#12 Implant Insights | Ceramic vs Titanium

Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body. Welcome to today's show. I want to talk about ceramic versus titanium dental implants. There's still so much controversy regarding this topic. And if you probably went to 10 different dentists, most of them will say ceramic implants are not reliable. They're going to break. They wouldn't recommend it, and that is actually old news. I really want to bring some light to this topic. Some of you already know the difference, but let's discuss about the history of both titanium and ceramic dental implants. In the beginning, we only had titanium, and titanium was actually an accidental discovery. While Professor Branemark was actually working in a lab and he used some titanium pins in animals just as a marker, he was studying something completely different. And lo and behold, about six months after, when he had to sacrifice the animals to look at his experiments, he noticed that these titanium rods would not come out. They were actually fused with the bone. That's when he had the idea, wow, how can we utilize this in order to perform surgeries in orthopedics? Titanium implants actually were first used in orthopedic surgeries and the first patient that was treated with a titanium dental implant actually passed away with all his titanium implants. It was actually in the 80s and he had them for a good 40 years. We know titanium dental implants can last a long time once they're fused with the bone. Other materials have been tried since then, different alloys that didn't work because the cells actually could not attach. Zirconia based ceramic material was first created in 1975 and it was used in the beginning in hip replacement. In the 1960s, Professor Sanhuis created the first ceramic implant made from aluminum oxide. Aluminum oxide is actually a ceramic. It's not aluminum that actually will leach in the body. We started playing with ceramic implants back in the 1970s. However, in the early 2000s, the most common type of zirconia used for ceramic dental implants was this ytzp and we saw more breakages than titanium. As a matter of fact, some of the early studies in ceramic implants showed up to 25, 30% failure rate due to fracture. However, since then we've had a lot of advances in ceramic dental implants. The way the crystals are arranged inside the structure actually changes, changed to allow us to have today for, let's say the XeroMex implant system. 20 year studies to show similar success rates when comparing titanium and Ceramic dental implants. Ceramic dental implants have been used in Europe since 1987 and they actually got FDA approval here in United States in 2007. When I first started using ceramic dental implants, I want to say around 2010, the only available implant system on the market was a one piece system. The one piece system essentially combines the root form implant together with the abutment. For those of you who are new to dental implants, dental implants are made out of three parts. The root form or the implant itself that goes into the jawbone, then the neck of the implant, or the abutment that gets screwed on or cemented inside the implant and then of course the crown that goes on top. You can very well compare this with like a human body. The implant is actually the body from the shoulder down. The neck would be the abutment and of course the head is a crown. So so think of it in that way as a three part system. So in the beginning, ceramic dental implants had the neck connected to the body and then the crown on top that would get cemented. And the problem with this is like if we actually had a fracture at the neck, then we would have to replace the whole implant. We couldn't just replace what is called the abutment. So today actually the titanium implant system and the ceramic implant system are very similar in that they both are what it's called a two piece system, not a one piece system. In the titanium world, we as restorative doctors always like to have the flexibility of changing out the abutment and the crown. That's why we want a screw retained system. The ceramic dental implant couldn't accommodate a metal screw, so we had to have a carbon fiber screw. So now both ceramic and titanium implants actually are two piece systems. The carbon fiber screw that connects the abutment to the actual implant in the ceramic implant system has been shown to actually be stronger than the titanium screw. In the titanium system, screw loosening has been quite a problem. In the past the abutments were actually always loosen. But nowadays that has definitely improved. In the ceramic implant system, people say, oh, you know what? Zirconia is actually a metal. So I do want to make that correction. We have zirconium, which is a metal. If you actually googled zirconium, you will find metal rods. Zirconium oxide is actually a ceramic. So what does it mean to actually have a ceramic? It means a metal, once been oxidized, it becomes, it takes on a shape that cannot be reverted back to the metal. So once it's a Ceramic, Zirconium oxide, aluminum oxide. It's a ceramic. It can now go back to its metal state. It cannot release ions. And that's why having aluminum oxide or zirconium oxide as a ceramic is not the same as aluminum or zirconium. So it is false to say that zirconia is a metal. Zirconium is a metal, but zirconia is a ceramic. So what are the properties here when you're looking at a zirconium or ceramic dental implants? They're lighter in body weight, they have no corrosion. Titanium, yes, it corrodes. What's the problem with corrosion? Corrosion can actually make a metal weaker. Can titanium implants break? Absolutely. Especially