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Archive for the ‘Dental Implants’ Category

SWELLING IN THE MOUTH. ABSCESS OF THE NERVE OR OF THE GUMS?

Friday, July 14th, 2017

Something that most patient remember about dental pain is referred to tooth pain and tissue swelling. Sometimes this problem refers to the loss of vitality of a tooth but it can also be referred to periodontal problems. We will analyze the second scenario and we will compare it with the classical tooth that needs a root canal therapy by the endodontist.

The periodontal abscess is a localized purulent inflammation of the periodontal tissues. It can be classified according to the structure that it affects in gingival, periodontal and pericoronal abscess. The gingival abscess affects the marginal gingival and interdental tissues. The periodontal abscess is an infection located in the periodontal pocket and may result in destruction of the periodontal ligament and bone. The pericoronal abscess refers to the area next to a tooth crown that is not fully erupted in the mouth.

Periodontal Abscess
The periodontal abscess is typically found in patients with active periodontitis and in association with moderate-to-deep periodontal pockets. Periodontal abscesses often arise as an acute episode of a preexisting periodontal disease. Among the difference causes, the most common is the incomplete calculus removal from a gingival pocket. Abscesses can occur after periodontal surgery, after preventive maintenance, after systemic antibiotic therapy and recurrence of periodontal disease. Other causes of periodontal abscesses can be tooth perforation or fracture and foreign body impaction. The importance of periodontal abscesses is high. Their presence is a leading cause of tooth loss. However, proper treatment and constant follow up can help to retain affected teeth for many years.

Acute versus Chronic Abscess
Abscesses are categorized as acute or chronic. The acute abscess is often a sudden episode of an existing periodontal lesion with no liquid drainage through the gums. The result is a painful, red, smooth swelling of the gingival tissues. The tooth may be percussion sensitive and feel elevated in the socket. The chronic abscess form after the infection spontaneously drains or it’s treated by the periodontist.

Periodontal versus Pulpal Abscess
The following table summarizes the main differences between Periodontal and pulpal abscesses. Sometimes symptoms are mixed and do not help with correct diagnosis and an interdisciplinary consultation with the endodontist may be necessary

Treatment of the periodontal abscess includes the resolution of the acute lesion, followed by the management of the resulting chronic condition. Treatment options include drainage through pocket retraction or incision, scaling and root planning, periodontal surgery, systemic antibiotics or tooth removal*. The treatment of pulpal abscess is usually the completion of a root canal therapy by the endodontist that in severe case may have to associate this pathology with systemic antibiotics and drainage of the swelling for acute abscesses.

Acute abscesses can be a very bad experience for the patient. Due to complexity of appearance, it may be difficult to differentiate between endodontic and periodontal abscesses, It is important to urgently contact the periodontist that is trained to tackle and treat this pathology and improve the fate of the affected tooth.

References

*(Modified from Sanz M, Herrera D, van Winkelhoff AJ: The periodontal abscess. In Lindhe, J: Clinical periodontology, Copenhagen, 2000, Munksgaard).

The body of this article is referred to Carranza’s Clinical Periodontology, 12th Edition By Michael G. Newman, DDS, Henry Takei, DDS, MS, Perry R. Klokkevold, DDS, MS and Fermin A. Carranza, Dr. ODONT.

- Lorenzo Mordini DDS, MS

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Dental Implant Malposition

Monday, June 19th, 2017

Dental implants are a successful and predictable tools to replace missing teeth. If planned and executed with precision the risk of failure can be reduced to a minimum.

Among risk factors for implant placement one could list patient related risks and technique related risks. Among patient related, uncontrolled systemic diseases (diabetes), smoking and poor oral hygiene are the mayor risk factors.

As far as technical, malposition and mechanical parts breaking may lead to implant failure or disease.

We report a case where the implant on the central area of the upper jaw of the patient was placed partially outside the bone volume available.

Since the patient was already missing a tooth, a new plan was offered to replace it along with extraction of the failing implant and simultaneous replacement with a correct-positioned one.

Due to lack of bone, an augmentation was performed simultaneously in order to prevent future resorption of existing bone.

It has to be noted that the use of modern tools to explant existing implant and the use of digital implant planning with surgical computer guide, helped the surgeon to provide a correct and precise placement with a decrease of technical risks of failure.

- By Dr. Lorenzo Mordini

Fig 1 a, b. (below). Frontal and lateral view of the implant (crown right to the space) and missing tooth.

