Detox Blog

Do you know in eggs, is it the white or the?

I don’t know.  Gluten-containing foods.  This is a big category.  So, wheat, oats, rye, barley.  By the way, barley is found in what substance?  Alcohol.  Beer, specifically, and soy products.  Soy also falls in that category.  Some people are fine with tofu, but if they drink soy milk, they have some kind of reaction.  So, you have to think about how you are with consuming that.  Yes?

If you don’t have allergies to gluten-containing products, is it still better health-wise to not eat?

That’s a great question.  If I’m not sensitive to gluten, in other words if I know for sure I’m not sensitive to gluten based on laboratory results, is it still healthier for me to avoid?  The answer is yes.  It takes a lot for the body to process.  Great question.

Other foods.  Tomatoes and sauces.  Corn, including corn tortillas.  Peanuts.  Beef.  Pork.  Bacon. Shellfish.  Processed foods.  Hot dogs.  Canned meat sauces.  Meat substitutes.  Food additives and MSG.  This list is an order of things that I enjoy.  Notice that peanuts, pork, shellfish are italics, and there is a big old bracket.

So, I’m not a fan.  The Old Testament in Leviticus is not a fan.  So, the Jewish are not a fan.  It’s considered unclean foods, well peanuts not so much but the pork and shellfish, and these peanuts and shellfish are known to have allergic responses.  Now, the people can actually die by eating peanuts if they’re allergic to it.  People can actually with shellfish by eating it.  That should give you some indication that it’s not a great thing for you to consume.

Why are peanuts bad?  I get organic peanuts. I don’t get organic peanuts.  Both are bad.  Let me explain this.  The peanut shell or the peanut grows in a shell. In that shell, fungus grows. They cannot prevent that fungus from growing unless they use pesticide.  That pesticide is toxic for you.  So, you want the fungus, which is unhealthy for you, or do you want the chemical? Both are bad.

Catch-22.

Okay. So, you avoid it.  Do so. I mean, we all love almond butter now, right? Well, there’s a cashew butter, too.

Is it okay if I eat almonds instead of peanuts?

Totally fine.  Almonds, cashews, all those other things that you’ve probably been eating.

Pork.  When we were in El Salvador, I stayed with a family, and the family owned a pig farm.  They said, based on American standards, the most clean facility.  They said, “you want to visit?”  Seriously? No way.  I’m not eating pork, but pork.  We don’t need to go over the whole parasite, right?

Alright.  Shellfish of all types are bottom feeders.  They clean the bottom of the ocean.  That’s what they do.  So, realize that.

Most poop sinks.

Most poop sinks.  Then, processed foods.  You have to be very careful with processed foods. Hot dogs.  I’m not a very big fan of hot dogs.  Canned meat, you guys are probably consuming a lot of canned meat if you guys go out to eat.  Most restaurants used canned meat.

And the food is microwaved.

And the food is microwaved.  Have you worked in food service before?

For a very, very long time.

Yes. Meat substitutes.  Sausage, by the way, be careful of sausage.  There’s a lot of things in sausage.  If you know a person that works with sausage, but be careful.  Meat substitutes, I’m not a very big fan of that. A lot vegetarians consume meat substitutes and food additives.  There’s a huge list. You see hydro-blank when read ingredients.  You see hydrolyzed blank.  Be careful with those things as well.

Okay.  So, that’s all we need to go over with the list.  Use it.  Everyone’s going to be a little bit different so if you guys are a family and you guys are adding these things back together, someone realizes this could complicate things because the last 21 days, you guys have been eating pretty much the same thing.  Well, if someone’s sensitive to eggs but the other two people are not, you’ve got to realize, “Are we going to wait for this person to get cleaned up before we add it back on or are we going to leave her in the dusk because I want my X, Y, Z?” So, you’ve got to realize that dynamic exists.  That’s why this is a tough part of the recuperation process.  Yes?

Hot dogs.  What if they’re turkey dogs?

Even them.  You’ve got to be careful.  Hot dogs.  Processed foods have nitrites in them.  Be careful.

Even kosher ones?

Even kosher ones have some nitrites in it so you’ve got to look at it and see.  I mean, Whole Foods got some awesome varieties of sausages, of hot dogs, all sorts of good things.  So, if you guys ever want to take a trip to Whole Foods, I can meet you guys there, and we can have this tour or something.  The other name of Whole Foods is Whole Paycheck because it’s not cheap.  When you’re there, you’re like, “Oh, look at this gluten-free stuff.” Yes?

I was a little confused.  If you find that you’re a little sensitive to something, is it you wait seven days of just not eating it or anything else?

Exactly. So, that’s a great question.  Let’s talk about that actually. For example, it’s like you led me this way.  Let’s add milk back to the diet, not cereal, milk and your health oats, Quaker Oats.  No, no, no.  That’s too much. Adding milk back into the equation somehow, some way.

So, for up to three days, you may feel symptoms that include fatigue, gasp, bloating, diarrhea, constipation, body aches, headache, sleep disturbances.  You can feel those different things, and that’s not even the exhaustive list.  Everyone’s a little bit different. You’ve got to really listen to your body now.  I mean, this last week has been pretty easy for most of you guys.

Rashes?

I’m sorry.  Rashes?

If you get rashes?

No, that’s not.  We’ve got to talk more about that, but could you have rashes as a result of this?  Yes, you could have rashes as a result of this, skin issues, breaking out like me with the yogurt. Okay.  So, be observant to what’s going on with your body.  Irritability also.

So, if you have an adverse reaction, you want to remove that food for seven days again.  In other words, you’re in this process.  Okay, so I’ve gone through this process.  Now, it’s time for me to add milk back in again. Alright, I had milk.  I’ve been having milk for a day.  The third day, uh oh, I don’t like this. I’ve got to step back.  I’ve got to throw the milk away from my system. At that level that you were, and then after the seven days of symptom-free, not seven days after your symptom.  So, you have to be symptom-free for seven days.  Then, you can add in something else.  Tomatoes.  So, no sooner than seven days, right?

So, at that point, you would be considered sensitive to milk?

Yes.

So, the idea is for you guys to observe and leave it alone. 

Yes, identify the food sensitivities.  Now, many of you guys may be thinking, “I don’t want to wait. I just want to take that little kit that you held up front and find out what I’m sensitive to.”  You can do that, but realize that you still have to go through this same process to really get the full grasp of what you’re sensitive to because that list has much more than the top four.

By the way, any questions on that? Has everyone got it?  I need you guys to get that.  Yes?

So, the whole pizza issue.  You can’t have a piece of pizza?  You have to do tomatoes, cheese, bread?

Exactly.  This is, again, why this space-free guys, tomorrow, is so dangerous for you because you’re like, “I’m free,” and if your choice is not to go back to the dark side, you want to stay in the course, then you have to do it the right way.  The right way is not to jump on pizza because pizza’s got the gluten from the crust.  It’s got the cheese, and it’s got tomato sauce.  If you put pepperoni on it, it’s got the pork, sausage.  You’ve got a lot of stuff there.  So, you’ve got to be systematic about it.

So, yes.  This will take some time for you, but you do it once.  You do it right.  You won’t have to do it again.  That’s the cool thing about it.  If you plan on living for more than a year, which should be everyone here in this room, three months is nothing compared to the amount of time that you’ll be living with this lifestyle.  So, put it in perspective.

By the way, you guys have heard me talk about eating a cheeseburger or eating pizza.  To live some lifestyle, you have to realize that there’s some premium.  When you go out for a party or something, you want to enjoy the party.  You don’t want to be like so against it unless you are really sick against something.  My mother, her reaction to gluten, she’ll vomit because she’s so sensitive to it.

So, you have to realize where you are and what price you’re willing to pay. My will when I help people lose weight is get clean, get good. Once you kind of know your system, live the 90%.  The 10% diet if you will.  Every 10 days, you can eat as bad as you want.  So, for nine days, though, you’ve got to be on.  So, you start scheduling every 10 days. You start looking forward, “Hey, were are we going this 10^th day? Here, here, and here,” and I just want to be loving it and sick because when you have those experiences like, “I feel so nasty right now. I can’t believe I ate all that. I can’t believe it.  I can’t believe I’ll do it in 10 days again.”

When you have a negative or adverse reaction to these different things, it hits home to like, “I just want to stay.  It’s not worth it for me.  I’m not going to feel good about it,” unless you’ve got a close friend, a business partner that will say, “Let’s go.  My treat.”  It goes both ways.

So, remember what you’ve learned.  Realize that you being clean for the past 21 days, you’ve had no alcohol, I hope, no caffeine, I hope, and no sweets, I hope.  If you’ve been that tight, then that’s awesome.  So, have you ever eaten this healthy before?

No.

No, never?

Maybe as a baby.

Maybe as a baby.  You know, if you’re being breastfed, yeah, but when you’re that small, you don’t have a choice.  Right? Unfortunately, there’s things are terribly given to children at too early an age, a whole other topic, but realize that you guys have achieved something for your health.  Very impressive.

Is that about the young guy, the chef?

He goes all over.

Yeah.  It’s scary.  Yeah, another show, “Super Size Me”.  Have you guys seen “Super Size Me?”  So, I said we need your help, but really, I want your help.  You know, need is a very basic level. If I say, “I need your help.  Mom, I need you,” it’s more of like a responsibility or you feel obligated because there’s a need relationship to do that so I want your help.  So, that’s a bit higher, but even higher than that is I’d love for you to help to achieve.  There’s no way I can do it all alone.

It’s much easier for someone to listen to us when you say listen to them rather than for me to say listen to me.  Okay.  It’s a third party endorsement.  That’s why many of you guys have showed a testimonial, and we appreciate that because we want to use that to tell other people.  So, can I count on some people’s help here tonight?

So, let’s talk about what’s next.  Are you guys ready?  Here are your options:  You can go back to the old ways and lifestyle.  Who’s on board with that one?  No one, really?

Hugo lost 10 pounds just watching his wife and family.

Ridiculous.  That’s ridiculous. That’s crazy.  Number two:  You want to stay with what you now know and stay in the course?  Anyone interested in that one?

Yes.

Then, there are those of you who will say, “Really?  How far does this rabbit hole go?” I don’t know if I really want to know, but I’m curious.  So, we’re going to talk about all these options tonight because some of you might say, “Yeah, number one.” So, let’s start that.

So, back to the dark side option.  I’m a Star Wars fan at heart.  By the way, I have a confession.  It was my birthday on Tuesday, and I cheated.  Yes, I cheated.  Yes, I had popcorn.  I love popcorn. I could eat popcorn all day and had some butter, too.  That was good. So, I want to confess that.

It’s okay, Troy.  We love you.

Hi, my name is Troy, and… Oh, come on.

Tomorrow is my other birthday, which is the day I accepted [17:42].  That’s 1993.  It was special.

Okay, so who heard that knowledge is power?  They lied.  Knowledge is not power.  Applying knowledge is power.  You guys now have the knowledge.  You guys already applied that, and you guys can see and experience benefits.  So, the fact that you guys, if you want to go back to the dark side, it’s okay.  The fact that you know something is huge.  The ability now to do the seasonal cleanse.  You have the awareness.  You have an idea of what is possible.

So, if you choose to go down the unhealthy eating lifestyle, it’ll just take a crisis for you to make a change, but now, when or if that crisis occurs, you now say, “Well, I remember this.  I think I’m ready to do this now.”  So, that’s a big thing.

