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Implant Assessment for GDPs: from Space Requirement to Ridge Preservation – PDP052

Learning Dental Implants can be confusing. There are so many layers of complexity, from space requirement, restorative components and surgical nuances. This 2nd part of the 2-part series on Implants with Dr Hassan Maghaireh looks to guide us through the fundamentals of assessing your patient for implants.

We cover A LOT of clinical Implantology for GDPs

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

  • How do you assess the Implant space for the right mouth in the right patient?
  • When patients ask how long Implants last for, what should we tell them?
How long will my Implant Last? How to respond to this?
  • Can you place implants on Smokers? What is the protocol?
  • Bisphosphonates – at what point are implants contraindicated?
  • How can you tell if it’s going to be a complicated case?
  • How about Perio Susceptible patients and placing implants?
  • How will Parafunctional patients fare with implant restorations?
  • Who should take the tooth out?! GDP or Implant placing Dentist
  • I routinely section molars. Is that a good practice?
  • What is ridge preservation and when to consider this?

Protrusive Dental Pearl: How to use a pencil to draw line angles for anterior aesthetic composite restorations. I learned this from Dipesh Parmar on the Mini Smile Makeover course (next course in 2021)

Please do not use your wife’s Eyeliner

If you enjoyed Dr Hassan’s style of teaching, do check out the BAIRD Implant Course.

If you liked this episode, you will love revisiting Complete Dentures with Mark Bishop!

Click below for full episode transcript: 

Opening Snippet: Name two patients gave you hell in these 35 years. And he said, people who had history of periodontitis before having implants are going to get or at high risk of getting peri-implantitis after having an implant, so there will always be at high risk. And people who have parafunctional habits will always go into grind and break these implants for you...

Jaz’s Introduction: Hello, Protruserati. Welcome to Episode 52 of the Protrusive Dental podcast. This is the part two of the implant series with Dr. Hassan Maghaireh. Hope you enjoyed that part one we think about when you’re actually getting into implant when you’re thinking about starting implant journey. Is it right for you? Because that was the last episode. In this episode. We’re getting a little more clinical, reassessing, like what’s suitable for your first case? How would you assess the space, the mouth, the patient that might be suitable for implants? What are the patients to avoid? What about smoking? What about Peri-implantitis? What about bisphosphonates? So you really look into the nitty gritty clinical details about selecting patients that are suitable for implants particularly if you’re starting out. And in fact, I had to listen to this episode again, because so many gems in there about the timing of extraction. Sometimes I wonder, should I be the one extracting this tooth? Or should the person who’s placing the implant be extracting it? So we cover that as well, as well as something I do a lot which is sectioning molars. I’m a big fan of sectioning and elevating molars. And I asked Hassan, Dr. Hanssan what he thought about that, is it right that I’m routinely doing this? Is that a good thing? Or can we run into trouble? So lots and lots covered in this very clinical episode with Dr. Dr Hassan Maghaireh. This episode is sponsored by enlightened smiles and mini smile makeovers. So I want to share a great pearl that again, I get from Dipesh Parmar from the MSM course, which I went on over a year ago. It’s one of the best composite courses or courses at all I’ve ever done. The setup was great, the hands on was awesome. The food is always on point. Thanks to Payman Langroudi, that man. So the pearl I want to share with you is about line angles, right? So when we’re placing our restorations, let’s say composite restorations direct and we’re wanting to create those perfect line angles anteriorly. How do we do it? But you might have seen the trick where we can use a pencil to draw the line angles, and I’m going to show you two different ways to apply the pencil. And because I’m in the studio and not the practice, I don’t have a pencil. So instead of a pencil, I’ll be using this video and eyeliner. It’s my wife’s eyeliner. The funny thing is, I don’t even know if this is eyeliner or not, and I’m just assuming it is. So maybe the ladies can correct me but I think this is eyeliner is Maybelline ‘maybe it’s Maybelline’. Anyway, I’m getting distracted. And she’ll never know because she doesn’t listen to the podcast anyway. So I’m going to use it in two different ways. So if you’re watching the podcast and great, you’re gonna get see it. If you’re listening, I can describe it in a way that’s useful if you want to draw where your line angles want to be. So if you want to draw where you would like for the line angles to be, you should draw it with the tip of the pencil, like you’d normally use a pencil, right? So you draw it in, you know, left and right exactly mesial distal, exactly where you would like the line angles. So then you can use your soft flexed disc or burs or whatever you’d like to use to recreate exactly what you’ve drawn. Right? Now. If you want to see or assess where the line was currently are, so you know whether to push them in or bring them out. It’s a different way of doing it. So you have to hold the pencil, or the eyeliner, in my case on its side. And if you hold it on its side and you just brush against the tooth, the height of contour the tooth, ie the part of the tooth that sticks out the most, which is the line angle will pick up the pencil. So if you want to assess where the line angle currently is, you use the pencil on his side, if you want to draw where you’d like your line angle to be, you use it normally. So that’s a little tip on how to use the pencil. Now, how can we use it clinically in the best way obviously you won’t be using my wife’s eyeliner clinically, you the best bet you have clinically is using those clicky led pencils. So click click click because the beautiful thing about that is once you’ve used it, it’s been the patient’s mouth, you just break away the lead and then you click click click and you know that there’s no contamination there. And of course you can use one of those light cure covers plastic sleeves when you’re using it. So this is like the most infection control friendly way of using it. So hope you found that useful. And thank you again to MSM, minismile makeover for sponsoring this podcast. Episode now right over to Dr Hassan Maghaireh on a very clinical episode part two of the implant series. This is all about assessing your patients for implants. We even go all the way in depth from you know, from the start, we start basic all the way to talk about rich preservation. So, follow along, and I’ll catch you in the outro.

