Why do dental implants fail?

Hi everybody. I'm Dr. Sandhya Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body. As we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy. So take care of it in the most natural way. Hi everyone. Welcome to today's show. I'm your host, Dr. Sandhya Moldovan, periodontist and nutritionist. And today I want to address the topic, why do dental implants fail? Because patents usually like to blame this, oh, he did a bad job, which could be the case. A misplaced implant could be a problem. However, there's so many other reasons that you can do something about. So that's the whole point of today's show. I want to bring to your attention the reasons why an implant might fail so that you can be aware of it and you can do something about it. For example, something like smoking tobacco. Smoking tobacco. Know that if you do smoke, you're going to have 10% more risk of failure when you smoke. And you want to get a dental implant. So studies show that if you stop smoking actually a month before your procedure, your dental implant placement, that is, you will heal a lot better and you'll have stronger chances of survival, just like a non smoker. But let's back it up a little bit. Why should you listen to me about dental implants? Why? Well, I finished my residency at UCLA as a periodontist in 2004. I can't believe, but that's 20 years ago this year. And I had the privilege to learn dental implants from many experts as part of my residency. And my mentor was Dr. Sasha Jovanovic, who I hope I can have as a guest on my show because he really helped me with my dental implant knowledge with looked at a lot of different articles historically of dental implants. What happened from the beginning? What is it that makes a dental implant succeed? What makes it not succeed? And we can really make an educated decision about the future, about the future of our patients, and especially about individual patients wanting to get dental implants. During my residency, I placed quite a few implants. My residency program specifically at UCLA was focused on dental implant placement. And at the time we only had titanium implants that I was working with. But implants can fail whether or not they're ceramic or titanium. The factors why implants fail can be local. What does that mean? Just around the mouth or they can be systemic. So we started with smoking tobacco. So let's address some other systemic factors. What does that mean? Systemic is something in your body that can cause implants to fail. So smoking tobacco decreases your risk of implant success by around 10%. So historically, if we look at the research of dental implants, dental implants are around 90 to 95% success. And we have 10 and 20 year studies on dental implants for both ceramic and titanium dental implants. And they all show the same thing. If you smoke tobacco, and that's a personal choice, and blame the dentist if your implant fails. If you smoke cigarettes, smoking marijuana. We don't have enough data yet on failing dental implants and smoking marijuana. However, one of the things that we're noticing with smoking marijuana is that there's a change in the oral microbiome and it becomes more pathogenic, so it creates more inflammation. So stay tuned. I'm going to do an update on this. Why do implants fail? As we get more research. If someone has generalized chronic inflammation, also it predisposes you to implants failing more. So what do we mean by implants failing? Let's step it back a little bit. When we place the dental implant, it's basically like a foreign fixture. It could be titanium or ceramic, and it's meant as a replacement body part that we put in the jawbone. And we're depending on the health of your cells, of your cellular bone to incorporate the dental implant or allow it to fuse with your cells. If your cells are chronically inflamed, what could cause chronic inflammation? Or diet, for example, High levels of heavy metals, high levels of microbes, leaky gut can cause generalized chronic inflammation. All these things can cause your cells to be inflamed and therefore overreacting to any kind of treatment that we do, whether it's a tooth removal or an implant placement, but especially an implant placement. Diabetes is another big one for my patients who have diabetes, and it's uncontrolled and untreated. We always check the HBA1C. The HBA1C marker is a marker in the blood that indicates to us how well is your diabetes controlled? On how well especially it gives us a snapshot of the last three months, because if we're just checking blood sugar level that day, that doesn't give me enough information. If you're diabetic and your HbA1c is under control, meaning around 5.0 or less, then you are okay to undergo surgery. Of course, we get patients that are maybe a 6.0 HbA1c and that's okay as well. But now if you're moving up higher, the higher your HbA1c, the higher your inflammation, the higher your risk of implant failure. If you're diabetic, I highly recommend that you check your HBA1C prior to implant placement to make sure that you're going to have a successful surgery and definitely inform your doctor that you have diabetes. Now, if you don't know, and by the way, there's millions of diabetics walking around in the United States. They have no idea that they even have diabetes. How do you know you have the diabetes? Well, there are some symptoms. So excessive thirst, for example, overweight, craving sugar. One simple thing you can do is actually check your blood sugar level or the HBA1C. You can order these tests nowadays either at your local pharmacy or you can order them online. And it's a finger prick and it gives you the results like within 30 minutes. I highly recommend that you check yourself, especially if you don't have the means or the ability to go to the doctor. One of the factors is also medication. I was actually just reading a research study on SSRI medications. These are antidepressant types of medications. And there's data to show that people would take ssri, take med inhibitor medications, basically will have a higher rate of implant failure, that your implants won't integrate as well as somebody who's not taking antidepressants. So it's very important as you visit your dental implant surgeon to let them know