Fig 2.(below). Implant guided placement after malpositioned implant extraction with dedicated tools.

Fig 3 a, b.(below). Healing after implant placement and bone grafting.

Fig. 4 a, b (below). Radiographic image of implant (white image) that is outside the bone volume. In green, the digital plan of the new implants.

Fig 5 a, b (below). Software combining 3D radiograph with digital implants in order to create surgical guide.

Fig 6. (below). Radiographic image after placement of two new implants

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TOOTH HYPERSENSITIVITY. CAUSES and TREATMENT.

Tuesday, May 2nd, 2017

Dentinal hypersensitivity is a diffused problem that patient complain about, usually associated with exposed tooth root surfaces. Any age patient can be affected (20–50 years, with a peak between 30 and 40 years of age 11) and most of the times is present on the canines and premolars of both the arches. A slightly higher incidence of sensitivity is reported in females than in males. It is clinically described as an exaggerated response to application of a stimulus to exposed root surface (dentin). Dentin hypersensitivity is characterized by short-lasting, acute pain arising from exposed root or dentin in response to insults that most of the time is thermal (cold or hot food/drinks). Direct pressure on the exposed dentin or substances may trigger this sharp pain too (Dentin hypersensitivity: Recent trends in management Sanjay Miglani, Vivek Aggarwal, and Bhoomika Ahuja J. Conserv Dent. 2010 Oct-Dec; 13(4): 218–224).

The identification of this condition can be obtained by clinical examination. Some patient self report to the dentist this condition due to its severity. A simple clinical method that the dentist can use includes a jet of air or using an exploratory probe on the exposed dentin, examining all the teeth in the area in which the patient complains of pain (Gillam DG, Orchardson R. Advances in the treatment of root dentin sensitivity: Mechanisms and treatment principles. Endod Topics. 2006;13:13–33). The severity of pain can be quantified either according to categorical scale (i.e., slight, moderate or severe pain) or using a visual analogue scale (Orchardson R, Gilliam D. Managing dentin hypersensitivity. J Am Dent Assoc. 2006;137:990–8).

Fig 1. Patient presenting with gingival recession, root exposure and subsequent dentinal hypersensitivity on canine and first premolar. The cause of this situation was attributed to heavy tooth brushing with hard bristles and use of abrasive toothpaste.

The cause of dentinal hypersensitivity can be found in incorrect and too aggressive tooth brushing, poor oral hygiene, gingival recession caused by other dental therapies (i.e. periodontal treatment, dental bleaching). Incorrect tooth brushing includes hard brushes, excessive forces associated with the use of abrasive toothpaste, excessive scrubbing at the cervical areas or even lack of brushing which causes plaque accumulation and gingival recession (Suge T, Kawasaki A, Ishikawa K, Matsuo T, Ebisu S. Effects of plaque control on the patency of dentinal tubules: An In vivo study in beagle dogs. J Periodontol. 2006;77:454–9).

The first approach is to teach the patient the correct method of tooth brushing to avoid further extension of gum recession and dental wear at the gingival level. Highly abrasive tooth powder or pastes should be avoided (Orchardson R, Gilliam D. Managing dentin hypersensitivity. J Am Dent Assoc. 2006;137:990–8). Also, the patients should be instructed to avoid brushing for at least 2 hours after acidic drinks to prevent agonist effect of acidic erosion on tooth-brush abrasion (Dentin hypersensitivity: Recent trends in management Sanjay Miglani, Vivek Aggarwal, and Bhoomika Ahuja J. Conserv Dent. 2010 Oct-Dec; 13(4): 218–224).

Erosive agents (carbonated drinks, citrus fruits, wines, yogurt and cosmetic products) are also important in initiation and progression of this condition. They act by thinning the superficial layer of teeth (cementum on the roots and the enamel on the crown) and exposing the most porous part of them (dentin) (Eisenburger M, Addy M. Erosion and attrition of human enamel In vitro. Part I: Interaction effects. J Dent. 2002;30:341–7. Osborne-Smith KL, Burke FJ, Wilson NH. The aetiology of the non-carious cervical lesion. Int DentJ. 1999;49:139–43). Dietary counselling should be suggested. Other sources of acid come from gastroesophageal reflux or regurgitation (patients with eating disorders too). A medical consult should be requested from the dentist. By removing the causative factors or limiting them, the condition can be prevented or at least limited.