Main Interview:

[Jaz]
Okay, Dr Hassan Maghaireh, Welcome back to this part two that we were doing on implants. So the theme’s implants. The first episode, we talked about where your true self as well, we talked about the implant journey, getting into implants, some challenges, the role of mentorship and continued development. And this one, we want to make a little bit more clinical, because you mentioned something fantastic in that first part whereby, if you’re a general dentist, and you don’t provide implants, we still need to give our patients the option of an implant. And then if a patient turns around to us and says, am I suitable? What’s involved? Is it as simple as this straightforward? We need to have some background knowledge. So I’m hoping this episode will just scratch the surface about that topic. So, Hassan the question to ask is, how do you know that the patient in front of you, the mouth in front of you, or the space in front of you, is correct for an implant versus a different approach? How do you even begin thinking about this massive topic?

[Hassan]
Okay. The first thing you need to remember that when you look at a space, you need to be looking at like in bigger picture, rather than looking space that can mouth, look at the patient, okay? And as the patient comes to you asking for an implant, try to look at that patient as a series of risks and start to tick box. Do they have that risk? Do they have that risk? Do they have that risk? And if they don’t. Have all the threads, then you could say right, it’s safe now to proceed to dental implant therapy. To keep it simple. The only absolute contraindication for implant dentistry is as simple as uncontrolled medical or dental disease. Everything else is suitable. So you’ve got a diabetic patient, their diabetes are well controlled, perfect, no problem. Is their diabetes uncontrolled? then we cannot go ahead with implant dentistry. We’ve got someone with perio, is perio well controlled? Yes, then we can go ahead with implant dentistry. Their perio is not well controlled, let’s stabilize the perio and then talk about implant dentistry. Now there are some medications which can complicate the implant work. And the most popular ones are obviously Bisphosphonates. And I highly recommend looking at the document by the ADR called the white paper. And it’s basically it’s a consensus document done or the review document done by one of the professors invited by the ADI and it summarizes the guidelines. When is it safe to go ahead and put implant for someone in bisphosphonates or all the grip of that medication and when is it isn’t safe. To summarize that document, basically anyone on intravenous bisphosphonates is a high risk. And that’s to do with the fact that people who take intravenous bisphosphonates, they take it in high dose. So that’s one thing to remember, anyone taking oral tablets for long, long time, which means more than three years that also become medium risk. Now, all of this bisphosphonates less than three years can be a minimum risk, but the risk is there. And you need to be talking to patients about the exact risks involved in having implant dentistry while being on these medications. Another good thing to do with people on bisphosphonates or similar medications is basically to go for a staged approach. So try to you’ve got a patient needing three teeth out, take a single tooth out and see how things go into here. And then if that heals, well, you could move to the second tooth and so on. And then [ ? ] well after tooth extraction, you could say right, then maybe implant too can be safer. There will be some preoperative and post operative antibiotics needed and you need to have a minimum traumatic surgery. So I would highly recommend go and check that white paper by the ADI and I think it’s available for reference.

