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.