As far as treatment, the severity of the condition may dictate a more invasive intervention rather than topical solutions. The patient can correct their faulty habits by utilizing some desensitizing agents (fluorides toothpastes with 5% potassium nitrate and 0.454% stannous, mouthwashes or chewing gums) and modifying their predisposing diet. Professional treatment includes topical application of agents that can cover the porosities of the teeth and block nerve triggering (0.4% stannous fluoride along with 0.717% of fluoride can provide an immediate effect after a 5 minute professional application) (Thrash WJ, Dodds MW Jones DL.

The effect of stannous fluoride on dentinal hypersensitivity. Int Dent J. 1994;44:107–18), restorations to cover exposed tooth surface that is creating sensitivity, root coverage in terms of gingival augmentation to replace or augment the tissue lost during the development of hypersensitivity.

-By Lorenzo Mordini DDS, MS

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Maxillary Sinus Elevation for Implant Placement

Monday, April 3rd, 2017

The American Academy of Prosthodontists reports that more than 35 million Americans do not have any teeth, and 178 million people in the U.S. are missing at least one tooth. These numbers are expected to grow in the next two decades.

Most of the time, the teeth that are missing are the molars, either in the upper or lower jaw. After missing a molar in upper jaw, the patient experiences both bone resorption and expansion of the maxillary sinus. With the increase in popularity of dental implants and the increase quality of life of patients, rehabilitation of the edentulous posterior jaw often represents a clinical challenge.

Before the utilization of dental implants, patients with missing teeth and deficient bone in the posterior maxilla could only be rehabilitated with removable prostheses or short implants that prevent invasion of the sinus. Sometimes bone resorption and sinus expansion is so advanced that even short implants cannot be placed.

In those cases, advanced procedures like maxillary sinus elevation are needed to increase the amount of vertical bone height in the posterior maxilla for the placement of implants. Generally speaking, two procedures are available depending on the quantity of bone left.

In case of small augmentations needed, the use of a tapping motion on blunted posts can create sufficient space for implant placement (Internal or Direct Sinus Lift).

Internal Sinus Lift. Before and After augmentation, a dome of grafting material and the implant can be noted after healing (right image). The red line highlights the contours of the sinus before and after. The orange line shows the initial lack of bone.

In case of more bone required, a more invasive procedure is required. A small perforation on the lateral wall of the sinus is performed and the creation of a window in that area can favor deposition of more grafting material for larger augmentation (External or Indirect Sinus Lift). Also, the quantity of bone available before the augmentation can allow the simultaneous placement of the implant, which tip will be surrounded by the graft material used for sinus augmentation.

External Sinus Lift. Before and After augmentation, a dome of grafting material can be noted after healing in the right image). The red line highlights the contours of the sinus before and after.

In case of minimal bone levels before the augmentation, the sinus lift is performed and implants are usually placed 6 to 9 months after healing. It is very important that patients are healthy individuals with no uncontrolled systemic pathologies and conditions (uncontrolled diabetes, uncontrolled hypertensions for example). Also, the sinuses need to be clear from any diseases like cysts, sinusitis and infections.

In conclusion, sinus augmentation can be a valuable option to restore the posterior upper jaw in case of long absence of teeth, bone loss and sinus expansion.

- By Lorenzo Mordini DDS, MS

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Periodontics Blog Update: Tips for Patients’ Implant Care

Tuesday, March 7th, 2017

Dental implants are gaining more and more popularity among patients and dental providers. Many implants are being placed everyday in USA and in the world. The represent a tool in the hands of the dentist that can solve many problems when the natural dentition in failing or classic treatment does not provide long term expectations. Even though dental implants do not suffer from the same pathologies as teeth, they are prone to suffer from the so-called peri-implantitis.

This inflammatory and infectious process determines problems of bone resorption and gum inflammation around the implant, that can eventually lead to implant loss. The most important step to avoid peri-implantitis is to prevent it by correct professional and patient oral hygiene. This article reports the most important questions and answers on implant maintenance extracted and adapted from a book chapter “Patient’s plaque control around implants (Clinical Cases in Implant Dentistry Wyley Blackwell. Edited by Karimbux N. DMD, MMSc, Weber HP. DrMedDent. 2017)“ by the same author.