[Jaz]
I will add that on the show notes on the website, Protrusive website and the Facebook group as well. So that’s a really good point, and it’s good knowledge to have about bisphosphonates when it comes to you know, surgery, extractions and implants is no exception. So if when your patient, your little old Mrs. Smith comes in, she wants to have some implants to restore her sort of ability to choose something. And she has been on implants where the oral implants for seven years, you can think okay about the white paper and then that’ll help to inform you what the next step is, would you refer? should you place,? whatever you need to do. So that’s a good point. I’ll make that available.

[Hassan]
So the thing is about oral bisphosphonates that, nowadays, you know, GPs prescribed it regularly. And some GPs wanting to make it easier for their patients rather than taking the tablet once a day, they start offering to give injection to the patients, like twice a year or what whenever. So they move them from a low risk to high risk, although their medical history hasn’t changed. So don’t assume that, oh, she’s only osteoporotic, surely she’s not on injections, some of these patients are on injections, and you have to be double checking that.

[Jaz]
That’s a good point, because I just assumed if they asked what’s your [inaudible], there’ll be an oral and it’s the more the cancer risk, or whatever that would be taking the infusions at all very severe. So yeah, it’s a good point to double check your medical history.

[Hassan]
So basically, going back to the very first point, unstable dental, unstable medical diseases all these people want to keep away from. Now, as you go into implant dentistry further down further deeper, you need to start to think about, okay, what are the things which can complicate the future treatment? And I remember was attending a lecture by someone who had 35 years experience in implant dentistry. And it was a beautiful lecture at the end of the lecture, the moderator asked him and said, name two patients gave you hell in these 35 years. And he said, people who had history of periodontitis before having implants are going to get out at high risk of getting perio-implantitis after having an implant. So there will always be at high risk. And people who have parafunctional habits will always go into grind and break this implants for you. And I watched your episode about stents. And it’s really amazing. And I think this is something else every dentist needs to know about. Because if you’re going to offer implant dentistry to a patient, like it or not, they become [inaudible] implants. And you become somehow responsible for this long term success of these restorations. And this is where communication is very important at the very beginning. Because like it or not even in the United Kingdom, you will have patients thinking that the fact they’re paying you 3000 4000 pounds per implant that said, it’s going to be there forever. And they will forget the fact that they bought a car for 20,000 pounds. And that car is not forever. So I think that sort of education needs to be there in the assessment visits to our patients that, you know, yes, you’re having an implant, but there will be lots of maintenance and review visits needed afterwards.

[Jaz]
Just the flash question, Hassan, when a patient asks you, how long will my implant last? What do you say?

[Hassan]
Well, that’s a very good question. Because obviously dentists are under pressure to say, my implant will last you for life, don’t worry. But actually, you worried because if you go to the person and say, I cannot guarantee them, but do you worry that this patient might go somewhere else? So the best way to do it is to go and say, and this is why I say evidence based studies. So basically, it’s not my theory, it’s proper research, suggests that if implants are looked after really well, we can have a survival rate of 95% up to 15 years, maybe longer. Having said that, the same study suggests that if you fail to keep the implants clean, and if you get gum disease around your teeth, and your implant, your implant going to fail within the first couple of years. So basically, I’m making it clear that we will do everything to make sure you get that long term survival. However, it’s a two way equation. I need your help and your support to look after by two brackets your implant and I think patients need to understand that it’s their problem. They came to us with a failing tooth. They came to us with a missing tooth, and we’re doing our part and I genuinely believe every dentist is going to be an honest dentist trying their best to help the patient. But the patient needs to understand that they have in a role in these long term success should they wanted to be there,

[Jaz]
That’s a really great point. And it’s the same thing I talked about parafunction splint, you know, the reason I coler in my splints and then they grind it, and then they see the markings is that so they can begin to own the problem, because quite often, they have no idea that it’s there. And then when they see, and then they own the problem, to just start that, they to own that implant and own the problems that could happen with their implants, because it’s in their mouth, and they need to uphold the basic level of care and maintenance as well. So I’m sure that’s drilled into them excuse upon in some from the beginning as part of the consent process.

