Dental Implants 101

Dental Implants 101

As adults, we lose teeth for many reasons.  75% of adult tooth loss is due to periodontal disease.  However, we may also lose teeth into adulthood due to traumatic injury.  After tooth loss, it’s important to replace with an artificial root and crown.

We tend to think of our bone as a very static system.  In fact, our skeleton is very dynamic, constantly undergoing breakdown balanced with rebuilding.  One of the major stimuli for bone rebuilding are external forces.  Just as weight-bearing exercise is important to keep our large bones strong, chewing applies forces to our jaw bone that keeps them strong!

When we lose a tooth, the bone that once supported that tooth no longer experiences the forces applied when we chew our food and the bone begins to resorb (i.e., deteriorate).

If left for long enough periods of time, this bone loss can eventually alter the integrity of your facial structure, changing your appearance.  It can also compromise the function and security of the adjacent and opposing teeth (without a tooth to chew against, the opposing tooth will also suddenly lose the chewing forces it was once used to).  Ultimately, this may even change your ability to maintain a healthy diet and proper digestion.

In some cases, bone has deteriorated so drastically that Dr. Fritz or Dr. Schuldt may need to use additional bone material during the implant placement procedure to stabilize the implant.  Or, your periodontist may even need to perform a preliminary procedure to add bone, allow time for it to calcify and harden, before inserting the dental implant.

The only way to know if you are a good candidate for a dental implant and if you may require additional bone to support an implant is to visit your periodontist for a comprehensive examination.  A CBCT, 3D X-ray, is also essential in the planning stages of your dental implant to allow your periodontist to visualize in 3-dimensions your exact anatomy and the quality and quantity of your bone into which the dental implant will be placed.

Dental Implants 101

How does a dental implant integrate?

A dental implant is an artificial root that is used to replace a natural tooth root that has been lost.  Dental implants are made of titanium.  Titanium is a natural element with non-reactive properties.  That is, it causes very little, if any immune response in the body. 

Titanium does have a unique property, it attracts bone cells.  When a titanium dental implant is inserted, it undergoes a process known as osseointegration.  In this process, bone cells fuse to the implant and secure it firmly in the jaw bone.

This process of osseointegration takes several weeks.  Therefore, it is important to allow the body this time to create a strong anchor on the implant before loading it with an artificial dental crown.  Just like glue needs time to set, if a crown is placed on an implant to early, it can lose its grip and fall out.

To test the strength of the integration of the implant into the bone, an Implant Stability Quotient (ISQ) value can be calculated by your periodontist.  If your ISQ value falls within a specific range, it is safe to proceed with the final stage of your implant process, fabrication of an artificial dental crown.

Post-Operative Instructions – Care after a Dental Implant

Post-Operative Instructions – Care after a Dental Implant

After your dental implant surgery, there are some steps to follow for quick and smooth recovery.  Healing after a dental implant can be broken into periods.

In the first 24 hours:

  • Only after freezing has completely warn off, you can apply ice to the area as needed in 10 min ON/10 min OFF for 3 cycles.
  • Do not apply heat to the area as this can stimulate blood flow and increase bleeding in the area
  • Do not brush or floss the area
  • Rest with your head elevated to avoid blood pooling to the area, discomfort, and swelling
  • Do not do any activity that raises your heart rate
  • When sleeping, use an old pillow case in case your bleed through the night

After 24 hours:

  • Do not apply ice
  • Brush the area and neighbouring teeth very gently with the post-surgical toothbrush that was given (this toothbrush is even softer than a ‘soft’ toothbrush and is made specifically for surgical sites)
  • When using the post-surgical toothbrush, avoid the sutures and the gum line at the surgical site
  • Pool Peridex rinse at the surgical site twice per day (morning and night) for two weeks.  Peridex mouthrinse works like a “toothbrush in a bottle” and works to keep the surgical site clean without the manual disruption by a toothbrush at the sensitive site.
  • Do not spit, gargle or swallow Peridex.  Simply let it fall from your mouth.
  • Do not eat or drink for 2 hours post-Peridex rinse.
  • Do not floss the area
  • Brush and floss all other areas of the mouth with your regular electric toothbrush

After 48 hours until your 2 week post-operative appointment:

