Why are implants used at all?

[TSDentSurg]

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Here's a very interesting question: why are implants used at all, barring endodontic lesions that require extraction? Could this be done to regenerate the PDL?

1. Spin patient's blood for L-PRF
2. Raise a Widman flap to expose the affected area. Perform SRP.
3. Wrap the roots of the preserved tooth in Osiris Therapeutic's Grafix (http://www.osiris.com/grafix), an MSC-rich biomembrane, and then L-PRF, which will assist the Grafix in regenerating the PDL. Cover roots with Bio-Gide, rough side facing gingiva, so the MSCs in the Grafix will differentiate into chondrocytes as opposed to osteocytes.
4. Place Bio-Oss into the alveolar defects, cover with Bio-Gide (smooth side facing gingiva), and close the flap
5. Place periodontal splints to provide stability, if not already present.

MSCs are progenitors of chrondrocytes, and should help rebuild the PDL. The addition of L-PRF will assist this process.

I've been reading some papers on stem cell therapy in orthopedics, and the orthopods have had good results with using MSC-containing materials in tendon and ligament repair, so it seems like their results could translate to periodontics.

 

[wigglytooth]

Because you can only get back bone up to what you have. If your defect is too wide or too deep, then you are asking a lot of your regenerative materials. Also, add up all of those materials in terms of patient cost. Can the patient afford all of that? Someone else commented to you to embrace the concept of Ockham's razor (http://en.wikipedia.org/wiki/Occam's_razor), and while I like to save teeth when I can, I implore you to think about this concept when treatment planning as well. On the flip-side, if you feel strongly about the MSC graft, then go for the research project. Contact the company and see if they will fund it for use in periodontal defects.

 

[TSDentSurg]

Because you can only get back bone up to what you have. If your defect is too wide or too deep, then you are asking a lot of your regenerative materials. Also, add up all of those materials in terms of patient cost. Can the patient afford all of that? Someone else commented to you to embrace the concept of Ockham's razor (http://en.wikipedia.org/wiki/Occam's_razor), and while I like to save teeth when I can, I implore you to think about this concept when treatment planning as well. On the flip-side, if you feel strongly about the MSC graft, then go for the research project. Contact the company and see if they will fund it for use in periodontal defects.

I think I just might do that! They'd potentially get a bigger market, and we periodontists will have another weapon in our armory in the battle against gum disease.

Honestly, I'd offer both choices to my patients: I can extract these mobile teeth, do a bone graft to replace the lost bone, and put implants, or, we can try to save these teeth by also grafting mesenchymal stem cells to regenerate the lost periodontal ligaments that keep your teeth attached to the bone. Putting implants in will require two surgeries, one for the bone grafting, and another to place the implant. This MSC and bone graft to regenerate the lost PDLs will only require one, but it may not work, and is costly. How badly do you want to keep your natural teeth?

 

[Noble6]

Tooth loss due to caries? Even if you replace the tooth, you still have to restore it.

Implants can be cheaper and less labor intensive then RCT/BU/Crown lengthening/Crown and have a nice success rate.

 

[Mackchops]

People will always lose teeth and there will always be a need for replacement in addition to regeneration. That replacement may not always be a titanium screw. But saying that people won't lose teeth if we can figure out how to regenerate the PDL is like suggesting that there shouldn't ever be a need for root canals because fluoride and a fillings can cure caries. Ultimately there's a person attached to that tooth and frequently that person sucks at getting their teeth taken care of early enough to prevent more aggressive treatment.

The perio gods have been trying to unlock the secret to regenerating the PDL for years. It would have therapeutic indications but nothing's a cure-all. Now, if you want to figure out how to regenerate an entire tooth, THEN you'd be on your way to a Nobel Prize!

 

[DrJeff]

Here's a very interesting question: why are implants used at all, barring endodontic lesions that require extraction? Could this be done to regenerate the PDL?

