What Can Doom Your Implants? Uncovering the Risks of Implant Failure

I think it'll be a recognition and acknowledgement of the growing number of lawsuits against dentists who don't use a CBCT. And once those begin to become more clearly elaborated upon, I think that eventually it becomes at least the minimum standard of care to have a CBCT. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. Today's episode takes a deep dive into one of the most important areas of modern dentistry, dental implants and the factors that determine their long-term success. We'll be covering both the patient's role and the clinician's responsibilities in helping ensure implants last. First, we'll explore what patients can do on their own to reduce the risk of peri-implantitis and ultimately lower their chances of implant failure. Then we'll turn to the clinical side and ask, has CBCT imaging become the new minimum standard of care in implant dentistry? We'll also examine how certain systemic health considerations come into play. Many of our patients are taking bisphosphonates. So we'll discuss how this ties into the risk of osteonecrosis of the jaw and implant outcomes. And finally, we'll address the ongoing debate about antacids, particularly proton pump inhibitors and their potential impact on implant success. Our guest is Dr. Jon Suzuki. He's a professor of microbiology and immunology and of periodontology and oral implantology at Temple University. A former dean at the University of Pittsburgh, he has chaired the FDA Dental Products Panel, led the ADA Council on Scientific Affairs, and served on numerous NIH committees. A diplomat of the American Board of Periodontology, he has published over 200 papers and a textbook. and continues to teach and educate dentists all around the world. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases, and our entire production team will really appreciate it. Dr. Suzuki, it's a pleasure to have you on the show. Thank you very much for having me, Phil. Yeah, we're very honored to have you. And as I mentioned in my introduction, you have done quite a lot for dentistry and our paths crossed again after, I don't know, 25 years when I first met you. And you did some speaking for us in an old version of what we have now for Viva Learning. And it was always great stuff and it continues to be. So again, we're very grateful for your time. So let's begin this podcast with a... General question regarding patient responsibility when it comes to periimplantitis. What are the most important things patients can do on their own to help lower the risk of implant failure? I think the first step really begins in the clinician's office and their interaction with the patient. The patient has to be educated as to their responsibilities before the dental implant is even placed. So this includes at least quarterly recalls. Secondly, an optimum oral hygiene regimen. And third, an update on medical and medication history anytime that it occurs after the implants are placed. So the patient has to be cognizant of their responsibilities before the implant is placed, in my view. Yeah, now the implant placement is a... collaboration between several dentists usually, right? It's not typical where the general dentist does everything, the planning, the surgical end, the restorative end. So the patient is kind of passed between different dentists. So I think it's important that the general dentist who ends up with the patient for the restorative work takes that responsibility on as far as patient education, right? I think you're absolutely right, Phil, that the restorative dentist has a greater burden of responsibility placed upon them when a patient has a dental implant. It just couples the entire equation of clinical surveillance and clinical maintenance of the dentition and an implant. So as a periodontist who has done so much, You were chairman of the department at Temple. You've been with the FDA. There's so many things you've done in dentistry that focused on your expertise in the field of periodontics. Do you see, because of the number of implants that have been placed, now we're looking at 5 million a year right now, and there are tens of millions of implants that are out there. Are you seeing a trend where peri-implantitis is becoming a very serious condition among our dental patients? Well, the answer is yes, and part of it is due to the increased surgical placement by both general practitioners, periodontists, prosthodontists, and oral and maxillofacial surgeons. And you're right, 5 million a year is a big number. But I think the second overriding factor is that the lifespan and the life expectancy of especially citizens of the North American continent, the United States, is longer. And so the expectancy of an implant also goes along with increasing age. So as time goes on, you would expect to see more complications with this implant in the oral cavity, as well as other implants placed in the human body. Right. But that home care seems to me needs to be more carefully understood by the patient because the resistance to peri-implantitis may be less by the body than a normal tooth, right? Because we don't have a PDL. a ligament to protect it. Is that true? Or do you think I'm just throwing things, throwing ideas out there that may not be accurate? No, you're absolutely correct, Phil, that the oral hygiene of the patient must be at a higher level than with the dentition only. And it's majorly due to the impact of the lack of PDL. because there's no vascularity no nervous innervation of the implant like there is in the tooth but the second reason is that there's generally speaking no soft tissue attachment of the gingiva to the implant as there is with the teeth Yeah, without a doubt. So I