  • Apply a warm compress to cheeks as needed
  • You may begin to exercise at 50% intensity being careful to monitor for any bleeding at the surgical site
  • Eat only soft foods on the opposite side of the mouth.  A general rule of thumb is to eat foods that require 3 chews or less.
  • Do not eat extreme temperature foods as this can damage the tissues and can increase blood flow in the area – eat room temperature foods only
  • Avoid alcohol, tobacco and cannabis during the healing phase (2 weeks)
  • Do not pull at the lip to see the healing area.  This may loosen the stitches and can disrupt the healing tissues.
  • Do not use straws, whistles, wind instruments as the force applied may damage the delicate healing tissues
  • Avoid wearing a denture or flipper as much as possible as this may rub against the healing tissues

It is important to take all medications as prescribed, especially an antibiotic.

To manage pain, Ibuprofen can be taken by the clock, as necessary.  Any antibiotics prescribed are essential to take until completion.  Use the Peridex mouthrinse twice daily for 2 weeks.

Patients report experiencing their peak discomfort immediately following surgery and experience a steady decline in discomfort through to Day 5.  However, patients report the greatest level so swelling, which can sometimes be accompanied by bruising, 3 to 5 days following surgery.

Should you experience any bleeding, swelling, bruising, or discomfort that is out of greater concern, it is important that you contact your periodontist.

How do I care for my implant?

How do I care for my implant?

Just like natural teeth, dental implants require care and attention to remain healthy and viable.  Although the implant is artificial, the gum and bone tissues that anchor and support it are living and susceptible to infection and deterioration.

When the tissues around an implant become infected with bacteria, they can become red, inflammed, sore, and can bleed.  The tissues can even have a thick, yellow, pus-like substance come from the gums when the infection has worsened.

Together, these symptoms cause peri-implantitis.  Similar to what happens around natural teeth in periodontal disease, in cases of peri-implantitis, bacteria infiltrate the spaces around the implant and cause infection, inflammation, and deterioration of the supporting bone tissues.

Any deviation from health at the implant site is a cause for concern and requires immediate assessment by your periodontist.

The best strategy to keep your implants healthy and sturdy for years and years is proper home care and regular visits with your dentists and periodontist.

If you have a removable crown or denture, it is important to remove it daily and to thoroughly clean the locators.

If you have a fixed crown, it is important to clean around it using the cross-over floss technique.

Intra/Extra-oral Examination

Intra/Extra-oral Examination

The intra-oral and extra-oral soft tissue examination is an essential part of all dental exams.  This examination is performed in a thorough and systematic nature to ensure that no parts of the head and neck region are missed or overlooked.

This examination can be broken down into sequential steps to review all tissues and to determine if they are within normal limits (WNL) or if there is an abnormality noted.

If an abnormality is noted in an intra/extra-oral examination, further detailed notes about the abnormality such as size, colour, location, surface texture, and consistency are made.  Information about the onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, and treatment are all considered by your dental hygienist and periodontist.

As part of a full intra/extra-oral examination for abnormalities in our oral pathology, a detailed medical history, family history, drug/medication history, and social history are taken.

As a patient, we can prepare for our intra/extra-oral examination by being aware of any abnormal colouration, bumps, textures, or sensations in our head and neck region. 

A full video of what to expect during a full intra/extra-oral examination by your dental hygienist or periodontist can be viewed below.

3D Dental X-rays

3D Dental X-rays

Cone beam computed tomography (CBCT) is a recent advancement in dental imaging and provides a 3D image of the tooth and jaw with high spatial resolution and diagnostic ability.

The dental CBCT does not replace conventional 2D x-rays, but is an additional tool that your dentist or periodontist uses to gain more information, to avoid exploratory surgery, and to perform a ‘virtual surgery’.

A CBCT works by three basic steps: Acquisition, Reconstruction, and Analysis

1. Acquisition
CBCT technology uses the same basic technology of conventional 2D x-rays.  That is an x-ray source sends a beam of x-rays through the object of interest and an x-ray detector collects them on the other side.

As the x-ray beam travels through the object of interest (i.e., our teeth), some x-rays pass through the less dense material and others are absorbed by the dense tissue.