Should implants be cleaned similarly as natural teeth?
Studies demonstrated that an effective and accurate oral hygiene technique prevents an increase in the severity of gingival inflammation if performed at least once every 24 hours. Nonetheless it appears that often patients have not been taught accurate plaque removal techniques and some have difficulties with manual dexterity. It is usually recommended that a patient with implants perform oral hygiene based on their individual needs between 1-2 times a-day. Devices that are effective in removing plaque from a crown on a natural tooth will be also effective in removing plaque on an implant crown.

However, there are differences found in the shape of implant crowns when compared with a natural tooth. Thus, although plaque control techniques for dental implant supported restorations are generally similar to traditional oral hygiene procedures on natural teeth, modifications are dependent on the crown design.

Is there a contraindication to using toothpaste when cleaning implants?
The agents contained in these pastes are multiple and they offer different functions (i.e. detergents, abrasives, polishing agents, binders, humectants, water, flavoring, coloring agents, active ingredients such as fluoride, anti-plaque, anti-calculus, desensitizing). It has been noted that the abrasives in the dentifrice mainly cause hard tissue damage when proper brushing technique is not practiced. However, there has been no evidence suggesting contraindication of toothpaste for patients with dental implant prosthesis.

What brushing technique(s) should be used?
Various studies demonstrated that different brushing techniques are almost similar in plaque removal efficacy. Cleaning the gums around the implant may be more challenging for the patient because the weaker nature of the implant gums compared to teeth. It is recommended a thorough instruction from the professional dental provider in order to customized the technique for every case and patient. The wrong technique may create damage and problems on the implant. Some studies have suggested that electric toothbrushes might be more better than the manual brushes, however the most important factor is the technique used not whether the brush is powered with a battery or by hand.

What is the optimum stiffness of the bristles of a toothbrush and why?
There are many different toothbrushes available in the market. Some have harder bristles some very soft. However, it is generally recommended to prescribe soft bristle toothbrushes to avoid damage of the gingival tissue around teeth and implants and to better access the areas around the implant gums. The shape of the toothbrush is not so important. The important step is how to use it in the right way.
What interproximal oral hygiene aids are available to remove the biofilm from implants?

The oral hygiene aids for proper plaque removal around implant-supported restorations are the same as those commonly used for natural teeth. Dental floss, interdental brushes and rubber tips can be used safely around dental implants, and just as with natural dentation, it should be customized on an individual basis. The patient’s manual dexterity, the design of the prosthesis, and the type of the prosthetic component must be taken into consideration when customizing interproximal hygiene techniques.

- Dental floss: It is generally recommended to use floss around implant restorations for each individual unit, once or twice daily, doing plaque control techniques the same as for natural teeth. The number of times per day to use floss depends upon the patient’s susceptibility to peri-implant inflammation.

Super Floss®

- Super Floss®: It is known that the use of regular dental floss can be extremely difficult when attempting to remove plaque deposits in implant supported Fixed Partial Dentures. The great advantage of Super Floss® stands in its stiff end that can be introduced between the crowns.

- Interproximal brush: Also known as interdental or proxy brush is used as an effective device in plaque removal in the interproximal tooth surfaces. It is important to select the brush head of an appropriate size to fit into the interproximal area without creating damage to the soft tissue and to the root surface. In order to minimize the risk of hard tissue abrasion it is also advised to avoid the use of dentifrice with an interproximal brush. The brush should be replaced whenever the filaments appear to be deformed.

Toothbrush

Proxibrush

Despite the strong structure of dental implants, they should be respected and treated like a normal tooth. Even though patients are the responsible for everyday oral hygiene, implants should be evaluated regularly by a periodontist and dental hygienist to complement their cleaning.

-By Lorenzo Mordini DDS, MS

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Digital Implant Planning. A Revolution.

Monday, January 30th, 2017

Digital technology has already abundantly embraced multiple aspects of our everyday life. This is definitely involving the dental world as well. Digital Radiograph devices, digital impressions, digital photography, digital manufacturing of prosthetic devices as well as dental implant planning software are more and more commonly utilized by general dentists and specialists.

Digital dentistry may be defined as any dental technology or device that replaces manual activity with digital or computer-controlled activities. In this sense, speed and precision are most of the time achieved in a more predictable way, decreasing human error.

