing one or more teeth, with close to a third of these individuals missing all of their teeth in one or both jaws. Over 69% of adults ages 35-44 have lost at least one permanent tooth to decay, failed root canal, gum disease or accidents. A third over 65 have no teeth at all.

Individuals with teeth loss age prematurely and have compromised nutritional state due to inability to eat a proper and balanced diet. Many also suffer from altered self image and self confidence and cannot talk and smile comfortably. If not replaced in a timely fashion, tooth loss also results in shrinkage of surrounding jawbone.

Modern-day dentistry has devised an excellent way for people to replace their missing teeth and improve their smile and chewing, while avoiding loss of jaw bone and damaging effect of dentures or bridges. Rather than removable dentures resting on the gum line, or fixed bridges using adjacent teeth as anchors, dental implants are long-term replacements that your oral surgeon surgically places in the jawbone. Implants are visually indistinguishable from natural teeth, and if properly cared for, can last a lifetime.

Dental implants are growing in popularity -- there were 5.5 million procedures performed in 2006. Unfortunately, many Americans avoid getting implants because they have been misinformed about its success, overall experience, and risks. Here are the five most prominent misconceptions about dental implants -- and an explanation for why each is dead-wrong.


Misconception #1: Implants are too invasive and painful!

Implant dentistry is a subtle and conservative office procedure performed with precision and finesse. An experienced surgeon can place the implant in 10-15 minutes. It is significantly less invasive and less traumatic than conventional bridges that require ‘cutting down’ of natural teeth. Patients often report significantly less discomfort with their implant surgery than even with a simple tooth extraction. Recovery is quick and most people return to work or school the following day.


Misconception #2: Implants are expensive!

Dental implants save you money in the long run by preserving jawbone and keeping adjacent teeth healthy. With proper cleaning and care, an implant will likely last a lifetime.

Compared to the alternatives, there is a much lower chance that a dental implant patient will need additional, costly dental procedures after the initial placement. Bridges require unnecessary cutting down of the surrounding teeth, exposing them to possible decay, root canals, or fractures resulting in further extractions and replacement with a costly new longer bridge.

Dentures cause gradual loss of jawbone due to traumatic shrinkage, therefore needing numerous relines to maintain their fit. With increasing loss of bone and support dentures become loose. To avoid slippage, denture adhesives are used which add significant cost over the years. By using as little as two implants, these adverse effects are prevented.


Misconception #3: Implants are frequently rejected by patient’s body!


The overall success rate for dental implants is 96 percent with almost 50 years of clinical research to back them up. Because implants are made of completely biologically compatible ‘bone-friendly’ titanium material, they naturally heal and integrate with the surrounding tissues. Rejection does not occur with dental implants. Other complications such as infections or ‘soft’ healing are extremely rare.


Misconception #4: I don’t have enough bone or I am too old for dental implants!

Jawbone may become thin or missing due to tooth loss, gum disease, or trauma. Using current grafting techniques and available materials oral surgeons can easily and predictability build up the necessary jawbone for healthy support of dental implants. Grafting procedures are highly successful when performed by a skilled oral surgeon providing every person with the benefits of dental implants.

Some older patients fear their jawbone is too weak for implants due to their age or osteoporosis. The fact is dental implants are equally successful in these patients, improving their quality of life by being able to enjoy their favorite food and maintain social interactions.


Misconception #5: Any dentist can perform dental implant surgery!



According to Dr. Harold Slavkin, dean of the University of Southern California dental school, ''a well-educated and well-trained clinician is imperative'' for a successful dental implant procedure. Malcom Gladwell, in his recent book, Outliers, talks about the 10000-hours rule which says: Achieving Excellence at Performing a Complex Task, True Mastery & Greatness Status as a World-Class Expert in Anything Requires 10,000 Hours of Practice. Hence choosing a skillful and experienced surgeon placing the implant and a dentist restoring it is crucial in achieving aesthetic and functional success.

In this regard dental implants success is twofold. First, it requires skillful surgical techniques, best performed by surgeons or dentists with formal surgical training. Second, it requires precision fitting and highly cosmetic overlying crowns, bridges, or dentures made by an experienced restorative dentist. The best success is achieved when a team of dentists work together along with a quality laboratory.

Reality: Dental implants are the most ideal and predictable way to improve your smile and chewing while saving you significant cost over the years. They are safe and highly successful in virtually every patient, regardless of their age or jawbone health, especially when performed by skillful and trained dentists. Implants are the future of dentistry here today with cutting edge technology and techniques that will benefit many for a better and healthier life.

Check out my podcast on itunes on this topic: Search 'dr. kazemi'; or on www.youtube.com: search word 'implant guru'

If any questions, please call me at (301) 654-7070

Dr. H. Ryan Kazemi