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