Dental Implantology

Dentures may soon become a thing of the past. This may or may not be good news for the approximately 47 million Americans who wear them. But certainly implants are changing people's lives, and as new materials and new techniques for using this material evolve, they are rapidly being put to use. Dr. S.N White, a noted implantologist and teacher in this specialty, gives detailed answers on implants, artificial bone material, and growing new bone.

Q. What is a dental implant? 

A. Dental implants serve as a means of replacing missing teeth. Basically, there are two types of implants, and each is used for a specific purpose. The endosteal implant, fabricated from titanium, is inserted directly into the jawbone, while the subperiosteal implant, made from vitallium, is inserted on top of the jawbone and is used in cases where there is inadequate bone for the endosteal implant.

Q. What benefits do dental implants offer? 

A. Dental implants improve a myriad of situations. Missing teeth can be replaced by dental implants; implants can eliminate the need for removable dentures, full and partial, which are uncomfortable or loose, can be eliminated; loose teeth can be strengthened with implants and can therefore be saved rather than removed or lost. In addition, implants can help improve speech, appearance, and the ability to chew and enjoy food, as well as improving comfort. For those who cannot tolerate or adjust to a removable denture, there is an enormous psychological and physical improvement. Quite often, bone is stimulated to grow.

Q. Who should or should not have dental implants? 

A. Most patients who can undergo routine dental procedures are usually able to have dental implants. Patients should be in good physical and mental condition with a healthy jawbone. Sometimes it is not advisable for a patient to have dental implants because of the structure of the mouth. Each person must be evaluated separately.

Q. What is the procedure like? 

A. The implants are usually performed in the dental office, with the same type of local anesthesia used for routine fillings. During the procedure, there is usually no discomfort. As the area begins to heal, there can be a slight tenderness for a short period of time. Once in position, the implant feels similar to a natural tooth.

Q. How long does the procedure take, and can one function while work is being completed? 

A. Under normal circumstances and in well trained hands, each endosteal implant is inserted in approximately 6 to 15 minutes. All implants are usually inserted in one or two visits. Additional visits are necessary to complete the regular dentistry. The patient is usually never embarrassed or without teeth. Implants function at approximately 85 percent of the efficiency of natural teeth.

Q. Can implants be rejected or cause infection? 

A. Dental implants are not rejected because they are made of biocompatible materials and the body does not recognize them as a foreign substance. If the implant is inserted and cared for properly, infection is unlikely.

Q. How long do implants last? 

A. Patients have reported having stable implants for more than 25 years. Replacement of body parts with artificial means cannot be guaranteed. The prognosis for the implant is determined by the quality of the surgery, the quality of the prosthodontia, and the care the patient gives to the implant. The implants and the bridgework require the same care as natural teeth.

Q. Can you describe in detail what actually takes place when the procedure is performed? 

A. A small incision is made in the gum, and then a tiny channel is prepared in the bone. Then the implant is inserted into the channel. The gum tissue is closed over the implant, and on the same day the patient walks out with a temporary set of teeth until the permanent teeth can be fabricated.

Q. What happens when a dental implant fails? 

A. If an implant fails or has to be removed for any reason, it is removed in much the same manner as natural teeth. Usually, an implant that fails can be replaced by another implant.

Q. Are dental implants expensive? 

A. The fee for endosteal implants is usually the same as the fee for fixed bridgework. One implant can usually support from one to five crowns. The fee for the bridgework is usually separate from the fee for the implant. However, subperiosteal implants usually carry a fixed fee.

Q. Can a rejected implant patient ever be able to have an implant? 

A. Yes. The field of implantology is in the state of continuous development and improvement. New means are constantly being found to help dental sufferers. For example, I have developed a tomographic technique to be used for evaluating and treating potential implant patients more safely and effectively. This three dimensional X-ray technique allows the implantologists to see bone tissue they could not see before, making it possible for rejected patients to receive implants. In addition, I have recently invented a new implant that should greatly improve the overall treatment of all potential and present implant patients.

Q. What is the history of dental implants? 

A. Dental implants were done in the time of the ancient Egyptians and other ancient civilizations. Since other parts of the body have enjoyed success with implants for over 50 years, it was reasonable to assume that dental implants would have equal success. However, it was only in the last 30 years that modern implantology developed and proved successful.