Most digital devices help the restorative dentist to shorten the dental appointment, decrease the use of dental material and increase the precision of the prosthetic products. Along this rationale, digital dentistry was developed to favor surgeon’s procedures too. Nowadays, dental implant software is very used by clinicians to simplify complex cases and increase the speed of regular ones. Yes, this is not the main reason why the introduction of digital implant software revolutionized implant dentistry.

The most important advantage for surgeons and restorative dentists is that implant software has the feature to pre-visualize the final location of the implant when matched to a radiographic image or a dental digital impression.

First, a 3D radiograph (CBCT) of the patient is obtained. The radiologist can identify pathologies and clear the case for implant therapy. The joint analysis of surgeon and prosthodontist is then crucial for the definition of implant number and location.

A digital dental impression of the patient’s teeth can be obtained with a digital scanned. The file can then be uploaded in the implant software and matched with the same patient’s CBCT. At this point the clinician can visualize the bone sections of the patient as well as the teeth shown by the dental impression.

The prosthodontist usually completes this picture by adding the future teeth design requested or planned for this patient. After these steps, the computer monitor will show a combination of superimposed images that represent the real clinical scenario of the patient. With the dedicated software tools, the clinicians can now move and adapt the dental implants on the images above mentioned.

The great advantage of this process is to know in advance where, how many and how an implant can be placed, which surgical complications may arise and a visual guide for the surgical procedure itself. After this plan, the clinician can fabricate a physical device that can capture the location of the planned implants and make it reproducible.

Thanks to other digital software, the dentist can digitally draw a “surgical guide” for implant placement and fabricate it thanks to specific machinery connected to the planning software.

Fig. 1. Digital scan of the dental impression of the patient.

Fig. 2. Radiographic sections with the planned implant (in blue) positioned on the ideal crown restoration location. Lateral and frontal view of the jaws of the patient in order to control the correct angulation of the implant in all directions.

The final device will reproduce precisely the location of the implant that were just planned. The case now can be executed by the surgeon that will apply this device in the mouth of the patient and perform the surgery using the surgical guide as reference. Many scientific studies validated this protocol and working strategy. The precision is very high with small deviation from the original digital design.

Guided implant surgery is a cutting-edge concept that is more and more employed by the dental community.
The help of machines and software helps the clinician to decrease potential of implant misplacement due to inexperience or complexity of the case.

It can be concluded that guided implant surgery is a mean of increasing working speed, comfort of the patient and precision on the execution of an implant surgery.

- By Lorenzo Mordini DDS, MS

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Metal-Free Implants: White Ceramic Option

Tuesday, January 17th, 2017

Thanks to advances in modern technology, there’s an option for the rising number of Omaha patients curious about a metal-free alternative to dental implants. That option is pure white ceramic implants, which we’re now proud to offer at Metro West Dental Specialty Group.

How Do Metal-Free Implants Work?

For starters, ceramic white implants have a natural-looking ivory color that makes them mimic the appearance of a natural tooth. While you may think a ceramic implant wouldn’t be as strong as a titanium implant, pure ceramic white implants undergo a 100% proof test to ensure reliable implant strength. With a 97.6% success rate, they’re just as dependable as traditional titanium implants.

Made from pure ceramic, these implants qualify as a high-end esthetic solution for missing teeth. Patients who receive pure white ceramic implants can expect an implant that is strong, natural looking and comes with a variety of other benefits.

The Advantages of Metal-Free Implants

The fact pure ceramic implants don’t contain metal is a benefit in itself, but what other advantages to metal-free implants offer? While traditional implants are a perfectly adequate solution for a large number of patients, some in Omaha may consider the following benefits reason enough to choose pure white ceramic implants instead:

Strong and reliable: As mentioned above, metal-free implants go through rigorous testing to ensure reliable implant strength and a long life.
Metal-free: The entire implant is made from 100% premium ceramic and doesn’t contain any metal.
Esthetic: Unlike titanium implants, pure white ceramic implants have a natural appearance even below the gumline, making them ideal for patients with receding gums or thin gum tissue.
Clinically proven: Pure white ceramic implants also have a high predictability rate. They’ve been clinically proven to be predictable and stable, and fuse easily with the bone in your mouth via osseointegration.

To learn more about your metal-free dental implant options in Omaha, schedule a consultation with Metro West Dental Specialty Group today!

