The problem tooth: when should we pull the plug?

“Herodontics” is a term used by some to describe measures far beyond reasonable to salvage a failing tooth. After all, the oath traditionally taken by dentists is to save the tooth, no matter what it takes.

For example, let’s say you have a tooth with deep decay and your dentist tells you that, sure, it can be saved — but only with a root canal, some bone and gum tissue removal to create space for the crown, and a large post and build-up to support it.

Or perhaps your tooth was twice treated with root canal…and you are still in pain. Of course, you would hate to lose a tooth that you’ve already spent so much money and time on. So your dentist suggests a root surgery and maybe a root amputation and then a new build up and another crown. And he gives it a 50/50 chance of long-term success.

Heroics like this are costly, time-consuming, difficult to perform, and, sadly, ineffective in the long run.

Thankfully, current industry knowledge and technology have created a paradigm shift in treatment recommendations. Today, if a tooth is significantly compromised, we can take a longer and broader view of the available options and outcomes. Even when we can perform procedures A, B and C to save the tooth, as dental professionals dedicated to the health of our patients, we have to ask ourselves, “Should we?”

Sometimes, saving the tooth for the short term may cause more complications in the long run, as with herodontic procedures such as root hemisection, aggressive crown lengthening, apicoectomy of a tooth previously treated with root canal, and even crown supports on teeth with massive missing structure. Of course we can perform these procedures, but the onus is on us to determine if there are better, more successful, evidenced-based treatments that may not include actually saving the tooth. Sad as it seems, chances are that we’re only saving the tooth until the next necessary procedure.

I say it’s time to pull the plug on that problem tooth and spare patients the pain, frustration, and disappointment of fix after fix that only prolong the inevitable. In fact, I propose that dental professionals start practicing “simpractidontics,” simple and predictable dentistry that’s current, successful, cost-effective and longer lasting. I want to educate my patients about all of the possibilities — short- and long-term — and engage them in making better decisions for their overall oral health. Now, don’t you think that’s an entirely different kind of hero?

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Risk of jaw bone necrosis with patients on Fosamax or other bisphosphonate drugs

Bisphosphonate-induced osteonecrosis of the jaw adversely affects the quality of life. American association of oral and maxillofacial surgery recently published a position paper on this condition. Majority of patients are on the oral form such as Fosamax, but some are receiving IV therapy which have more serious consequences. It is important that we continue to educate our patients with this condition and its implications, and current knowledge on management strategies. This quick reference guide reviews important facts for every patient on bisphosphonate therapy and their treating dentist.

What is it? Bisphosphonates are used for treatment of osteoporosis, hypercalcemia of malignancy, Pagets disease of bone, multiple myeloma, and metastatic bone disease in a number of cancers

What are the various forms of this drug? Intravenous forms: Zometa and Aredia (for management of cancer related conditions) and more recently, Reclast (for osteoporosis). Oral forms: Fosamax, Actonel, Boniva (for treatment of osteoporosis and osteopenia); Boniva is available in oral & IV

What are the reported effects on jaws? The primary concern is osteonecrosis of the jaws characterized by poor healing of the bone following common oral surgery procedures (i.e. extractions, implants, periodontal surgery, etc.)

How do I know I have osteonecrosis of the jaws? When all the following are present: 1) current or previous treatment with a bisphosphonate, 2) Exposed bone in the oral region for more than 8 weeks, 3) No history of radiation therapy to the jaws

What are the risks for developing bisphosphonate-induced osteonecrosis of the jaws (BIONJ)? Increased risk with use of IV forms, duration of therapy more than 3 years, over areas where there is thin gum tissue, and patients using steroids at the same time. There is 7-fold increase risk in cancer patients exposed to IV form with history of dental disease. It occurs more commonly in the lower jaw.

How can it be prevented? Before treatment with IV bisphosphonate, patients should have complete oral evaluation and treatment to avoid surgical procedures later. In patients on oral form of the drug, if possible, may discontinue oral bisphosphonate for 3-months before and 3-months after elective invasive dental surgery to lower the risk.

What are the treatment strategies?