1. Spin patient's blood for L-PRF
2. Raise a Widman flap to expose the affected area. Perform SRP.
3. Wrap the roots of the preserved tooth in Osiris Therapeutic's Grafix (http://www.osiris.com/grafix), an MSC-rich biomembrane, and then L-PRF, which will assist the Grafix in regenerating the PDL. Cover roots with Bio-Gide, rough side facing gingiva, so the MSCs in the Grafix will differentiate into chondrocytes as opposed to osteocytes.
4. Place Bio-Oss into the alveolar defects, cover with Bio-Gide (smooth side facing gingiva), and close the flap
5. Place periodontal splints to provide stability, if not already present.

MSCs are progenitors of chrondrocytes, and should help rebuild the PDL. The addition of L-PRF will assist this process.

I've been reading some papers on stem cell therapy in orthopedics, and the orthopods have had good results with using MSC-containing materials in tendon and ligament repair, so it seems like their results could translate to periodontics.

Long term, what will be the more reliable result? That titanium implant covered with a porcelain of some type, both of which can't get decay regardless of what a patient does to them, or a re-implanted, splinted tooth, which more often than not becomes a candidate for extraction and some type of replacement because of long term poor patient oral care habits?

This is one of those things where sometimes just because we have the technology to do something utilizing mother natures "original equipment" that it may not be a good a LONG TERM result as what our modern manmade options can provide.

After all when it comes down to it, most patients are concerned most with how long it lasts, then how much will it hurt getting it done and then what it costs (feel free to shuffle that order if you want)

 

[yappy]

But Dr. Jeff... isn't natural always better?

I think you raise some good points, Dr. Jeff. The sentiment you explained in the second paragraph is a growing one IMO. I think it's because of the marketed "organic", "natural" and anti-GMO culture spilling over into science and healthcare. If you look around you'll see people accepting any therapy as long as it's "natural" despite its pseudoscience origin or obvious limitations. At the current rate of change I wonder how soon it will be when providers lose perspective and we're back to full-on homeopathy.

Long term, what will be the more reliable result? That titanium implant covered with a porcelain of some type, both of which can't get decay regardless of what a patient does to them, or a re-implanted, splinted tooth, which more often than not becomes a candidate for extraction and some type of replacement because of long term poor patient oral care habits?

This is one of those things where sometimes just because we have the technology to do something utilizing mother natures "original equipment" that it may not be a good a LONG TERM result as what our modern manmade options can provide.

After all when it comes down to it, most patients are concerned most with how long it lasts, then how much will it hurt getting it done and then what it costs (feel free to shuffle that order if you want)

 

[TSDentSurg]

Long term, what will be the more reliable result? That titanium implant covered with a porcelain of some type, both of which can't get decay regardless of what a patient does to them, or a re-implanted, splinted tooth, which more often than not becomes a candidate for extraction and some type of replacement because of long term poor patient oral care habits?

This is one of those things where sometimes just because we have the technology to do something utilizing mother natures "original equipment" that it may not be a good a LONG TERM result as what our modern manmade options can provide.

After all when it comes down to it, most patients are concerned most with how long it lasts, then how much will it hurt getting it done and then what it costs (feel free to shuffle that order if you want)

What about peri-implantitis? Poor oral hygiene is a contributing factor.

No matter what advances are made in prosthesis, patients will always find a way to ruin them by not taking care of them.

But Dr. Jeff... isn't natural always better?

I think you raise some good points, Dr. Jeff. The sentiment you explained in the second paragraph is a growing one IMO. I think it's because of the marketed "organic", "natural" and anti-GMO culture spilling over into science and healthcare. If you look around you'll see people accepting any therapy as long as it's "natural" despite its pseudoscience origin or obvious limitations. At the current rate of change I wonder how soon it will be when providers lose perspective and we're back to full-on homeopathy.

Yappy, I'm talking about using MSCs, which have shown good results in orthopedic surgery for repairing torn ligaments and tendons, and repairing OA-damaged cartilage.

http://www.healio.com/orthopedics/j...y-Enhanced-Healing-of-the-Rotator-Cuff?full=1

http://www.sciencedirect.com/science/article/pii/S1063458401905047

You talk like I'm trying to offer patients TCM.