Center for Oral & Maxillofacial Surgery Newsletter: Spring 2021

PRACTICE INSIGHTS SPRING 2021

FROM THE CENTER FOR ORAL SURGERY & DENTAL IMPLANTS 3

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Optimizing patient care with EpicCare Link

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All-on-4: A proven implant solution

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Inside the debate over chairside CAD/CAM

Teaming up for optimal outcomes

Our surgeons, from left: Julie B. Billups, DDS, Richard W. Panek, DDS, Emily J. Van Heukelom, DDS, Roseanna P. Noordhoek, DDS, and Justin M. Pisano, DDS.

COMMITTED TO EXCELLENCE Welcome to our new clinical update newsletter! We hope you find it helpful, and invite you to suggest any topics you’d like to see covered (just give us a call to request).

We’re committed to providing expert, compassionate care for the whole patient, spending extra time to build comprehensive treatment plans that we share with you. For example, we use EpicCare Link, which gives us access to a patient’s medical and clinical history, test results and medical imaging.

Understanding each patient’s medical background supports our mission to provide the best possible outcomes.

Both our Rockford and Grand Rapids offices are fully equipped for fullscope oral and maxillofacial surgery procedures, including state-of-the-art anesthesia, monitoring and imaging systems. We welcome referrals from colleagues and invite you to speak to any of our surgeons to discuss the needs of your patients. Informal inquiries are welcome. We look forward to hearing from you!

Warm regards, Richard W. Panek, DDS Julie B. Billups, DDS Emily Van Heukelom, DDS Roseanna P. Noordhoek, DDS Justin M. Pisano, DDS

Contact one of our surgeons at 616-361-7327.

OUR OFFICES

4349 Sawkaw Drive NE Grand Rapids, MI 49525 158 Marcell Drive, Suite B Rockford, MI 49341

IS THERE A LINK BETWEEN VITAMIN D DEFICIENCY AND IMPLANT FAILURE? EACH YEAR, there are some dental implants that, although they are placed in adequate bone volume, fail within two to eight weeks of the implant placement for unknown reasons.

Early research suggests that vitamin D deficiency could be a contributing factor.

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IS THERE A LINK BETWEEN

VITAMIN D DEFICIENCY AND IMPLANT FAILURE? Vitamin D supports the immune system and the integration of biomaterials and other metabolic processes, such as new bone formation on the implant surface. It also decreases oxidative stress and minimizes surgical inflammation.

Early studies are suggesting that adequate vitamin D can enhance healing.

One study of 885 dental implant patients found that patients with vitamin D deficiency (serum levels of vitamin D <10 ng/mL) had an early implant failure rate of 11.1%, compared to a failure rate of 2.9% in patients with normal levels of the vitamin (>30 ng/mL). Some experts estimate that vitamin D deficiency is associated with an up to 300% increase in early implant failure.

But the data must be interpreted with caution. “This research is interesting, but the data is really new and has not yet been published in any of our peer-reviewed oral surgery journals,” says Justin M. Pisano, DDS, an oral surgeon at the Center For Oral Surgery & Dental Implants. “Yet, we’re excited to follow the developing research.” More research on the relationship between vitamin D, healing and dental implant failure is needed.

the consumption of unhealthy foods and fast foods. Even when patients have a healthy diet, it is very difficult to get sufficient vitamin D—600 IU/day for adults up to age 69 and 800 IU/day starting at age 706— from food.

Natural sunlight is a key source of vitamin D. Exposing the face, arms and hands to the sun for about 15 minutes two to three times a week should provide sufficient vitamin D for light-skinned patients in Michigan.

Patients with darker skin need 30 minutes to three hours longer in the sun to get sufficient vitamin D. The season and time of day also impact the length of time required for adequate sunlight exposure.

Obese patients with a body mass index greater than 30 are at higher than average risk for vitamin D deficiency.7 Patients with kidney disease, celiac disease, cystic fibrosis or Crohn’s disease are also at increased risk.