So, that’s how we’re going to talk about that.  Next, let’s talk about staying the course. So, a few things we’re going to talk about staying the course because people are asking a lot of questions about this after the third week.  “What are we going to do after 21 days?”

So, if you kept living like this, just the way you are right now in this phase, your completion phase number two, you guys would be amazingly more healthy in three months, in nine months, a year, two years.  With the statistics that every cell in your body changes after how long? I can’t remember the statistics.

Seven years including nerves. 

So, it’s crazy.  Your body’s replacing itself.  Eating the right stuff, that DNA and RNA, I don’t mean to lose anyone of you, but if it’s got better building blocks, if it’s got less toxins that it’s exposed to, it will be better, stronger, faster.

So, if you were just to keep living like this, long term results are freaking.  Important question:  Can I still [20:12]?  Yes, you can.  We’ll talk about that.  In fact, I got that a couple of times today. Food selection process, we’re going to talk about that tonight.  We’ve got a couple of things to help you with that and the last diet, we’re going to talk about that, if you want to stay in the course.

So, let’s go for it.  Daily Clearavite.  This is what I did.  This is my personal program after I’ve done the whole thing.  Clearavite, in case you guys haven’t seen it before. It’s a great nutritional support.  It’s a great probiotic. I mean, you guys have heard enough commercials about probiotics and how important they are.  Your family might be pushing you, “You’ve got to take stuff. It’s a cure.  It’s amazing.”  So, it’s a great probiotic.  It’s a great digestive food.  It’s even got enzymes to help you digest the food better.  So, there’s a lot of good things in here.

Please understand, and I know I told you this before, it is not a meal replacement program.  So, this is not like I’m just going to get my Clearavite in the morning and I’m out.  It’s better than nothing, but there’s much more to it.  Clearavite in a canister by itself is $69.26.  One canister should last you 21 days on one serving a day, and you order it as needed from us.

You guys ready to take some notes on this one?  Okay, so food reintroduction process.

Can you do the shake without the pills?

Yes. Yes, Clearavite, you’re not taking the supplements.  Okay, so, here we go.  Step number one, list all the foods you want or need to have back in your diet and order them, the ones you miss the most on the top of your list.  Can you do that?  So, let me help you guys with that.  Here’s a list that I’ve put together that I’ve used.

Alright, the list.  What you have there is a complete list of the things that you guys already removed from your diet based on the plans or you were supposed to anyway.  Okay.  So, this is a process that I use.  It’s kind of my order that I have them back in because this is the order of things that I love the most.  So, we’re going to go through that in just a second.  We’ll come back to that list. You don’t need to look at it right now.

So, step number two, once you have that list, add one back to your diet.  I need to have you guys listen very carefully here.  You guys are at a very critical point.  You guys have just finished 21 days of a food elimination diet.  You’ve removed pizza, removed hamburgers, fried chicken, onion rings. So many of the things that you love and enjoy have been out of your diet for the last 21 days.

So, here’s what tends to happen when people are deprived of something that they love and desire for 21 days.  Eat it all the next day.  You say, “I’m just going to add one thing back to my diet.  I’m just going to add pizza.” Pizza’s got cheese.  It’s got the gluten, the tomatoes, so right there.

So, when I said this is the hardest part, the hardest part is being patient with the process. So, I want to stress to you the importance of taking these and just adding things back in slowly.  If you really want to ride the biggest benefit of this cleanse, do it this way.

For how long?

I will explain it later.  Hold your horses.  You guys are bad, chomping at the pizza.  So, how many are you going to add back at a time?

One.

Okay, so you add that one back.  You observe how you feel for how long? Three to four days post-consumption of that food.  So, on the list, my number one item was dairy.  I love cheese. I mean, I’m like half-Wisconsin.  That’s just how we roll.

So, what I would do is add that back in. See how you feel.  I’ll give you an example in a second, but I can eat that for two, three, four days.  Usually by the third day, if you haven’t had any symptoms, you’re good.

What kind of symptoms are you talking about?

Hold on.

I have a question.

I don’t know if I want to answer it.

So, if you cheese, does that mean you can’t have milk?

Great question.  Let me clarify.  Hold that thought.

Number four, if you have no adverse, no bad reaction, I’ll explain what that means in a second, add another food.  So, if you’re golden for that day three or day four, guess what?  Yes, you can add tomatoes.  So, this is my list.  So, you guys can swap it around.

However, if you have an adverse effect, this is where it gets tricky.  You need to remove that good again from your diet.  For how long?  Seven days.  Assuming now that your gut’s working better, you’ve got to purge it out again from your system for seven days. So, if you have that chocolate milkshake and your body just reacted to it, you’ve got to stop with the milk for seven days, get back to symptom-free at that point because at this point, you’re being very observant to how you’re feeling.  This is really the best way to regulate and see how you’re doing.  Assuming that you feel better after seven days, then you add it back in, and you just repeat that process.

So, let’s talk about the list, and I’ll answer the questions that you guys gave in a second.  So, dairy products.  You asked the question, does that include everything dairy?  Yes and no.  Milk and cheese are different forms of the same thing.

Some cheeses are processed in a certain way, too.  Certain catalysts are added.  So, you might actually be sensitive to the catalysts that are in the cheese but not the milk.  For example, I’m fine with milk and cheese, but if I eat yogurt, the next day I will break out.  There’s something in the yogurt.  I don’t know what it is.  That’s just from my experience of observing what and how I eat, and I encourage you guys to all get there. It’s like when we go have a cheeseburger, I know what to expect.  I will feel lousy the next day or something like that.

Eggs. Eggs are pretty easy, but it is in fact one of the top, these four here are the top food sensitivities out there. These are the ones that we can actually test for.  In fact, I even indicated on your form that these are the ones where a test can be given.  This test right here can be given in which case you will take the vial out.  There’s a [01:09] inside.  You soak up your saliva, mail it in the laboratory.  They send me the results which looks something like this.  It’s a form that looks like that, or they’ll e-mail me the results.  I’ll let you know if you’re sensitive to that food.

see the video: http://vimeo.com/12764225 | http://vimeo.com/12772364

First of all, congratulations, guys.  You guys really need to, yes, absolutely. That’s quite the accomplishment that you guys were able to achieve.  That’s very admirable.  There’s a lot of people who won’t do what you guys just did primarily out of ignorance.  They just don’t know.  You’re probably heard of different, “Oh, I’ve got all these plans.  I’ve got this,” but you don’t really know what to expect with a “cleanse”, right?  Most people think of, “I’ve got to run to the bathroom all the time.” So, I don’t want people to think that.

Just sometimes.

Just sometimes.  So, alright.  Welcome back.  So, are you guys ready to get back into a normal lifestyle after this?

No. I like this lifestyle.

You’re liking this lifestyle? Yeah, a lot of people are liking how they’re doing.  So, let’s get into it.  By the way, who wants copies of lectures?  We have it.  We’re recording it.  You can get all five DVDs for personal reference, for use, for refresher.  Granted only one family needs it at a time. If you want, you can get them $75 for the full set.  It’s interesting to have.

So, you thought the first 21 days was tough, but before we talk about what’s next, I need to fill in some gaps and give you guys a little bit more information that’ll help you to get a better appreciation of your health and give me some feedback as well.

So, can someone tell me what the master control system of the entire body is? Anyone?

The stomach.

The stomach? The what? Absolutely.  The brain works system, the central nervous system which consists of the brain, spinal cord, or the master control centers. They run every single tissue in your body, including the heart, including your gut.  Why is that important?  Well, very simple.

You’ve got your brain, and you’ve got a tissue.  Pick a tissue. Let’s pick the stomach.  Okay.  The brain will communicate with the stomach, I hope, and the tissue will communicate back with the brain.  For example, you’re about to take a bite of a big, old vitamin, a big, old fat juice cheeseburger, and immediately, your brain will start sending a message to the stomach to say, “Prepare yourself and start producing a lot of acids because you need to break this thing down.”

So, let’s say the stomach does that, but then, on a good day, as you’re eating the hamburger, the stomach will send a message back saying, “Alright, we’ve got this under control,” in which case the brain will turn off the message to say, “Produce acid.”

Unfortunately, a lot of times what happens is there can be some interference in that nervous system, in this feedback loop.  In other words, if the tissues aren’t getting the message to the brain, what will the brain continue to do?  Send the message to produce more acid, and so what will happen?  The stomach will get the message and then start to produce more acid.  What happens as a symptom?  What do you get when that happens?

That’s why a lot people, when they seek services from a chiropractor, one of the side effects or benefits of them getting work on their mid-back is they don’t have heartburn anymore.  The reason I bring this is up is because it’s a key component to understanding what optimal health is.  So, let’s talk very briefly about that.

So, Chiropractic First by Dr. Terry Romberg was one of the first chiropractic books I ever read, and before chiropractic college, I suggest you check it out.  In fact, as a gift, I’m going to give every one of you guys a copy of that book.  If you take one, pass it around.

I strongly suggest, if you guys have appreciated the way that Dr. King and I look at the body, then you’ll enjoy this book.  Do we have enough?  You got it?  So, don’t look at it now.  That’s not the textbook for this evening, but I suggest you look at it another time.  It’s a very easy read, a very easy read.

So, there are three areas of optimal health.  I’m just going to touch on this briefly because you need to realize that they exist because we’re working on the nutritional aspect.  Many of you have already experienced positive benefits just by this aspect alone.  So, you, as our chiropractic patients have experienced benefits from that side.  So, many of you are getting a double benefit now like, “I’ve got nutrition improved. I’ve got my neurologic system improved.”  That’s cool.  So, now, you’re even going to get more benefits.

There’s another one, which is emotional.  Emotional is a very big category.  In fact, on this we put stress.  We put finances.  We put our relationship with our higher power.  We put our relationship with our spouse or our business partner or whatever, children.

So, realize that these three key components are really, really what support health.  Any lack thereof, you’re not going to have complete health.  Now, optimal health is not defined as the absence of symptoms.  In other words, please do not define health as, “I feel fine,” because there are thousands of people that have undiagnosed cancer that feel fine. So, realize this.  It’s funny. As you get to know patients as family, you start that you’re working on the emotional side of it, too, but that’s not our cup of tea.

One thing that you need to talk about before you talk about what’s next in your cleansing process is I need feedback.  So, by a nod of head or a show of hands, just give me some feedback because some of you I’ve heard a lot of information from, some of you I have not.  So, who here has noticed improvements in the digestive system?  How about energy improvements?  Sleep improvements? Weight loss?  That’s fantastic.

Let’s play a game on that.  Keep your hand up if you’ve lost 5 pounds, 8 pounds, 10 pounds, 15 pounds. Seriously?

Seriously, 280 to 260.

Wow.  Remember when we started this, I said do not do this to lose weight.  Do this for health.

Who here lost 4 pounds?  I just want to be able to raise my hand.

How about skin improvements?  Have you guys gotten comments from your friends?

I’ve gotten a lot. 

It’s crazy. In fact, your liver is very important.  By the way, thank you for sending me that e-mail.  She sent me this e-mail that was a cartoon about a liver talking about how important I am and how to take good care of me because these are the nine things that I do, right? At the end, it says, “Don’t drink alcohol.  Don’t do this because you’re going to hurt me.” Things like that, but it’s cool because I’m like, “We talked about that.” So, neat.

Skin improvements is one of those things.  Your skin. Your liver will take are of a lot of things that will show up on your skin.  Eczema is one of those things.  As a child with eczema.  It’s a good thing they’ve got some liver stuff going on. Overall, feel better about yourself.  I mean, the fact that you guys have done this thing for 21 days, that’s good stuff.

