4 Ways to Boost Osseointegration of Your Implants – PDP155

We speak with Dr. Pav Khaira, a total implant nerd, who shares 4 of his top tips for maximising osseointegration:

  1. Biological ageing: discover the time-sensitive nature of implant bioreactivity and its impact on integration (and how to improve the bio-reactivity of your implants)
  2. Mastering the osteotomy: fine-tune your skills in shaping the osteotomy based on bone quality and type
  3. Disinfection: explore disinfection techniques of the osteotomy
  4. Systemic factors: optimise early-stage healing and understand long-term immunological balance

Don’t miss an upcoming exclusive live event on “Superosseointegration” on 15th and 16th September 2023 in London hosted by @Dr.Pav.Khairawww.academyofimplantexcellence.com

Check out PDP155 on YouTube

Maximise the osseointegration of your implants and uncover the intricate relationship between the skeletal system and the immune system (known as osteoimmunology) and its impact on implant success.

Need to Read it? Check out the Full Episode Transcript below!

Highlights of the episode:
00:00 Intro
01:19 The Protrusive Dental Pearl
03:11 Dr. Pavandeep Khaira
04:29 What is osseointegration?
05:04 Osteoimmunology
07:39 Early-stage failure
09:52 Success and survival rates
12:33 Biological ageing
15:45 Decarbonisation for Implants
21:18 Bone density
24:10 Overheating the bone
27:16 Disinfecting the osteotomy
29:21 Systemic factors
33:03 Superosseointegration
36:58 Outro

If you enjoyed this episode, you will love Why Should You Avoid Flapless Implants? – GF015

Did you know? You can get CPD from the Web App or Phone App and watch premium clinical videos, for less than a tax deductible Nando’s per month?

Click below for full episode transcript:

Jaz's Introduction: We know that implants are a great way to restore an edentulous area. It is not a replacement for a tooth, because teeth are still the best, but the next best thing for a missing space at least, are IMPLANTS. Now, implants can get very complicated, different stages, surgical, restorative, but the very initial stages is all to do with ossteointegration, which is essentially, in a crude way to describe it, would be the fusing of the implant to a patient's bone.

Jaz’s Introduction:
Or as I like to call it, how long it takes for the implant to cook, so it’s ready to accept load. Today on the show, I’ve got Dr. Pav Khaira on again, he’s our resident implant expert and a titanium nerd, and he’s going to cover four techniques he uses, and most of these are very quick to act on, very simple, and something that you can apply straight away.

One of them does involve you to buy some extra kit, but the reasoning is really solid, and it’s something I hadn’t heard of before, so it’s four ways to BOSST your OSSEOINTEGRATION. That’s the success rate overall, and the quality of your osseointegration itself. Like Pav taught me in this episode that most implants, when they’re placed, about 56% of the implant is covered by bone, or rather 56% of the implant is actually directly contacting bone.

And with his techniques, he’s getting that much higher, which he believes results in a longer lasting, more successful implant. So he calls this all super osseointegration.

Protrusive Dental Pearl
Now before we join Pav to reveal those four ways, I’ve got your Protrusive Dental Pearl. Now please bear with me because I do have an ulcer on the inner side of my upper lip. It’s a little bit painful, but the show must go on. And my son is home today because of school holidays. So I’m hoping he doesn’t barge in and have to record this all over again, but let’s go, let’s do our Protrusive Dental Pearl, which is not an implants one. I don’t do implants myself, but I can tell you is about COMPOSITE BONDING.

Here’s a tip I picked up when it comes to anterior composite bonding. You need to evaluate what percentage of your appointment are you going to actually devote to the placement of your composite and what percentage of your appointment is going to be the finishing and polishing. And if you think about your last few cases, what percentage of your appointment was the placement.

Well, if you’re like most dentists and certainly me many years ago, I would do like 90% of the appointment actually placing the composite and 9% of it checking the occlusion because that’s very important to me. And then you’re looking at the time and you’re running late and then you quickly, you know, finish and polish and you try and make it as shiny as possible in that valuable one minute you have left before your nurse starts giving you the eyes.

And really, if you look at what the masters do and how they get wonderful results in their composite bonding, we need to really change this. So I was always advised 50% of your appointment length should be the actual placement of the composite. And the rest of the appointment should be, yes, checking the collusion thoroughly at the end, but a huge bulk of that will be finishing and polishing because that’s how you get a stunning, long lasting, unstainable result.