if you're a heavy bruxer. The titanium is not as wide as it can be if it's over stressed, definitely. A titanium implant can break and so can a ceramic, and so can a tooth. Nothing is unbreakable in dentistry that I've seen so far. Titanium has this low grade conductivity, which can represent a problem from a health perspective. There's this notion of galvanic current. And I've actually seen situations where if you had a, let's say a metal crown or a mercury filling next to a freshly placed titanium dental implant, we see more inflammation around the area due to the galvanism that's caused in a site. Zirconia or ceramic implants have no conductivity. So no electric conductivity is actually good for ourselves because it becomes inert. Our body is electric. It functions via energy at the smallest level of the atom and electron. We are energy. So that's why sometimes introducing something that conducts electricity might not agree with everyone. And I have to tell you that I've had patients that were not comfortable with their titanium dental implants. Those are not many. And some of you are just more in touch with the energetic of metals. So I had to remove them. I had one of my patients who actually felt symptoms on the side of the body through the fingertips and the same side that she had the titanium implants. After removal, her symptoms went away. Ion release. I do want to talk a little bit about that. We've also had some studies in the literature to show that titanium particles were actually found in the peri implant tissues. This was a study published in the Journal of periodontology in 2012, where we can see a slide of the peri implant tissues, meaning around the implant with titanium particles. So you might say, how do the titanium particles end up there? Well, oftentimes you go to the Dentist, the hygienist decides to scrape around the dental implant that's titanium. They can scrape off some of those particles that end up in the tissues. And then what lives in the tissues are immune cells. So here comes a macrophage, which is our immune cell, and it sees a foreign body, it gobbles this up and says, oh, this shouldn't be here. And it starts to create inflammation. That's what per implantitis or bone loss around implants with inflammation can cause you to lose a dental implant. But let's talk about this notion of allergy. Some of my patients are like, well, am I allergic to titanium? So according to Dr. Von Baer, who is a environmental, MD and environmental MDs really look at what could affect your body that may make you sick. So if you don't feel well, your doctor tells you everything's fine, you might want to go see an environmental MD to test everything else that in your environment that might affect you. And titanium can affect us as well. For example, there's also food additives called titanium dioxide. And recently, especially in California, titanium dioxide actually became a big issue because it causes inflammation in the, in the stomach, in the intestinal tract. So it is on a ballot right now to see if it might get on the banned food additives because of this issue. So what does titanium do inside our tissues? Well, Dr. Von Baer says that it cannot be a true allergic reaction like you are to nickel, for example. Nickel is very specific because it is a larger molecule. But when we're looking at the titanium particles, this is a very, very small molecule that he says it cannot actually cause a true allergic reaction. However, these kind of splinters or particles or ions that come off the titanium actually act in a non specific way. So when you get a splinter in your hand, for example, it's not that you're, you know, and it starts to swell up and become red. It's not that you're allergic to the wood splinter, right? You don't have an allergy. You just create a foreign body reaction. Your body is reacting to the fact that's in your body. So essentially, that's what titanium does. It can have this foreign body reaction and create this inflammation of the, of the peri implant tissues. What's also interesting is we know there's a genetic component to the foreign body reactions. Not everybody's going to have the same reaction. If you take 10 people with titanium dental implants, maybe one of them will have a really high reaction to these titanium particles that are living in the tissues. We know that polymorphism in certain genes such as IL1a, IL1b and IL1RN affects peri implantitis or this bone loss around implants. Unfortunately, today is not the norm for us to test your genetic makeup before having titanium dental implants. However, there's a small percentage of patients that have titanium implants and no matter how good they are about cleaning those implants, inflammation persists and eventually they lose bone. And at year 10 or so, actually the implant needs to be removed for those particular patients. Oftentimes the suggestion is, well, let's place a new set of implants also titanium. And my recommendation would be no more titanium, go with ceramic. Because we don't see the same issues with ceramic implants like we do with titanium. Especially nowadays, it's so much easier to test for this IL1a or IL1b genetic phenotype. So, you know, if you have a strong predisposition to this foreign body reaction. There's also an article written in Journal of periodontal research in 2016, how titanium ion form particles that activate IL1 beta release from LPS primed macrophages. So what does that mean if you already have high levels of bacteria in the mouth or you are predisposed to periodontal disease, you haven't addressed that aggressive bacteria, definitely you're going to have a higher predisposition to losing bone around titanium