Compromised Healing After a Dental Implant

What can compromise healing after getting an implant? There are a variety of causes, said Dr. Robert Schoor, DDS, a Clinical Associate Professor and Academic Director at New York University’s College of Dentistry. “Chief among these causes include the soft plaques that, if allowed to accumulate, can increase the risk of infection and periimplantitis. The number two villain is diabetes,” said Dr. Schoor.

Researchers believe that early failure rates are more common than later failures because of the risks inherent in the early-stage healing process. Researchers estimate that about 1.2 to 3 percent of all implants fail in this early period, as compared to late failures with rates of 0 to 1.8 percent. Interestingly, more implants tend to fail in the maxilla, or the upper jaw, than mandible, or lower jaw, though researchers are unsure of the exact reason why.

The reason the first two or three months is a vital and fragile time is because the implant itself is “biologically integrating,” or binding, with the jaw bone. “It’s very important that there is enough bone to support the implant to begin with so the implant has enough structural support, and that the implant is protected while it binds to the bone in that early time period,” said Dr. David Cochran, D.D.S., M.S., Ph.D., professor and chairman of the department of periodontics at the University of Texas Health Science Center at San Antonio dental school. “This healing period is crucial to implant success.”

Poorly Controlled Blood Sugar

One study found that the risk of dental implants failing was more than 2.5 times greater for patients with diabetes compared to those without. One bad habit in diabetes patients is being lax about checking blood sugar. Poorly-controlled blood sugar can lead to poor dental health, periodontal disease, poor circulation and dry mouth, and problems with healing, all of which may contribute to implant failure. Taking care of one’s implants should also include routine dental care and daily brushing and flossing, whether you have diabetes or not.

Smoking and Chewing Tobacco

More than 24.8 million men and 21.1 million women smoke in the United States. Because smoking is still so pervasive, it is one of the most-studied risk factors for dental implant failure.

“Smokers certainly seem to be more susceptible to dental implant failure compared to non-smokers, with double the failure rate,” said Dr. Scott Tomar, D.M.D., Dr. P.H., department chairman and professor of community dentistry and behavioral science at the University of Florida’s College of Dentistry. Dr. Tomar says that chemicals in the cigarette smoke, including nicotine, may interrupt collagen formation and wound healing, not to mention disrupting circulation. “We know the chemicals in tobacco smoke have immunosuppressive affects that increase the risk of infection and conditions like periodontitis, so it’s not the temperature of the smoke per se.”

Will an oral surgeon refuse to place implants in a smoker because they want to increase their overall success rate? Probably not, says Dr. Schoor. “Smoking…we don’t condone it but we don’t go out of our way to not treat patients if they are smokers.” Dr. Schoor says heavy smokers – who smoke more than 10 cigarettes a day – are more at risk for implant failure. “We tell patients that smoking is bad. Don’t smoke. It will not only hinder your chances for implant success, but it will hinder your health in so many other areas.”

Although there are obvious health benefits to stopping smoking, including a better prognosis for dental implant success, dentists and oral and maxillofacial surgeons understand it is actually difficult to achieve.

Dr. Thomas Dodson, D.M.D., M.P.H., an associate professor of oral and maxillofacial surgery at Harvard University and Massachusetts General Hospital, incentivizes his patients. “If I have a patient who smokes, I detail all the risks of smoking,” he said. “I can get you to stop if I get you thinking seriously about the risks of dental implant failure, not to mention all the other damage smoking causes in the mouth. And then I tell them ‘If you stop smoking and the implant fails within six months, I buy the new one. If you don’t stop smoking and the implant fails, the cost is on you.’”

The risk of chewing tobacco, however, is not as well known as with smoking, but the same principles of harm may still apply. “We know that tobacco use in general, smoking it or chewing it, has been clearly related to the microvasculature of the mouth,” said Dr. Dodson.

But why hasn’t the effects of smokeless chewing tobacco on dental implants been studied as much as smoking cigarettes?

“Maybe one reason is because smokeless tobacco is typically used more by younger people, who are also less likely to need implants. Also, the prevalence of people who chew tobacco is a much less population proportionally compared to smokers, said Dr. Dodson. “Because of that, it’s also been difficult to demonstrate definitively that chewing tobacco causes cancer. But that should never condone its use.”