And of course, if you nail those line angles and that secondary anatomy, even tertiary anatomy, you make it look more lifelike. So the way you can action on this tip is either you need to book longer for your appointment. So you got more time to do finishing polishing, which is such a crucial step, or you just need to be a little bit quicker in your placement and actually devote more time to getting it all perfect in the finishing and polishing.

So less time placing, more time finishing and polishing. That’s the tip for today. Let’s join Dr. Pav Khaira for the main episode and I’ll catch you in the outro.

Main Episode:
Dr. Pav Khaira, the titanium nerd. Okay. You are Mr. Implants for me, you know that. And we bring you back again to talk about, I don’t want to ruin the surprise, but ossteointegration and then how you do ossteointegration and all the levels of details that you go into.

You’ve done so many episodes of us four. So if anyone hasn’t heard of Pav, check out the dental implant podcast or listen to some of the previous ones we’ve done covering all sorts of things such as can you probe this implant to how to clean under your implants to finding your niche and dentistry. So lots of different implant topics that we’ve covered already. So if anyone hasn’t, for those few people that haven’t heard our episodes before, just tell us about yourself, Pav.

Jaz, thank you very much for having me back. I am a titanium nerd to the core and I’ve mentioned this several times, but you’re the one who inspired me to start the dental implant podcast. And I just, all I do is place implants, restore implants.

I absolutely love it. And I just love studying. I love teaching. I love helping patients. I love helping other dentists increase their skills. So anything titanium related, my wedding ring is made out of titanium. My daughter got me a a chain for father’s day. That’s made out of titanium. Everything’s just titanium for me. So that’s why I call myself Titanium Nerd to the core.

I love it. And today what we’re covering is Osseointegration, which you can explain what it is for the dental students. We know is how you get the screw to fuse to the bone. I’m sorry. If it’s said very crudely by a non implant dentist, but you say it more elegantly, but how to get your implant to, it’s fuse the right word?

I don’t want to get too technical about it because technically fused isn’t the right word, and effectively what integration is nowadays, we classify it as a controlled rejection of the implant but for simplistic terms, yes, let’s call it fusing to the bone, yeah.

And this is something that if it fails to happen, it’s a heart sinking moment for a dentist and a patient. And we can find out, we can get an idea from you, what are the signs to look out for? At what point does this happen? So let’s say you place an implant and it fails to osseointegrate. When would that typically happen? And what is the number one cause of that? Before we then delve in to your multiple levels and layers of tips to make sure that we increase our percentage chance of osseointegration. So what commonly causes the downfall of implants?

So there is a concept now called osteoimmunology, which is an interplay between bone and the immune system. So this is why I called it a controlled rejection. Because what happens is, if you think about it in terms of fusion, the perception is that the bone fuses to the surface and then kind of like, that’s it, it’s like a cement post in the ground, you put the cement in, the fence post goes in, and the cement sets, that’s kind of like it for a very, very long time.

So we know that that doesn’t happen is the body recognizes the implant as a foreign body. And it almost, it wants to reject it, but it kind of like encapsulates the implant within bone. And then there is then healthy bone around the implant. It’s aiming to contain the implant and not have it kind of like leach out into the body.

So it’s a paradigm shift in its definition. But what that then tells us is there’s this balance backwards and forwards, Jaz, of the body being successful, and it is a balance, the body being successful versus the body’s starting to reject the implant, and this is why implant rejection can happen many, many years down the line.

So if the patient gets sick, if they get put on certain medications, all of a sudden this implant that you’ve had success with for 15, 20 years, it may start to give you problems and fall out within the space of six months. So gone are the days where we think about an implant as being fused to the bone and kind of like, that’s it. There is a constant backwards and forwards, the bone remodeling around the area constantly.

Dynamic situation, right?

Completely dynamic situation. So what we can do is we can split up this lack of integration. And to clarify integration of an implant is not just this. Again, let’s keep it simple. It’s not just this fusion to the bone Jaz.

It’s the absence of any types of inflammation, disease, and it’s the ability for the implant to bear load as well. Because if the implant can’t bear load, what use is it? So the definition is multifactorial. Now, there’s a number of points at which we can have failure. And one of the failures is early stage, which is from when the implant goes in to when you take compressions.

