Today we pick up where we left off on the 1st part of Group Function Episode 13 “Can I Probe This Implant?” In this episode I asked Dr Pav Khaira about bone loss around implants - what is normal and when should I worry? Another very interesting and controversial issue we tackled is how to manage implant screw loosening as a GDP?

https://youtu.be/C1Y_AdDhLzU

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“If every single year you're losing one millimeter (of bone) that's obviously an issue and we need to intervene and do something,” Dr Pav Khaira

In this episode we discussed:

Normal bone loss for average implants 1:53Guidelines for GDPs managing loose implant screws 5:03Universal Implant Drivers? 10:45

If you liked this episode, be sure to check out the first part of this series Can I Probe This Implant?

Click below for full episode transcript:

Opening Snippet: Because screws become stressed and they become strained. That may be one of the reasons why it's come loose. And if you retighten a strange screw you can you can cause it to break, then you're in trouble because you may not be able to retrieve it from the implant head...

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,