Challenges and Solutions in Managing Implant Disease

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the challenges and solutions in managing implant disease. Our guest is Dr. Samuel Low, professor emeritus at the University of Florida College of Dentistry and an advisor member of the Panky Institute. He is past president of the American Academy of Periodontology and a current officer of the Academy of Laser Dentistry. Dr. Low, it's a pleasure to have you on the Dr. Phil Klein Dental Podcast . Well, thank you, Phil. I always appreciate the opportunity to share a little bit about implants. You gave a great webinar recently, so I encourage all of our listeners to tap into that on Viva Learning.com. Just look for Dr. Low. You can type his name in, L-O-W, in the search field, and you'll come up with his webinar. The most recent one, again, was done a couple of weeks ago, and it was on implant disease. Excellent presentation, so take a look at that one. So to begin this podcast, let me ask a simple question. Why is there an acute focus right now on patients with implant disease? I would assume, Phil, that the reason that it is such on everyone's mind right now is, first of all, been placing implants for many, many decades, and especially in the last two decades. So now we have a bevy of patients who have implants. Therefore, naturally, the more patients out there that have implants, the more possibility that there could be, for some of those implants, implant disease, whether it be the reversible mucositis. or the implantitis itself. With that, we've got patients asking about their implants as far as whether they can survive or not. We have hygienists asking about how to manage them, both suggesting for the patient at the chair and in the bathroom. So now what is occurring is when you see seminars about implants, you're also seeing not just about the equivalency of placing them, but how do we maintain them, and especially after they do show some signs of disease. Right now, there is, we believe, there are approximately 3 million implants a year being placed just in the United States alone, and therefore, it is now critical to us. determine how to maintain them. Since I got out of grad endo, which was back in the mid 80s, implants was still something that was somewhat experimental. But at this point, it's the real thing. I know the late Carl Misch used to talk about how a single tooth implant is pretty much determined at that point when he was doing that research, more successful than a lot of root canals. Does that still hold that concept? Well, Phil, talking to you as a former endodontist, I have to be careful answering that. However, you will like the answer. The answer right now is that we are suggesting that natural teeth, one should always consider endodontics first. In a dentureless basis, you don't have that option. But it totally depends, as you know, in practice, it totally depends upon the tooth, the situation. But for now, for me, even though I enjoy implants, I always say try to keep your natural tooth first. And then if the endodontist or the restorative dentist or the periodontist suggests that you have no other option, then you should consider an extraction. But you can always take them out, but you can't necessarily put them back in. So it's not that I have a bias one way or the other, because I still believe it's the appropriate data collection. But the needle is moving. from where it was in 2002 2003 2004 where everything was take it out put an implant in to actually listening to the science and listening to our patients who want to retain their teeth yeah so i would suggest phil uh endodontists are going to be around for a very long time actually they're doing exceptionally well now uh because of the concepts of people wanting to keep the teeth yeah no that's a very good point Dr. Low, and when I practiced, the concept and the prevailing opinion was retreat if we have an endodontic failure. We're certainly going to do the root canal first if it's a standard molar root canal. Most of the work we did as endodontists were the posterior teeth. But if it was a virgin root canal, nobody ever touched it before as far as endodontics. We would do the treatment, and the success rate was always very high, 98%, 99%. If we got a case where... Another dentist did the root canal, whether a GP or whatever, or done out of the country or whatever. We would retreat it. And if that failed, then we would consider an implant at that point. Exactly. And endodontics has incredible new technologies. When I say new, I mean, you know, new in general, you know, with microscopes and now the addition of some laser technology. decision tree on a treatment plan. So tell us how a patient discovers that they have a problem with their implant and what happens after that? Well, the question basically is, for the most part, very much like what we see with periodontitis in patients. Most patients have no earthly idea that they have bone loss periodontitis. We call it the silent disease. And likewise, Most patients have basically no idea that they have implant disease of any kind, whether it be mucositis or implantitis. A recent study demonstrated that in a group of patients, 56% of them had rip-roaring implantitis and 90% of them had no earthly idea that they had it. What this is actually suggesting is that it is us as dental health professionals that actually determine the level of implant disease and we scrutinize that with both radiographs especially and to a certain degree a periodontal probe without us determining it if a patient does not see us they could end up actually losing an implant very quickly because we now know that implant disease is not like perio disease from the standpoint of stages Perio is more linear until it really gets into that moderate to severe. Implant disease is absolutely episodic. So they have to see us to be able to determine the level. The home care that a patient carries out every night, let's say they floss, is that going to work with implants as well as it does natural teeth if they can get in there through the embrasure? Well, I may not gain any friends when I suggest something, but floss doesn't work in periodontitis. There's not a study yet that shows it. And floss absolutely does not work with implant disease. In fact, if you're not careful, it will actually cause damage because of just the sharing nature of the floss and tearing in foreign bodies. The way that you manage periodontitis and implant disease. is interproximal devices like interdental brushes such things like soft picks it doesn't really matter to me what one uses but we now know that it is the disruption of biofilm not necessarily even the complete removal of it, but the disruption of the biofilm that has to be done by mechanical means. Although my patients do dip their interproximal brushes in solutions, whether it be periosciences, whether it be something that has essential oils, again, that is not as critical to me as the fact that they do it. The physical debridement using this brush, you're saying is the key? It's the key. You can come back with oral irrigation. I'm fine with that. But please, let's not play a joke on ourselves thinking that oral irrigation by itself is going to disrupt the biofilm to the degree that is necessary. And so when we talk about what they do at the chair for dental