And sometimes we get patients coming back and they come back because they’ve called after two weeks and they’re like, ‘Pav, I’ve got a lot of pain. It feels really weird.’ And all this, but there’s a strange taste coming from it. And you look at the implant and you’re looking at it and you can just tell something’s not quite right.

And at that point you need to make a decision. You’re going to take it out or you’re going to wait. And normally the best thing to do is take it out. So that’s kind of like the early stage failures before we’ve even managed to put a crown on the tooth.

What I’m already thinking about, Pav, in terms of my restorative background is, resin bonded bridges, for example, we know that they could fail within the first four years, but if they make it to four years without any issues, they’re going to make it 10 plus years without an issue.

So most failures, when they’re going to happen, are going to happen within four years. Do you have such stats for implants or your experience that you’ve learned that when you get implant failure? Because the way you suggested it is that even 20 years later, it could have a failure, which is a really obviously we know that they don’t last forever, but the type of failure may change. Any stats on if you get past this point, then you’re looking good?

Yeah, 12 months, 12 months after loading. And the reason for that is quite simple. If the bone metabolism is compromised, if the patient’s not quite as healthy, there’s the number of factors which come into play. It may be that at the time of impression that the implant’s absolutely fine and then you put a crown on it and you start to function on it and that may tip the balance that there’s too much force going through the implant into the bone and then the body decides, no, I can’t deal with this and just splits the implant out.

I generally tend to find once we’re past that 12 month mark, at that point, we’re kind of into average territory. And there’s a number of factors we, I do a risk assessment, which tells me based upon these parameters, I’d expect a lifespan of the implant of 10, 15, 12, 15, 20 years, whatever it is, but that danger zone is really within the first within the first 12 months, because if you’ve made a technical error or your labs made a technical error is going to come to light really quite quickly. And so I generally say 12 months is kind of like the point after which I’m just like, ah, okay.

Good. And then with my endo hat on, how an endo, they’ve got studies like survival versus success. And survival was like, well, the tooth is still there. Yes. There’s an apical infection, but the patients don’t choose on it. So it’s survival, but it’s not success. Is there such stuff about implants? Like you could have an implant with peri-implantitis it’s oozing, it’s pussing. A patient still chews on it, and it’s just slowly dying its death. Do you have such data like endo, like survival and success?

Yes, absolutely. So most of the statistics where people talk about success rate with implants, they actually referring to survival rates. And this is a clarification that a lot of dentists need. And then we need to define what success is, there’s a number of different parameters to it. There’s a mechanical success, there’s a biological success, and then there’s an aesthetic success.

So all of these factors kind of like come into play, but most of the stats that you hear when people talk about success, they’re actually survival. So when people say, oh, implants have a success rate of 98% over a 10 year period, the caveat to that is actually that that’s normally a survival rate. The success rate is normally significantly lower around the 68% to 70% mark.

Now, a lot of these problems are iatrogenic and they can be avoided, but in order to avoid them, we end up needing to do more complex treatments such as more complex bone grafting and soft tissue grafting. So this goes back to the osteoimmunology principle that I spoke about before Jaz, and the best way to think about it is the plaque, the bacteria, the biofilm, they cause an inflammatory wavefront.

Okay. And it’s about two millimeters away from where the biofilm is. Now, what all of the evidence tells us is we need two millimeters of bone around an implant and two millimeters of soft tissue as well. And it’s not just any soft tissue, you need keratinized tissue. And what that does is when you have that, the survival and the success rate significantly goes up for the implants.

So when people do that, that’s when you have true success rates of 98% over a 10 year period. Because what you’re doing is you’re keeping that inflammatory way front away from all of the sensitive area. And when you do that, all of the remodeling, all of the dangerous stuff happens at a remote distance.

And this is why all of the studies suggest you need two millimeters of bone, you need two millimeters of keratinized tissue, because what it’s doing is, that then falls in line with the osteoimmunology principles, which we’re starting to employ nowadays.

Okay. Well, if you’re a young dentist and you’re starting new or if you’re an established dentist and maybe you’re getting into implants or you don’t do implants, but this is something that’s quite fundamental to know, right?

It’s like even though you don’t treat lots of perio, you should know about perio. Implants is obviously everywhere now. So we should appreciate how our colleagues can get better osseointegration. Some of it is actually factors that the GDP can help with while they’re on the way to see an implant dentist or, and their journey into implants. So what are some things that you employ in your protocols to boost that percentage? That at 12 months, everything and beyond, everything’s going to be hunky dory.