[Hassan]
100%. And that’s the other thing, you know, in the consent process, you talked to them about pre operative assessment, and then you talk to them about what we’re going to do during the surgical and restorative stages. But then the third part, which is as important is what’s going to happen after completing the work, and this is, again, where we’re talking about general dental practitioner, you know, every dentist should have the absolute minimum knowledge on how to maintain a dental implant, at least how to diagnose peri-implantitis, how to diagnose continuous bone loss around the dental implant, and when to refer that patient back to the dentist. I had one of my lovely referring dentist bless her, she referred me a central incisor case, I’ve done the case everything went perfect. And then they for one reason or another patient driving with teeth at night, the screw went loose. So then the patient went to see his dentist and then don’t worry about it, we’ll wait for it until it comes out. She didn’t know that you biting on a a tiny loose screw is going to break that screw. And then that case was sort of converted from a simple case where you tighten the screw in three minutes, to a very complicated case where we have to put the patient through one hour of screw removal, which was very stressful for the patient and for us as well. So these little things, I mean, this is an invitation to every single dentist to go and look for these open evenings, continuing education conferences, they need to know about implant dentistry. And I think that’s something you and I covered in part one.

[Jaz]
Absolutely. And I think you raise a great point, if you’re a general dentist and you know, we’ve all seen it, the patient that comes in and their implants are swiveling around. And if you don’t know anything about that you think oh my god, what’s happening? the implant’s loose. You know, if you’re newly qualified, like, Oh, my God, what’s happening, I need to call someone This looks really serious. But it’s just as simple as just removing the implant restoration composite that’s on top and removing the ptfe your cotton revolute place there and just giving a little Titan quarter turn whatever, and then putting the restoration back and your patients are happy and you’ve avoided this complication. So it’s about that, just like I said, again, that level one, level two knowledge which is which is so key. And we don’t get that why certainly didn’t get that in my undergraduate to the extent that I’ll be confident to deal with that situation. Unless I had and sort pursued extra courses and knowledge to do that and or add mentorship and guidance. Hassan, that tell me about smokers? Because that’s a huge one, right? My patients smokes. And I need to let’s say refer them to my, our in house dentist who places implants. Is there any point where an implant dentists will say no, I definitely will not. Is there a minimum number and the evidence says that if you smoke above this point, there’s no implant for you. If you smoke between here and here, we might do it if everything else in our favor. Do we have a magic number?

[Hassan]
Yes. Well, I mean, we have very good research from Professor Bain. And he’s basically he’s a British Professor based in Scotland and he’s done amazing research on smokers and implants in the mid 80s, early 90s and at the time, it showed that smokers will have higher risk of implant failures okay? But then that most of that research was done on machined implant on the polished implants which let’s say the old style implants. Now, more research was done by Professor Bain and his group and other you know, research in the dental literature. When we have the modern implant services which are implant services treated differently, to encourage better osseointegration it shows the actually smoking will not really influence osseointegration as we felt before, having said that, we do have good research showing that let’s say if we talk about survival and implant dentistry 97% as a smoker, it goes to mid 80s so there is a risk. And that’s to do with the fact that we know, when you smoke, you’re going to affect the oxygenation to the little capillaries supplying blood supply to the bone and the surrounding bone. When you smoke, you’re going to get high risk of wound dehiscence. When you smoke, that normal flora inside your mouth gonna be converted into very aggressive bacteria. So that balance inside your mouth is not going to be right anymore. So you’re always at higher risk of having complications. Now, if you are a smoker, and you have a perio disease, that’s when you get like synergetic negative effect. And that’s when things start to even cause more damage. Now, to summarize, when it comes to implant dentistry, some research suggests that if you smoke 10 or less, you’re classified as light smoker, and that will not have as negative effect if you’re heavier smokers 20, 15 cigarettes a day. That’s really number one. So I’ll go talk to smokers. And I tell them, do you know what I know you will never stop smoking, despite whatever I’d say at least cut down to less than 10. Having said that, there are very good articles and studies showing stopping smoking for about 60 days or so will bring you back as a healthy person when it comes to blood oxygenation, and good healing abilities. So there are some random control trials done on rats. And they found that these rats who smoke they have very low bone density, very low ability of healing. But then when they make them stop smoking on within 60 days, they come back to as healthy as the control group. So stopping smoking does make a huge difference.

