What Should You Do? Bone Loss Around Implants and Screw Loosening – GF014

Jaz’ Introduction:
Hello, Protruserati. I’m Jaz Gulati and welcome back to this second part of the group function. So we split it into two. On the first group function, if you haven’t listened to it already, it was “Can I probe that implant?” Is it cool to probe around implants? Because there was a myth that you may scratch the implant? So is there any truth to that? Should we be concerned? That’s all covered in part one. In this part two, we’ve got Dr. Pav Khaira, we’re talking about What is the normal amount of bone loss around implant? So when I am reviewing patients who had implants placed elsewhere, potentially, and I take a peri-apical radiograph, it’s been five years since they had the implant and my expecting bone loss. At what point do I get concerned? And what point should I refer? So we’re gonna find that out. And another very interesting controversial issue is, how do you as a GDP manage a screw loosening? So if the implant crown is loose, is it cool for us to be going in and tightening it? What about if you don’t have the right equipment? Or how to even identify which system it is. You have to stop every single driver there is? The very real world question there and I think Pav does great justice. So let’s hear it from Pav, and I’ll catch you in the outro.

Main Interview:
[Jaz] When you see a radiograph of an implant, let’s say a peri-apical. And I don’t know when this implant was on, I can ask the patient, the patient like a long time ago, five years ago, 10 years ago, they give me a vague answer. But anyway, am I expecting ever, is it acceptable to have threads exposed supracrestal, ie, all the threads are not in the bone, some of the threads are outside the bone, Is this acceptable? And be what amount of bone loss is normal? Because I understand that after you place an implant, after about a year, you expect to lose “some”, you’re probably gonna say yes, by do all this crazy voodoo magic that they don’t lose any bone. But for the average implant, what is normal in terms of bone loss.

[Pav]
So historically, what’s been considered acceptable is as a rule of thumb, bone loss down to the first thread, then about 0.2 millimeters per year, as you quite rightly said that these is, the modern techniques, the modern concepts, were really shouldn’t be seeing anything at all. But you know, I see loads of patients where they come in to see me where they’ve had implants placed 20 years ago, okay? And I think the issue is in the absence, in the absence of any inflammatory responses, like what we’ve discussed about before, there’s no bleeding, there’s no suppuration, the implants been there 20 years, if you’ve got a 15-18 millimeter long implant, you’ve got three millimeters of thread exposed, I’m really not bothered about it, okay? If an implant was placed last year, and I’ve got three millimeters of threads exposed, all of a sudden, I am bothered about it. So I think it very much depends on the case. And with regards to how many threads are acceptable to be supracrestal, again, that depends on the implant, okay? Because some implants like the Southern that I use, the top three or four threads, it’s actually a machine surface. So if there are threads exposed, it’s not really that impactful, it’s not really that significant. But if you had an implant, such as Nobel, they integrate nicely, but if you look at the surface topography of them, there’s tiny little caves. So what happens is, as soon as that’s exposed, and you start to get inflammation, it zips down the surface of the implant. So it depends as to the surface treatment of the implants. As a general rule of thumb, you should see a bone off down to the first thread in the first year, but even then, I wouldn’t be overly happy with that. But I think if you’re taking consecutive radiographs, and you see everything’s nice and stable, then why should we bother and intervene and do something right? If you’re taking PAs once a year and over a five year period you know, if in year one you’ve had two millimeters bone loss and no bone loss since then, it’s a stable outcome. But if every single, year you losing one millimeter half of it, that’s obviously then an issue we need to intervene and do something. So again, I’m sorry, it’s not a you know, clear cut but…

[Jaz]
Nothing is clear cut but that’s a useful guideline, Pav. I really appreciate that because it’s a bit like a periodontal patients, age is a factor and obviously age of teeth. In your case age of implants, we can apply similar logic to that, so that makes perfect sense and I think that’ll help on the Protruserati and th, have you got a word for the dental implant podcast listeners? Have you listeners have they got like a fan word?

[Pav]
I’ve used the term titani-nerds a few times.

[Jaz]
Say that again? Titani-nerds.

[Pav]
Titani-nerds. Yeah.

[Jaz]
Okay, I love it. Titani-nerds. Okay, so Protruserati, Titani-nerds, I hope you’re getting some value from that. I imagine the Titani-nerds are just know all of this stuff already. But maybe someone who’s interested in implants, interested in getting into implants. And this might be helpful because they’re seeing patients in their helping to maintain implants, which is what this episode is about. So my last question is now that emergency phone call you get, the nurse says or the reception says okay it’s a patient with a loose implant. The first time I had this is embarrassing, the first time I had this as a DF1, patient came in, and the crown was spinning. And in my head I thought, wow, this is like a grade three mobile tooth. I don’t know, I think the implant’s spinning. So I call my trainer and I said, Hey, Reg, I think the implants are like, fully loose. But the X ray looks okay, what’s going on? And he just like took-took-took, took out the access cavity restoration, just tighten it by quarter turn. And that was it. And I was like, wow, that was so easy. And then later on when I got to do this, one, the implant dentist told me that Jaz, you know, I read your notes, you tighten it too tight. And I’m like I didn’t know, what was I supposed to tighten it to? Because that’s what Nobel taught me when I went on course once. So A) Do you think all general dentists should know how to manage this emergency and be any guidelines, any helpful things that you can tell us, is there a standardized number of Newton’s that were tightened to for example, is the kit standardized? Am I expected to have all these kits.