If you would like to read more, the first three references below link to articles that provide detailed information about this topic.

REFERENCES

Deficient, Insufficient and Optimal Vitamin D Levels Vitamin D deficiency is most common in older adults, people who are obese, nursing home residents and hospitalized patients. In the United States, 61% of older adults, a group that receives many dental implants, are vitamin D deficient.4 Serum 25-hydroxy vitamin D (25-OH) is used to reliably measure vitamin D. According to the National Institutes of Health: <12 ng/mL = Deficient 12-20 ng/mL = Insufficient >20 ng/mL = Optimal.5

Causes of Vitamin D Deficiency The most common causes of vitamin D deficiency are an unhealthy diet, lack of sun exposure and certain medical conditions. A leading dietary cause of vitamin D deficiency is

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1. Forum S. Vitamin D deficiency: Impact on wound healing and implant failure. Perio-Implant Advisory. Feb 3, 2020. Accessed 2/3/21.

2. Mangano FG, Oskouei SG, Paz A, Mangano N, Mangano C. Low serum vitamin D and early dental implant failure: is there a connection? A retrospective clinical study on 1740 implants placed in 885 patients. J Dent Res Dent Clin Dent Prospects. 2018;12(3):174-182. doi:10.15171/ joddd.2018.027. Accessed 2/3/21.

3. Miron RJ, Pikos MA, Bishara M. Vitamin D deficiency and early implant failure: what every clinician should know. Dentistry Today, April 1, 2020.

Accessed 2/3/21.

4. Palacios C, Gonzalez L. Is vitamin D deficiency a major global public health problem? J. Steroid Biochem Mol. Biol. 2014 Oct;144 Pt A:138-45.

Accessed 2/3/21.

5. NIH Fact Sheet for Health Professionals, Vitamin D. October 9, 2020.

Accessed 2/3/21.

6. The National Academies of Science, Engineering and Medicine. Dietary Reference Intakes for Calcium and Vitamin D. 2011. Accessed 2/3/21.

7. Khosravi ZS, Kafeshani M, Tavasoli P, Zadeh AH, Entezari MH. Effect of vitamin D supplementation on weight loss, glycemic indices, and lipid profile in obese and overweight women: a clinical trial study. Int J Prev Med. 2018;9(1):63. doi:10.4103/ijpvm.IJPVM_329_15. Accessed 2/3/21.

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have cared for the patient.

“As essential healthcare providers, dentists and oral surgeons can close the gap between medicine and dentistry,” says Emily J. Van Heukelom, DDS, an oral surgeon at the Center for Oral Surgery & Dental Implants.

“We can use EpicCare Link to integrate dentistry and medicine more closely to provide better patient outcomes.” The practice has been using EpicCare Link since 2018, the year that Epic began offering technology to unify dental and medical patient records.

OPTIMIZING PATIENT CARE WITH EPICCARE LINK

HAVING A PATIENT’S complete medical history is always an important detail in determining their optimal dental treatment. Yet many patients can’t provide accurate medical information, and others may have a lack of understanding, or omit details about their health problems.

“Relying only on what patients remember to tell us can hinder our ability to provide optimal care,” says Roseanna P. Noordhoek, DDS, an oral surgeon at the Center for Oral Surgery & Dental Implants.

This is especially problematic because more dental patients now have complex medical histories. In the U.S., 60% of adults have at least one chronic disease and 40% have two or more chronic diseases.1 Most older adults—90%—take at least one prescription drug. Nearly 80% take at least 2 prescription drugs and 36% take at least 5 prescription drugs.2 Even younger patients are taking more prescription drugs and have more health problems than in the past.

Medicine and Dentistry: Closing the Gap That’s why, in cases where the oral surgeon suspects that a patient can’t or won’t provide accurate and complete information, the Center for Oral Surgery & Dental Implants uses EpicCare Link to review a patient’s medical history and prescription drug use.