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November 2017 Study Club

Tuesday, December 13th, 2016

Course Date: Nov. 8, 2017

Course Title: Periodontal Maintenance of Dental Implants

Course Objectives: Following this course, participants should be able to:

Recognize the etiology, risk indicators, signs, and classification of peri-implant disease.
Describe clinical and radiographic dental implant evaluation procedures.
Describe periodontal maintenance procedures and rationale for dental implants.

Course Description:

What is the prevalence of peri-implantitis? Which radiograph should serve as the baseline for the comparison of future peri-implant bone levels? Is it safe to use a stainless steel instrument to clean a dental implant? This 1.5 hour lecture course will explore the current classification of peri-implant disease, etiology, and evidence-based periodontal maintenance procedures for the prevention of peri-implant disease.

Biography:

Melissa S. Lang, D.D.S., M.S. is a 2004 graduate of the University of Nebraska Medical Center College of Dentistry. In 2007, she received a Certificate in Periodontics and a Master of Science in Oral Biology from the University of Nebraska Medical Center College of Dentistry.

Dr. Lang is an Associate Professor in the Department of Periodontics at Creighton University School of Dentistry and maintains a private periodontal practice in Omaha, Nebraska. She is a Diplomate of the American Board of Periodontology, a member of the American Academy of Periodontology, the Academy of Osseointegration, the American Dental Association, the Nebraska Dental Association, the Omaha District Dental Society, Omicron Kappa Upsilon Honor Dental Society, and past-President of the Nebraska Society of Periodontology.

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Short Dental Implants. An Insight

Thursday, December 1st, 2016

The dental implant industry constantly offers new options to increase the success these devices. Besides innovations on their surfaces, there is also a large list of implant shapes and lengths. In many clinical situations, it is impossible to place dental implants since there is not enough residual vertical bone height. The so called “standard implants” cannot be placed because they would interfere or damage anatomical structures and created problems to the patients.

That is to say, not every patient has adequate bone volumes to receive dental implants. This condition commonly appears in the posterior areas of upper and lower jaws. Tooth loss in the posterior jaws favors the resorption process of bone, causing greater proximity to the inferior alveolar nerve (lower jaw) and maxillary sinus (in the upper jaw), limiting the use of longer implants called “standard”. The most common procedure to solve these problems is bone augmentation. This provides the amount of bone needed to compensate the lost structures and host the total length of the standard implant without damaging anatomical structures.

Figure 1. Digital planning of a short dental implant to avoid invasion of sinus (black image above the implant outline in blue).

Generally speaking, there are two options commonly used to increase the ridge height in the posterior maxilla such as sinus floor elevation procedure in the maxilla (internal or external) and vertical bone augmentation in the mandible. However, the drawbacks of these procedures could be the cost and duration of the treatment, the morbidity and the possibility of complications associated to these surgeries. It is important to understand that short implants are very different from “mini implants.”

The last ones are only used in severely resorbed jaws in terms of thickness and not height. Their mechanics and healing is very different from the classic dental implant.

Fig 2. Clinical radiograph of the short implant with crown. The 8mm length avoided a sinus lift. The length of the crown is slightly longer than the implant but not enough to increase risks of failure of the implant.

To prevent all these interventions, the implant market offers the so called “short implants”. These devices have the same surface and designs of standard implants but their main feature is the reduced length. There is no consensus about the definition of short implants. Some consider them less than 10 mm while others consider short implants those less than 8 mm.

Short implants are used since they are considered to be simpler and more effective tools to treat resorbed jaws. Currently, implants up to 4mm in length are available and appear in scientific papers (Calvo-Guirado et al 2014, Slotte et al. 2012).

Despite these benefits, short implants with length less than 8 mm (extra-short implants) should be used with caution because they may have greater risks of failure if compared to standard dental implants (Lemos et al. 2016).

The possible complications derive from an unfavorable ratio between crown length and implant length. If the implant crown is more than double length of the short implants, complications may occur. The biting forces may be too much to bear for the short implants. In case of long crown and short implant, it is recommended to attach 2 crowns and 2 short implants together to improve the resistance to biting forces

In summary, the results of scientific reviews suggest that no statistical difference between the survival rates of short implants (5–8 mm) and standard implants (>8 mm); Short implants showed the same survival rate as standard implants. Complications such as implant marginal bone loss, prosthesis failures and complication rates are similar to standard implants. Short implants can be considered a predictable treatment for posterior jaws, especially in cases that require complex and unpredictable surgical procedures to provide bone for standard implants (Fan et al. 2016).