[Pav]
So this is a real bugbear and it’s a real pain in the backside for me, because there are literally hundreds, if not thousands of different implant systems out there. They all use different screw heads, they all use different torques, it can be due to a number of different problems. It could be screw loosening, it could be what’s called a titanium base that’s come loose, it could be the hex that’s threaded, it could be the implant head that’s fractured. And you’re basically taking a shot in the dark with this type of stuff. While probably recommend to a general dentist who doesn’t place implants, the only thing that you should really be looking at doing is at the most is tightening it finger tight, and then sending it to somebody else to deal with, okay? Because I had a patient come out to see me. So what I never do is I never just re-tighten screws, always have to order a brand new screw, okay? So I’ve had a couple of patients recently, come out to see me, the works absolutely beautiful. It’s come loose. So what I’ll do is I’ll hand tighten it, I’ll say, I’ve got to order new screws, I’m going to swap the screws over, because screws become stressed and they become strained. That may be one of the reasons why it’s come loose. And if you re-tighten a strange screw you can cause it to break, then you’re in trouble because you may not be able to retrieve it from the implant head. So you only want to tighten it at finger tightness, and then you want to refer it on somebody else to deal with. So the issue that you have is certain systems like Ankylos, they’re quite happy to take 15 to 20 Newton centimeters. The Southern implant that I use take 14 Newton centimeters, if you get it wrong, you’re going to give yourself a problem. So you need to know exactly which system it is. And there are have been a number of occasions where I haven’t known what system it is. And I’ve had to take an educated shot in the dark. And that’s all that I can do. So the answer to that question is, is are you going to see it? Yes, you are. Okay? And I think another big aspect, another big problem that this is caused by is very frequently, when dentists get the lab work back from the lab, they’ll use the same screw that the labs been using, they won’t order a new screw. And I’d say historically, that’s what I used to do, because I didn’t know any better. But people like why should I spend another 40, 50 quid on a new screw and all that one, there’s one that’s here. Thing is the lab has been screwing it on and off, on and off. And that screw’s strained, it’s not appropriate to use anymore. So this is something that Riaz and I discussed in our podcast as well, Is the lab should order a brand new lab screw and you should get a brand new prosthetic screw for every single case. Not be reusing impression copings you should not be reusing lab analogs, you should not be reusing healing abutments everything should be fresh brand new for every single case. The other issue that you can have, we spoke about this lollipop type appearance on a number of occasions. So another issue that you have is particularly monocytes is if you’ve got a narrow implant, which has had a small healing abutment on it. And the lab is they’re trying to create some sort of contour to the crown. Quite often the lab will put in a little bit of compression onto the gums to try to give it some sort of contour as it’s coming out. And what happens is as you’re torquing it down, let’s say you’re torquing it down to 35 Newton centimeters, that compressions going on to the soft tissue not onto the actual interface itself. So you get patients back quite quickly with loose crowns.

[Jaz]
Yeah because all that’s happening is a soft tissue is getting compressed, but the screw is not engaging where it should be, right?

[Pav]
Yeah, so the screws not fully seated. It’s partly seated. And sometimes you get away with it but a lot of the times you don’t, so my protocol is A) make sure that the crown’s completely passive is going in. I will then torque my abutment to whatever torque it is, depending on which implant it is that I’m using, I will then wait 10 minutes, and then I will re-torque it. Because re-torquing after minutes, make sure that everything’s really nice and secure.

[Jaz]
Amazing. I think that makes perfect sense. But I think the message for someone like me, which I took away from that is, if in doubt, which I’ll always be in doubt, because I don’t know which system was used, I’m going to finger tight in it, and send it back to the person if I don’t know who, you know, what brand of implant it is, and I’ve got my implant placing dentist comes in once a week, they can easily deal with that. And I’m sure they’d be grateful that they get an opportunity to properly deal with that. However they would and like you would. So I think finger tightening is something that a lot of dentists can do. And the drivers, the universal ones. Are they as universal as the name suggests?