Q. What are the possible complications that can develop in this operation? 

A. Such possibilities are pain, infection, numbness, and nasal or sinus penetration. Complications are unlikely when the patient is selected carefully, when the prosthetic and surgical procedures are done properly, and when the patient takes proper care. Occasionally, however, there are complications.

Q. Dental implants seem to be very controversial. Why does it cause such debate? 

A. There are many different types of dental implants. Some have proven to be unsuccessful. Many dentists and patients have had some experience with these failures. Unfortunately, some of these outdated implant techniques are still being utilized, and hence the controversy exists.

Q. What is the current state of the art? 

A. Fortunately, much progress has been made. The latest position of the American Dental Association is that oral implants can benefit patients who cannot otherwise be helped with conventional dentistry. The association goes on to state that standards for many oral implantology devices have been developed by the ADA Council on Dental Materials, Instruments, and Equipment. Such standards in all likelihood reflect some of the findings of the National Institutes of Health, Harvard Consensus Development Conference.

Q. Can people who have had periodontal disease have dental implants? 

A. Yes, this is in spite of the fact that many people may have lost most of the bone around their natural teeth and or may have lost some or all of their own teeth. As implantologists, we are not concerned with the lack of bone around natural teeth or with the fact that no teeth are present. Instead, we deal with the remaining bone.

Q. What are the surgical steps for an endosteal implant? 

A. The surgery for endosteal implants is very simple. As I indicated, a small incision is made in the gum tissue. After the channel has been filled with the implant and the gum tissue is sutured back in place, the patient is ready for final bridgework. The subperiosteal implant is more complicated. It requires two surgical steps. First, an impression of the bone is taken. Second, the implant is fabricated by the laboratory and then inserted into position.

Q. How many teeth must be missing for a person to have a dental implant? 

A. We can replace a single tooth or an entire mouth of teeth.

Q. Is there a time limit on when a person can have a dental implant? 

A. No, even if a person has been without teeth for over 20 years, we can usually still perform dental implants.

Q. Is there an age limit for this procedure? 

A. It can be done at any age, providing there is adequate bone and the procedure is indicated.

Q. Can new bone be formed if there is not enough natural bone remaining? 

A. Fortunately, we now have methods for bone replacement. We can take bone from one part of the body, such as the hip, and transplant it to another part of the body, such as the mouth. We can also implant artificial bone into the mouth.

Q. What decision would be made for an area where the lower first molar is missing? Should it be with an implant or with a fixed bridge? 

A. Conventional dental procedures would recommend a fixed bridge. However, some people are reluctant to have good teeth filed and healthy tooth structure destroyed. These individuals may prefer the option of an implant.

Q. What type of specialty is implantology? 

A. Implantology is considered a special interest area. The latest position of the American Dental Association is that dental implants can benefit patients who cannot otherwise be helped with conventional dentistry, and that they are accepted for use when used within certain guidelines. The American Academy of Implant Dentistry is making great strides in obtaining specialty status in the near future.

Q. Is there any truth to the rumor that dental implants and their bridgework don't last more than several years? 

A. According to a recent survey, it has been reported that conventional bridgework only lasts an average of 10.2 years when it is done properly and cared for routinely. Comparatively speaking, a reasonable service and benefit would have been rendered to an implant patient if the implant bridgework lasted several years. Some implants have remained in patients' mouths for over 20 years. Should the implant or its bridgework fail, replacement of either component is usually still possible. When properly done and with proper care, it is possible for the implant and its bridgework to last as long as its conventional counterpart.

Q. In other areas of interest, can headache and neck pain be caused by dentally related factors? 

A. Yes, quite often headache and neck pain are symptoms of TMJ dysfunction.

Q. What is TMJ dysfunction? 

A. It is the atypical functioning of the mouth joint, which is made up of the temporal bone, the lower jaw, and its joint. This area can be easily located by placing the index finger approximately one half inch anterior to the ear. The palpated movement indicates the location of this joint.

Q. What are the symptoms of TMJ? 

A. Symptoms are headaches, neck pain, joint noises, and muscle pain of the head and neck.

Q. Are there other terms for these symptoms?

A. It is called myofascial pain dysfunction syndrome when the discomfort is limited only to the muscles. This condition is usually associated with middle aged women.