implants. When we're looking at zirconia implants, we don't see the same problems we don't see. We actually see a much lower rate of inflammation around the tissues. Why? Well, I think the reason is because we don't have this ion release bacteria in general like a low grade electrical field because they can communicate better between colonies. But zirconia in the mouth actually oftentimes looks healthier than a tooth because a tooth also has this electrical field around it. It has a nerve and nerves really function on this electrical impulses. When we look at a zirconia implant in the oral environment, it actually has the least amount of plaque and least amount of gingival inflammation, even when compared to teeth or titanium dental implants. Whenever I choose any system to use during my surgical procedures, I ask myself three questions. Number one, is it predictable? Can I predictably do the same procedure on several different patients and get a good result? And I can tell you that when it comes to the zirconia dental implants, the studies are there in terms of the surface, the osseointegration of the implant into the jawbone. So the AC integration time is really about four to six months similar to titanium. And when we're actually looking at the studies that were done on 15,000 implants in Europe between 2010 to 2014, this was actually a retrospective studies, the success rate was 97 to 99.4% successful on a two piece zirconia implant system. We also have a nine year study of almost 600 patients that look at over 2, 300 implants to show that the success rate is similar to titanium, 97 to 99%. But the higher odds ratio for early implant loss was for smokers and patients with an initial diagnosis of periodontal disease. And of course implants shorter than 10 millimeters. So yes, titanium versus ceramics, they're both predictable. So I would choose ceramic because it's predictable. The second question I asked myself is is it easy to use? And ceramic implants actually are similar in placement as titanium. The same sequence, the same care. So yes, it is EAS easy to use. And does it serve a need for my patients? And definitely it serves a need for my patients. And the reason being is recent studies have come out looking at the autoimmune conditions. What happens actually on in patients with connective tissue disease and fibromyalgia. We know rheumatoid arthritis, Sjogren's syndrome and other rheumatic diseases are often accompanied by sensitivity to metals and different kinds of metals. I'm not talking just about titanium. In this particular study published in 2018, the main source of metal exposure was nickel, mercury, gold, palladium, titanium and chromium. And what they noticed out of the few hundred patients that they were looking at is that all systemic lupus erythematosis. So lupus, rheumatoid arthritis and Sjogren's patients had an increased frequency of delayed type inflammatory reaction or allergic reaction. So it made it worse when they were in contact with these metals. So for that reason, I wouldn't recommend titanium in anybody that has an autoimmune disease in the connective tissue disease family. And unfortunately, rheumatoid arthritis and lupus is on the rise. There's a much better option. Ceramic. I think our patients need to be aware. You need to be aware about what's going in your mouth and how will it impact your body. Any kind of biologics actually has a reaction to your cells. Zirconia implants also are easy to take care of. You will take care of it just like you would any other tooth, except for one thing. We know that string floss is not sufficient. So if you're planning on getting a ceramic or titanium implant, for that matter, make sure you use a water flosser. For that reason. I worked on the Orasana water flossing tip. That's a tufted tip to be used around dental implants. Studies on the Waterpik actually has shown that the water jet itself in contact with a surface for three seconds reduces plaque for 99%. So that's pretty amazing. And another reason why I think the water picker and water jets itself are better is because the implant surface is round and it's hard to reach that surface using dental floss. And water floss actually can flow around between the gum and all the way up to 3 millimeters under the gum to clean the layer of bacteria that might be accumulating in that site and also debris and food. Another reason why you should choose zirconia dental implants, especially in an aesthetic zone, is because of the white. My titanium implants are gray. Zirconia implants are white. So when you have a high smile like myself if I was to lose a front tooth, I will always choose ceramic because that gray of the titanium can actually show through the gum, especially when you have a thin biotype or thin gum tissue. In zirconia, what we do see is even if the gum is thinner, you know, you have the white kind of showing through and it's much more aesthetically pleasing. We don't, we don't have to thicken the gum tissue as much as we did in having titanium dental implants in the front. So that's it in a nutshell. I hope I answered your questions about how to choose titanium versus ceramic dental implants. Just know that they both have similar success rates. We no longer have to worry about them breaking. You know, they, they, they're actually healthier at the gum level and it's a great option for replacing immussing tooth. Please make sure you check out the show notes for any links mentioned in the show. Do you have a question you'd like me to answer? Message me on Instagram. DoctorsAnda. This is Dr. Sandha. And remember, your mouth is the gateway to your health, so take care of it in the most natural and best way possible.