guess I was on the right track there. I'm happy that I wasn't drifting off because I can't let anything slide by you. You know too much, Dr. Suzuki. So let me ask you this. CBCT is a very talked about technology today. I mean, as an endodontist myself, retired, I would have loved to have CBCT in my practice. I didn't have the opportunity to use it. In fact, the microscope was just becoming popular when I was leaving the profession. CBCT regarding implant dentistry, would you say at this point in time that it has become the minimum standard of care in implant dentistry? Before we jump back to our guest, I want to take a moment to thank our sponsor, EMS, the company behind guided biofilm therapy, or GBT. If you haven't heard of it, GBT was developed with leading universities and clinicians, and it's quickly becoming the gold standard for managing biofilm. What makes it so effective is the minimally invasive, evidence-based approach. With airflow, perioflow, and piezon technologies, GBT gently removes biofilm, stains, and calculus with impressive precision. Patients really notice the comfort and speed, and hygienists love how efficient the workflow becomes. No surprise that thousands of practices worldwide are already seeing great results, and EMS makes it easier. Actually, for several years, Phil, I've considered the CBCT as the minimum standard of care in any, even a single dental implant placed by either the general practitioner or the specialist. What about? once it goes back to the GP, for instance, where they're restoring it? Once it goes back to the restorative dentist, I firmly believe that the onus responsibility of monitoring the implant is likewise placed on the restorative dentist and also to monitor it perhaps every three to five years by a CBCT, in addition to the diagnosis stage. So in your mind, how long do you think it's going to take? for the dental profession to adopt CBCT as a minimum standard of care? Because that's not the way it is right now. You know, if someone's practicing dentistry and they don't have a CBCT, they're not leaving themselves vulnerable to malpractice suit. So what do you see the future as as far as a timeline to when they should be all using CBCT, not only for implants, but for many other things in the office, including basic diagnostic capabilities? In my opinion, that time is here right now, that the restorative dentist should be mandatory that a CBCT be in place during the diagnosis and previous to the surgical treatment plan. I think it should be now. I can't project how long the United States... dentists will take to adopt it completely, but I think the time is here. What has to happen for a dentist that's practicing to say, okay, I need to get a CBCT or else I will be not practicing minimum standard of care? I think it'll be a recognition and acknowledgement of the growing number of lawsuits against dentists who don't use a CBCT. And once those begin to become more clearly elaborated upon, I think that eventually it becomes at least the minimum standard of care to have a CBCT. So doctors that are looking to purchase one might as well do it now, right? I mean, why wait? Yes. And if they don't have it now, make sure you farm it out to an imaging center and get the results back in your office. Yeah. So let's get back into talking about peri-implantitis and the importance of a good medical history. And before I ask you the next question, Dr. Suzuki, I do want to mention to the audience that, just to clarify for them, some of our patients are on bisphosphonates, okay? And for those that don't know what bisphosphonates are, it's basically a class of medication commonly prescribed to prevent or treat bone loss. And the way it does this, and correct me if I'm wrong, Dr. Suzuki, it kind of slows down the osteoclastic activity on a cellular basis. And obviously, osteoclasts break down bone, and we want to maintain bone in these patients. So that's what this drug does. Talk to us about bisphosphonates and osteonecrosis, especially of the jaw, as they relate to the treatment planning and prognosis of dental implants. Well, first of all, if you look historically, back in 2006 or 2007, published a landmark article and journal of the american medical association on what i believe to be the first case of osteonecrosis of the jaw stemming from periodontal surgery so it was quickly reviewed and other articles also appeared about the relationship of dental invasive procedures with the increased risk of osteonecrosis to the jaw in those patients who take bisphosphonate drugs to more specifically answer your question is that yes with dental implants In patients with osteoporosis taking bisphosphonate drug, they become at a heightened risk of osteonecrosis of the jaw, perhaps not immediately, but within three to five years after implant placement is when the ONJ can be diagnosed. So it is becoming an increasingly risky procedure with the biological gradient of bisphosphonate drugs. Without getting into excessive detail, because we could write a chapter on this, you probably have in some textbooks, what is the mechanism for bisphosphonates to cause osteonecrosis? And by the way, the acronym that Dr. Suzuki used was ONJ. That stands for osteonecrosis of the jaw, just so we all know. And there's another acronym, M-R-O-N-J. which is medication-related osteonecrosis of the jaw, which is what we're talking about here. What is the mechanism we're talking about? Well, actually, the current terminology is AR-ONJ, anti-resorptive osteonecrosis of the jaw. But the biological mechanisms appears to be the killing. and the inhibition of osteoclasts, which decreases the bone metabolism in favor of bone growth and bone apposition. So you're correct, Phil, that it is the osteoclasts