EpicCare Link is available through Epic, one of the largest providers of health information technology. Large U.S. hospitals and health systems, as well as other organizations, use Epic to access, organize, store and share electronic medical records. Currently, Epic has records on more than 250 million patients in the U.S. A secure online portal, EpicCare Link provides convenient access to patient information to registered providers at any time on the safety of your own computer network. It includes each patient’s clinical history, test results, reports and images.

Also, it lists the patient’s primary care physician and other physicians who

How to Sign Up All the doctors at the Center for Oral Surgery & Dental Implants encourage oral healthcare providers in West Michigan to register for EpicCare Link to gain access to their patients’ complete medical histories. Read-only access to EpicCare Link is provided through health systems, at no cost to providers. In West Michigan, EpicCare Link is available through Spectrum Health, Mercy Health St. Mary’s and Metro Health – University of Michigan Health. EpicCare Link uses industrystandard encryption technology to ensure that only registered providers can access the system.

REFERENCES 1. CDC. Chronic Diseases in America. Accessed 2/3/21. (www.cdc.gov/chronicdisease/ resources/infographic/chronic-diseases.htm) 2. Aging and Drugs. Merck Manual. Revised 2018. Accessed 2/3/21.

To sign up for EpicCare Link contact: SPECTRUM HEALTH physician.relations@spectrumhealth.org

METRO HEALTH – UNIVERSITY OF MICHIGAN HEALTH Greg Henry: greg.henry@metrogr.org

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All-on-4 treatment requires no grafting and is a cost-effective implant solution for many patients.

ALL-ON-4:

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MANY PATIENTS in need of dental implants are unable to receive individual tooth implant replacement due to moderate-to-severe bone resorption or the high cost of implants.

All-on-4 treatment requires no grafting and is a cost-effective implant solution for patients with failing dentition and for many with edentulism. The latest research shows good long-term clinical outcomes and high patient satisfaction.

“The All-on-4 protocol allows implant placement in patients who

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would otherwise require bone grafting,” says Dr. Richard Panek, a surgeon at the Center For Oral Surgery & Dental Implants. “With All-on-4, the need for grafting is avoided due to tilting the implant position and lowering the risk of possible complications. Over the past 15 years, we’ve seen similar success rates as those published in the scientific long-term studies.”

Proven Clinical Outcomes and Patient Satisfaction Research shows that All-on-4 treatment predictably provides good clinical outcomes and high patient satisfaction.

The following results show longitudinal data for use of All-on-4 treatment in the mandible and the maxilla. Results were published in two articles in Clinical Implant Dentistry and Related Research in 2019.

Follow-up data at 10–18 years on 471 patients with 1,884 mandibular implants showed: • 93% implant cumulative survival rate • 98% prosthetic survival rate.1 Follow-up data at 5–13 years on 1,072 patients with 4,288 maxillary implants showed: • 93.9% implant cumulative survival rate • 99.2% prosthetic survival rate.2 In terms of patient satisfaction, a study of 250 patients found: • 95% of patients are satisfied with their new teeth • 98% of patients would recommend All-on-4 treatment to other people.3

Overview of All-on-4 All-on-4 treatment provides full-arch rehabilitation without bone grafting using only four implants per arch: Two axial anterior implants and two implants tilted up to 45° in the posterior.

Tilting the two posterior implants

PATIENTS WHO MIGHT BENEFIT Most patients treated with All-on-4 have failing dentition. Many patients with edentulism are eligible for this treatment, too. Patients who already have dentures but are dissatisfied with them are another group that might benefit from All-on-4 treatment.

At the Center for Oral Surgery & Dental Implants, we perform a thorough evaluation on each prospective patient to determine whether he or she is eligible for All-on-4 treatment. The evaluation consists of: •M EDICAL HISTORY, including any conditions that might affect the treatment outcome or the patient’s ability to have oral surgery, such as conditions or habits that could interfere with healing (diabetes, smoking).