Alright, so more feedback.  Was this fun?

Yes.

Are you glad you did it?

Yes.

Could you see yourself doing the cleanse, again?

Yes.

Even you? You could see the power of this, just to keep yourself cleaned up. We’re going to talk about the different directions you can go after we’re done tonight, and even seasonal cleanses are quite powerful for you.

More feedback.  So, were the lecture’s reliable?

Yes, definitely.

How important would you say the lectures are to your success with the cleanse?  Very important?

Yeah.

There are many people who are like.  If you can’t make the lecture, we know it’s going to help them by just doing the cleanse, but we know how much more impactful the cleanse will be by them getting this information.  So, there are many faces that you don’t see here that you saw on the first night, and some of you have missed a class here and there that you shouldn’t have missed that really, for you, when you’re checking your list, and you want a list of these certain issues, you’re that much powerful.

So, most you paid about $185 for this program.  Would you say it was worth more?

Yes.

Wait, do we have to pay more? I don’t know.

Well, I’d say it’s worth more just because of how much time I put into this, but alright.  Do you think the topics shared in the lecture need to be shared with other people?

Yes, definitely. 

It’s crazy stuff, right? I mean, every night, I see your eyes open more and more and more and more as to how you and many of your friends and family are being taken care of by people you’ve entrusted your health with. Hopefully, as a result of us talking for the last however many weeks, you now realize that the person responsible for your health is who?

Yourself.

You, as individuals.  Don’t be afraid or intimidated by a doctor. Be proud of the fact that you’ve done more research about the subject that you have, the condition that you have.  Feel comfortable at talking at that level.  Ask questions.  Put them on the spot.  You’ll find many doctors get very defensive, many.  So, we need your help.

Dr. Pete and I, you guys, when we very first met on the discover day, we talked about how he and I will no longer commit the sin of omission review on this topic of helping someone by sharing with them something that’s potentially life-changing for them.  We want to do that more. In fact, on a much bigger scale.  I mean, imagine the impact it’s going to have on your family.

Danielle. Again, many of you are related to Danielle. Danielle.  She really loves you, guys.  She said, “I need this person to come.”  What can we do?  So, imagine that for your extended family.  Imagine that on your church.  There are churches that are sick, physically, and they need a health message that will get up in there face.

Imagine this is our community. I mean, you guys heard some of the statistics about diabetes last time, about how they think that diabetes is going to be the thing to bankrupt our nation.  So, I think I just saw something in the newspaper pertaining to the Pasadena.  It’s got this huge deficit.  All this crazy stuff.

There’s a documentary about it. It’s called “Food Nation”.

Dr. Lavine:

Okay.  Can you pull up the slides where you showed the website again?  We have a couple of questions about the actual course.  So, there it is.  It’s rockymountaindentalinstitute.com.  You can see all the courses there, and we’ve been very fortunate to have Dr. Lingo and Dr. Cummings and Dr. McCracken who are all speakers.  They’ve done webinars in the past, and I would encourage people to come your course.  You said it’s March 14^th, correct?

Dr. Domingue:

It’s March 14^th.  Yes, yes.

Dr. Lavine:

Okay.  What about the restoration.  Screw-retained, cement.  Do you have a strong preference for one or the other?

Dr. Domingue:

Screw-retained, we do both in our practice.  We screw retain implant crowns, and we also cement retain implant crowns.  There’s protocols to both.  If you’re going to have less than ideal vertical dimension, you’re going to have to screw retain your implant crown.  You’re not going to have enough room to make an abutment and a crown.  If you have anything less than 8 millimeters, it’s going to have to be a screw-retained crown.  If you’re going to have anything more than 8 millimeters, it really doesn’t matter.  You can do either or.

I do often screw retain implant hybrids. We do single unit crowns.  We do full arch screw retain.  It just depends on the patient’s needs.  It depends on what I feel is necessary for the case, but there is a place in implant dentistry for both.

Dr. Lavine:

Okay.  Immediate implants, implants around sockets are not. Is there a general rule of thumb about when you’re going to graft?  Is there a certain amount of space that you’re comfortable with or not comfortable with?  Does it depend on how integrated the implant is?  How do people deal with the fact that there’s almost always going to be some space there?

Dr. Domingue:

Graft it.  Graft it routinely.  A lot of the patients that I see and I really feel that most dentists see now are the ones that come in and say, “My tooth is broken.”  Well, you need to take it out.  We’re going to do this.  We’re going to do it that day.  The best service in the world is to remove the implant, place the implant that day, and if it is an aesthetic area, to immediately provisionalize out of occlusion.

Like you said, we either have one root, two roots, or three roots sometimes, and implants are conical tapered.  They’re not definitely the same anatomy as a natural tooth, but they don’t have to have the same anatomy as a natural tooth.  Typically, maxillary anterior teeth are going to be much more buckle-oriented that your implant is going to be.  So, you’re going to have to create a different emergent profile for the implant and have plans for that.

Let’s say, picking on a maxillary anterior region, if we’re going to place an implant more towards the palate and gauge the palatable bone to get a semi-force torque, we’re going to have a big defect where the roots of the maxillary anterior where. So, that’s going to grafted.  We’ll show techniques on how to deal, but the technique I use is engage the implant properly into more a lingual aspect than the root of the maxillary anterior tooth.

Screw down a cover screw to prevent bone from getting to that area.  Grasp the buckle defect with some bone. Unscrew the prosthesis, and I use thick abutments routine in our practice.  Use thick abutment, which is a plastic temporary abutment, and use these dental teeth formers to make a provisional crown, and always, when you need to provisionalize, you need to worry about sculpting the thick abutment to create a nice soft tissue profile.

Dr. Lavine:

Yeah.  Do you recommend any resorbable membranes that stick around long term when left exposed?

Dr. Domingue:

A lot o people like GORE-TEX® membranes.  I don’t remember the name of the company, but they make GORE-TEX® titanium-reinforced membrane.

Dr. Lavine:

But I said resorbable so…

Dr. Domingue:

Oh, resorbable that lasts a long time when exposed?  I don’t know a lot of membranes that last for a long time.  Once they get inside and saliva pours into the membrane, usually they degrade pretty quickly.  So, I don’t have any.  Whenever you use resorbable membranes, it’s advised to get, if not primary closure, get as close to primary closure as possible, but if you’re going to have a big exposure of resorbable membrane, you have to expect that membrane to resorb pretty quickly.

Dr. Lavine:

Okay.  Any thoughts on foundation?

Dr. Domingue:

Yeah.  I believe I used to use foundation in residency, but it’s a bovine collagen material.  It’s conical in form, and there’s different sizes, small, medium large.  They’re very, very inexpensive, and they’re used for socket preservations.  It’s porous.  So, the idea would be when you remove a tooth degranulated area, instead of using bone graft material that’s expensive, you can use these bovine collagen membranes.  It’s a membrane/socket preservation seal.  They work. They absolutely work, and there is a place for them in there.  So, yeah, that is a good one.

Dr. Lavine:

Okay.  What’s your e-mail address again?  I know some people were interested in being able to follow up with you.

Dr. Domingue:

My e-mail address is on the website for Rocky Mountain Dental Institute, but if you have any questions, my personal e-mail address is my last name, domingue.danny@gmail.com. Feel free to e-mail me all questions, any questions you guys might have.

Dr. Lavine:

We did have a question about the graft kit that Dr. Moody uses.  He’s on the call. I don’t know, Justin, if you want to talk about the graft kit, or do you know more about it, Danny?  Are you there?

Dr. Domingue:

The graft kit.  I don’t know if where you would get the graft kit from.  I just got it from Dr. Moody just because he’s a friend of mine.

Dr. Lavine:

Okay.  He’s not mic’d up.

Dr. Domingue:

They do have them at the Rocky Mountain Dental Institute for sale.  You can purchase one.  They’re not very expensive.  They’re I don’t know. I don’t remember the cost or how much I paid for it, but they’re fairly inexpensive.  They’re really, really accurate.

Dr. Lavine:

People could call up if they want to get more information about the kit.

Dr. Domingue:

Absolutely.  You can call the 1-800 number and ask to speak to Genie, and she’ll give you much more information on that.

Dr. Lavine:

Okay.  What about tumor bone?  Have you ever used it or recommended it?

Dr. Domingue:

I have not used that so I don’t really, I can’t really make a statement on that.  Tumor bone?

Dr. Lavine:

Okay.  Another follow-up question on the foundation.  Are you striving for a 100% primary closure when you’re using foundation?

Dr. Domingue:

I do.  I try to get primary closure whenever I use foundation.  It’s great to use, and it’s really easy.  It’s already pre-formed.  Bring it into the socket, and what I do is a non-surgical envelope flap so without making any real instrument incisions, release the periosteum full thickness, bring it over to the lingual, and try to get as best a primary closure as I can.  Yes.

Dr. Lavine:

Okay.  For most of your cases, since they’re relatively easy cases, are you always using a splint, a stent, or are you free handing it?  How do you typically handle most of your cases?

Dr. Domingue:

Like I said earlier, I don’t have the statistics in front of me and I need to work on that, but I’d probably say that about 60% to 70% of the implants that we place in our practice are immediate placement.  Because of that, you’re not going to use a surgical guided stent for that.  What I’m trying to get to, Lorne, is I’m trying to get using surgical stents more in my practice because it’s a quicker surgery time for me.  It’s a quicker surgery time for the patient.  There’s less morbidity associated with guided surgery.  It’s quicker.  There’s all types of advantages.

The disadvantage to using surgical guidance is there’s a lot more work before the patient gets in the office.   There’s a lot more work for me on my computer, dialing in in English, getting the implants in the proper orientation.  Then, getting that outsourced for a surgical guide and there’s a cost associated with that.  Implants are expensive enough as they are, you’d hate to add that cost to the patient, but I am looking for a less expensive route to be able to give guided surgery for my patients.

It’s an area of implant dentistry that’s a nuance for a lot of guys that haven’t done a lot of implant surgery.  Like I said, I’ve only done a handful of guided surgeries, but it’s something that I definitely want to incorporate more in my practice.

Dr. Lavine:

Okay.  We’re running out of time.  If there are people that want to know more about that Moody kit, Dr. Moody is on the call, and he said you can certainly call Rocky Mountain Dental Institute or you can e-mail him directly.  His e-mail is justin@rockymountaindentalinstiitute.com.

Danny, it’s always a sign of a good webinar to see what the attendance is like, how many people dropped off towards the end.  We actually have significantly more people on the call than we did when it started.  So, that is always a good sign.  So, I really want to thank you.  This was a really great webinar.

As I’ve mentioned, a number of our clients have been to some of the other courses that Dr. Lingle’s done and Dr. Cummings and Dr. McCracken.  We don’t have any reports on yours yet, but, again, that’s still six weeks away.  I would highly encourage people to consider coming out to take the course.

Obviously, you’re going to be covering a lot of information, live course.  You can’t beat it.  I just want to thank you again for being on the call because this has been one of the best webinars we’ve had.

Dr. Domingue:

I appreciate it, Lorne.  Thank you so much.  Thanks, everybody, for sticking around, and, again, if you have any questions, let me know.  I look forward to seeing all of you guys in March.

Dr. Lavine:

Thank you, everyone, for being on the webinar.  We know you have lots of things to keep your life busy, and taking the time was very much appreciated.  Thanks, again, to Rocky Mountain Dental Institute, just a real class act.  I highly encourage you to go to the website, check out their courses.