hygienists, that is absolutely also going to be an issue because if you don't use ultrasonics appropriately, metal to metal, you're going to have an adverse effect on the implants. And that's why, again, we are so into chairside by hygienists actually utilizing these new glycine and erythritol types of airflow polishing devices, which are phenomenal on biofilm. But for home care, it's interproximal brush-like soft picks. that go in and truly disrupt the biofilm. How subgingival do we have to get with these brushes to be effective? And at what stage of implant disease will these brushes not really help anymore if it's too advanced? Yeah, we know that everything is one to two millimeters at best with anything out there, maybe three if they're a little fanatical. After that pocket depth fill, things have to change. We either have to change the gingival anatomy. Or we have to now go into, we don't like to do this, but one point that I do want to make, we have got to intercept implantitis very early and quit waiting until it's three or four threads down and expect that we can do something. My message on that webinar that you referred to is the first time you see bone loss with a thread exposed, you've got to flap it. I am a laser person. I suggest that you use an erbium laser to debride, to detoxify, and decorticate, and then stop it in its tracks instead of waiting to where the bone is like halfway down. Because, Phil, as an endodontist, you've done surgery. You know trefinding an implant out is not a pretty sight. You've got to get it before that. What would you recommend for a dental office to implement as far as a protocol? Are we talking about every six months or in the first year, less than that? Theoretically, every implant placed should have some type of air flow polishing, erythrofol, some kind of debriving every three months, just like teeth. And I know that's not easy to do, but especially at least every six months to one year, radiographs need to be taken, standardized. to determine. And if you've progressed into implantitis, either the dentist or the oral surgeon or the period, whomever, it doesn't matter to me, needs to reflect it and detoxify that implant surface to move on and ensure that that patient's going to have that implant for life. One thing that's important, when you take out a tooth, nobody likes it. The patient doesn't like it necessarily. But Phil, you take out somebody's implant, they are not thrilled. Yeah, that's got to be prevented. That is the truth. So as far as home care, as soon as someone gets their implants delivered, the final prosthesis, you're recommending soft picks. And I think Sunstar makes that. And that's something they can use at home. Now, if they use that religiously with someone with your experience, would you say that in most cases, they probably will not even get implant mucositis? If they used an interdental brush or a soft pick. and they used it religiously, and they were able to have access to it. Theoretically, they cannot get implant mucositis of any significance because that is still, to a certain degree, biofilm related. Now, if the implant was not placed appropriately, and all of those kinds of dynamics, and they have a systemic situation, you know, immunocombinized, that's a different thing. But what you just said, theoretically, is right on target. If we can make the prosthesis to where it is accessible and they use the appropriate materials and they do it daily, the chances of them getting mucositis, unless the prosthesis was poorly placed or poorly made, that is correct. So it's two parts. I mean, it could be iatrogenic if... It's impossible to access this area where you can't prevent biofilm from building up based on the architecture of the implant placement. And the other part is home care compliance. So once a day, even if it's at night, before you go to sleep, you use this particular soft pick or whatever you're going to use, this interproximal brush and physically debride the biofilm. And you have the accessibility. If you do that every evening, very unlikely you're going to get implant mucositis, which is somewhat reversible or even worse than that. That's pretty much the case. Absolutely. Unless somebody, you know, created a restoration with an open contact or an open margin, there's a fracture of the screw. There's 50% of what we're starting to believe is prosthetics and not just biofilm. But you are correct. If it's placed appropriately, restored appropriately, and they have access to it. I don't see how they could get implant mucositis, not with the tools that we have now. That's up to the hygienist and the dentist to convey that very important message to the patient, especially like you said, one thing is extracting a tooth, the other thing is extracting an implant, two different animals. One last question, Dr. Low, how does technology fit into managing the implant patient? Well, naturally, technology is money to a dentist. You have to consider the ROI, but there are two areas that I think will make a big change. One I mentioned was airflow technology. The powders now are very, very different with glycine, erythritol. They are not like what we've experienced in the past with sodium bicarb. One really needs to take a look at that. Several companies like EMS make those kinds of things. And then that's for mucositis. For technology, for implantitis, it really is the Erbium laser. Every study shows that the most effective way to really detoxify that implant surface or degranulate once that flap is reflected is an all-tissue erbium laser. And those are my two high-tech things for the implant business as we speak. That makes total sense. And also the erbium laser, if, God forbid, there is an extruded cement, a resin, the laser could go after that too. The laser is looking for the water and the resin. perfect that's exactly right in fact uh if you have an erbium laser and you have to take a cemented crown off the implant body the uh in a zirconium the laser will literally go through the zirconium exactly what you just said create micro implosions in the resin with the water and it should just basically come off. We take zirconium ceramic veneers off in 30 seconds with an off tissue laser. Scott Benjamin, I don't know if you're Scott Benjamin, he's a dentist who lectures a lot on lasers and he's done some podcasts with us on dental lasers and he's a big fan of lasers. He can't live without it in his practice. Yes, we both are, you know, I am, I will be president-elect at the Academy of Laser Dentistry and Scott Benjamin. has been very, very, very, and still is very important to the Academy of Laser Dentistry with everything that he's published, his research, and just his advice has been very, very positive. Yeah. Both of you guys are just amazing with your knowledge. It's such a pleasure to have you on the show, Dr. Low. And again, thank you so much for your time. Thanks. for being on Viva Learning for the webinar, which you did a phenomenal job. I loved it. I saw the recorded version. I didn't get to see it live. And this podcast sums it up nicely. And hopefully we can get you on more shows coming up. Again, it's always an opportunity to be able to express some opinions, but primarily just to do what we can to make those patients keep their teeth or keep their implants. Absolutely. Stay well. Thank you. Thank you very much.