[Jaz]
I couldn’t keep a straight face that I’ve just got this image of this rat holding the cigarette.

[Hassan]
I have the image of the Big Bang Theory. Well, let’s say men. Yeah,

[Jaz]
Sheldon.

[Hassan]
Sheldon. His girlfriend, Amy?

[Jaz]
Okay, I forgot the name of the girl. Yeah,

[Hassan]
She’s, like studies on monkeys, if you remember, I’m giving them about six. So rule number three, we talked about, you know, smoking less than 10 is better than heavy smoking. Rule number two, as we talked about stopping smoking makes huge difference. And first, all that negative effect. And rule number three, smoking itself can work with implant dentistry. But I go to the patient and say, don’t come and ask me why I had no papilla or why I have recession after my surgery. So don’t expect to get cosmetic implant dentistry or aesthetic, soft tissue come to if you’re a smoker. And rule number four. If you need bone grafting, or sinus grafting, it’s an absolute contraindication in my book, because this is where things start to be more complicated. I will now with confidence, say I will never do sinus graft for a smoker. I will hesitate 100 times before I do bone blocking grafting for a smoker. Because anything needs advanced surgery needs huge amount of blood supply, smokers will just won’t work for them.

[Jaz]
Brilliant. That’s a nice little summary. So less than 10. 60 days you mentioned and really to avoid it in patients who might need advanced work and to tell the patient is that not expect a cosmetic benefit from the soft tissues. That’s a really nice, I’ve certainly gained from that myself. So when I’m seeing smokers now I have a bit more confidence speak about them and be make sure that my referrals to my Implant Dentist are more appropriate. Of course, I’ll send it to my Implant Dentist anyway to have that chat. But I can have that little bit of confidence in myself that you know we’re on the same page. So that’s grant. And lastly I want to talk about clinically because we there’s so much we could talk about and I want to make it most valued for those listening mostly GDPs, when you have a patient who has an unrestorable molar, let’s say and it may or may not have a apical infection, how do you decide between ‘Hey, should I send it to my, if they’re asymptomatic, should I send it to my implant dentist to assess before the extraction or should I extract the tooth then send it or can I can you predict whether something will be an immediate placement or will the implant dentist or wait a bit? How do you even begin to come to those sorts of decisions?