Oh, how much time have we got Jaz? This could be a very long podcast.

Six minutes, no I’m joking. It’s got a bit longer, as long as it takes, but let’s cover some quick tips to help people out to maybe some of, oh, I didn’t appreciate that or, okay, that’s a really good point.

So my master’s thesis, cause my MClinDent is in implantology. My thesis was on ‘What’s called Biological Aging of Implant Surfaces’. And what happens is once implants are manufactured and they are sterilized and they are packaged, their bioreactivity, which is their ability to interact positively with the body, reduces very, very quickly. You can get a measurable drop within 24 hours.


And after four weeks, Jaz, the bioreactivity has reduced by 50%. Okay, so this bio reactivity is reduced by 50% and the bone to implant contact ratio that we’re getting of integrated implants and bone to implant contact, very simply it’s an indicator of how much bone is touching the implant and it’s an indicator of success.

And a successful implant generally has a bone to implant contact ratio of 56%. So there’s only 56% bone around an implant and these implants are still lasting a long time. Now, what I found out is if you decarbonize an implant chair side, just before it goes into the patient’s mouth, that bone to implant contact ratio jumps to 98%.

It’s a huge increase. So the discussions that I’ve had with colleague is yes, but is it clinically impactful? Because we’re still getting a very high success rate with this 56% bone to implant contact ratio. Well, the answer to that is really simple Jaz is what’s the other 44%. It is soft tissue, it’s biofilm, it’s all sorts of stuff.

So we want to exclude that as much as what we possibly can. And in addition to that, when you decarbonize an implant before it goes in, it reduces the biofilms adhesion to the implant surface as well. There are also what are called finite element analysis studies, which show how much stress and strain go into certain systems. That they’ve shown that when you decarbonize an implant and you put it into place, the forces around the neck of the implant are significantly reduced because you’ve got this tighter bone seal around.

Now I’ve seen some videos Pav on Facebook. Is this the purple beaming light on the implant that you’re doing? Is that the decarbonizing because it literally looks like you’re in Wakanda and is vibranium implants is why I commented ones on your Facebook post. So that’s what you’re talking about I mean, is this a machine you got to buy or how does this work?

So there is a number of ways to do it. One of the first ways that came out was a UV-C chamber. The issue that we have with that, A) That chamber is incredibly expensive. B) It’s not available in Europe anymore. And C) The cycle is about 12 minutes long. So basically, if I want to decarbonize an implant, I take it, I put it in that chamber, and it takes 12 minutes for the implant to be spat out before I put it into place.

And another way of doing it is to use an alkali solution. Now, alkali solutions are used by a company called Thommen, and their implants come pre packaged in this alkali solution. You press a little button, it surrounds the implant, give it a little bit of shake, count to 60 and place it. So some people, I know they purchase the alkali solution, they just use it like that way, but other people are, I don’t want to add anything to the surface of the implant, particularly something which is kind of like they’re just like, I’m not comfortable doing that.

And this new plasma unit, which is the Actilink. It’s nice because it’s only a 60 second cycle. And that’s that really cool video that you saw. You put the implant into the chamber, you press it and it goes, activation starting, and then it does this whole, Emperor Palpatine zaps it with this electricity.

And at the end it goes, activation finished. And the patient goes, what on earth was that? And so it’s nice because it works incredibly effectively and it’s only a 60 second cycle. Now, what I would say Jaz, on top of that, there are certain implant systems, which come prepackaged in a sodium chloride solution, because they’re trying to prevent this contamination as to happening on the surface.

So there’s two things that I would say to that. Firstly, when I take these implants and I condition them just before they go into place, I still get a better result with them. And secondly, there is a link between implant surface corrosion and peri-implantitis long term. And all of the people that I’ve asked, I’ve asked some very high-profile people, ‘Does storing the implants in this salt solution increase corrosion of the implant surface?’

Nobody’s been able to tell me yes or no. So in my mind, it’s actually an untested system. It’s an untested surface, but not only that, is even if it were a tested surface, you still get a better result by chair side treatment just before the implant goes into place. And this is one of the most impactful things that I have done for my implants.

I’m not worried about marginal bone loss. I generally don’t see that anymore. I’m getting vertical bone growing around it. And it’s not just the amount of bone that you get adhering to the surface, Jaz. The quality of the bone is significantly increased and the speed of integration is significantly increased as well. So it’s upregulated on every level.