•D ENTAL HISTORY, including periodontal disease and habits such as clenching and bruxing that can impact long-term outcome.

•R ADIOGRAPHIC ANALYSIS, initially with a panoramic radiograph usually followed by a full-mouth periapical series, a CT scan or a cone-beam CT analysis.

• I NTRA- AND EXTRAORAL EXAMINATION, to evaluate the remaining teeth and the soft tissue.

“The preoperative evaluation assesses the whole patient, including their fitness for surgery,” says Dr. Richard Panek, a surgeon at the Center For Oral Surgery & Dental Implants. “Most reasonably healthy patients are excellent candidates for this treatment.”

in the maxilla and the mandible enhances the bone-to-implant contact.

This optimizes bone support even in patients with minimum bone volume, avoiding the need for bone grafting.

In the maxilla, tilted implants are more firmly anchored in better quality anterior bone. Tilted implants in the maxilla and the mandible also help avoid vital structures, more efficiently distributing implants along the alveolar crest. The final prosthesis can contain up to 12 teeth. For patients who meet the criteria for immediate loading of implants, a fixed acrylic bridge provides immediate function.

“Overall,” says Dr. Panek, “we’ve

found that patients are quite pleased with the experience and outcomes made possible with this treatment.”

REFERENCES 1. M alo P, de Araujo Nobre M, Lopes A, et al. The All-on-4 treatment concept for the rehabilitation of the completely edentulous mandible: A longitudinal study with 10 to 18 years of follow-up. Clin Implant Dent Relat Res. 2019;21(4):565-577.

2. M alo P, de Araujo Nobre M, Lopes A, et al. The All-on-4 concept for full-arch rehabilitation of the edentulous maxillae: a longitudinal study with 5-13 years of follow-up. Clin Implant Dent Relat Res. 2019;21(4):538-549.

3. i Data Research U.S. and European Markets for Overdentures, 2014.

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CHAIRSIDE CAD/CAM DENTISTRY: BENEFITS AND DRAWBACKS DESPITE THE LENGTH of time since digital dentistry’s inception in 1985, there’s still an ongoing, healthy debate about its value and place in general dentistry practices.

If you’re considering investing in chairside CAD/CAM, we hope you find this overview of its advantages and drawbacks helpful.

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What Proponents Love Time Savings. The principal advantage of chairside CAD/CAM is that it saves both doctor and patient time by delivering the final restoration in a single day. No second appointments, no provisional to make or to re-cement.

In fact, the technology allows clinicians to work on and deliver multiple single-

tooth restorations in one visit.

In addition, by training assistants to scan the arches and bite and to handle other tasks, the doctor can be available to see other patients and perform separate procedures, thereby maximizing his or her time.

Staining is an art form. Some doctors use the lab for anterior

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restorations initially until they build their comfort level. But once they’re accustomed to staining, they find that having an in-office unit gives them the ability to modify the restoration shade without having to send the product back to the lab, saving both time and expense.

No Physical Impressions. CAD/CAM technology doesn’t require physical impressions, which creates several advantages. For one, it removes the risk of impression shrinkage, leading to fewer adjustments and less chair time.

In addition, it eliminates the need for repeat impressions. If there’s a void in the image, you can rescan the selected area or the whole tooth depending on what’s needed.

Creating only digital impressions enables you to archive patients’ impressions for as long as desired without the need for a physical space to store casts. Digital impressions also eliminate the need to purchase impression trays and materials, as well as the cost of shipping impressions to the lab. A related benefit: reduced environmental footprint.

Multiple Use. Chairside CAD/CAM enables doctors to fabricate crowns, bridges, veneers, inlays and onlays and to create implant surgical guides. Some scanners, such as iTero, provide the ability to make night guards and clear aligners in-house. Alternatively, digital impressions can be remitted to a lab for those products.

Fun Factor. Many doctors who do digital dentistry truly enjoy the process.