Obviously, a lot of you on this course are really interested in becoming at placing implants, but this importantly dealing with all the issues and all the complications that can come up.  So, I want to thank you both.  I thought this was a great presentation.  As most of you know, we do webinars on a regular basis.  We’ve got more coming up.  I think our next one is on nitrous oxide next week.  We’ve got a couple of other ones, six months smiles.

We look forward to seeing everyone in future webinars.  Good night, everyone.

Dr. Domingue:

Good night.

Dr. Domingue:

That’s what it is in literature.  Literature says if you have anything 5 millimeters or more, consider doing an internal sinus lift.  The reason why that is is because if it’s anything more than 5 millimeters, you’re going to be making a very large, very full thickness elevation flap.   If you’re going to try to do a lateral technique sinus lift, it’s going to be really huge, and there’s going to be a lot of edema.

So, the technique to do would be to do a crestal approach if it’s more than 5 millimeters.  If it’s 5 millimeters or less, you’re going to need a lot more room and also a lot more bone growth.  So, a lateral technique would be the one recommended.  Look, we do teach a technique on internal sinus lift that the founder of RMDI, Dr. Moody, invented. It’s a great technique to get vertical ridge augmentation in patients that have 5 millimeters to 10 millimeters of bone, and you want to get an extra 3, 4 millimeters.

Dr. Lavine:

It’s like the lift graft, the Moody Kit.

Dr. Domingue:

Yeah.  You heard about it?  It’s actually a great kit.  I’ve had great success with it.  It’s pretty impressive, and when I started doing that in my practice, I just saw improvements in the success rates.  I just started doing it in my practice.  I’m like, “Oh my gosh.  This is just too easy.”  It makes lift grafts a whole lot easier, and he has a whole kit.

Dr. Lavine:

Yeah.  So, you showed that case where there was a cyst that was removed.  Can you place an implant in the future there?  If so, what’s the time frame to attempt to put an implant into an area like that?

Dr. Domingue:

I’m guessing it was that patient that was had the [01:08:28] on.

Dr. Lavine:

You showed on where it looked like there was a huge cyst distal to number 18.

Dr. Domingue:

Oh, the patient with the pathology, right?

Dr. Lavine:

I think so.

Dr. Domingue:

Yeah, yeah.  For her, she was seen by the local surgeon.  He removed the whole cyst out, closed back the area.  She is now going to be on her regular recall.  The recall and the recommended recall for the odontogenic keratocyst is initially once a month for first six months and then follow up once a year for the next five years.  Then, after five years, once every five years, and she’ll continue coming to the office every six months for a routine hygiene.

Now, for her, in particular, we haven’t addressed it yet, but we’re going to assume obviously a re-appointment.  We’re just letting her heal a little more, but whenever she comes back into our office, we will talk about if her tissues have healed well enough in that area, it’s not contraindicated to place an implant local to an area that had odontogenic keratocyst.

That tooth is still giving her issues.  We’re not sure if it’s a fracture molar.  We just know she’s had continuous pain and has been treated several times.  So, we’re going to look at removing that tooth in the near future and putting in an implant.

Dr. Lavine:

Okay.  A couple of questions here related to antibiotics.  I’m not sure if I totally understand this one:  What’s the gentamicin amount used?  Do you place antibiotic in with the allograft material? Another question is if tetracycline is not available anymore, what do you use instead?

Dr. Domingue:

Okay.  To address the tetracycline, doxycycline.  Use doxycycline if you don’t have tetracycline available to you.  To address the gentamicin, I don’t remember the doses off the top of my head.  I’ll have to look it up for whoever asked that question.  Please send me an e-mail, and I’ll e-mail you back the response after the phone call.

Dr. Lavine:

Okay.  How do you know that you actually have a stable implant?  Are you doing some resonance frequency? Are you just tapping it? How do you know that it’s ready to be restored?

Dr. Domingue:

I don’t have the Osstell unit that measures if it’s integrated and to what degree. I don’t have that.  We never had that when Dr. Branemark was placing implants.  So, usually what I do is at 3 months, 4 months, we’ll take a periapical radiograph, make sure everything looks fine, the bone has collectibly gotten better, there’s no radiofrequencies around there, everything looks perfectly fine.  Intraorally, the soft tissue looks perfect.

We’ll first work out the healing abutment, place on a standard abutment, take our impression, and I’ve never had an issue with losing an implant.  When you go to reverse torque, the healing abutment, if the patient yells, “Ouch,” when you do that, that’s a clear indication that the implant is not osseointegrated.  You’re going to have some granulation tissue around the implant, and it’s not healed yet.  So, either advised to remove the implant if it’s that bad or continue and let the patient heal for another four to eight weeks.

Dr. Lavine:

Okay.  What about, let’s say you’re placing the implant, and the bone cracks as you’re screwing it down.  What would be the typical course of action?  Would you take it out and regraft the membrane at that time?

Dr. Domingue:

Great question. I’m really excited because we talk about this.  So, this is one of those operative complications.  You’re creating this perfect osseotomy.  The bone looks amazing.  You’ve got great healing, great flaps, and then you’re going to put the implant in.  You’re not just paying attention, either you get cocky or you’re focused on something else.  All of a sudden, you’re buckle bone just fractures.  What do you do?

You spent all this time making the perfect surgery.  We’ll show cases of where I’ve had complete bone fracture. Then, we’ve grafted it the day, and it healed perfectly.  I’ll also show cases where we’ve grafted the same day we had buckle bone fracture, and there’s an aesthetic risk associated with it.

Then, we’ll actually show cases where this is a clear indication to remove the implant, graft the site, suture the tissue, let the area heal, and then, come back again another time because this is going to be an aesthetic nightmare.  It’s also going to be a spinner implant, and it’s just a poor area for wound healing.  It’s just a poor area for implant, and you need to abort it, graft, and come back at a later time.

So, that happens often.  It even happens when you’re doing your osseotomy.  You create the perfect osseotomy, and then, all of a sudden, you blow out the bubble because you weren’t paying attention.  We’ll cover how to treat that with membranes, bone grafting, and ridge augmentation, site preservation to either get primary closure and place your implants the same day or just get primary closure with a bone graft.

Dr. Lavine:

What do you do with those spinners?  You’ve got that spinner.  Do you bury it in weight, assuming that you can’t put a larger diameter implant in there?

Dr. Domingue:

That’s the first thing I would say.  I didn’t show a case today, but I’ve had a case where I put a 4.6 millimeter implant, and it was a spinner.  What a disappointment because I did a beautiful internal sinus lift.  Then, I come out with a spinner.  Well, I moved over to a larger diameter implant, and it was able to suffice.  If you can’t, what do you do?

If you can go with a longer implant, that’s advised.  If you have a 10.5 millimeter implant, why not drill the osseotomy a little bit deeper then put a longer implant?  If you still can’t get away and you still have a spinner, do you take it out and graft it?  If it’s an anterior site, that’s a good question.  You’re going to have to weigh the risk associated with the patient coming in.  There’s going to be an infection there.  You’re going to remove the implant and graft again.  That’s going to cost you tons of time and tons of money, and you’re never going to make enough money off that case. That’s something we’ll talk about, too.

Bone graft is expensive.  Membranes are very expensive, and what are we charging to preserve a socket?  What are we charging to implant and bone graft and soft tissue graft whenever we do these procedures?  Commonly, dentists will work a patient up for a single unit implant and say, “Look.  We’re going to charge for the implant abutment crown.  Let’s do it,” and they’re not really focusing on the big picture.  The big picture is when you get in there, it’s like, “Oh my gosh.  There’s absolutely no bone.  I’m going to have to bone graft this area.  There goes $150 of bone graft that I have to eat.  I’m going to put a membrane on that area. There goes another $100.”

So, instead of pre-operatively charging the patient and realizing that ahead of time, we just ate up $300 worth of material, which could have potentially posed a lot better off with the patient.  Then, say you do put a spinner in, there you go losing the implant.  Now, you have to re bone graft that area, wait for it to heal again, and put them in the provisional.  That’s tons of your time.  Talk about losing money out the door.  That’s tons of your time and effort that just gets completely lost.

So, the economics behind dental implants is something that we’re definitely going to be addressing and how that’s related to complications related to the implant industry.

So, for the spinners, weight the risks. If you want to risk putting an implant in, that’s your choice.  I’ve done it both ways.  I’ve placed a spinner in, and I’ve had success.  I’ve placed spinners in and have not had success, and it’s just something that if you’re willing to risk the complications associated with spinners not working out.  If you’re not, take it out and graft the area.

Dr. Lavine:

Okay.  We did have a question about whether this session’s being recorded.  The answer is yes.  All of you are going to be a sent a link, probably by tomorrow, that you can download and watch the entire recorded webinar at your convenience.  So, don’t worry about that.

A few more questions here, and then, we’re probably going to wrap it up.  Do you use internal or external implants?   I guess they’re asking about the hex.

Dr. Domingue:

I used internal hexed implants.  If I ever would use an external hexed implant, do you guys remember that case that we showed earlier where it was a full arch, six implants on the lower where I increased the band of attached tissue?  On that case, the prosthetics was very difficult, and again, we’ll talk about this in historic complications.  It was very difficult with internal hex, and the way we did it was we had to use non-hex abutments to restore that case.  In that case, it would have been really nice to have some external hexed implants to restore that case, which would have made my life so much easier.  Typically, internal hexed implants as well.  I used platform switched laser lock implants.

Dr. Lavine:

Okay.  So, you have mentioned the need to degranulate these immediate sites.  Have you ever used or read a literature about using a laser for that, a hard soft tissue laser, or is there a risk of damaging the bone if you did that?

Dr. Domingue:

I’m guessing you’re talking about a diode laser.  A diode laser does remove soft tissue.  It just takes forever.  Mechanical removal of granulated tissue is so much more effective and so much quicker.  I wouldn’t consider using a diode laser for those instances.

Dr. Lavine:

Okay.  At least we’ve got some great questions here.  I hope you’re not in a rush.

Dr. Domingue:

No, not at all.  Please ask away.

Dr. Lavine:

You used that case where you were using the alloderm.  It looked like it was partially exposed.  Are you typically trying to get primary closure?

Dr. Domingue:

Primary closure, all the time.  What I didn’t show was post-operative from that so that’s a great question.  Whenever I do graft soft tissue around teeth or implants around the buckle aspect, 100% closure, 100% of the time.  Whoever asked that question was a great question.

In that case, I didn’t have it.  So, that piece of alloderm never got revascularized, and that piece of alloderm did wind up coming off.  What I wish I could show you guys is what it looks like now. It looks tremendous, but there still remains a soft tissue deficiency in that site.  It’s a lot better than what we started.  It’s tremendous.  If we had to put it on a percentage scale, it’s about 95% success rate with the 5% soft tissue where I did have some exposure.  So, yes, ideally, I would have preferred to get 100% on those areas.

Now, I having said, if we’re going to extract the tooth and graft a socket, if there’s a very thin band of connective tissue, nobody teaches this better than Louis Cummings.  He says, “You can leave that site of alloderm exposed on, and you will get revascularization of that area.”  There’s tons of literature to support that, and there’s tons of examples to support that.  If you’re coming to the meeting, we’ll go in depth and dig into that on why that works so well and why it doesn’t dig into the roots and the cervical region of natural teeth and implants.

Dr. Lavine:

Just to clarify, the alloderm you’re using, you’re typically using the GBR, the stuff from BioHorizons, not root covered alloderm?