that is targeted by this drug so that they simply don't work anymore. There's no resorption pattern. The bone homeostasis is dramatically disrupted. When we're talking about implants, we're looking for osteointegration, right? So by having that osteoclastic suppression, tell us what happens at the interface between the actual implant and the bone when we're looking for that osteointegration. Well, osteointegration is more than just bone apposition. Osteointegration requires a very carefully orchestrated bone homeostasis of combination of both osteoblasts and osteoclasts. So when osteoclasts are in fact disrupted, there appears to be some disruption of the overall osteointegration mechanism, potentially leading to increased risk for anti-resorptive osteonecrosis of the jaw. So if a patient came into your operatory, Dr. Suzuki, and they were on Fosamax, how would you approach that patient and how would you handle that? Yes, Fosamax is the largest example of an oral bisphosphonate drug along with actinol and along with Beneva. And there's generics too, but those are all the class of oral bisphosphonate drugs. Right. And if a patient came in, and you took their medical history, and they're loading up on this oral Fosamax, and they're looking to get an implant because they were referred to you because their neighbor just had beautiful implants, and they had a full rehab case. It looks like everything's all set where they could get an implant. What would you do then? If you're listening to this podcast, chances are you're always looking for ways to take your restorative and aesthetic dentistry to the next level. And it really all starts with great dental photography. And the right camera can be the difference between getting the photos you need and actually using them to boost case acceptance. That's why so many practices choose the iSpecial digital dental camera from Shofu. It's designed specifically for dentistry, making clinical photography fast, easy, and incredibly consistent. So there's no guesswork and no frustration for your team. With high-res images, simple one-touch operation, a lightweight design, and a large touchscreen you can use even with gloves on, the iSpecial fits seamlessly into your workflow. And those clear, compelling before and after photos? They make treatment conversations easier and help patients say yes. Bottom line, this is a camera that pays for itself in no time. So check out the iSpecial digital camera from Shofu. You'll be glad you did. Visit Shofu.com and use the code VIVA for a special offer. I have a three-year rule of thumb with regarding oral dysphosphonate drugs. It's predicated upon the basic biological sciences as well as clinical observation. And that rule of thumb is three years, which means that if it... If a patient were taking an oral bisphosphonate drug, it is probably relatively safe to perform an invasive dental procedure up to about three years of time. Some European clinicians claim four years or even five years is safe too. But that's my rule of thumb based upon data available in the basic literature. So if they're taking it for three years straight when they come to see you, that's where you draw the line. Yes, but even up till three years of time, I believe that they should have the proper medical consultation, of course, whether attending GYN if they're female or attending PCP or rheumatologist if they are a male with osteoporosis. And I also believe very firmly that the patient needs to sign a separate consent form recognizing those risks of A-R-O-N-J. because they're having an invasive dental procedure. Now, what about oral bisphosphonate versus IV? Is there any difference in that as far as the risk and the timeline? Yes. The three main IV bisphosphonate drugs in the United States approved by the FDA are Iridia, Zimita, and Reclast. Those three IV bisphosphonate drugs are primarily for multiple myeloma, other types of cancers, and also in a certain drug, the Reclast drug, it is also designated for osteoporosis. The risk of IV bisphosphonates causing potentially osteonecrosis of the jaw is much, much higher, at least 10 times higher, according to the information published by the University of Miami. So if a patient came in on these drugs, and let's say they were doing oral and they were taking it for three years or two and a half, close to three years, it wouldn't be incorrect for that dentist to... encourage the patient to go with a different treatment plan other than implants, maybe a removable denture, a bridge, or something like that. Does that make sense? That makes total sense, that the biological gradient for risk factors begins at about three years and increases exponentially after three years that they've been on the oral bisphosphonide drug. So perhaps a more conservative dental treatment plan would be the best option. Right. Now, what happens if a patient has an implant and it's integrated and then they start this drug therapy later? Is there any problem with that? That data is not known. Those clinical outcomes have not been determined yet. And to my knowledge, there's no publication looking at the longitudinal effect of bisphosphonates after an implant is placed. Yeah, I was just wondering that if they develop peri-implantitis and then they started taking these drugs, would it be... deleterious to the healing of the peri-implantitis by being on these drugs I don't know and I guess as a biologist I would speculate the answer is yes that there would be a deleterious effect on the bone homeostasis of that implant after surgical placement it's speculation on my part though yeah so I do want to ask you about antacids because that was you know something that Kind of surprised me when we were talking about doing this particular