I mean, it makes sense. It’s one of those things where it just makes sense to do because like you said, what’s the other 44%? Are there any long-term clinical trials yet to support this? Or is this something that we’re waiting to see if it actually results in clinical differences?

So there are some clinical trials as with everything it started with animal trials and things like that. But we’ve known of this concept since about 2008. So it’s not a new concept.


As with everything it kind of takes a little bit of time to get the ball rolling with this. There are some good studies coming out now, which is what they’re showing and these are human studies taking what are called ISQ readings and ISQ reading, you use a little peg and it gives you a numerical number as to how much your implant has integrated.

So it gives you a numerical value as opposed to us just guessing. So these new studies, what they’re showing is we can take these implants and put them into patients who are very medically compromised or whose bone is so poor that these implants are just spinning. There’s a term for it in implantology, we call them spinners.

We’re always worried whether they’re going to integrate or not. And some of these, what we call ISQ readings, they’re so low to start with. That the ISQ is, it can’t even be measured because it’s so low. And then what we know is if we can achieve an ISQ of 70, again, it’s just a numerical value.

We know at that point, the implant has integrated. And what we’ve shown is we’ve shown that these patients who have this extremely low ISQ get an ISQ of way above 70 within 12 weeks. And normally we wait six months for these patients. So we’re getting integration within 12 weeks. And then from the point of restoration, these patients would be followed up for two years, showing that you don’t get an increase and then a decrease again, you get this increase in bone quality and then it’s maintained as well. So there are some studies starting to come out now, and I’m confident that as time goes on, we’re just going to see more and more of this.

Excellent. So the first tip there is decarbonizing. I’m just, all I can think about the whole time is this company that produces this, the unit they use, they need to make a Marvel Black Panther version. I would just love it. That if it just had the music going and then suddenly, like they said in Black Panther’s voice, like a vibranium completed, like, I would just love that. That’s mostly what I’m thinking about right now.

Maybe I should get like a bespoke one made just like that. For me, like all marvels.

I’d buy one. I’d buy one. I didn’t do it, but I just buy one and I zapped my crowns with it. And I just wait for that. And I’m patient. Be like, wow, what’d you just do to my crown? Like decarbonising. There’s all sorts. We can do that. The world’s our oyster. Okay. So tip number one, that is a decarbonize. This is brand new to me. So decarbonize your implants. Thanks for sharing the science behind that. Another thing.

So another thing is drilling in the correct sequence and in the correct manner with the right tools based upon the patient’s local and systemic factors. Okay, let me explain that a little bit more detail. So there are four different qualities of bone that you get bone, which is really, really soft. And then you get bone, which is really, really hard.

It’s like wood.

Yeah. Either one of those two extremes is not good. So when bone is very, very, very hard, it generally has a very poor blood supply. And when it’s very, very, very soft, it is generally not very metabolically active.

That’s the spinners. Yeah? The soft ones are more likely to be spinners.

Those are the spinners. Yeah. These are the patients where you open a flap, you drill and it’s just yellow fat-

Vanishes in there.

Yeah. It just vanishes. You put suction on it and all of a sudden it is, there’s no bone left. And you’re like, what am I supposed to do here? So we want something kind of like in the middle. And that’s the best bone to actually put it in. Now, one of the things that I always get into, let’s call them discussions about is there is something called initial torque value.

Okay. Initial torque value is kind of like how tight that implant goes in on the day of surgery. Okay. Now, a lot of people incorrectly state that if you put your implant in at too high torque that it causes pressure necrosis of the bone. Now, there are some really good studies to show that this doesn’t happen, but I think it’s a little bit more nuance than that Jaz.

Okay, so there’s two different types of bone. We have trabecular bone, which is the bleeding bone. It’s the soft bone in the middle, and then we have the hard cortical shell on the outside. So on that scale of very soft to very hard bone, we need to know what our bone type is so that we modify the shape of the recipient site called the osteotomy based upon that bone type.

So what I’m saying to you is if I’ve got softer bone, I can under prepare and squeeze in that implant and achieve the same torque value as very, very dense bone where I over prepare. And I get the implant to drop in almost to the apex and then it’s the last two turns where I achieve all of my what’s called initial torque value.