Dr. Domingue:

I use the thickest one.  GBR is a thinner one, I believe, 1 millimeter in thickness.  I use the root coverage one which is 1.5 to 2 millimeters in thickness.  I’m going to try to get as thick a tissue as I can.

Dr. Lavine:

That makes sense.  What about when you need to graft and use a membrane, is there a specific bone graft material and membrane that you have found effective in your practice?

Dr. Domingue:

That’s a great question.  There’s a lot of different companies that make a lot of different materials for bone grafting and for membranes, and really, it boils down to a couple of different things.  I’m not typically going to promote one company because there are a lot of companies out there.  [57:00] just happens to be one bone grafting material that I use, and it’s a mixture of corticocancellous bone material.  The important part is the mixture of cortical and a mixture of cancellous.  That’s proprietary, the percentage of what it’s composed of, but what you basically want to have is both cells.  You want to have cells that are cancellous that will degrades quickly so the host can lay down it’s natural bone, and you want cortical bone that’s going to last a little bit longer for soft tissue scaffolding.

As far membranes, you want a membrane that’s not going to resorb in 7 to 10 days.  You want a membrane that’s going to stick around for at least 12 weeks at most.  You just want to prevent soft tissue invagination of your grafting site, and I use frequently use another product called MemLock®.  That does a great job of decreasing the risk of soft tissue invagination around an area, and MemLock® does a good job.  It’s nice and flexible.  It’s has nice and easy handle properties.  It’s nice and easy to suture in.  So, that’s just one other product that I use.

Dr. Lavine:

Okay.  What about INFUSE®?  Did you ever use that for a bone graft material?

Dr. Domingue:

We have.  Yes.  We actually have done that are Rocky Mountain Dental Institute.  Last course was bone grafting.  What we did was socket preservation with INFUSE®, and we also did a bilateral maxillary lift with bone graft material with INFUSE®.  Now, INFUSE® is an incredible product.  It’s got great potential to grow bone.  You just need to know how to use it and when to use it. It’s only FDA approved for socket preservation and for sinuses.  It’s not FDA approved for other sites, but it is an absolutely great product.  We lecture on it extensively.

Dr. Lavine:

Okay.  I’m trying to get through as many questions as we can.  We have a few questions here about occlusion as far as the restoration.  Are you normally putting them in light contact, no contact? What about canines specifically?  Are you trying to avoid canines with implant restorations?  Is there a general rule of thumb that you’re typically suggesting.

Dr. Domingue:

Mike McCracken, next month in February, is going to go over this in detail, but I’ll go through it briefly for those that can’t attend.  Yes, I recommend groove function occlusion always.  Canine guidance is mandatory, whether it’s an implant or not.  You just have to avoid.  What a lot of people do is they get this beautiful implant placement, and they make this perfect all-ceramic crown, all-ceramic abutment.  Then, when they cement it in the patient’s mouth, they just grind down the occlusion so that anytime the patient even bites, even if they clinch all the way, it’s not even touching in the mouth.

That’s not recommended. That could be a $3000, $4000 tooth.  That needs to be an occlusion.  You just can’t have it in poor contact and protrusive contact and working contact for lateral excursions.  That’s a big topic in occlusions for implant therapy, but all my implants are in occlusion. It’s not the first tooth that touches, never, but it’s also not the last tooth that touches.  It’s  in groove function.

Dr. Lavine:

Okay.  What about your suture material?  Are you using sorbable, non-sorbable, vicryl?  Is there a specific one that you like using?

Dr. Domingue:

I use PGA, which is vicryl, and I use [01:01:25], which is polyglycolic acid, and it is resorbable.  For difficult cases, we use polytetrafluoride, which is a non-resorbable material.

Dr. Lavine:

Okay.  You talked about when you have someone in the chair.  You typically recommend they take their medications.  What if they were on something like ibuprofen or blood thinners?  Do you still recommend that they take those the day of the surgery, or are you adjusting for that?

Dr. Domingue:

Right.  You are adjusting for that if you can if the physician says.  I’ve requested to get the patient off Plavixx® or Coumadin®, and the doctor says, “Absolutely not. I will not let you take them off.”  So, if that’s the case and you still have to do the surgery and they need to take their medications, that’s a risk that I assume now.  Am I still going to remove this tooth and place an implant? That’s something that is a pre-operative complication.  There’s going to be a lot of bleeding if their INR is really high.

If the patient is taking ibuprofen on a regular basis and they take it the day before the surgery, I’m going to expect some post-operative edema, and I will explain it to the patient. If that’s a recommendation from the medical physician, I’m not going to touch that.  I prefer that they stay with their recommended dosage.

Dr. Lavine:

Okay.  Most of my failed implants are immediate implants for the upper anterior teeth, specifically endoteeth.  After placing implants and restoring implants, a few weeks later, I see swelling. Gingival bubbles appear on the buckle tissue.  The implant’s already integrated.  How do you treat this infected implant case, especially if there’s already restoration on it? 

Dr. Domingue:

Well, I would find out the source of the infection.  A lot of time what we’ll see, and we’ll talk about this in restorative complications, is one of the biggest things we see now is cement is a killer for implants.  People are loading too much permanent cement on the implant crowns, cementing the implant.  It extrudes out into the sulcus, and you will see, immediately after, some soft tissue swelling.  You’ll start seeing some facial involvement.

You need to make a nice flat, curette the cement out.  Clean the area, tetracycline bath, and try to regraft the area immediately the same day, and try to get primary closure around your restoration.  You don’t have to take the restoration out of the occlusion, but it’s always advised to immediately get back in there and clean that area because you can lose that implant if the infection continues.

If the implant’s integrated, that’s quite unusual when the implant’s integrated and everything’s integrated.  Then, once you put on the crown, you’re going to have some issues.  So, my first thought would either be occlusion, check the occlusion, or cement extruding out in the sulcus.  So, I’d start out with looking at those two regions.

You’re more than welcome.  My e-mail’s on the website.  Anybody that’s on this call, you’re more than welcome to e-mail me questions, and e-mail me photos or x-rays of cases and ask for my opinion.  I don’t mind helping people out, and you’re more than welcome to call me if you have any other questions, too.

Dr. Lavine:

Okay.  In your course, do you cover incision line opening during those three days?

Dr. Domingue:

That’s absolutely a post-operative complication, and we do see that at times.  Either it’s due to sutures, poor suturing technique or it’s due to lack of releasing the tissue enough to get primary closure or it’s patients chewing food in that area or trauma to that area that will tear a suture.  Absolutely, we cover that in detail, and the biggest thing is whenever you come across a complication, how to treat it, medicine-wise, how to educate patients, and what protocols should be set in place, for example, incision line opening.  What are you supposed to do?  Do you resuture that area immediately that same day, harming the tissue again and delaying working?  What do you do?

That’s something that we will cover.  Do you change the suture material that you’re using?  Do you start using non-resorbable?  Was it because the tissue was too thin?  All these, we’ll definitely do in great detail, but yes, we will cover that.

Dr. Lavine:

Okay.  Is it still recommended to have five millimeters of bone, coronal to apical, if one plans an indirect sinus lift versus a direct sinus lift?

Dr. Domingue:

Okay.  That’s a great question.  At the course, it’s going to be lots of lecturing on what we just talked about but absolutely in more details.  We’re also going to talk about complications during the surgery.  We’re going to talk about complications after the surgery and restorative complications like we talked about earlier, but we’re also going to do live surgeries.  It’s a Thursday, Friday, Saturday course, and we’re going to give a live surgery each day.  So, it’s going to be over the surgery, participation-involved surgeries.

We are also going to have a live hands-on course in the post-operative complications and restorative complications.  We’re going to talk about implants whenever they fracture, how to remove the implants from the bone.  We’re going to have some stuff on drills.  We’re going to use ex-plants, the ability to remove an osseointegrated implant if it’s at a bad angle.  We’re going to have some live hands-on participation as well.

Dr. Lavine:

Okay.  Are you ready for the questions?

Dr. Domingue:

Let them roll.

Dr. Lavine:

Okay.  We’ve got some great questions here. So, here’s the first question:  I have a patient who has a draining fistula from the neck of a healing implant.  At the covering, there was granulation at the neck of the implant, and approximately 1 to 2 millimeters of the implant exposed on the buckle.  How should I deal with this?

Dr. Domingue:

So, it was draining from the neck after an implant placement?  First of all, take a CT scan to figure out what’s going on.  If the implant is that infected, you might need to take the implant out to avoid any other complications.  Get the patient numb, remove the implant, degranulate the site, try to put some gentamicin or some type of antibiotic in the area, maybe some calcium sulfate or betadine hydrate.  Suture the tissues.  Get them on some strong systemic antibiotics like clindamycin 300 milligrams.  Get them back in seven days.  Check the wound healing.  That seems to be like a very, very bad infection.  I wouldn’t mess around with that, but you need to get the patient on the obvious recall to make sure the infection’s going away.  If drain is coming out, you don’t want that to get to any of the submandibular or sublingual spaces and spread.

Dr. Lavine:

Okay. Next question.  If a patient has two implants side by side in the mandibular molar areas, what’s the current thought on whether the implants should be splinted or restored separately?

Dr. Domingue:

That’s funny.  This is a very common question that a lot of people are asking nowadays, splint versus not splinting implants in posterior crowns.  This is a multifactorial answer.  It’s not a “always splint” “don’t always splint”.  There’s a lot that has to do with it.  If you’re going to be putting two 6 millimeter implants on the posterior mandible, and you’re going to be restoring with implant crowns that are 10 millimeters in width and 8 millimeters in height, it’s probably advised to splint those teeth, especially if they’re opposing the actual dentition.

If the patient is an 80 year old female and she’s getting two implants side by side and they’re 10 millimters in length and she’s opposing a natural denture, she doesn’t have problems, it’s not necessary to splint in that instant.  She’s not going to have impaired functionality.  She’s probably not a bruxor.  She probably doesn’t chew steak every single night.

The reason why we splint implants or increase the strength of the implants is if one implant is split into the next implant, if the value of each implant is 2, it’s not going to be 4.  It’s going to be a multiplication of that implant.  Do you follow me?  So, it does increase the strength of an implant if you do splint, but it’s not always indicated to splint.  However, I do splint many times when I see patients, and some patients don’t want their implant crowns to be splinted because they want to floss through them

Dr. Lavine:

Okay, what about splinting through natural teeth?  Let’s say, for example, someone’s got implants on 8 and 9, and you’ve got to restore 7 and 10.  Are you thinking of maybe making them bridges or something like that.  Is that contraindicated?

Dr. Domingue:

The patient’s missing teeth 8 and 9?

Dr. Lavine:

Let’s say there’s implants already on 8 and 9, and maybe the dentist wants to splint or do a bridge.  What’s the current thinking as far as splinting an implant restoration to a natural tooth?

Dr. Domingue:

That’s a great question, and for a long time, we’ve talked about not splinting.  We used to, back in the day 20 years ago, always splint implants to natural teeth.  Then, we saw a lot of failures, but with this failures what we saw was there was a 16% failure rate with whenever you splinted a natural tooth to an implant.  The thought was that were was a periodontal ligament around the natural tooth, and in the implant, there’s no periodontal ligament.  So, it has to be that the failure rate is associated with the periodontal ligament not being in the implant.

Well, that’s not necessarily true, and the research shows that there’s a low incidence of failure rate associated with splinting implants and natural teeth.  The only failure rate is whenever you splint implants to natural teeth with a non-permanent cement or if you use interlocks, locking mechanisms.