Alcohol Use

Although alcohol use is thought to somehow affect the risk of dental implant failure, researchers say we don’t know nearly enough about it compared to smoking. “Aside from tobacco smoking, we definitely have not collected enough data on substance or recreational drug abuse,” said Dr. Dodson. “But the thing about alcohol or substance abuse, including recreational drugs, is if the problem gets bad enough, it’s not a stretch to say that it probably affects dental care, including implants.”

But what little research we do have suggests that alcohol does indeed have a negative effect on dental implant survival. For instance, one 2004 study found that alcohol consumption can actually delay bone repair and healing in rats. One year later, this same result was confirmed in humans. Researchers also found that daily alcohol use in excess of 10 grams was linked to not just stunted bone repair around implants, but loss of bone, too.

If that’s not enough, heavy drinkers, or alcoholics, could add even more risk for dental implant failure because of their habit. “The liver is such an amazing, vital organ that has a number of crucial body functions,” said Dr. Schoor. “When that organ is compromised by being forced to metabolize excess alcohol, it impairs clotting factors, the immune response, and may significantly affect healing.”

Teeth Grinding (Bruxism)

Teeth grinding is a stress-related disorder that manifests itself during sleep or wakefulness in people of all ages. While children are known to sometimes grind their teeth (also known as bruxism), many adults tend to clench or grind their teeth during the day, which could potentially be a big problem with dental implants.

“Crunching and grinding is certainly an issue with dental implants because it loosens implants and crowns,” said Dr. Schoor. “They take their aggression out on their teeth. It’s a habit, and it’s usually very hard to break.”

One study released this year found that zirconia implants had a 10 percent failure rate from “mechanical overloading.”

“Anything that would ‘load’ the implant inadvertently during the integration period of the first two or three months could possibly increase its risk for failure,” said Dr. Cochran.

To help save teeth and implants, an acrylic mouthguard can be worn to help distribute the loading forces in clenchers and grinders.

Sources:

Anner R, Grossmann Y, Anner Y, and Levin L. 2010. Smoking, diabetes mellitus, periodontitis, and supportive periodontal treatment as factors associated with dental implant survival: a long-term retrospective evaluation of patients followed for up to 10 years. Implant. Dent. 19 (1): 57-64.

Bombonato-Prado KF, Brentegani LG, Thomazini JA, Lachat JJ, and Carvalho TL. 2004. Alcohol intake and osseointegration around implants: a histometric and scanning electron microscopy study. Implant. Dent. 13 (3): 238-244.

Courtney MW, Jr., Snider TN, and Cottrell DA. 2010. Dental implant placement in type II diabetics: a review of the literature. J. Mass Dent. Soc. 59 (1): 12-14.

Gahlert M, Burtscher D, Grunert I, Kniha H, and Steinhauser E. 2011. Failure analysis of fractured dental zirconia implants. Clin. Oral Implants. Res.

Galindo-Moreno P, Fauri M, Avila-Ortiz G, Fernandez-Barbero JE, Cabrera-Leon A, and Sanchez-Fernandez E. 2005. Influence of alcohol and tobacco habits on peri-implant marginal bone loss: a prospective study. Clin. Oral. Implants. Res. 16 (5): 579-586.

Johansson A, Omar R, and Carlsson GE. 2011. Bruxism and prosthetic treatment: A critical review. J. Prosthodont. Res. 55 (3): 127-136.

Palma-Carrio C, Maestre-Ferrin L, Penarrocha-Oltra D, Penarrocha-Diago MA, and Penarrocha-Diago M. 2011. Risk factors associated with early failure of dental implants. A literature review. Med. Oral Patol. Oral Cir. Bucal. 16 (4): e514-e517.

Snider TN, Cottrell D, and Batal H. 2011. Summary of current consensus on the effect of smoking on implant therapy. J. Mass. Dent. Soc. 59 (4): 20-22.

Zupnik JT, Kim SW, Ravens DP, Karimbux NY, and Guze KA. 2011. Factors Associated With Dental Implant Survival: A Four-Year Retrospective Analysis. J. Periodontol.

Implants are the modern, high tech alternative to dentures, but many denture wearers assume that they’re not affordable.   In fact, implants don’t have to be astronomically expensive and there are a number of alternatives when it comes to cost.  Overdentures, the least expensive alternative, are basically dentures that snap onto implants but are much more comfortable. Smaller than dentures, they require less coverage of the palate and lower gums, and they’re fixed, not mobile.   Since they’re anchored to the jawbone, they give you more chewing power, which in turn maintains bone density.