Q. How do these conditions have anything to do with teeth? 

A. The teeth, especially the bite, affect the joint and the accompanying muscles. The muscles of the head and neck are interrelated with other muscles of the body. When the muscles of the head and neck don't function properly, a domino effect is established, causing the other muscles of the body to be affected and thereby creating symptoms in other parts of the body.

Q. How is this condition treated medically? 

A. Physicians generally seek a causative factor for this condition. Their tests include EKGs, EEGs, EMGs, CAT scans, blood tests, and others. When no findings are positive, the pain is usually referred to other medical specialists for further evaluation. If all findings are negative, the condition is often considered psychosomatic, and some patients learn to live with their pain.

Q. What is the relationship of the teeth, bite, and muscles? 

A. If the bite is improper, the muscles are placed in a strained position, which can cause a muscle spasm. The muscle spasm squeezes the blood vessels that are located in the muscle, and pain follows.

Q. What is the treatment for this condition? 

A. First, the symptoms must be controlled. This can be accomplished through muscle therapy, drug therapy, and the use of an orthopedic appliance to properly position the bite with the muscles and with the joint. Supportive therapy may also be used, including physical and dietary therapy. Hypoglycemics have been found to have a prevalency for this condition. Once the symptoms have been alleviated, corrective therapy is instituted. This therapy may include prosthodontic treatment, occlusal or bite adjustments, or other therapy.

Q. What is periodontal disease? 

A. It is a chronic disease that causes destruction of the bone, ligaments, and gum tissue that surround and support teeth. Pyorrhea is the older term.

Q. What are its causes? 

A. It's caused by plaque, an accumulation of bacteria, saliva, and other material normally found in the mouth in the form of a sticky film.

Q. Does plaque have any symptoms? 

A. The classic warning signs of periodontal disease are bleeding gums, drifting of teeth, loosening of teeth, and swellings.

Q. Can periodontal disease be effectively treated? 

A. The first step is to educate the patient about the condition and oral health procedures. The next step is to control the disease. This is usually accomplished in various stages. First, home care is instituted that includes toothbrushing, flossing, rinses, dietary therapy, and other therapies if necessary. Next, correction of the gum and bone defects must be accomplished. This may be done with or without surgery. Other dental therapies may also be necessary. Prevention of further deterioration is the final stage.

Q. Are there certain foods that can inhibit the growth of bacteria that cause decay? This was reported by a study group. 

A. There are certain foods that are less likely to promote the growth of bacteria that cause dental disease in general. For example, apples, carrots, and similar foods have a slightly mechanical cleansing action. There are certain foods that have the opposite effect, such as carbohydrates, candy, and sticky foods. There is presently no food substitute for good oral hygiene to help inhibit the growth of the bacteria and plaque that cause all dental disease.

Q. How is tooth decay caused? 

A. When we eat sugar or sugar containing foods such as carbohydrates, bacteria present in the plaque found in our mouths convert this sugar into acid, which eats away the tooth structure and causes tooth decay.

Q. What method do you recommend to help prevent periodontal disease and tooth decay? 

A. The answer is 100 percent plaque control. This can be accomplished through efficient oral hygiene. Remember, plaque is a film composed of bacteria, saliva, food particles, and other material. The bacteria that live in the plaque convert the food into acids and produce toxins and other products such as tartar that help to destroy the teeth, gum tissue, and bone. Plaque deposits, which continue to form every 24 hours, must be continuously removed. Plaque can be controlled through good oral hygiene. Toothbrushing is most important. Brushing helps clean the exposed surface of the tooth and crevice of the gum. All surfaces of the exposed tooth must be kept clean. I recommend a soft nylon brush with two to four rows of rounded tip, polished bristles. Natural bristles are also satisfactory. Toothpaste is unnecessary as far as mechanical cleansing is concerned; this is accomplished just with the toothbrush. However, toothpaste makes the mouth feel fresh, and pastes that contain fluoride help decrease the incidence of tooth decay, especially in young people. Pastes that claim whitening and brightening abilities are usually abrasive. Mouthwashes are mostly used as refreshing rinses. Flossing cleans between the teeth where the toothbrush cannot go. It will also clean beneath the gum margin. Unwaxed floss is preferred. However, if the floss shreds or tears, waxed floss may be necessary.