You can splint implants to natural teeth.  However, the issue becomes, why would you do that? What you’re doing is if you going to crown and make a bridge from an implant to a natural tooth, the reason why bridges fail is because of recurrent decay or the tooth becomes abscessed and needs root canal.  You’re going to compromise the bridge integrity of the tooth.

So, yes, you can, but it’s not really advised to do that method, and if you are going to do it, use permanent cement.  Cement it all the way without using interlocking mechanisms.

Dr. Lavine:

Okay.  Have you ever heard of a patient being allergic to an implant?  Is there such a thing as someone having an allergy to an implant?

Dr. Domingue:

It’s been stated that patients can be titanium-allergic. However, the incidence is extremely low, and there has been no recorded data of a patient being allergic to titanium.  So, there was this big kick on doing a full zirconia implant, but, right now, the success rate, if you read the literature, is anywhere from 60% to 65% for zirconium.  We do know that zirconium, in liquid, fractures.

So, that is a complication that’s listed, but, again, there has never been a literature that suggests that they’ve had an allergic reaction directly to the metal.  Now, some people have had implants placed and then get migraines or they’ll have some temporary pain.  I’ll hear stories of, “My sister had her implants, and they gave her problems.  She had to take them out.” Well, that’s not really true allergy. I’m not too sure that’s a true allergy is what I’m saying.  I don’t know if that patient was relating it to her implants or actually had a metal allergic reaction.

Did that make sense?

Dr. Lavine:

Yeah, I think that answered the question.  We’ve got lots of great questions coming in here.  How would you treat a retrograde implantitis?

Dr. Domingue:

A retrograde implantitis, like a periimplantitis coming to an apical completion? I’m guessing that’s what the question is being asked.  Can you clear that up Lorne?

Dr. Lavine:

Yeah.  I’ll see if they want to add anything to that.

Dr. Domingue:

I’m guess that’s what they’re talking about, paripathology associated with implant dentistry.  Some people do apicalectomies on implant.  I’ve heard about them.  I’ve read about them. I’ve never had to do it before.  Most bacteria with implantitis is always associated with coronal lesion of the implant and have a down growth of bone on the implant.  I think I answered the question property if that was right.

Dr. Lavine:

Okay.  If you have a broken implant, what bur do you normally recommend for removing that implant?

Dr. Domingue:

There’s two different methods.   You can either use a trephine bur. If the core diameter of the implant is a 3.8, you might want to use a 4.0 trephine bur and hopefully restore the area with a 4.2 or 4.6 millimeter implant.  So, trephine bur is one option.

There’s also a kit that you can buy called the Ex Plant, where it actually locks into the implant, and you can reverse torque.  It’s pretty difficult, but you can reverse torque and implant out.  There’s some pressure associated with the Ex Plant technique.  I’ll show slides and talk amore about that later on.

Another technique that I was thinking of using before that I haven’t done myself is using a Lindeman bur, which is a side-cutting dental drill with copious irrigation on a surgical high speed drill, is another way to remove an implant that is either fractured or is osseointegrated at a bad area.

Lastly, if you want to be as least traumatic as possible, you can always use a [50:01] surgery to remove an implant and be less detrimental to the bone.  It just takes a lot longer.

Dr. Lavine:

Okay.  You were talking about smokers before.  Are you, then, with the smoker, placing the implant subgingivally, never leaving it exposed?

Dr. Domingue:

Absolutely.  Absolutely.  Absolutely.  Always place the implant subgingival and try to obtain primary closure, letting it heal for as long as you possibly can anywhere from four to six months just to be as careful as possible, letting the wound heal.  There is a risk of poor circulation with those individuals so you have to give it a little longer time period before you go and try to restore the implant.  So, yes, I do.

Dr. Lavine:

What about you go ahead and take a tooth out at the time of extraction and notice that there’s a periapical infection.  Would that be a contraindication to xenografting, or do you do it on a case by case basis?

Dr. Domingue:

Okay.  There’s literature that says whenever we see a periapical pathology, we should degranulate the area, get nice bone, clean bone healing, irrigate the site with sterile saline.  Clean it all out.  Irrigate it all out.  Then, start decorticating the area to get better wound repair and just the site with other bone grafting material.  There’s other literature to suggest to never graft the site because you’re going to worry about infection recurring in the area.

Now, in that particular site whenever anyone has a periapical pathology, in our practice, we will remove the infected tissue, completely clean the area, degranulate the area as much as possible, get nice healing points, decorticate the bone, get some nice injury in the area, get some nice vascularity.  We’ll also use gentamicin antibiotic and graft the same day with a grafting material to build back the bone.  If the site is deficient.

If you have less than two centimeters of buckle plate, it’s not necessarily needed in that instance.  You don’t necessarily need to bone graft the area, however, typically, when people have that much infection, they’re going to have a lot of bone loss.  I would always.

It’s harder to come back to that site and bone graft after the area is completely healed.  You’re going to have to do a veneer graft or a hard ridge augmentation and maybe a vertical augmentation, which is extremely difficult, using 10 screws or different other things.  So, yes, I always try to graft the same day, making sure that all the inspection is completely gotten rid of and making sure the infection is just localized in the bone tissue.

If the infection extrudes into the soft tissue and becomes a soft tissue infection in conjunction with the dental alveolar infection, it’s not necessarily a great area.  If it’s a canine space infection, you’re going to pull the tooth.  That’s actually the worse area to graft the same day.  It’s also the area you want to graft the same day because there’s going to be so much bone loss, but you’re graft material will get infected.  You really need to make sure all that gets out first and get them a very strong systemic antibiotic.

You can think about doing a vestibuloplasty.  Those aren’t very predictable, and they’re hard to do and very hard on patients.  So, pre-operative planning.  If we had don’t pre-operative planning on this before, we would have gotten tissue around this implant on the buckle aspects.

Collapse after extraction.  You will lose a lot of soft tissue and bone tissue.  This guy was in two days ago, and we have a lot of buckle bone and lingual bone lost.  We’re going to expect a ton of soft tissue collapse.  You’ve got an oral complication, some infection.  We can pull this tooth, and we can graft.  We’re going to have to extract and notify the patient that we’re going to pull this tooth, we’re going to bone graft, we’re going to lose a lot of soft tissue and bony structure.  So, next time we go, we’re going to have to either do a vertical ridge augmentation, maybe even an internal sinus slip soft tissue to augment this area, to grow this area back.  This is a very compromised site.

Hard tissue deficiencies in the maxillary interior, height and width ratios. This patient had these teeth pulled when she was 16.  She’s 35 years old now.  She has severe, as you can see, horizontal ridge loss.  She has [27:48] lower anterior teeth.  I would not recommend just getting her in and starting to put implants on the anterior maxillary area.  The treatment planning for this patient would be to intrude the incisors, bulk out the maxillary interior ridge areas for height and width.  You might even need to come up on the high tool of it, remove some bones, but this is a very difficult patient to restore.  As you can see, the crest of her soft tissue is roughly 3 millimeters to 4 millimeters away from the edge of the mandibular anteriors.

Maxillary posterior region sinus involvement in this lady right here.  She wanted two implants replacing these two teeth.  We thought about placing an implant here in site 15, however, she doesn’t have an opposing tooth because she wanted two implants.  So, the ability to pre-operatively plan internal or lateral augmentation graft, when to do an internal sinus and when to do a lateral internal sinus slip depending on the bone quality and quantity in this area.

Mandibular anterior hard tissue deficiency.  You’re not going to be able to put an implant on this tissue on the same day.  You’re going to augment this site with either a chin graft, a ramus graft, or a particular allograft.  Suture the site really nicely.  Let it heal and go back in here in a future date and place an implant.

Mandibular posterior area hard tissue deficiency.  We didn’t have a CT scan for this patient, and that’s something really nice to have nowadays is the ability to have the technology.  So, when we did this case in the residency program, we just flapped back, and we saw this super fine ridge, not a lot of bone, poor area to put an implant in.  What we just had to do was to graft the site with a particular graft material and come back in.  This is after 12 weeks.  We’ve got tons of bone from the lateral ridge augmentation of the near graft.

Occlusion is something that we had talked about, and Dr. Mike McCracken who teaches that and goes in depth with this and how to restore somebody’s vertical dimension of occlusion, whether it’s implant-supported bar over dentures, implant retained dentures, implant screw down hybrids, or fixed dentition.  If somebody has a closed vertical dimension of occlusion, we get them in.  We just take a Panorex and realize she’s edentulous on the lower right mandibular, and we just want to put in implants.  Well, that’s going to be a restorative nightmare to put in two implants up here. This is in the restorative phase.  When are we going to make this a screw down prosthesis and when we’re going to make this a [30:49] prosthesis.  Altered passive eruption.  This is the same lady before.  There’s no way we’re going to be able to sneak in some implants around here without intruding these lower anterior teeth to the ortho.

People that have parafunctional habits.  This is a classic case of a guy in his mid-forties, and he just grinds through his teeth all day, every day.  Occlusion is a big concern.  You’re not going to be able to place an implant in site number 8 and get a nice tooth form and function.  You’re going to have to do a full mouth rehab, open up this bite, crown the upper and lower anterior teeth, place an implant there, and try to scalp the tissues, and hopefully come out with a nice aesthetic outcome.

Joint instability.  Patients that cannot keep their mouth open for a very long period of time, patients that have a very limited mouth opening, patients that suffer from TMJ, these are also concerns and complications that can arise during the implant surgery.  So, you should also pre-operative plan for these cases.

Aesthetics.  People’s smile line.  This guys is not highly aesthetically demanding when I asked him to smile as big as he could.  He has hyper lip ability, and this is not really aesthetically pleasing for me, but for him, it really didn’t matter.  Pre-op planning, if we’re going to place implants on somebody, do they have a high smile line, do they have a normal smile, or do they have a low smile line?  Treatment plan accordingly.

Long white teeth versus pink porcelain.  If you’re going to do a full upper, full lower on somebody, are you going to shorten their teeth with pink porcelain, or are you going to create some long teeth and not use pink porcelain?

Flange, of course, are needed to support the lips of a person if somebody doesn’t have lip support.  If you take that from them, you bring them from a complete denture to a full fixed, those people are going to have some issues.  They’re either going to stick with implant-supported denture and just let them know their ability for aesthetic concerns with those patients, and we’ll talk how to treatment plan those patients and what to do beforehand.

Now, with the advents of cone beam CT technology, it has been tremendous, helping me out in my practice.  I feel like it helps me, and the cases seem to go a lot quicker.  I know the bone morphology.  Without cone beam technology, if we want to place and implant here in this area and we look on the CT scan and it didn’t have a mandibular posterior lingual area, they have a severe curvature, which would inhibit this area to get an implant.  So, we need to talk about other options for this area or even not placing an implant.

Pathology in an area.  Get a nice radiograph.  Patient came in with lots of pain on this tooth.  She was referred to our practice for extraction and implant placement.  I noticed something back here.  So, we had to take a CT scan to figure out what’s going on, and we got a nice Panorex to show you guys from that.

There’s this huge pathology, and she had this develop in the past two years.  We looked at a previous Panorex, and she never had this.  You could also see it extending into the inferior alveolar nerve canal.  This referred out to a local oral surgeon, and he removed the cyst. It came back as benign or odontogenic keratocyst, but knowing this ahead of time, if we just take a PA and we don’t know what’s going on back here, we can get in a lot of trouble.