So the initial torque value on both of those may be the same. It may be 50 newton centimeters. But where and how we attain that 50 newton centimeters is very, very different. It could be 70 or 100 newton centimeters. So it’s not just simply a sequence of going through your implant drill kit because your drill kit’s really nice quite often it’s color coded and you get told use this one then this one then this one then this one. Unfortunately, it’s not as straightforward as that so you need to shape the osteotomy based upon the implant and the type of bone as well.


The other aspect to that as well is You don’t want to overheat the bone. If you overheat the bone, that’s when you do thermal damage, and that’s when you’re definitely going to have issues as well. I’m actually surprised at the number of people who don’t track how often they’re actually using their burs, because they should actually be replaced very, very frequently. And the denser the bone, the more work that bur is having to do, so the more frequently you need to replace it.

And any guidelines? Some people might be doing this thinking, ‘Oh, I’ve never replaced my kit.’ What’s the life cycle of a drill kit?

Every 10 uses at the very most your burs should be changed, at the very most. And sometimes if I’ve got really, really, really dense bone, I will use the bur once and that’s it. I’ll get rid of it. I don’t want to take that risk. Just for the sake of saving a few pounds, a few dollars that all of a sudden that I’m going to increase my risk of problems, and lack of integration. Now, the other aspects of that as well, it’s really a nice biological drilling is we reduce the speed at which we’re actually drilling.

So what we know is if we put the burs in at 150 RPM or less, without irrigation that we don’t get that much thermal damage. Now there are certain bur designs which are even more efficient than that. So I have a bird design which I use very frequently, use it pretty much all my things and I could run that at, so the cardinal rule is, you don’t want to drill more than a thousand RPM, 1200 RPM if you’re really feeling like an absolute madman.

So with these burs, they’re so hyper efficient at how they work, I can run them at 2000 RPM without irrigation in the most dense bone and they still won’t generate heat. The downside to it is you don’t get much tactile feedback. So they’re only really for more experienced implant places, or if you’re using a guided system, then you can use it.

But by reducing the amount of thermal damage again, we’re just accelerating the body’s ability to heal. And in addition to that, if you do get thermal damage, firstly, you’re going to have more pain. You have this zone of death around the implant, which the body has to clear first, and then it reattaches the implant to the surface. So having the correct osteotomy shape for your implant design in the correct bone and using the correct burs in the correct fashion and reducing thermal damage, it plays absolute wonders.

So I love the zone of death that made me chuckle. And so the summary there is the right tools for the right job and respecting the bone in terms of making sure that it’s irrigated and preventing thermal damage.


Amazing. Shoot us with love. And you got to tell me roughly when you think, okay, we’ve covered the main things because this, as this episode is your baby in terms of your top tips for osteointegration. So we’ve covered two already. What else have you got? Because I think something more systemic and medical is coming soon as well, I think.

Yes, correct. So Just before we move on to the systemic stuff, I think we don’t disinfect the osteotomies as well as what we should. We just drill and then we just place. So there are good studies to show that if you have a big periapical lesion around a tooth and you take that tooth out, you degranulate it and you wait for it to heal, you come back in six months time, those bacteria that were present are still present.

They’re not cleared in the bone, even though the bone appears to be healed. So then if you are preparing your osteotomy and putting your implants into this position, the bacteria are still there and they are linked to failure long term. So what we need to get in the habit of doing is disinfecting the osteotomy.

So it’s a little bit too nuanced for this, but I would recommend that everybody should be disinfecting the osteotomy just before the implant goes in place. So the way that I do it is I know what implant I’m placing, I prepare the osteotomy, I start my disinfection process and I then put the implant into the decarbonization chamber and then it all starts to kind of like tie in together.

Are you squirting some chlorhexidine or some ozone or like, what’s your chemical or mechanical?

No chlorhex, should not be using chlorhexidine when it comes to implants or surgery. So there is risk of anaphylaxis when it comes to chlorhexidine. It also reduces fibroblast development as well. So I don’t like, even when I was doing general dentistry Jaz, I didn’t like it. There was always something that I preferred.

So my go to at the moment is Clinisept+ mouthwash, which is hypochlorous acid. It’s very, very mild. And then what I do is when I am disinfecting the socket, I will use either iodine or I will use a bluem gel or I’ll use a hypochlorous acid. It depends on what I’m trying to achieve, but there’s a number of ways of effectively doing that as well. Okay.

Okay, great. So decarbonize, respect the bone in terms of thermal damage and correct sequence and disinfect the osteotomy, osteotomy being the hole that you make in the bone.