Q. What type of oral hygiene care is necessary for implant patients? 

A. Implants need the same care that one would give to natural teeth or teeth with bridgework. This includes thorough brushing, flossing, and irrigation of the implants and their accompanying bridgework.

Q. What does the term "bridgework" mean? 

A. Bridgework refers to the replacement of missing teeth or defective tooth structure. It may refer to a single crown, a series of crowns, and other types of replacement methods such as inlays, onlays, and so forth.

Q. How do you describe a crown or cap? 

A. These two terms are synonymous. A crown fits over a prepared tooth as a thimble fits over a finger. However, the inner surface of the sewing thimble or crown fits exactly onto the tooth it is made for. The outer surface tries to duplicate the natural appearance of a tooth.

Q. Why would anyone have their teeth capped? 

A. Weakened teeth can be strengthened by capping. Furthermore, in those situations where a person has broken, badly decayed, or unsightly teeth, capping or crowning will strengthen weakened tooth structure and restore natural function and esthetics.

Q. What is a fixed bridge?

A. A fixed bridge is a replacement for more than one missing tooth. It is made up of a series of crowns, or inlays or onlays. Inlays or onlays are similar to fillings in that they fit into or onto the teeth; however, they are much stronger.

Q. What is a Maryland bridge? 

A. Researchers at the University of Maryland discovered that a bridge could be connected to natural teeth by bonding instead of drilling teeth.

Q. Is this type of bridge as strong as a conventional fixed bridge?

 A. The strength of the Maryland bridge is dependent upon the strength of the bond and the attachments. It is mostly used to replace missing teeth in areas that are not subject to great biting stresses. Bonding is a method of attaching a tooth colored resin to the tooth structure to create an esthetic improvement. A mild acid or etching agent is applied to the tooth to create a porous surface. These pores create micro and macroscopic openings where the resin can seep in and attach itself to the tooth structure. The resin is usually applied in layers. Simply speaking, the resin or bonding material is usually a stiff paste that is sculptured to the desired shape, form, and color and then hardened and polished to its final luster.

Q. Does bonding have particular advantages? 

A. Bonding is a wonderful procedure. It permits us to replace missing teeth, stabilize loose teeth, and improve the esthetic appearance of teeth in terms of shape, color, and position. It does so in a relatively inexpensive way and without injections or irreversible damage to the tooth structure. Bonding, however, has not yet been perfected. The bonding material can wear, stain, discolor, and chip. Quite often, it needs eventual replacement.

Q. A dental group that met in New York suggested that neck wrinkles, sagging skin of the jaw, and thin lips may not be natural signs of aging but may be a result of dental problems. How do you view this?

A. This is definitely true. There are many facial disfigurations that are a direct result of dental problems. For example, the height of the face is affected by the wearing away or loss of teeth. As a result, the facial contours are adversely affected. The natural creases and folds of the skin of the face become exaggerated and worsened, and people can develop what is called the characteristic denture look, whereby the lower jaw becomes more prominent. The lips take on a thin appearance, and there is the appearance of premature aging. In addition, the nose can become more prominent as the support and contour of the face collapse. These problems can be greatly relieved through modern dentistry. Full mouth reconstruction helps rebuild the oral structures and the supports for the head and neck. Dentistry can help restore certain facial contours and greatly improve the attractiveness of these individuals.

Q. Some dentists recommend placing crowns or bridgework to help eliminate facial wrinkles that have been caused by lost or worn teeth. Do you agree with this? 

A. If a thorough examination and simple tests confirm the fact that the facial wrinkles are caused by worn or lost teeth, then I most certainly agree.

Q. It has been reported that people who have periodontal disease can now save their teeth by restoring the bone, by connecting them to implants, and through other periodontal techniques. Are these new procedures? 