Being close to a nerve in an area.  This is a primary example of somebody who wants mandibular posterior implants, and these are two 10.5 millimeter implants.  We’re not going to be able to place these implants in without either shortening the implants or moving to a vertical ridge augmentation, but it’s too close to the nerve.  Cone beam technology gives us that.

Vascularity is also an issue.  You don’t want to sever and artery and have some bleeding issues.  So, this is a CT scan of a mandibular anterior lingual artery and also an incisal artery coming in the incisal canal.  You definitely don’t want to hit those during surgery. Guided surgery has been a nice for dentists.

Lab fabricated.  Some of this is what I used to do in my own practice.  I used to make my own stents, developed the crown-to-implant ratio, marked my middle, use a pilot drill, and flap back the tissue and get a nice outcome.  However, this surgery is only done on models.  So, we don’t really always know the morphology of the bone underneath so it’s not really recommended.

Originally, Cerec by Sirona, the scanning software where you can scan the adjacent teeth and mill out an acrylic surgical guide.  It’s really nice, and the technology has improved from whenever I did this.  This was done a while back, and we can get a nice implant immediately.  Again, it doesn’t account for the bones and the roots of the adjacent teeth.  Now, they’ve come out with a nicer system.  They’ve teamed up with GALILGEOS, and they’re outcomes are a lot nicer than this one.

CBCT aided guided surgeries.  This is a case that we did.  This is a laser-centered surgical guide done for the maxillary anterior region.  The surgery was done flapless.  It was a quick surgery.  She was in and out, just a great tool to use for a hard and difficult case.

Medication protocol.  A lot of people talk about pre-op antibiotics, and just recently, last week, the Journal of Clinical Oral Implant Research came out with a study with a multicenter randomized controlled clinical trial.  Dr. Chen Pan stated in his conclusions, “For a single implant placement prophylaxis, systemic antibiotics before or after single implant surgery does not necessarily improve the outcome or prevalence of post-operative complications.”  So, we need to dive in more to literature and talk about the antibiotic therapy in conjunction with implants.

Post-operative pain medications.   What do we recommend and not recommend, understanding that Motrin®, ibuprofen, does inhibit a prostaglandin.  So, you can get post-operative swelling after therapy.  People always come into our office and say, “I want an implant done.”  The day of the procedure, they come into our office, and we’re going to sedate them.  That morning, they didn’t take their blood pressure medication.  They didn’t take their routine medications.  We need to tell patients all the time to continue all prescribed regular medications, and after we do the procedure to continue taking their medications as prescribed.

This is just a brief summary, like I said, of what we’re going to talk about at Rocky Mountain Dental Institute.  If you go on the website, rockymountaindentalinsitute.com, and if you go under Courses, you’ll see a list of courses of what’s being offered.  There’s eight different courses anywhere from prosthetic reconstruction to bone grafting to complications, and marketing.  So, for the course, you can click on Implant Complications on the drop down tab.

You can read a little bit about the course overview, the course outline, a little bit about myself.  On the Start Here tab, you can see the different dates.  I want to make a note so that everybody who’s on this, the date that’s actually listed right here is incorrect.  It’s actually the week before, March 14^th.  Then, you just go ahead and click on Register Now to register for a course.  If you haven’t been to a course yet, you can create your own account, fill out the user registration information and hopefully we get to see you guys in March for the next course.

I’d like to open it up for other questions if you guys have anything.

Dr. Lavine:

Oh, yeah.  They’ve got lots of questions.  So, your course is March 14^th, and it’ basically all on implant complications, correct?  Is it a live course, or is it more of a didactic course?

Then, three years later, he comes back, and he’s got multiple issues here.  We’re not going to be crowning any teeth.  We need to remove all of his teeth.  He can’t control his caries risk. We can’t control his caries risk with the lack of saliva.  So, the ability to see this guy in one day, remove his teeth on the lower arch, degranulate the whole site, we able to place in implants on the lower arch, suture everything nice and clean, and do the same thing for the upper arch and have him, in three months, to heal like this is just tremendous service.  This is just for the lower arch.

Now, for the upper arch, if you’re not producing saliva, it’s going to be hard to produce a posterior palatal seal.  So, implant-supported dentures are going to be the way to go.  So, that’s exactly what we did.  We degranulated this area.  We removed all his teeth.  We did bilateral internal sinuses for this patient, placed implants on the maxillary anterior and posterior regions, let him heal for three months.  He came back in, and his tissues looked amazing.  What a service for a patient.  So, what we did was we didn’t give him a palatal strap.  The denture rests on these implants.  It’s a metal-reinforced complete denture.  The patient is an amazing guy, a great friend now.

Dr. Lavine:

Danny, can we go back to a couple of questions I’m seeing right here?

Dr. Domingue:

Yeah.

Dr. Lavine:

Talking about the uncontrolled diabetes patient, is there a specific A1c value that you’re comfortable with for those patients?

Dr. Domingue:

A1c value, I actually don’t recall that.  That’s a good question.  I don’t recall that data right now.  I have it in my notes somewhere, but I basically say to get the patient controlled, to get the levels under control.  Get it controlled.  Make sure he’s getting insulin.  Make sure he’s following up with his regular [15:21] before we go for an implant surgery.

Dr. Lavine:

I mean a lot of people hear from different places.  I believe it’s 7 for the A1c is the max value.  Anything under 7 is okay.  The other thing is can you define what a meth mouth is?  We have people from all over the place not understanding exactly what that term is.

Dr. Domingue:

Yeah.  Meth is just a lay term for a patient that has a previous history of drug abuse, and what meth basically does is destroy salivary flow.  It just ruins your teeth.   Meth mouth is basically a dental condition characterized by severe decay and lost of teeth or fractures of teeth, enamel erosion, and other oral problems with the use of a drug called methamphetamine.  It’s the methamphetamine drug, and we just call it meth mouth.  We just see the aftereffects of the methamphetamine abuse.  The reason why methamphetamine is so bad is because it causes xerostomia, and it also causes other conditions like people grind their teeth and become bruxers.

Dr. Lavine:

The slides that you showed before of that patient, was that a meth mouth or, you said it was a friend of yours so I’m assuming it’s not?

Dr. Domingue:

Well, now he’s a friend of the practice since he’s been coming for regular visits, and he’s a tremendous guy.

Dr. Lavine:

But, that was a meth mouth that you shuld?

Dr. Domingue:

That’s what a meth mouth looks like.  That’s exactly what it looks like.

Dr. Lavine:

Okay.  What about smokers?  Is that a contraindication?

Dr. Domingue:

Okay, that’s a great question.  A long time ago we used say that a lot of research supported there was a lower incidence of implant success whenever you have people that are smokers.  One of my good friends and I talk about this all the time.  If I didn’t place implants on patients that are smokers, I’d lose half my dental population.  That’s true to a lot of extent for a lot of different reasons.

You can still place implants on patients that are smokers.  You just need to make them completely aware and say, “Look, there’s a lower incidence rate in people that smoke a pack, two packs a day.  You’re going to have to taper that effect, get them on a smoking cessation program.  With that said, people still want their teeth.  They might not quit their oral habits like smoking.  Some people will still take the chance.  Other people that want to quit, that want to get off smoking, that want to break the habit, it’s a good excuse to. “Look, I’m losing my mouth.  I’m losing my teeth.”  They’ll blame it on that.  They’ll blame it on cigarettes so they’ll eventually stop smoking.  I wouldn’t say place implants on every single patient that walks in your door that is a smoker.

Dr. Lavine:

Okay.  Let’s keep on moving.  I want to make sure you get to your content as well, but there was just some good questions here.

Dr. Domingue:

Okay. Good.

So dental history.  Patients that come in for one tooth dentistry.  This is a patient that came into our practice these two lower left premolars.  They were a couple of months ago from a local dentist, and we got to get our minds off one tooth dentistry and focus on the big picture.  Once I took this picture and showed the patient how there’s multiple cervical lesions, caries lesions.  There’s external resorption on this lateral incisor.  This guy should not have root canals on these premolars.  He should not have crowns on these teeth.  He should have had these removed.  Educate the patient to have the teeth removed, place the implants, and three weeks later, lock down a full set of implant-supported teeth.  It’s just tremendous.  This is him healed after 12 weeks.  It’s just tremendous, nice way to treat your patients.  Again, focus away from one tooth dentistry.  Look at the whole picture whenever you’re looking at a patient.

Patients that are bruxors, this is a big topic.  How do you restore somebody that’s a bruxor?  Is it an implant supported tooth?  Is it a single unit?  Are they multiple units?  Is it a full arch?  Is it opposing natural teeth?  Is it opposing denture teeth?  Is it opposing fixed implant-supported teeth?  What you don’t want to do is restore it on a full occlusion, and this guy was in our practice this week.  This implant that you see was a healed ridge.  It was a restored, and a year later, he comes back.  We take the implant out with two fingers, and this whole side has granulation tissue ringing around there.

What we noticed was on lateral excursion whenever his [20:34] of the maxillary molar went into working function with a mandibular molar, and it was just restored poorly.  They just didn’t check for lateral excursions, and the implant eventually deosseointegrated.  So, the method of treatment is to clean the area, get rid of all the granulation tissue, and now we got some nice healing bone in this area. Ideally, what we did that day was to try and place another implant.  That’s what we did.  We just placed a wider diameter, planned the healing above it that day, and just did a little internal that day.  So, when we restore this guy in the near future, we’re definitely going to make sure that his occlusion is checked properly.

Infection is obviously a common concern.  If a patient presents with an infection like that, this patient is not going to get an implant in the same day.  What we’re going to have to do is make a laceration right here, remove the exudation in this area, clean the area really well, get them on systemic antibiotics, and either remove this tooth and make sure this area’s healed properly before we go and do implant therapy on this patient.  This is a shot of removing all that exudate, which was 2.5 cc which was just amazing.

Psych history.   This is possible needs for sedation.  Patient are [21:59] that have issues with laying on a dental chair and patients that are extremely nervous or have high anxiety in dental procedures would qualify for sedation.  Patients that are also have the inability to use denture and have a mandatory need for implants.  This patient loved her dentures.  Finally, she had her denture given to her six months prior to seeing her some time ago.  She said it finally feels nice in her mouth, and now she can use it.  The only problem is she can’t get it to stick to her palate, and at her home, she ground this down with a nail filer to literally nothing.

Now, she’s able to use this denture, and she is not a good candidate implant-supported dentures.  She’s going to be a good candidate for implant-supported fixe, and that’s pretty much it.  She just can’t tolerate anything with a palate on the back of her mouth.

Soft tissue deficiencies.  You need to have adequate connective tissue around the site before you develop the implant site.  This lady wanted fixed lower implant hybrid dentures.  There’s not a lot of attached tissue. There’s almost like 2 to 2.5 millimeters of attached tissue in the anterior area and very poor in the posterior area.  So, to get her to this level where we have six implants placed, we took a band of attached tissue either using subepithelial grafting tissue or alloderm grafting and really Louis Cummings is one of the best guys to talk about that.  He talks about it all the time on soft and hard tissue augmentation, and he had some really good advice for clinicians on site-specific areas, when to use, what to use, and what materials to use.

So, what you want to do is grow a band of tissue to these attachment sites so that you don’t worry about gingival defects around your bands.