For example; If your tooth has a crack in it, the x-ray beam will be absorbed by the tooth, but will pass right through the empty space of the crack and hit the detector.  This paints a picture on the detector of a solid tooth with an empty space through it.  Voila! Your dentist or periodontist can now confirm a crack in 3D, something they would have missed with the low resolution of a 2D x-ray.

The major difference in the acquisition stage between a 2D and 3D image is the sheer number of ‘pictures’ taken.  With 2D technology, only one photo is captured at a single angle.  With 3D technology, many many photos are captured as the x-ray source and detector move around the patients head.

2. Reconstruction
After all of the individual images are acquired, sophisticated software reconstruct the images to re-create the 3D volume.

Like a Rubik’s cube, the individual images are stacked on top of one another in the sequence they were taken in to build a 3D cube.

3. Analysis and Interpretation
The final stage involves the analysis and interpretation of the images captured.  A great benefit to CBCT technology is the ability to manipulate, maneuver and rotate the 3D volume to scroll through the “stack” of images created.

This drastically improves the ability of your dentist or periodontist to diagnose and plan treatment accordingly.

A question that we are asked all the time is “How much radiation is this going to expose me to?”

This is a highly complex question, with so many factors influencing the answer for each individual patient.  The simple answer is, not more than three dental film x-rays but the information we receive from a single CBCT is exponentially more!

There are many factors and settings in the acquisition stage of the CBCT scan that can be manipulated by the dentist or periodontist to limit the radiation exposure to the patient.  To stay informed, always ask your prescribing dentist or periodontist how they plan to limit you to the lowest possible radiation exposure.

Dental Radiation

Dental Radiation

Radiation exists in many forms, not all of which are ionizing, the form of radiation that poses a risk to our health.

Low frequency radiation, such as radio waves, thermal/microwaves, infrared, and visible light waves are to low penetrating power to cause changes to the atoms and molecules that make up our body, therefore classifying these types as non-ionizing.

However, higher frequency radiation such as UV, x-ray, and gamma-rays are able to displace electrons from their natural state, and therefore have the capacity to cause cellular damage and pose a risk to human health.

We are constantly and continuously exposed to radiation in the environment (i.e., cosmic sources, radioactive nucleotides) as well as through man-made sources (i.e., medical imaging).

All dental and medical professionals must always weigh the direct benefit and consequences to their patient when prescribing diagnostic imaging (such as chest x-rays, mammograms, CT scans, dental x-rays, etc.). They must ask themselves, “Is the information I will receive from this x-ray worth the size of the risk to my patient?”  They must also ask, “Is there an alternative to this x-ray?”

In the case of dental x-rays.  Most dental professionals can prescribe either 2D dental x-rays or a 3D x-ray, known as a CBCT.

The CBCT allows the clinician to see the teeth and their location in the jaw bone in all 3-dimensions and allows them to map critical structures, to view the quality and quantity of the bone, and to perform a ‘virtual periodontal or endodontic surgery’ without the need for gloves!

In many cases, this amount of information is unnecessary and a single (or multiple) 2D x-rays are sufficient for diagnosis of tooth decay, periodontal disease, or other common dental issues.

Although a dental CBCT does emit more radiation to the patient than a conventional 2D digital x-ray, the amount of radiation is still negligible compared to many other medical imaging devices and other common sources of radiation.

Concerns about radiation exposure and your risk are valid, but you should take every opportunity to speak to your dentist or periodontist about the safety measures and considerations to your personal health when they prescribe an x-ray to help in your dental care.

My dental implant/crown is loose – What should I do?

My dental implant/crown is loose – What should I do?

Your dental implant and artificial crown have been very carefully designed to fit together like two puzzle pieces.  Sometimes, for a multitude of reasons, these two pieces can be dislodged.  When the implant and crown do not fit together perfectly, over time, the dental crown can become loose.

If your dental crown becomes loose, it is important to see the dentist as soon as possible.  If left untreated, a loose fitting crown can cause damage to the underlying implant.  With many many small impacts from chewing and grinding our teeth, the crown applies pressure to the implant in a direction and angle that was not initially intended.

This repeated impact and pressure can impact the integration of the implant with the jaw bone and cause it to become loose.  Eventually, this can cause implant failure.

The decision to replace a missing tooth with an implant and a crown is an important one.  And therefore, if it becomes loose it is important to protect and care for it immediately by seeking the help of your dentist or periodontist.