[Hassan]
Okay, obviously I mean different implant dentists will like to work differently. Okay. But I think the most important advice is try to communicate with your implant dentist. Personally, I prefer to see them before having the tooth out. Because as an implant dentist, one of the things which will help us to predict the long term survival of this case, and to decide how to manage this case is to look at the tooth before it’s been out and know why that specific person needing to lose that tooth, was it due to perio or was it due to infection, or just unresolvable cracked tooth. So that makes a huge change in the workflow and in the long term survival. So that’s number one. Number two, try to think about an upper molar. And sometimes this upper molars have roots, either touching the floor of the sinus or sometimes even poking into the side. And you know, the moment you take that tooth out, the sinus flow will just collapse all the way down. And the way I described it to my patients, I tell them, think about posterior teeth, like a pole supporting a tent, you remove the pole, the tent drops down. And the same thing happens, the moment you take a posterior tooth especially if it’s touching the sinus or bulking to the sinus, you’re going to get what we call Sinus pneumatization, expansion of that air cavity, which will complicate the implant case later on. Because that patient might need to go through sinus elevation or sinus grafting. Now, if we did decide to take that tooth out, and maybe go for ridge preservation in the same visit, take the tooth out and pack some process bone into the socket with some soft tissue graft on the top. That will minimize bone remodeling in that area and preserve the outer shape of the ridge and keep that sinus floor high up. So then that case will be straightforward case 12, 16 weeks afterwards. Why I’m saying that? Because you know what we said there are people who do implants. But to do sinus graft, you need to even have more advanced training, and you need to even pay more for your indemnity. So not every Implant Dentist can deal with sinus grafting because of either they don’t have the training or they don’t want to pay this for time indemnity. Okay, so we’re talking about the difference between like 3000 pounds versus 12,000 pounds for indemnity for example, if you touch the sinus so by doing this, you avoid getting your patient through sinus grafting. And another important reason some patients especially in England, you’re going to or Glasgow or Scotland or UK in generally, you’re gonna have people with really inflamed sinuses, thick lining or infected sinus and it would be nice to not do any surgery close to the sinus. So by doing this ridge preservation can help. So in general, my advice to you whether it’s anterior or posterior, the moment you and your patient reach a decision that this tooth unepairable and beyond repair, refer to the implant dentist while the tooth still there, it will make a huge difference. Now, what protocol your Implant Dentist gonna go for, don’t do the very detailed assessment. And then we can decide to go for immediate or early or delayed. Anything within the first 24 hours called immediate, anything up to eight weeks according to Cochrane classification called airly and anything after that, we call it delete. Now this is Cochrane Collaboration classification. The ITI has a different classification is to do with the healing process. Fresh extraction socket, type one. Soft tissue healing but not bone healing, and that’s type two. Soft tissue healing with partial bone healing, type three. Soft tissue healing and full bone healing, type four. So the difference between the ITI classification and Cochrane classification, Cochrane is more time scale, while ITI is more like biology and certain healing process because type two for a molar let’s say after eight weeks time, that molar will be type two. The central incisor will be type three three, for example. So you know what tooth you’re dealing with. Each of them has its pros and cons. You know, I know some people like immediate because it says patients having too many surgeries and, you know, get the workflow quicker. But then immediate have some risks, if especially if they’re done in the wrong patient, you need to have a scan to check the bone volume, to make sure there is no latent or sleeping bacteria if you like or infection in that area, you want to make sure that the person has thick gum thick bio type, because if you have the thin body type, you might get recession, you want to check that lingual plate is intact or not. So there are certain criteria, a person need to know whether this patient is suitable for immediate or not. Cochrane Collaboration through their systematic reviews found that the safest is to go for early because with the early, where you if you have any remaining infection that would be gone, most of the remodeling would take place. So when you open the surgical site, you know what you’re dealing with. And you haven’t lasted too long, like delayed, so you don’t get too much bone shrinkage. But yeah, I think it’s all about communication. And I’m sure every Implant Dentist would love to talk to you as a referring dentist about what, you know, the best way forward.

[Jaz]
I mean, everyone has their own clinical preferences. So definitely what you mentioned that have an open conversation to say, yes, you said that generally, it’s nice for the implant dentist to see the tooth. And it makes so much sense to me, you know, to actually all those reasons that you mentioned, for them to have that opportunity. Because you know, you don’t always get that opportunity. So when you have the opportunity, we know this tooth needs to come out, to have that chat, to have the scan, potentially stent or whatever, that can all happen with the implant dentist. And that’s a really good idea. But to have that open conversation. So even just to send an email or some photos or some x rays to your implant placing dentist if you’re not placing yourself can carry a lot of weight I think. The next question I had is, do you or would you always section and elevate upper molars, which is like a routine thing for you to do?