They find that learning to use this technology and integrating it into their practices increases their professional satisfaction.

Improved Quality. Those who use a CAD/CAM system also argue that it improves care. Because the camera magnifies the prepped tooth, dentists can adjust and improve the form and margins immediately.

If you’re considering investing in chairside CAD/CAM, we hope you find this overview of its advantages and drawbacks, drawn from conversations with dental colleagues, helpful.

Competitive Advantage. In some communities, providing digital dentistry services might give you a strategic advantage. When deciding whether to invest in this technology, consider what your competitors are doing and whether patients have been asking you about “same-day dentistry” or “teeth in a day.”

What Critics Point Out High-Cost Solution. Chairside digital dentistry is a significant financial investment involving multiple pieces of technology, including the CAD/CAM system itself, a cone-beam CT for 3-D imaging, and an optical scanner for digital impressions and accurate color analysis for staining. There’s also the cost of software updates, as well as restorative materials.

Keep in mind that practices no longer need to take an all-or-nothing approach to digital dentistry. Today’s intraoral scanners save images via stereolithography files that can be read by the lab. This makes it possible to get started with digital imagery and add in-house milling equipment later, once your staff is more comfortable

with the technology.

When deciding whether to invest in digital dentistry, consider the savings as well as the expense. For example, fabricating prostheses in-house means saving on lab fees and improved efficiency will help to defray the cost of your investment.

Learning Curve. Doctors and staff will need to receive training on how to use the software that runs CAD/CAM technology.

Quality Concerns. While the quality of early CAD/CAM restorations has been a concern, as digital dentistry advances, so does the quality of the restorations. Research suggests that today’s CAD/CAM restorations are stronger and less likely to fracture than those milled from earlier materials, and that they fit better as well.

Many factors play into the decision to invest in CAD/CAM technology.

Success depends on several variables, including your own enthusiasm, your staff’s willingness to learn new technology and change long-standing processes, and your practice’s competitive environment.

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4349 Sawkaw Drive NE Grand Rapids, MI 49525

for complex cases, such as implants with unusual anatomical structures or insufficient bony volume, or complex aesthetic cases.

Team-Based Treatment

TEAMING UP FOR OPTIMAL OUTCOMES WHEN YOUR PATIENTS need dental implants or other types of oral surgery, they trust you to refer them to the best care. At the Center for Oral Surgery & Dental Implants, our five oral surgeons team up with you to provide care that’s professional, efficient, compassionate and safe. “Patients are reassured when they know that we’re working together behind the scenes,” says Emily J. Van Heukelom, DDS, an oral surgeon at the Center For Oral Surgery & Dental Implants. “It makes them feel good about the treatment they’re receiving.”

Convenient Communication Teamwork starts before you make a referral and continues until the patient’s

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treatment with us is complete. We offer many convenient ways to communicate: secure email to our business associates in our front office, the pMD HIPAAcompliant texting app and telephone.

The pMD app allows colleagues in different organizations to share sensitive patient information securely, even large photo and digital X-ray files. It’s available for iOS and Android.

Teamwork is especially important in assessing and planning treatment

“We would love to hear from you before you refer complex cases to us—that way we can all be on the same page before we see your patients,” says Richard W. Panek, DDS, an oral surgeon at the Center for Oral Surgery & Dental Implants.

Teamwork is also part of the process among our five oral surgeons, especially for complex cases. “We often collaborate amongst ourselves to determine the best treatment for a patient and make sure we’re offering the most current treatment options,” says Dr. Panek.

To make a referral, visit us online at www.grandrapidsoralsurgery.com and use our secure referral form, or feel free to use your own form.

Call us at 616-361-7327 to sign up for the pMD app or to reach any of our doctors to discuss your patients’ needs.

Want to text our doctors via a free HIPAA-compliant app? Call us at 616-361-7327 and we’ll send you an invite to download the pMD messaging app.

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