A. People with periodontal disease lose their teeth when the teeth lose their bone support. Previously, once a tooth lost its bone support, it could not be replaced. Currently, we are able to replace lost bone in certain instances. In addition, certain bone defects can be repaired through the bone replacement procedure we call bone grafting. Bone grafting is a method of taking natural or synthetic bone and placing it where it is needed. Other periodontal techniques help to save teeth by eliminating the causes of periodontal disease and by treating the diseased tissues. Teeth will stay in the mouth as long as they have adequate bone support holding them in place. Unfortunately, most teeth that have suffered the effects of periodontal disease have lost some bone support. Therefore, if a tooth that has lost too much bone support receives periodontal therapy only, that person may still lose teeth. That is because, although periodontal therapy may have eliminated the cause of the disease and may have treated the diseased tissues, some teeth are still unable to withstand the forces of chewing. Inevitably, these teeth may be lost. Fortunately, with the advent of dental implants, these weakened teeth may be connected to the dental implants, which will help support them and save them for an extended period of time.

Q. How many dentists are able to perform implant or bone grafting procedures? 

A. There are approximately 300 implantologists in the United States. In addition, there are periodontists, oral surgeons, and other dentists who may practice the bone grafting techniques.

Q. I am over the age of 60, and my teeth have already had reconstructive work and are pretty well worn. Now my dentist suggests that I have the bridgework redone. What do you think of this? 

A. If the bridgework is defective, or if the wear and tear on the teeth or the bridgework are creating problems, and if finances are not a problem, then redoing the bridgework would be acceptable. The lifespan of the bridgework is dependent upon several factors. These include the use of a suitable restoration to fit the given circumstance. This is determined through a thorough and accurate examination and diagnosis. In addition, the quality of the bridgework will influence its lifespan. Furthermore, the care the patient gives to the bridgework will also influence its lifespan.

Q. Are dental X rays really necessary, and how safe are they? 

A. According to the U.S. Public Health Service, the National Committee on Radiation Protection, and the American Dental Association, there is no reason for patients to be afraid to have a dental X-ray examination. X rays are taken with modern equipment, and the techniques are safe. An X-ray examination of the entire mouth produces approximately 15 millirads of radiation as compared to 300-600 millirads during mammography. Experiments at the Medical College of Virginia School of Dentistry have confirmed that it would take 2000 dental X rays to produce damage to the reproductive organs. The average person should be able to undergo about 75 complete dental X-ray exams in a given 30-year period.

Q. Would vitamin therapy be helpful in treating dental disease? 

A. Vitamin therapy has demonstrated therapeutic usefulness in treating dental disease. Vitamin C is particularly useful in the formation of connective tissue used to repair bodily tissues. Vitamin C has also been reported to be useful in treating bleeding gums and other conditions. Other vitamins that have been mentioned to be helpful are vitamin A and the B complex vitamins.

Q. I have been wearing dentures for many years, and now they are very loose. Is there anything I can do? 

A. There are approximately 39 million American denture wearers. Although many of these people are comfortable with their dentures, there are some individuals who do experience difficulty. Some of these difficulties can be overcome, and some cannot. Despite some people's opinions, dentures are not meant to last a lifetime. Although the denture maintains its basic shape, the gum tissue does not, and therefore the denture loosens or creates other problems. Sometimes these problems can be overcome by making a new denture or replacing the fit through what is called a reline procedure. For patients who are still unable to function comfortably despite the dentures that have been made for them, implants may be an answer.

Q. What is the practice of orthodontics? 

A. Orthodontics focuses on the prevention and treatment of improper tooth, jaw, or bite relationships. This is usually accomplished through the use of appliances that are either fixed or removable.

Q. I have gum disease. I was told that gum surgery is the only way to clear it up. Is there another way, since I am afraid of gum surgery? 

A. The treatment for gum disease is dependent upon the severity of the condition. There are times when gum surgery is the treatment of choice for certain severe stages of gum disease. This is usually the case when the patient has severe defects in the bone or what is called infrabony pockets. For patients who are afraid of gum surgery, there are alternatives. Certainly, excellent oral hygiene is a must. In addition, frequent gum treatments are usually necessary. These gum treatments usually consist of curettage and scaling. Simply put, this is a procedure whereby the tooth structure and gum tissues are scraped clean to eliminate as much of the tartar and diseased tissue as possible. The additional use of a paste consisting of baking soda and hydrogen peroxide may also be helpful in keeping the level of bacteria in the gum to a minimum.