episode. And there's been some discussions around the impact of antacids, particularly proton pump inhibitors on dental implant success. Now, we're all familiar with these PPIs. We could buy them over the counter. The products are Nexium, Prilosec, and they're basically either omeprazole or derivatives of omeprazole. Tough word for me to pronounce. But the fact is many of our patients are taking PPIs. And some of the data that I looked up says that between prescriptions and OTC, there could be 20 to 25% of the folks over 50 years old that are regularly taking PPIs. So can you tell us what the research shows related to why these medications might increase the risk of implant failure? Well, certainly. There is a strong connection of proton. pump inhibitors and the family of drugs called antacids for the control of gastric upset and basically it stems from early research in the archives internal medicine that Patients taking these anti-acid drugs alter their calcium uptake and therefore can be at much higher risk for osteoporosis. This has been published several times over and the measurement, in the medical literature at least, are the risk of hip fractures and increased hip fractures. In fact, there's a study in 2007 that indicates that Patients, mostly the studies are in females, patients taking proton pump inhibitors or antacids are at two and a half times the risk of a hip fracture after taking these medications only one year of time. The pharmacological reason for this is that the calcium uptake is greatly inhibited when the pH of the gastric mucosa is altered to a more basic, as opposed to what is supposed to be, an acidic pH. So without calcium absorption or appropriate calcium levels in the bloodstream, then bone homeostasis is again at risk. So in the long term, that bone homeostatic mechanisms causing osteoporosis could ultimately impact the success of dental implants. When these PPIs came out, they were designed to be miracle drugs to some extent as far as GERD. And this is something that's... very prevalent in patients that are over 50 years old. But the drug companies said that the treatment period for these drugs should not exceed two to three weeks. But what happened is these patients, you know, take this and the doctors are prescribing it for an ongoing period. It's continuous. They take it for three weeks, and then it's four weeks, and then it's six months, and it's their whole life. They're just taking one a day, and there are side effects. And we certainly, as dentists, should be aware of that. So I thought that was very good that we were going to be talking about PPIs as popular as they are among our patient population. So as we get to the bottom of this podcast, Dr. Suzuki, tell us some of the things we should be looking for. When a patient is getting in the realm of periimplantitis, we know it starts as periimplant mucositis. We need to be aware of that so we can catch it early so that it doesn't progress further. So tell us some of the things we should be looking for. Well, certainly some of the earliest stages of implant failure and periimplantitis. are in fact related to the gingival response of teeth so the first signs in the oral cavity are the erythema of very uh circumferential gingival inflammation and redness around a dental implant similar to what you see in gingivitis The hygienist upon probing would also elicitate bleeding upon probing as one of the earliest signs also of peri-implant mucositis. But peri-implant mucositis is the first step of an irreversible condition, which is peri-implantitis ultimately. So that is a very, very good first step. to diagnose. Now, when you identify peri-implant mucositis, or is that the right terminology? I've been saying implant mucositis. Is it peri-implant mucositis? Either way. Okay. When you identify that and you see there's an implant there, you see there's gingivitis, and you treat it through the normal, typical... methodology that a hygienist would treat any kind of gingival inflammation. If treated properly and then the patient goes back and does what they're supposed to do and they comply, how fast does that reverse itself typically? I know it's individual and I know the bite and the occlusion and the eating habits and all this other stuff comes into play. But we're talking about a patient who's fairly compliant, who's doing the best they can. Is that quickly reversible under those conditions? When a diagnosis is made of peri-implant mucositis, generally speaking, before the next recall visit, which is really about three months, that particular clinical diagnosis of peri-implant mucositis should probably be reversed. All right, so it's that fast. Yes. And if they're not seeing progress and the patient is claiming that they're following through with home care based on the tools they were recommended and the things they were told to do, but it's still persistent, what's your recommendation? Our recommendation is to explore more aggressive non-surgical approaches to treat the peri-implant mucositis, especially if it does not go away after the first recall examination. And that particularly more aggressive steps would include perhaps a deeper scaling, a deeper irrigation with antimicrobial agents, perhaps even considering local drug delivery, antimicrobial systems, and efforts like that that are non-surgical in nature. But peri-implant mucositis is generally reversible. No, I think that covers it because we're going to be doing a special episode with you, Dr. Suzuki, on non-surgical and surgical therapies for peri-implantitis, where you'll cover some of these in more detail. So we do appreciate your input. Thank you very much for joining us and have a very nice evening. Thank you very much for having me, Phil. Bye.