Post-Dental Surgery Meal Planning

Post-Dental Surgery Meal Planning

Proper care after your periodontal surgery will help your mouth to heal quickly.  This includes a healthy, soft food diet.

At first, your temporary soft food diet may seem challenging, but with some planning you can ensure that you have all of the nutrients you’ll need for your body to heal quickly.

As soon as you are able (after your local anesthetic has worn off), start drinking nutritious fluids such as real fruit juices, milk, milkshakes, and fruit and vegetable smoothies.

REMEMBER: Do not drink from a straw for at least two weeks.  The suction and force created when using a straw will be disruptive to the sutures and the delicate healing tissues.

A general rule of thumb for the first two weeks following periodontal surgery is to avoid any foods that take more than 3 chews to swallow.

Avoid hot food or drink for the first two weeks.  The heat of your food can increase the flow of blood to the area and can cause your surgical site to bleed.

Just because your diet is of a soft consistency, it is still important to eat a variety of nutritious foods.  Below are some general guidelines according to Health Canada’s Food Guide and some examples of food choices.

Fruit & Vegetables

Consume at least 7 servings of soft fruit and well-cooked vegetables per day:

  • apple sauce
  • stewed or canned fruit
  • peas
  • smoothies
  • soups
  • well cooked or pureed vegetables (potatoes, broccoli, cauliflower, carrots, turnip, other root vegetables)

Protein

Two servings of tender protein:

  • tuna
  • salmon
  • flakey fish served without a crispy coating
  • well-cooked poultry cut into small, bite-sized pieces
  • eggs
  • baked beans
  • lentils
  • Greek yogurt

Milk & Dairy

Two servings of milk or dairy products:

  • milk
  • calcium-fortified soy or almond milk
  • ice cream/frozen yogurt
  • yogurt
  • fruit sorbet
  • puddings
  • soft cheeses such as cottage cheese

Whole Grains

Chose whole grain foods over processed, simple carbohydrates:

  • porridge
  • oatmeal
  • cream of wheat
  • cereals without nuts or dried fruit
  • whole-grain pastas or noodles
  • soft bread without hard crust

Beverages

Make water your drink of choice.  It is important to stay hydrated.

Avoid alcohol and tobacco as much as possible during the healing period.

How much is my dental surgery going to hurt?

How much is my dental surgery going to hurt?

Many of our patients experience fear and extreme anxiety at the dentist and while we do our best to create a calm and tranquil environment, the fear of pain associated with periodontal treatment may still be a deterrent for some.

Therefore, to answer one of the most commonly asked questions “Is this going to hurt?”, we conducted a study that was published in the Journal of Clinical Periodontology.

Over a period of two years, we enrolled 213 patients requiring either dental implant or grafting surgery.  The average age of the patients that were recruited was 51 years, but ranged from 19-80 years.  Prior to their surgery, patients were asked to rate the amount of pain that they anticipated feeling from No Pain to Worst Pain Imaginable.  For 7 days following their surgery, patients were asked to rate the amount of pain they experienced on the same scale.

When all of the data was analyzed, we found that the actual pain that patients experienced after periodontal surgery was lower than the pain they anticipated feeling.

With these findings, we are now able to provide our patients with an evidence-based answer when they ask us “Is this going to hurt?”  Happily, we are able to put them at ease by sharing with them that in fact, periodontal surgery hurts less than they expect!

Some factors that we found did predict the amount of pain a patient would feel are:

  1. Anticipated Pain – if you expect it to hurt, you’ll report it hurting more
  2. Age – older individuals reported it hurting less
  3. Sedation – those who had their periodontal surgery under sedation with one of our Registered Nurses reported experiencing less pain

Some factors that we found did not predict the amount of pain a patient would feel are:

  1. Nervousness
  2. Gender
  3. Surgery Type (dental implant vs. soft tissue grafting)
  4. Smoking Status

Also collected as part of the study, we found that patients needed only 600mg of Ibuprofen for relief of their post-operative pain and discomfort.  This reinforces Dr. Fritz’s mandate of never prescribing narcotics to any of this patients.

This study was conducted by Jennifer Beaudette as part of her Master’s of Science research through the Faculty of Applied Health Sciences at Brock University.  Jen has since completed her M.Sc. and is currently pursuing a Ph.D at Brock University.