Q. Do patients with medical problems need to take any special precautions when having dental treatment? 

A. Yes. For example, people with a history of rheumatic fever or heart murmurs ought to receive antibiotics before dental treatment. This is because, during dental treatment, bacteria can be introduced into the bloodstream, find their way to the weakened heart valve, and possibly contribute to a condition called bacterial endocarditis. Also, diabetic patients are usually prone to infections. They should receive antibiotic coverage during traumatic dental procedures. Patients with a history of hypertension ought to receive a local anesthetic that does not contain epinephrine. This component tends to raise the blood pressure.

Q. Is it true that mouth odor is caused by a bad stomach? 

A. Except for times when vomiting or belching occur, odor should not escape from the gastric area because the esophagus helps prevent this.

Q. What are the advantages of root canal therapy? 

A. The purpose of root canal therapy is to save teeth that would have to be removed because the nerve tissue has been or is in jeopardy. This procedure involves the removal of the nerve tissue from within the tooth, followed by the removal of bacteria from the tooth and the filling of the nerve chamber.

Q. Does root canal always work? 

A. In properly selected cases, the prognosis is usually good. However, there are times when it may not work.

Q. What are some of the newer techniques or methods that will make dental implants safer or more reliable?

A. One of the methods I have developed is called tomography in implantology. Up to my development, diagnoses for dental implants were based upon conventional dental X rays, which reveal two dimensions the width and height of bone. If inadequate bone was present, the patient was rejected as an implant patient. My technique consists of a threedimensional analysis of the bone tissue, showing bone height, width, and thickness. As a result, patients who were previously rejected for implants are now acceptable candidates. In addition, the implants could be placed in more strategic positions. The overall result is an increase in implant safety and long term survival.

Dental Implants



Q. Is this new method also controversial? 

A. Dental implants have created controversy in the past because of outdated methods. My implant device is a result of modern materials and modern methods. One of the problems of the outdated implants were the materials, which caused corrosion when placed in the body. Another problem was the actual placement of the implant, which left much to be desired. In addition, if things went wrong, repair was virtually impossible. Fortunately, things are different now. Most of the mentioned problems, as well as other problems, are now solved.

Q. Can plastic coatings prevent tooth decay? 

A. You are referring to dental sealants. A panel of experts at the National Institutes of Health recently reported that dental sealants could prevent half of the cavities in children in the United States today. Sealants are a thin plastic film applied over chewing surfaces to seal grooves and pits in which food and bacteria can be trapped. They last about as long as amalgam fillings but are less expensive. Critics of this procedure claim that possible dangers of trapping bacteria within the seal could occur with this technique. Studies to date have not indicated that this danger is real.

Q. I understand there is a new X-ray technique that is safe. What would that be? 

A. There is a form of diagnostic X ray called xeroradiography. In preliminary studies, this promises to be more economical and to produce better images of the teeth, bones, and soft tissues of the mouth than conventional dental X rays, and it will expose the patient to about half as much radiation. This technique has not been developed for dentistry as of now. Xeroradiographs are imprinted on reusable metal plates instead of the photographic film currently in use.

Q. Can new bone be produced? 

A. There is a substance called Synthograft that helps the body in regenerating new bone. The material was approved three years ago by the Food and Drug Administration. This is mixed with the patient's blood and then placed against existing bone, and little blood vessels begin to form within the material. Other products have similar abilities.

Q. We don't usually think of tooth decay as an actual disease, but it is, isn't it? What is the bacteria called? 

A. Streptococcus viridens is the scientific name. There are several bacteria that are common to the mouth. The filmy substance in your mouth called plaque, as was mentioned, is produced by saliva, by foods, by glandular secretions, and by many factors other than these. The bacteria that live in the mouth live in the plaque. In their daily cellular activities, they will produce and contribute certain ingredients to the plaque. When these bacteria find or come into contact with any sugar, they will convert this sugar through their bodily functions into acid. This acid will in turn cause dental cavities. In terms of periodontal disease, when this plaque comes in contact with foods containing calcium, it will calcify in a very short period of time. This action produces what is called tartar or calculus. This calculus adheres very tenaciously to the tooth structure. It causes an inflammation of the gum, and it will cause destruction or inflammation of the bone.

Q. What happens when we eat sugar or sugar containing products? 

A. The bacteria will eat the sugar and convert it to acid, which will mix with the plaque substance and adhere, and as a result will eat away the enamel and cause a carie or a cavity.


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