[Hassan]
That’s a very good question. Because, you know, preserving the bone can make a huge difference. And the way we teach and the way I was taught that rather than taking an upper molar, try to section it into three small anterior teeth. So imagine this big molar with three roots section into three small roots, and then they’ll come out easily. So that case will be converted into an easier case. And then the chance of you damaging the bone will be much less. Definitely that’s the way forward. But the question is, what do we do after having that tooth removed? Are we going to leave it? But are we going to do immediate placement, or are we going to do ridge preservation? And that’s where and this is another invitation for general dental practitioners to know more about ridge preservation even if they don’t want to do implants. Imagine you’re taking that upper pemolar , let’s say you’re taking up a second premolar out. And the treatment plan is to go for a bridge, just a conventional bridge from the first premolar to the first molar, right? So you remove the five, out then you do nothing, what’s going to happen to the ridge? It’s going to collapse all the way right? Buccal Lingually. So you come to restore it, you have two options. Either your lab technician gives you a nice looking tooth with like a ridge lap. So you don’t see that collapse. But then that ridge lap going to attract food, so it’s not going to be hygenic restoration. Or you go to your dentist, to your lab technician say no, don’t get me ridge lap, give me enough of a contact. So it doesn’t trap food, but it’s going to look ugly. Well, if you’ve done ridge preservation, it’s going to preserve the ridge for you. And then you can have a nice looking but also hygienic restoration. And hence, this is an invitation for every single dentist to look into ridge preservation techniques. Even if you don’t want to do implants and it’s simple. You take the tooth out, you clean the socket really well, you debribe the socket really well. Either with an excavator, or if I can say there are very good, deep granulation burs you could buy and then they clean the socket really well for you. They remove granulation tissue but they don’t remove bone on your slow handpiece and then you decide what bone material you’re going to use according to whether you’re going to leave it and not and put implants at all. So you could use xenograft calf bone for example. Or you could if you want to come back and put an implant then we can use allograft or alloplast and then you get a little piece of the gum which you can take it from the retromolar area, cut like a circle and stitch on the top, obviously that’s a very simplified way of it. But what I’m trying to say it’s not complicated. You don’t need to be someone really experienced in oral surgery to be able to do ridge preservation. And I strongly believe every general dental practitioner should know how to do ridge preservation, even for conventional dentistry.

[Jaz]
Hassan, I love the point that you made about actually forget implants, even for a bridge to do that socket preservation, it really brings the point home really nicely. So I really appreciate you making that point in that way that you did it. That’s really clever. And I think it’s a really good skill I can be really I’ve been a few courses that takes heads. It’s not rocket science, I have say, a silly GDP that myself, I think it’s very possible to pursue. And I think it makes a great difference. So the last question I have as a GDP, who wants to learn more about implant dentistry about the clinical side from you just a flavor is just on the very theme of let’s say, you remove a premolar and then you get that buccal, lingual sort of resorption natural healing process if you like, Is there evidence that early or immediate placement implants or preserve bone or is that false thinking?

[Hassan]
Okay, there was an old school of thoughts thinking that immediate placement will preserve bone and that’s false thinking. There are very good study on animals, random control trials, john, where they took it tooth out and then put an immediate implant and they found on no change in the bone loss. Let me just throw out some numbers here. Your buccal lingual bone shrinkage will depend on the biotype of that case, if you have thin biotype which means thin gum thin layer plate underneath you’re going to get 50% buccal lingual bone loss so that ridge of eight millimeter can go to four millimeter within the first 24 weeks which is huge damage. If you have thick biotype, you get up to 20% buccal lingual shrinkage within the first 24 weeks. So that’s sort of evidence base fact. Now people thought okay, let’s put an implant there and stimulate the ridge and see what happens. They found the same level of bone shrinkage. Other study said Okay, what about if we put an implant and do immediate loading to stimulate the bone even better, they found no difference, you will still get the same level of bone shrinkage and the risk here if you put a wide implant as people used to do in the past, to get good stability in that socket as the bone shrinks, these threads will start to get exposed and you start to get a dirty implant infected area. Therefore, nowadays even if people want to go for immediate placement, we know that we go for a narrower implants and allow for a little gap and that little gap will be filled with bone. So if we get that buccal bone shrinkage, the process bone will stop the gum collapsing further down. And we get our primary stability whenever we do immediate placement from the apical 1/3 rather than the coronal 1/3. So we always go for longer implant getting bone stability from the bone beyond the socket. So to summarize, no immediate placement will not minimize or stop bone loss. Putting diamond in the socket will not stop bone loss. So bone loss will take place just because you and I and everyone else listening are humans made it biology.

[Jaz]
Should you be doing socket preservation for every single extraction, then?