that you're taking antidepressant medication to let them know so that we can at least monitor you closely in terms of your healing alcohol consumption. There's some data to show that alcohol increases chronic inflammation. Therefore we go back to that chronic inflammation problem. Higher your chronic inflammation, the more inflammation you're going to have during the healing and the more risk of failure of the implant. The last thing I want to talk about in terms of systemic issues that can affect dental implants is actual allergies. And you know, this issue comes up a lot. Yeah, Am I allergic to titanium? Am I allergic to zirconia? Today we actually have blood tests to see if you are allergic. I like personally a biocompatibility test that actually we draw blood, we send it into the lab and they give us a report of 600 plus different dental materials that you might be allergic to. But I attended a lecture from Dr. Von Baer, who is an environmental doctor, an MD and he basically looked at the titanium particle itself because that's where I get most of the questions. Is titanium a True allergen. So he explained that titanium cannot cause a true allergy because the size of the titanium ion comes off the implant. And yes, we know that the titanium will release titanium ions. How do we know? In the Journal of Periodontology, we had an article published in 2012 that showed the titanium particles around the implant tissues in the mouth. So we know they're there. How do they come off? Aggressive scaling by the hygienist, maybe even brushing. Because anytime titanium comes in touch with saliva, it corrodes and with the oxygen. So what does corrosion mean? Basically, titanium ions coming off the titanium implant. Titanium particles are seen by our macrophages, which is part of the immune cells. And I say, oh, this looks like a foreign body, let me chew it up. They take it up. When they cause inflammation, they alert basically the rest of the macrophages, the immune cells, hey, there's something foreign here. You all be on alert. That increases inflammation. The way Dr. Von Baer explained this is titanium cannot cause a true allergy. It can cause a foreign body reaction, but because of the size of the particle, it cannot cause a true allergy. Now, how do you know if you're going to have a foreign body reaction? Well, this is actually a genetic component of your makeup. There were articles basically that looked at the genotype polymorphism and this is just a genetic variation in IL1a, IL1b and IL1rNGs. And what we know today is that these polymorphisms can actually increase your incidence of implants failing. Why? Because the body sees them as foreign body and it expels them or cause them to get loose and lose bone. That's what really happens. And I can think of only a handful of patients throughout my 20 year career where I actually saw that all titanium implants, once placed, they were doing fine. And then over time they were losing bone. No matter what we did, we couldn't stop the bone loss because it was really the immune system that got triggered, that these things are foreign and they shouldn't be here. And it because of the titanium ion release and essentially eventually implants were lost. Probably in the future, near future, we could look closely at the genetic makeup of someone and see if they have IL1A, polymorphous, maybe IL1A, IL1B, and this particular article that was published in 2013, so this is not really that recent. We've known about this and Ijomi is that when you have patients that smoke, when they have positive IL1A, IL1B genotype, we see more bone loss than if they didn't smoke IL1RN, which is another variation of that gene, the interleukin gene is associated with peri implantitis. So definitely we can test today for these genetic snippets to see if you have it. So if you do have these snippets, especially if you have Both of them, IL1A, IL1B, we know those two together are associated with a more progressive course of the disease of basically peri implantitis and worse therapy response if you do have bone loss around your implants and they're going to end up failing. So those are the systemic factors that I wanted to go over. Generalized inflammation, smoking, tobacco, diabetes, alcohol consumption and a titanium allergy. And actually medications such as SSRIs and probably there's other medications out there that we don't have studies yet. So the cleaner your body is, the better results you'll have. Now let's look at the local level. What can actually happen when you have an implant? Place the number one thing in your mouth that can happen to cause an implant to fail is if you don't clean it or you don't clean it correctly. And I see this problem a lot. I think this is the most common reason why implants fail. So you get a dental implant. It's a round structure, cylindrical, that gets inside the jawbone. And then you get the crown placed on top. Then you come back six months later, the hygienist looks at it. Oh, you know, now there's inflammation. Oh, you know what? I see there's a pocket here. It's bleeding. Please brush and floss more. Unfortunately, that's not enough for dental implant. The best thing you can do for cleaning a dental implant is using a water flossers. All the studies show that today when we look at string floss compared to water flosser, the water flosser is 80% more effective than string floss in cleaning around that implant. So anyone out there, any practitioner listening to this? If you have a patient you see inflammation around their implants, they must get on a water flosser. Or if you're somebody who has dental implants in their mouth and you're not using a water flosser, I highly encourage you to use one, especially right around the gum line of dental implants. We actually have a special tip that we use in order to keep the dental implants clean. Clean from what, you might ask? Well, biofilm bacteria. Why? Because, you know, if you're not cleaning under the gum line, you're actually going to have that bacteria advancing down in the gum. So why is that? We need to look a little bit, and I want to explain the anatomy and the difference between a tooth and an implant. When you're looking at a tooth, the gum surrounds the bone into which the tooth is sitting in. And the gum