Yep, correct. So systemic factors. Now this is where it starts to get interesting. There are a whole host of factors which can interfere with your early stage healing but are also involved in this osteoimmunological balance in the long term as well. And what we need to look at is we need to look at generally how fit and healthy the patients are coming in.

So there’s a number of things that I’m looking for. If a patient comes in and they are at increased metabolic syndrome risk, so their blood pressure is elevated, they are looking overweight, they don’t do much cardiovascular exercise, is what I know is the level of systemic inflammation within their body is significantly increased.

If somebody is diabetic, they generally have low vitamin D as well. If somebody takes antidepressants, that can significantly impair how your implants are healing. If somebody’s got high cholesterol, then that can also impact with how your implants are going to heal as well. So, I think it becomes a little bit unreasonable that if somebody was to walk through the door, that you just turn around and say, well, hang on before we do anything for you that we’re going to, you know, check your vitamin D levels.

We’re going to check your blood pressure. We’re going to check your HbA1c levels. We’re going to do this, check that, check, we’re going to check your cholesterol, because you’ll just turn patients right off. So my point being is that if a patient comes in and I’m doing more complex work, so if I’m doing full mouth, if I’m doing zygomatics, if I’m doing big sinus lifts or large bone grafting, things like that. I’m more likely to do these checks beforehand and the way that I say-

It’s like a risk assessment. It’s like case by case-

Risk assessment, systemic risk assessment. If a patient’s coming in, I’m a little bit worried, but it’s a single tooth. It’s just kind of like, well, I may pitch it to the patient, but if they don’t go ahead with it, then I’m not overly insistent on it.

Sometimes you get this odd patient where it come in and you put an implant in and it doesn’t take, you wait for it to heal. You put the implant in and it doesn’t take again. And you’re like, let me do a blood test. I’d say that 90% of the time. That blood test shows something undiagnosed, which has been impairing the healing for the patient. So we need to look at kind of like the general overall health profile of the patient and take it into balance with regards to what we’re doing as well. And the main thing-

I think, Pav anything surgery, like, I think even perio, just general perio, looking after periophile patients, these are often diabetic patients. There’s a rise in getting clinicians to take a step back and look the patient as a whole and look at their medical history and try and promote better habits and vitamin D and get checked out to boost even your perio outcomes. So it goes hand in hand with we’re doing if implants, and I saw one of your social media posts maybe eight years ago about how many patients are low in vitamin D and how it’s important to check this. I think I remember Hatem Algraffee also posted about this as well in his perio patients.


So these are things for healing. It’s all about wound healing.

So in fact, all of these things link back to osteoimmunology. So vitamin D deficiency and diabetes are linked. And they are also linked to MetS risk, and they are also linked to osteoimmunology. So what we’re finding now is all of these random things, which is kind of like, wow, we didn’t understand that that would be linked.

Actually, when you trace them back, they’re all kind of like falling underneath this umbrella of osteoimmunology. This is why over the next, I’d say, five to 10 years. The paradigm shift is going to be more towards the osteoimmunology way of thinking as opposed to just pure biomechanics. And it’s the right way to approach things because it helps us treat and plan for the future and it helps us understand the risks of what’s potentially going on now as well.

So, these protocols are essentially what you, I see you talking about it, super Superosseointegration. I love the term. Everything’s sort of like superhero base, Marvel base. I like it at zone of death, et cetera. I just, these are cool terms for me. So I love what you post about Superosseointegration. Obviously, we’ve just crashed the surface. You’ve got a two-day summit coming up about it. Please tell us more about how you’re talking about Superosseointegration. What kind of format is it going to be this event?

So it’s going to be a live two day event in the middle of September. It’s 15th and 16th of September and day one.

2023 in case you’re listening next year, 2023.

And it’s going to be what we’ve discussed in a lot more depth. So we’re going to be going into depth about osteoimmunology, how we do things, why we do things, decarbonization of implants, I’ll show full disinfection protocols, osteotomy protocols.

So we’re going to basically flesh all of this out that we’re talking about. Day two is a full arch treatment planning masterclass with a heavy emphasis on pterygoid implants. We’re going to tie in the osteoimmunology and all of what we discussed on day one into the full arch treatment planning masterclass and we’re going to have like a round table as well where we’re all going to kind of like brainstorm. So if anybody has cases that they want to discuss bringing together that they’ll get to look at it kind of like as a group, I think it will be a good exercise for everybody. So that’s the-

That sounds very engaging and group work. I love that way going. But is this like, is it a two day package or can someone who’s not doing pterygoid implants come to day one only like, who is the ideal person at what stage of the implant journey should they be coming to learn about Superosseointegration and your day two kind of thing.