[Pav]
No, they’re not. They’re just called universal drivers. But they’re just…

[Jaz]
Oh my goodness

[Pav]
It depends what or what extent you want to go to, you can get little kits for about 300-400 quid, which you’ve got loads of different drivers in and you just try whichever one so the case that I had today, I knew which implant brand it had. But when it was originally placed, it was over torqued to the head of the screw it stripped. So getting it on and off was really, so even with the correct driver getting it on and off was really difficult, okay? So you can have 0.9 drivers, you can have 1.2 millimeters drivers, you can have 1.22 millimeter drivers. Straumann have got their own driver, Nobel have got their own driver. Neodent, they’ve made their driver similar to Nobel, it’s called the Unigrip driver, okay? But Nobel’s, Unigrip driver, and Neodent’s uni driver, they look almost identical, but they don’t fit in the same way. If all companies said, we’re gonna have a standardized universal driver, that’d be one of the best things ever, but it’s just not gonna happen. It’s just not gonna happen.

[Jaz]
It’s not gonna happen, just like Apple’s not gonna switch to the USBC and get rid of that white thing that you have to buy. It’s just not gonna happen. And you can see why. But mate, that has been so helpful. So we have covered in this episode probing, Can you probe? Yes, you can. But take a look at the radiograph first because those lollipop ones good luck, it ain’t happening. Threads are exposed kind of like perio, you have to depends on the patient’s age or ie the implant age, not the patient, the age of the implant and that should guide you. And the loose implant, perhaps consider finger tightening it and sending it back to someone who can deal with it in a more comprehensive manner. Like you would. So Protruserati, I know you found that helpful. Titani-nerds, I hope you did, because you guys are like you know, you’ve been following Pav. Pav taught you so much already. So you know, we could have easily gone on for like five hours talking about each minutiae. You just have so much knowledge and I want to distract. But please, for those people who haven’t heard your podcast, Pav, tell us, remind us how we can listen, how we can tune in, and what’s next on the horizon for your podcast?

[Pav]
So it’s The Dental Implant podcast on Spotify, iTunes and Google podcasts. And, you know, obviously, inspired by yourself Jaz, you know, I’ve said this before, you know, you’re the one that seems to be probably got a lot of knowledge, you need to get it out there. So it’s aimed at kind of like beginners and those kind of like partway through the implant training pathway. There is stuff on there for more knowledgeable people, but they tend to know a lot of this stuff already. And I just cover so many different topics. I mean, as you said, you know, I could write a lecture just on screws, which could last two hours, I can then write a lecture on how to tighten screws for another two hours. So you know, it goes into..

[Jaz]
All the complications in there and whatnot.

[Pav]
Yeah. And, you know, how to avoid complications, and, you know, what we should and what we shouldn’t be doing, you know, taking a part, the bad signs, et cetera. So I just tried to, again, I always say, look, it’s my perspective, you know, this is how I do things. This is my interpretation of the data. You don’t have to agree with it. You don’t have to like it, you know, but as you know, you can take one topic and you got two people arguing both sides of the coin, they’re both right, you know, it’s just, but I just want to help people deliver better care for their patients. This is one of the reasons why, you know, I mentor people as well. So when people like, I want to learn how to place immediate molar implants, it’s like fine, no problem, I’d show you how to do and bring your patients to me. This is why we do the EVO experience at EVO Dental, where you just come shadow us for days and see what we do. Because before I start at EVO Dental I thought I was proficient at full arches. But what we do there is just I wouldn’t do a full arch externally because just because of the way that the place is set up. So I’m done. Just you know, I’m very passionate about dental implants and trying to help others be just as passionate and get better outcomes for their patients because you know, it goes back to what we were discussing today, you know, is if I can teach dentists how to develop emergence profile properly, you’re not going to have these issues, if I can teach them how to place crowns properly and have soft tissue adhesion to the neck of it. We’re not going to have these issues in the future. So you know, that’s just my passion. That’s the reason why I’m doing it basically.

[Jaz]
And if anyone needed one more reason to listen to Pav’s podcast, he hired Morgan Freeman to do the intro. Can you believe it? He got Morgan Freeman. If you haven’t listened to it, you have to listen to it right now. Scroll on, go to Spotify, type in The Dental Implant Podcast. Listen to the intro. You will love it. Pav, thank you so much. Thank you so much for giving your time, really appreciate it. Thanks for all your mentorship and help and I think I won, I gained so much value I know what to do a little bit more now around those three scenarios which confused me every time, so I’m not going to, no longer gonna have my head in the sand now. Really appreciate it and hope you have a fantastic weekend.

Jaz’ Outro:
There we have it guys hope you enjoyed this group function series. As always a pleasure to do this and Pav is just amazing. He answered it really well, both parts of them. So Pav, thank you so much. Do check out The Dental Implant Podcast if you haven’t already, and I’ll catch you in the next episode guys. Be sure to join the Protrusive Dental Community on Facebook