embeds with little fibers around the tooth, well, around an implant. The gum doesn't do that. The gum basically just lies right in close proximity to the implant, but there's no fibers that are actually connecting into the implant. So there's really no barrier to prevent bacteria once under the gum to not go close to the bone. Because we don't have those fibers surrounding a dental implant, Bacteria goes straight from the mouth into the gums and straight to the bone, causing what we call peri implantitis, which is bone loss around dental implant. Nothing that your dentist did that's wrong walking. Maybe he made a space, a crown. Maybe it's a little too big that you can't clean it properly. But typically we notice these things and we correct them. Second reason why implants fail is if you had or currently have gum disease, especially gum disease that's not treated. We always like to treat gum disease prior to any implant placement. And gum disease, of course, are bleeding gums and actually losing bone around teeth. But we also have gum disease around implants. And why is gum disease even present? Usually it has a genetic component as well as bad bacteria in the mouth. So highly recommended to treat the bad bacteria first to decrease gum disease, to get it under control. We can't do much about your genetic component. We look at the IL6, which is a genetic component involved in periodontal disease or gum disease. Because if you have high IL6 and you get dental implants, you are at a higher risk of developing disease around your dental implant, otherwise called peri implantitis. So what can you do about it? You can actually go to get your dental cleanings more often and more. So get dental cleanings using airflow by ems, which is basically an antibacterial erythritol powder that is treating around the implant surface, not just scraping the implant. Another factor why dental implants fail is because of leftover cement. When a crown for dental implants get placed, we can place it one of two ways. Either we screw it down into the implant or. Or we actually cement it on top of the abutment. When we cement on top of the abutment, there's always a risk that the cements get under the ground. If the cement stays under the ground, it can actually cause the same foreign body reaction. It can gather a lot of bacteria and cause inflammation. And it happens sometimes to have a little bit of cement left behind, but we always usually detect it at your next hygiene visit. So we can actually scoop it out. If it's not detected and left behind, that this is just all a matter of the technique of placing that crown, then it can cause per implantitis, bone loss and gum loss. I actually had a situation and I have a great video which I'm actually going to post on my YouTube channel, of a patient, very nice man. You know, he came a year later that the dentist detected bone loss. And of course they were pointing the finger at me. And I looked at the action, I'm like, you know, I think there's cement there. Oh, no, that it's absolutely impossible. I didn't leave any cement there. So I actually recorded a video in which I was scooping chunks of cement from underneath the gum. What actually caused, sadly, this implant to lose bone. So you have to be very careful who you go to to do your dental implant treatment. That's why, for that reason, in my practice, I usually like to do everything from beginning to the end, or at least work with dentists that I really trust to finish the crown on the dental implants to make sure that nothing gets left behind under the gum. Let's talk about forces of the bite. This is another reason why implants fail. So as you see, there's so many factors involved. Everything has to be in harmony in order for implants to survive. If you clench or grind, you will have a higher likelihood you will lose your dental implant because you're going to lose teeth. You probably lost that tooth that was replaced with the dental implant because it was cracked from clenching and grinding. So highly recommended to wear night guard whenever you have a dental implant. Why it's a great insurance. I say to prevent you losing the dental implant. Another reason is, let's say if it's too heavy, let's say you decide, you know, I'm only going to place this one implant. I'm missing four teeth. But let's just put that one implant there because I want to have one tooth to eat on. You can't do that with dental implants. You will overload that implant and it will fail because one implant cannot withhold the entire bite. We need to have a holistic approach to rebuilding someone's bite. So we need to add as many implants as teeth that have been lost. And there you have it. These are the factors and the reason why I wanted to bring this up because Some of these things, you as a patient can do something about it. Local factors like poor oral hygiene, you can do something about this. Now you know that using a water flosser or brushing an implant is more important than using strip floss. If you had gum disease in the past, this is your body, it's your genetic component. But it is important to understand that keeping your regular cleanings is the best thing you can do to extend the lifespan of your dental implants. The residual subgingival cement that we used to cement the crown and the occlusal overload, those are things that your dentist will let you know and make sure that everything's clean but are common reasons why implants fail. And it's very, very important to understand all these things before you're getting a dental implant and really, you know, do your homework. Who are you choosing to place your dental implant and why do you trust them? Because it's very important that we have explained things to you in detail, especially when it comes to the systemic factors to get your body fit for receiving a dental implant. Because if you have proper nutrition, proper sleep, hydration, the right levels of nutrients, you will heal great and you can maintain your dental implants. Like many of my patients from 20, 30, 40 years, I hope this was helpful. We will talk about in the next episode what to do if your implant is failing. See you next time. Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. 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.