So it’s not an independent package for each day. This is going to be best suited for those people who are placing implants and who are kind of like early on in their full arch career or are about to get into full arches and things along those lines.

Even if they’re not doing full arch, they’re still going to get a lot from the diagnostic aspects of it and from the Superosseointegration that we’re and the biological principles that we’re going to do on day one. It’s going to be really, really interesting because I’m going to take a lot of dogmatic paradigms and just throw them out the window Jaz and what’s the best way to describe it? I’ll take my fingers and put them into people’s heads mix their thoughts around a little bit. Yeah, that’s the way that we’re going to do it

Well, the other good thing about events like these is the networking, right? Implant dentists meeting other implant dentists around the country now, around the world who will be able to lean on for support set up, exchange WhatsApp numbers, keep in touch. It’s a great opportunity to meet like-minded people, maybe already doing full launches as well, or earlier on in the journey.

So it’s a good opportunity I think, even if it’s just some, if it’s a course that you’ve already done before, but it’s the ability to learn further from your protocols and also to just network. Networking is so, so important what we do and mentorship. So it’s always something to be gained there. I think.

Yeah. Absolutely agree with everything you said there, Jaz.

Amazing. What’s the website so people can just log in? I’ll put it in the show notes, obviously, but please just let us know the website so that people can book on.

So you can go to academyofimplantexcellence.com, reach out through there. Or if you go to Instagram and look for Dr. Pav Khaira, message me from there as well. And I’m pretty swift at responding to messages. So, because a lot of my time is now focused on the academy and mentoring. So yeah, I’ve got plenty of time to respond to messages.

What I’ll do as well is, protrusive.co.uk/AIE. Academy of Implant Excellence. So /AIE, it will take you straight to that event page. So when you share the event page with me, I’ll stick it on there. In case anyone didn’t get it, it will be a /AIE. And then that’ll just take you to the page. Cause I love to support you, get your people to network and mentored and do all the lovely things that you’re doing. So Prav, thanks so much for giving me time to talk about Superosseointegration, four ways that we can boost our osseointegration.

Thank you, Jaz.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end, as always. Whether you are chopping onions or on your commute, I hope you found that useful.

If you’re new to Implant Journey, amazing. Pav’s a great guy to learn from. If you’re more advanced, and I’m hoping some of those tips are going to be applicable to you to really elevate and raise your game, sometimes the whole systemic factors of patient, it can get neglected a bit. So this is a great thing, even in the world of periodontology, as we discussed.

After recording a few episodes with Pav, I really get an idea that implants, like many other things in life, are all to do with marginal gains, right? Getting those one or two percent things correct, and overall, they add up to get you a good result. So it’s really paying attention to detail, so if you want to learn from Pav, please do go on the website /AIE, that’s Academy of Implant Excellence, and that’ll take you to the event.

And of course, if you want a quick win and you want to answer a few questions to get CPD for this episode, so half an hour’s worth of CPD for this episode, just head to protrusive.app. That’ll take you to the web app and then all my episodes there, all my premium content’s there. We’re doing live webinars every month now.

I think the next topic is about vertipreps, so watch out for that one. And if you are going to sign up to Protrusive Premium, whether it’s CPD you want, because you’re already listening to the podcast or for the premium clinical videos, my request is that you sign up via protrusive.app and not via iOS and Android, ideally, because Apple and Android, they actually take a really huge percentage.

So if you want to support the podcast, you go on protrusive.app, make your login. And the cool thing is, once you download the app from iOS and Android, the same login that you made on the web app. That’s protrusive.app website. You can then use on Android and iOS basically. So that will, you get all the premium features without anything going to Apple, Android and supporting the podcast the most.

So thank you so much for the hundreds of you who support the podcast so that I can continue to do what I’m doing. I’m always happy in the comments below. If you’re watching on YouTube, or if you hit me up on Instagram @protrusivedental to have your recommendations, what would you as a Protruserati like next on the podcast? I’m all ears always. Thank you so much. Once again, I’ll catch you in the next episode.

Hosted by
Jaz Gulati

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