The simplest, most inexpensive overdenture is attached to two implants in the lower jaw and four or more in the upper.   These overdentures are still partially supported by the gums, but they’re much more comfortable, are removable and can be cleaned daily.  If there isn’t enough bone for traditional implants to support overdentures, Manhattan periodontist Nicholas Toscano, DDS, Co-Editor in Chief of the Journal of Implant and Advanced Clinical Dentistry uses an “all-in-four” system.  “Four implants are placed on both the top and bottom angled in such a way as to avoid the nerves and provide stability for the denture,” explains Dr. Toscano.

“If you want a more permanent solution you can go for the more expensive fixed bone anchor bridge, requiring six or eight implants to be placed on the top and bottom —to support a denture which is screwed in permanently,” explains Tim Kosinski, DDS Assistant Professor at the University of Detroit Mercy School of Dentistry.  “For some people the permanence of the denture is very important, they don’t want teeth that come out.  However, the fixed overdenture can be difficult to keep clean so we try to design them so they’re maintainable.”

Kyle Salsburg, of Olympia, Washington got full upper and lower fixed implant- supported overdentures when she was 83 from  Jim Janakievski, DDS.  Even though he says “Many patients have difficulty flossing and effectively cleaning this type of prosthesis, which can lead to gum inflammation and new decay,” she has no problem cleaning them.  “I clean them myself with a waterpik and Jim takes them off twice a year for cleaning.  They cost quite a bit of money but luckily I could afford them. These are so much better than dentures.   You can forget about them.  They’re like your own teeth.”

The next, most expensive, restoration is implant-supported crowns, which are the most like your real teeth.  “With 10 implants you can create regular porcelain crown and bridgework” says Dr. Koskinski.  “These teeth are done with the latest high tech cad cam (computer-aided) technology.  Depending on how much bone you have, you could even have individual teeth that are indistinguishable from your real teeth.”

The cost for any of these restorations ranges from the price of a Hyundai to a BMW, or more, depending on where you live.  In Detroit where Dr. Kosinski practices, implants range from $1,000 to $1,700 each.   In New York City, where Dr. Toscano practices, they start at $1,800 and go up to $2,500.    Then you need to pay for the overdenture or crowns.   An overdenture costs from $3,000 to $5,000 and crowns range from $1,200 to $2,500 a tooth.  In total you will pay from $10,000 to $50,000 per arch, depending on how sophisticated a restoration you choose.

There is no doubt that the cost is worth it.  Freelance writer Mary Mihaly of Cleveland, Ohio wore dentures since she was 20, but by 50 her lower jaw had eroded significantly, impacting both her looks and chewing function.   It took her a year to afford her overdenture, even with financing, but she doesn’t regret it.  “I look better, my face is longer, and you can see my bottom teeth.”    Many dentists will make credit arrangements.

Before you sink your life savings into implants, however, be sure to do your homework.  Dr. Kosinski suggests asking your dentist the following questions:  “How long have you been doing this?  How many overdentures have you done?  Where did you get your training? Can I talk to your patients who have had this done?”  Dr. Kosinksi asks his patients to write a letter that new patients can read.”

Dr. Toscano also emphasizes the importance of educating yourself about implants before you sink thousands on your mouth.  “Ask the dentist what lab he uses. Then look into that lab’s quality on the internet.  Ask the dentist how much of the bill is lab work and how much his labor.   Some dentists save money by having lab work done in China and it doesn’t last.  When you buy a car you’re looking at craftsmanship, so why not look at the same thing when you buy a new set of teeth.”

Sources:

Kosinski, Tim, DDS, Detroit, Michigan, www.drkosinski.com, phone interview by author, May 15,  2011.

Janakievski, Jim DDS, Tacoma, Washington, “Dental Implants for Long-Term Oral Health,” unpublished article, May 15, 2011.

Mihaly, Mary, Cleveland, Ohio, phone interview by author,  August 30, 2005.

Salsburg, Kyle ,  Olympia, Washington, phone interview by author, May 18, 2011.

Toscano, Nicolas DDS, New York City, New York, www.manhattanperiodontist.com,  phone interview by author, May 15, 2011.