Asymptomatic patients on IV bisphosphonate: Maintain proper hygiene and dental care, Avoid surgery if possible
Patients on oral bisphosphonate less than 3 years: Elective surgery is safe. There is always a small risk however and informed consent should be discussed for any elective surgery.
Patients on oral bisphosphonate less than 3 years along with steroids: Consider discontinuation of oral bisphosphonate for at least 3 months before surgery; restart drugs once healed.
Patients on oral bisphosphonate more than 3 years: Consider discontinuation of oral bisphosphonate for at least 3 months before surgery; restart drugs once the surgery site has healed.


Dr. H. Ryan Kazemi is a board certified oral and maxillofacial surgeon in Bethesda, Maryland. He is a clinician and lecturer on the topic of dental implants, bone grafting, and other oral surgery procedures. He also produces video podcasts on dental implants and oral surgery to educate dentists and patients for making better and more engaged decisions about their oral health.

To reach Dr. Kazemi for this story and others:

Email: Hkazemi@facialart.com
Tel: (301) 654-7070

web: www.facialart.com

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

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Teeth Extractions- What Patients Should Know...

Extraction of a tooth is is an emotionally traumatic experience, but the actual procedure does not have to be. If performed by an experienced oral surgeon, the procedure can be done easily and quickly with minimal complications and optimal comfort. IV sedation is a marvelous anesthesia option making the experience great.

Teeth require extractions for several reasons. These include:

• Severe caries (decay)
• Significant periodontal disease
• Significant pain due to infection / inflammation of the pulp (nerve of the tooth)
• Non-restorable due to position or significant caries
• Non-responsive to endodontic therapy (root canal procedure)

With modern day techniques and skills, teeth extractions can be done with minimal invasiveness and time. In fact, surgical removal of teeth takes only 5-10 minutes in most situations. The initial healing takes place in 48-72 hours and typically stable in 5-7 days. Complete healing of any extraction site takes about 6 weeks. Dental implant replacement can be done in 6-8 weeks after an extraction. It is crucial that at the time of extraction the supporting bone is inspected for any defects. The bone undergoes significant resorption and loss following a tooth extraction resulting in defects that are unsightly and difficult to maintain proper hygiene. Also, they create a poor site for implant placement later.

Therefore a site preservation grafting is recommended in the following situations:

• Augmentation of bone loss due to periodontal disease or abscess
• Enhancement of the tissue architecture in the upper front area (Aesthetic zone) to optimize aesthetics and smile line
• Preservation / Augmentation of bone necessary to allow placement of dental implants or other prosthesis at a later time

A transitional prosthesis may be fabricated and placed in the extracted site on the same day.

So here are the key information to remember about a tooth extraction:

1) Best performed by experienced oral surgeons

2) IV sedation is the preferred anesthesia option

3) Always replace the missing tooth with an implant to maintain oral health and condition of other teeth

4) Consider grafting procedures to preserve your jaw bone and maximize on function and aesthetics once restored

For more information, contact Dr. H. Ryan Kazemi at hkazemi@facialart.com

Visit our website: www.facialart.com

Office Telephone: (301) 654-7070

Office location: Bethesda, MD

Visit our video podcasts on:
1) iTunes: search word- 'dr. kazemi'
2) Vimeo.com: search 'dr. kazemi's oral surgery channel'
3) YouTube: search 'implantguru'

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Common Misconceptions and the Truth About Dental Implants

I am often asked by people if dental implants really work as they tell me their difficult stories or others' poor experiences. There seems to be a lot of misconception and misinformation out there. So What is the truth?

Tooth loss is a big problem in America. Approximately 100 million Americans are missing one or more teeth, with close to a third of these individuals missing all of their teeth in one or both jaws. Over 69% of adults ages 35-44 have lost at least one permanent tooth to decay, failed root canal, gum disease or accidents. A third over 65 have no teeth at all.

Individuals with teeth loss age prematurely and have compromised nutritional state due to inability to eat a proper and balanced diet. Many also suffer from altered self image and self confidence and cannot talk and smile comfortably. If not replaced in a timely fashion, tooth loss also results in shrinkage of surrounding jawbone.