-Lorenzo Mordini DDS, MS

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Smoking and Periodontal Disease. Facts and Consequences

Thursday, October 27th, 2016

Smoking is very diffused and can be considered a world wide epidemic. In 2012 roughly 44 million American were smokers, with 9 million people suffering from a severe smoking-related disease and almost half a million deaths attributable to smoking and exposure of secondhand smoking each year. Tobacco kills up to a half of its users. Globally, smoking accounts for 1 in 5 deaths among men 30 years old and older and 1 to 20 deaths among women 30 years old and older (WHO 2013).

Smoking is harmful to almost every part of the body. It is associated with multiple diseases that reduce life expectancy and quality of life (lung cancer, heart disease, stroke, bronchitis, and cancers of the oral cavity among all). Almost half of long-term smokers will die early as a result of smoking, and those who die before the age of 70 years will lose an average of 20 years of life (Doll 1994). Tobacco smoke contains thousands of dangerous chemicals (carbon monoxide, ammonia, formaldehyde, hydrogen cyanide are some) and many substances that can lead to cancer.

Smoking and Periodontal Disease

Besides the effect on the general health, smoking is the major risk factor for periodontal disease. It affects the occurrence, the magnitude, and severity of disease. Studies demonstrated that, on average, smokers were 4 times more prone to periodontitis as compared with persons who had never smoked. Former smokers were 1.7 times more likely to have periodontitis than persons who had never smoked. Is important to understand that that approximately 42% of periodontitis cases in the US adult population are linked to current smoking and that approximately 11% to former smoking (Tomar 2000).

Smoking can be deceiving. Smokers wouldn’t see many signs of inflammation in their gums (redness and bleeding gums), but they would hide higher incidence of bone loss deep pockets and increased chances to loose teeth if compared to non-smoking individuals. People may think that her gum status is not bad but they would be wrong. The effect of smoking is slow and subtle.

FIG 1

Fig 1. Global Smoking Prevalence. Percentage of smokers among world adult population. North America shows prevalence between 20 to 25%.

Periodontal Therapy

Numerous studies have indicated that current smokers do not respond as well to periodontal therapy as nonsmokers or former smokers do. The pocket depth reduction and gain of tissue destroyed by periodontitis is more effective in nonsmokers than in smokers after nonsurgical and surgical periodontal therapy (including oral hygiene instruction, scaling, and root surface debridement)*.

Research showed that short- and long-term outcomes of implant therapy in smokers increased the risk of implant failure* (implant loss, implant bone loss, mobility, pain, and periimplantitis). Overall, the risks for implant failure in smokers appears to be approximately double the risk for failure in nonsmokers.

Even with more intensive maintenance therapy given every month for 6 months after surgery (Scabbia 2001) smokers had deeper and more residual pockets than nonsmokers. Smokers also tend to experience additional tissue destruction than nonsmokers after therapy (MacFarlane 1992, Magnusson 1996). Tobacco smoking is associated with tooth loss even when regular recall maintenance care was performed (Chambrone 2010).

FIG 2 a and b

Fig 2. (a) Smoker subject affected by periodontal disease. Notice the bleeding, inflammation and tobacco staining.

(b) Outcome of non-surgical therapy alone and smoking cessation. Tissues appear healthy, pockets were reduced and no bleeding was present. The teeth are now ready for esthetic improvement.

Strategies to Quit*

There are some ways for a smoker to quit. These are listed in order of success.

1. Willpower Alone
This is the least effective method of smoking cessation, with only 3% of smokers managing to quit after 12 months.
2. Self-Help Materials
3. Brief Intervention Program
4. Nicotine Replacement Therapy. Success rate at 12 months is 10% to 20%. Nicotine replacement therapy generally doubles the success rate of smoking cessation (patches, gums, nasal spray,  inhalator).
5. Other Methods. Intensive counseling, motivational interviewing, behavioral therapy, hypnosis, and acupuncture.

In conclusion, smoking is the major risk factor for periodontitis, and smoking cessation should be considered as a strong part of periodontal therapy in smokers.
Smoking cessation should be treated as a priority for the management of periodontitis in smokers. The result of smoking cessation improves periodontal health and increases the success of therapy delivered by the hygienist and periodontist.

*Carranza’s Clinical Periodontology. 12th edition.

- Lorenzo Mordini DDS, MS

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