Recession is a concern around single tooth.  This guy comes and wants an implant placed right here.  Well, soft tissue is supported by the bone, and if you don’t have the bone, you’re not going to have the soft tissue.  So, this is going to be a difficult case to restore the bone and the soft tissue back in one piece.  So, what we’re going to have to do is place the implant in one day.  It’s nice to place a piece of alloderm around this to let the area heal properly before you go back and restore the patient.  Again, all these pre-operative complications, you need to be aware of soft tissue deficiencies.  If you’re gin got place an implant on this guy, you need to be aware that you’re going to have to augment the site with bone and soft tissue.

Dr. Lavine:

Is there a specific alloderm that you recommend using?  I know you don’t necessarily promote any companies, but is there one that you’ve had good luck with?

Dr. Domingue:

Well, I use alloderm, and I buy it from a local sales rep.  I know there’s AlloDerm®, and I think that’s specific for a company BioHorizons.  I believe Salvin has a product now that’s a derm material as well.  I’m not familiar with the term off the top of my head, but I usually just buy from a local rep.  We’ve had fantastic results with it.  Again, it’s all about knowing how to use it, where to use it, and one of the most important things is suturing technique associated with these grafting sites.

Dr. Lavine:

Okay.  Thanks.

Dr. Domingue:

Shallow vestibules are concerned.  In this patient, if we had properly treatment planned him, you can see the mucogingival junction at this area around the implants here.  You have a nice frenula pull around this implant.  You’re starting to get some exposed thread for some thin tissue.  This is going to be a very difficult cleaning complication.  So, we need to augment the site back with some tissue in this area, clean these implants properly, get rid of this muscle pull. We don’t want to have to treat any complications.  It’s just difficult in these small vestibules.

see the video: http://vimeo.com/58581515

Dr. Lavine:

Well, we are going to go ahead and get started.  Welcome, everyone.  This is Dr. Lorne Lavine.  Many of you know me as the Digital Dentist. I wanted to welcome everyone to tonight’s webinar.  As of this morning, we had over 650 people that were registered for the webinar.  I’m really just so thrilled with the attendance that we’re getting for our webinars.  We’ve obviously found some great topics that excite everyone.  There’s a good number of you already here.  I’m only going to speak for a couple of minutes. I want to make sure that Dr. Domingue has enough time to speak as long as he’d like and to make sure we leave enough time for questions as well.

On your screen, you should have a little webinar go-to panel where you can ask any questions.  Feel free to ask your question throughout the lecture as you think about them.  What Danny has requested is that unlike most of the webinars that I do where we tend to save the questions until the end, he’d like to answer as many questions as possible during the webinar.  So, I’m going to keep an eye on that question panel, and I’ll interrupt him if it’s relevant to what’s he’s showing on the screen.  I think that’s really going to make it interesting for everyone.

By tomorrow, you’re going to get a number of things.  Tomorrow, you should all get a little survey when you log out.  Just take a minute to answer it if you’re interested in having one of us follow-up with you at Rocky Mountain Dental Institutefollow-up with you.  So, if you have to take a phone call or can’t stay until the end, don’t worry.  You’re not going to miss anything.

I also wanted to thank our sponsor tonight Rocky Mountain Dental Institute.  They are graciously agreeing to provide everyone with an ADA certified CE credit.  They will be following up with that as well.

Just a brief introduction about myself for those of you who don’t know me.  My name is Dr. Lorne Levine.  I am known as the Digital Dentist.  What I’ve been doing the last number of years is to present webinars that I think are topics of interest in the general dental practice even though it’s not necessarily my area of expertise, which is now technology.

I practiced as a periodontist for 10 years.  I placed a lot of implants, but my focus right now is technology.  My goal is to provide information content that I think is stimulating and interesting, maybe controversial.  That’s okay.  Hopefully, beneficial.  I think we’re going to hit on those things tonight.

So, the topic for tonight’s presentation is to talk about complications in implant dentistry.  We’ve had a number of presentations already on implants.  We talked about all the great things that implants can do and all the indications for them, but, as we all know, it doesn’t always work out that way.  There are all kinds of complications, whether it‘s pre-operative, during the procedure, post-operative.

There can be anatomical complications, those surprises that you get sometimes when you open things up.  Obviously, there’s more to implants than just the fixture, but we have prosthetic concerns and complications there.  Of course, unfortunately, we’re not working on mannequins.  These are real people, and they have real health concerns and complications as well.

So, as I said, even though I have placed implants for a long time, it’s been a while, and certainly, as much as I’d like to talk, there’s a lot more people out there who know a lot more about it than I do.  So, it gives me great pleasure to introduce Dr. Danny Domingue tonight.  He is a graduate of LSU.  He graduated a number of years ago.  He did a GPR at Brookdale Hospital Medical Center.  He was the chief resident there.

He got all kinds of awards and recognitions.  He’s a fellow of the ICOI.  He’s an associate fellow at the American Academy of Implant Dentistry.  He’s a diplomat from the American Board of Oral Implantology, and as far as I know, he’s the youngest person in the entire country to have that award given to him.  He’s in full time practice in Lafayette, Louisiana, focusing mostly on implant dentistry.  Hopefully, he’ll also talk about his work with Rocky Mountain Dental Institute by the number of courses.

We have a number of our clients that have signed up for our courses through the webinars that we’ve given, and I’m certainly sure he’ll mention that during his presentation.  So, it gives me great pleasure to turn the mic and the screen over to Danny, and we’re looking forward to tonight’s presentation.

Dr. Domingue:

Thank you, man.  I appreciate it.  So, as you said, there are a lot of complications associated with implant dentistry, and this normally is a three-day seminar on Rocky Mountain Dental Institute.  This is just going to be 30 minutes to an hour webinar.

Like you said Lorne, there’s going to be pre-operative complications associated.  There’s operative complications associated with implant dentistry during the procedure such as blood, nerve damage, damage to adjacent teeth.  We’ll go through these at RMDI, but this is just going to be a quick overview of what we’re going to talk about, also post-operative complications that can and do arise with implant dentistry such as edema, swelling, pain, post-operative numbness.  We’ll talk about management issues, medications recommended for these patients, how to treat these patients, recommend a recall for all these patients.  We’ll give you an outline of what to do, how to do it, and researches backed up on the best therapy, the treatment.

Last but not the least restorative complications always arise, whether you do the best restorative dentistry you could possibly do.  When you go to see the implant, the implant doesn’t fit properly.  The implant crown doesn’t fit properly, or the implant trajectory is off at a bad angle and it’s hard to restore.  It’s too close to a neighboring tooth, or you have papilla issues, not enough tissue, so you have a restore a pink porcelain.  All of these are going to be in depth, like you said, at Rocky Mountain Dental Institute.

Today, we’re mostly going to focus on pre-operative complications that arise in implant dentistry.  We’ll start off talking about medical history and just a quick overview of bisphosphonates.  This has been a hot topic for many years, and the research that we have now has changed from what we were first told. Initially, we were told if somebody’s taking a bisphosphonate, oral or IV, it’s contraindicated to place an implant.

Well, that’s no longer the recommendation from the ADA, AMUS, and the Journal of Oral Maxillofacial Surgery.  Recently, they published an article saying there’s no evidence of bisphosphonate-associated osteonecrosis of the jaws of patients evaluated when taking oral bisphosphonates.  Now, they do suggest if a patient is taking oral bisphosphonates to get a medical clearance, but it is not a direct contraindication to simple implant placement with an extraction.  It should not be a contraindication.

Now, it’s different whenever somebody’s taking long-term IV bisphosphonates.  Most of those patients have previous forms of breast cancer, and we would suggest not using dental implant therapy in those patients.  They’re a little bit thicker, and implant therapy should not be recommended.  Again, patients that are taking oral bisphosphonates such as Actonell®, Fosamax®, Boniva®, the ADA study that the risk of developing bone osteonecrosis on patients with oral bisphosphonate therapy appears to be low.  So, it exonerates oral bisphosphonate therapy in conjunction with implant dentistry.

People that are taking blood thinners, this is just something that you should be aware of.  People that are taking aspirin daily or people that are taking Plavixx®, again, it is not a contraindication, but you just need to be aware of it.  Review their medical history.  Make sure that they’re taking their Plavixx® the way they should be.  They don’t have any heart concerns, issues.  Always get a cardiologist’s clearance if you’re going to do implant therapy just to be aware of other health issues that could arise. Most commonly in people taking Plavixx®, people taking Plavixx® are not just going to have a heart condition.  They’re probably going to be predisposed to other medical conditions, and it’s good to get a full range and consult with their physicians, find out what else is going on.

Another thing is warfarin, which is Coumadin®.  Patients that are taking Coumadin® or warfarin, you really need to know their PT and pTT level, and that’s going to tell you their INR, which is the international normalized ratio.  What the American Academy of Oral Medicines suggests is not to alter their medications without the advice or us as the dentists.  So, what we should do is find out their INR levels first of all from their physician, and the American Academy of Oral Medicine suggests INR levels of anywhere from 2.0 to 3.0 is not contraindicated to placing an implant.  With anything above a 3.0, you’re taking a risk.

What that number coincides with is if a patient’s INR number is roughly 2.0 that equates to a coagulation time twice the number value of a normal healthy individual.  So, if a normal individual coagulates in 5 minutes, if an unhealthy individual has an INR of 2.0, it’s going to take them 10 minutes to coagulate.  It’s a simple way to think about that, but always, again, medical clearance.  Patients that aren’t taking coagulation therapy and they want multiple implant placements.

This is a lower interior mandible we did this week, it’s got one of four implants.  Great health.  He was taking a daily aspirin so that was a concern, but not a lot of bleeding, and the ability to place four implants on the lower interior mandible was very controlled bleeding.  This was a very in depth surgery.  It was full thickness and flap reflection from distal premolar to contralateral distal of the second molar.  Full thickness operation, full osteotomies, four implants placed.  It wasn’t a very lengthy procedure, but, again, a lot of soft tissue elevation, which can lead to a lot of bleeding. It’s just good in the medical industry.

Dr. Lavine:

Dan?  Getting back to the bisphosphonates, what CTX values are you comfortable with?

Dr. Domingue:

That’s a great question, and that’s a common question that we get asked a lot.  There’s a lot of research that supports different levels, and we’ll talk more about that at Rocky Mountain.  Some literature suggest to always get medical clearance, and based off the physician, even if that level is high, it’s still okay to do the surgery.  If it’s multiple site implant placement as opposed to single site implant placement, it plays a big role, and we’ll talk more about that and all the literature that backs it up.  Great question.  Thanks to whoever asked that.

Uncontrolled diabetes, type II diabetes is a significant relative contraindication only due to the poor peripheral blood circulation in the patient.  If the patient has uncontrolled diabetes just don’t place the implant.  Get the diabetes under control.  Have the patient see their physician.  Typically, if they’re not well-controlled, they’re not going to be responsive to their medications.  They’re probably not going to be responsive to your medications.  They might not be very good patients to do implant surgery on.

Patients that are “meth” mouth, these patients are going to be difficult to do surgery on.  You can sedate them if you want to, but they definitely need some implants.  They need their teeth removed.  They’re going to need some work done, but they’re hard to sedate.  They’re hard to work on.  They’re not very compliant, and just getting trying to get a feel of their history is always good pre-operatively for your patients.

Then, moving on to dental history, patients that have xerostomia, again, if they lack saliva, they lack the ability to clean off bacteria around teeth.  They’re going to have more bacteria on the teeth surfaces.  They’re going to have more issues, and this is a prime example.  This is a great friend of mine who’s been a patient, and he just stopped coming to the practice.  He’s got tons of multiple class V lesions as you can see, root surface caries, and eventually, what he just did is he just gave up.  He just stopped coming in to the office.