Modern-day dentistry has devised an excellent way for people to replace their missing teeth and improve their smile and chewing, while avoiding loss of jaw bone and damaging effect of dentures or bridges. Rather than removable dentures resting on the gum line, or fixed bridges using adjacent teeth as anchors, dental implants are long-term replacements that your oral surgeon surgically places in the jawbone. Implants are visually indistinguishable from natural teeth, and if properly cared for, can last a lifetime.

Dental implants are growing in popularity -- there were 5.5 million procedures performed in 2006. Unfortunately, many Americans avoid getting implants because they have been misinformed about its success, overall experience, and risks. Here are the five most prominent misconceptions about dental implants -- and an explanation for why each is dead-wrong.


Misconception #1: Implants are too invasive and painful!

Implant dentistry is a subtle and conservative office procedure performed with precision and finesse. An experienced surgeon can place the implant in 10-15 minutes. It is significantly less invasive and less traumatic than conventional bridges that require ‘cutting down’ of natural teeth. Patients often report significantly less discomfort with their implant surgery than even with a simple tooth extraction. Recovery is quick and most people return to work or school the following day.


Misconception #2: Implants are expensive!

Dental implants save you money in the long run by preserving jawbone and keeping adjacent teeth healthy. With proper cleaning and care, an implant will likely last a lifetime.

Compared to the alternatives, there is a much lower chance that a dental implant patient will need additional, costly dental procedures after the initial placement. Bridges require unnecessary cutting down of the surrounding teeth, exposing them to possible decay, root canals, or fractures resulting in further extractions and replacement with a costly new longer bridge.

Dentures cause gradual loss of jawbone due to traumatic shrinkage, therefore needing numerous relines to maintain their fit. With increasing loss of bone and support dentures become loose. To avoid slippage, denture adhesives are used which add significant cost over the years. By using as little as two implants, these adverse effects are prevented.


Misconception #3: Implants are frequently rejected by patient’s body!


The overall success rate for dental implants is 96 percent with almost 50 years of clinical research to back them up. Because implants are made of completely biologically compatible ‘bone-friendly’ titanium material, they naturally heal and integrate with the surrounding tissues. Rejection does not occur with dental implants. Other complications such as infections or ‘soft’ healing are extremely rare.


Misconception #4: I don’t have enough bone or I am too old for dental implants!

Jawbone may become thin or missing due to tooth loss, gum disease, or trauma. Using current grafting techniques and available materials oral surgeons can easily and predictability build up the necessary jawbone for healthy support of dental implants. Grafting procedures are highly successful when performed by a skilled oral surgeon providing every person with the benefits of dental implants.

Some older patients fear their jawbone is too weak for implants due to their age or osteoporosis. The fact is dental implants are equally successful in these patients, improving their quality of life by being able to enjoy their favorite food and maintain social interactions.


Misconception #5: Any dentist can perform dental implant surgery!



According to Dr. Harold Slavkin, dean of the University of Southern California dental school, ''a well-educated and well-trained clinician is imperative'' for a successful dental implant procedure. Malcom Gladwell, in his recent book, Outliers, talks about the 10000-hours rule which says: Achieving Excellence at Performing a Complex Task, True Mastery & Greatness Status as a World-Class Expert in Anything Requires 10,000 Hours of Practice. Hence choosing a skillful and experienced surgeon placing the implant and a dentist restoring it is crucial in achieving aesthetic and functional success.

In this regard dental implants success is twofold. First, it requires skillful surgical techniques, best performed by surgeons or dentists with formal surgical training. Second, it requires precision fitting and highly cosmetic overlying crowns, bridges, or dentures made by an experienced restorative dentist. The best success is achieved when a team of dentists work together along with a quality laboratory.

Reality: Dental implants are the most ideal and predictable way to improve your smile and chewing while saving you significant cost over the years. They are safe and highly successful in virtually every patient, regardless of their age or jawbone health, especially when performed by skillful and trained dentists. Implants are the future of dentistry here today with cutting edge technology and techniques that will benefit many for a better and healthier life.

Check out my podcast on itunes on this topic: Search 'dr. kazemi'; or on www.youtube.com: search word 'implant guru'

If any questions, please call me at (301) 654-7070

Dr. H. Ryan Kazemi

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