Are implants becoming unaffordable for the average American? Do sealants really work? What is the standard of care for patients on bisphosphonates? These are just some of the audience questions fielded by Gordon Christensen, D.D.S., M.S., Ph.D., and a panel of experts at the Chicago Dental Society's recent Midwinter Meeting in their session, "Controversies in Dentistry, 2010."
In addition to Dr. Christensen, who served as moderator, the panel featured:
- Jay Beagle, D.D.S., private practice, Indianapolis
- Karl Koerner, D.D.S., head of the oral surgery department, Scottsdale Center for Dental Education
- Samuel Low, D.D.S., associate dean and professor, University of Florida College of Dentistry
- Peter Yaman, D.D.S., clinical professor of dentistry, University of Michigan School of Dentistry
Here are some of the Q&A highlights:
If implants are relatively inexpensive to manufacture, why is the fee to the patient so high?
"We are outpacing middle-class America when it comes to them being able to afford dentistry," Dr. Low said.
While he realizes that it takes a lot of work and energy to be a dentist in the trenches, "unless it becomes more affordable someone else will regulate it" -- and that's the last thing he would want.
Implants are a perfect example of this issue, he noted. "In the last few years, implant companies have seen an increase in net profits of 25% to 30%," he said. "But 12% to 13% profit is what you like to see for most dental equipment."
In the 2008-2009 economic scenario, patients would come in and get four implants, Dr. Low said. "But now patients come in and say, 'If you need to take that tooth out do it, but I may have to wear that flipper until I am able to gather enough dollars to be able to do implants,' " he said.
"I truly believe that we are going to have to control our fees," he concluded.
Sealants: Do they work?
Dr. Yaman feels that sealants are working. However, he does not like to seal a lot of teeth. Instead, he looks at patients and judges their caries activity. Even if it is a young child whose primary teeth had no caries and who is developing permanent teeth with no hint of caries, he said he is sometimes a little reluctant to seal those teeth.
"Maybe because once you seal that tooth, you actually put something on it now that may be worse than leaving the tooth alone," he said.
If the teeth have deeply fissured grooves and pits, that may be an indication that sealants are needed, he added. But he would not arbitrarily place sealants on somebody with a very low caries risk.
But sealants do work if they are applied properly, he concluded.
What is the standard of care for patients on bisphosphonates?
According to Dr. Koerner, it is critical to first understand whether a patient is on oral or intravenous (IV) bisphosphonates. For patients on oral bisphosphonates such as Fosamax and Boniva, the standard in the literature is that if they have been on the medication for three years or less, the surgery -- be it an extraction or implant -- can be performed without a high degree of risk.
"Personally, I would be a little more conservative than that and go with two and a half years," he said. However, if it's the IV form of the bisphosphonates, they need to be on it for less than five months for the risk to be low.
These patients can also take the C-terminal telopeptide (CTx) blood test, which can provide additional guidelines.
"I think the test has merit, but currently there is a debate going on in the profession about whether or not it is reliable and appropriate test so we don't have that to fall back on," he added.
Bottom line: If a patient has been on oral bisphosphonates for more than two and a half years, or on the IV form for more than five months, he would refer because they are higher risk and should go to somebody who has the ability to treat that osteonecrosis situation.
When would you do immediate placement of implants versus delayed placement?
Dr. Beagle would place an immediate implant virtually every single time he can achieve primary mechanical stability and has no concerns about immediate placement.
"Based on the literature, immediate placement has similar success rates as late placement, so we are looking at success rates of around 95%," he said.
However, there is one stipulation that needs to be acknowledged, he said: "Immediate placement is a complex procedure and needs to be done by a very skilled practitioner. Otherwise the success rates are not going to be nearly as good."
At what point should a tooth be extracted versus leaving it in and placing an endodontic crown?
This is a multifactor problem, Dr. Beagle said, because dentists have to look at the patient and determine the following:
- What the patient's caries control issues have been
- How experienced is the dentist in performing the treatment
- Whether conservative therapy is appropriate with that particular patient
"If a patient has a high caries rate, the tooth is severely broken down, and chances of failure are very high, I think we need to start thinking about extracting," he said.
But there are so many variables in the equation that you really can't single out just one example, he added.
What are your opinions on antibiotic prophylaxis, and what do you practice in your office?
Dr. Low feels that from the standpoint of surgical procedures, antibiotics are rather overrated when you look at incidences of infections.
"But anytime I put anything in somebody that's not theirs, I cover them with antibiotics," he said.
One that he has used for the last decade is doxycycline. He prescribes one tablet a day for 10 to 12 days for compliance, he said.
Do adjunct oral cancer detection devices work?
Dentists should be looking for lesions at all times, according to Dr. Koerner. "To see a lesion and not do anything about it is malpractice," he said.
There are different ways to approach it, he noted. If it is a lesion that you can see that needs a biopsy, you need to be willing to do that if it is small and in your comfort zone, he said. If not, you need to refer it. "Occasionally, if you wait a couple of weeks -- which is permissible -- the lesion may resolve itself," he added. "Otherwise, you need to have someone take a look at it."
Answering a specific question about the VELscope, Dr. Koerner said that he is a proponent of such fluorescence devices but, in his opinion, the VELscope works better when used with a camera.
"You need to be able to identify where the lesion is," he said. "I don't use the VELscope, but if I did I would use one with a camera so I could document the exact location of the lesion and communicate it to the surgeon."
Dr. Low noted that most dentists don't consider the head and neck exam part of the comprehensive dental exam. "That's where corporate enters the room," he said. "Many oral pathologists will tell you to go back to what we taught you in dental school and you will probably do OK, but you have do it."
Platelet-rich plasma (PRP) is highly promoted for grafts, but is it worth the time and the money?
A number of other products are available that you can consider to stimulate grafts, Dr. Beagle said. PRP may have some value in wound closure and healing, but may not have a tremendous amount of value in getting bone grafts to work better, especially when you compare it to growth factors that are coming out on the market today, he said.
"The BMP [bone morphogenic proteins] are certainly viable, and even something as simple as Emdogain would be a better choice than PRP," Dr. Beagle said. "I am not sure PRP has really stood the test of time and research to be the panacea agent in bone grafting."
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