[Hassan]
Okay, personally, if I want to use the correct term, I like to use ridge preservation because we cannot preserve the socket. Okay? So that’s number one. Number two, depends what you’re gonna do afterwards. If I’m doing a conventional bridge, I will do ridge preservation. If I’m doing, if I’m placing an implant after the year, I will do bridge preservation. But if I’m placing an implant after eight weeks no, I mean, eight weeks is good enough for blood clot to form nicely. I will come back, place my implant and do my guided bone regeneration at the time of my implant placement.

[Jaz]
Amazing. Well, that’s a lovely sort of overview on some of the clinical aspects, you know smoking, you quite quite correctly said ridge preservation, and a few patient related factors such as bisphosphonates, which are such common things that we see in practice, day in day out. Hassan, any closing comments on clinical implantology for the GDP, or the ones who are sort of starting out in their implant career.

[Hassan]
I like what one of my friends told me the other day, you are, the average of your best two friends that the two best friends you have. So my advice to you always try to link yourself with successful people. Because you know, try to always be part of the group. And by doing that, you’re going to have motivation to take you forward, you’re going to have this push from your colleagues to become a better dentist. You need to be closing your eyes, not while you’re driving, but later on, closing your eyes and try to think Where do you see yourself five years down the line, how to target and work towards that target. And if you see yourself five years down the line doing implants dentistry, pick up the phone, and start asking friends look for a good course. And don’t allow anyone to put you down getting into this beautiful field of dentistry. It’s one of the most rewarding aspects of general dentistry is to try to build something out of nothing, or restore people’s confidence. I know putting veneers are great. I know straightening the teeth is amazing. But do you know what? I think there is nothing as good as converting someone from a conventional denture to a fixed bridge and giving them their life back. So you know, guys, the market in the United Kingdom needs more Implant Dentist, just to give you an idea. UK has the least number of implant dentists compared to Europe, when it comes to comparison number of implant dentists per population. And there is huge potential there for you, go for it if you think you can do it. But if you want to do it, remember, it’s a marathon. It’s a continual education, just like any other aspects in dentistry. Thank you very much.

[Jaz]
Hassan, Thanks so much. And any details of Hassan course? Is it part of the BAIRD? Is that the umbrella for your course?

[Hassan]
I am the scientific advisor. I’m the head of the Scientific Committee of the Bridge Academy Implant Restorative Dentistry, which is B-A-I-R-D. And please, if you have time, you can look at our Facebook page or our website, which is baird.uk.com. And we do run short courses, long courses. And we do collaborate with different universities in the UK and in Europe as well. And you know what? Pick up the phone come and speak to us, even if you just want to have a chat about how to pursue a career in implant dentistry, or whether you want to double check if it’s the right thing for you or not.

[Jaz]
That’s amazing. Hassan, I just want to say as well, I think the next step for anyone listening or watching this, and you haven’t started on the implant journey is would you agree, Hassan, maybe the next step is to pick up the phone and maybe find the person in your area who’s placing implants at the moment. And hopefully the pandemic is going to be by the time this come out on the downward slope. And hopefully, you can start shadowing some Implant Dentist, Wouldn’t that be great?

[Hassan]
Golden advice, Jaz, golden advice.

[Jaz]
I got it from you, my friend. Hassan, Thank you so much. I really appreciate you coming on and sharing your sort of journey, ideas about getting started and also a few clinical things that a lot of dentists tend to ask misconception dentistry about, you know, ridge preservation stuff. So really appreciate all that. And I wish you all the best. And it’s been great connecting with you. Thank you so much.

[Hassan]
Thank you Jaz and good luck with your beautiful podcasts. They’re very useful. And well done. Keep up the great work, man. Thank you.

[Jaz]
Thank you so much.

Jaz’s Outro: So there we have it. Thank you so much for listening all the way to the end. Listen, if you found value from this episode, if you’d liked the implant sort of themes that we covered and you like the content I’m generating, please do me a favor and share it with a friend who you think will benefit. If you want CPD out of it currently it’s on dentinal tubules. So if you’re tubules member, check it out. You can get your CPD by answering a few simple questions. If you’re not a tubules member, then that’s just another added value you can get from tubues so check them out. And again, I really appreciate your listenership always, please do hit that subscribe button. I’ll catch you in that next episode. Thank you.

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Jaz Gulati
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