Wednesday, May 20, 2009

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'

Friday, May 8, 2009

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'