A Sign Of The Times…

May 22, 2011 § Leave a comment

Yet another indication that today’s technology is changing the way we do things is this video segment by WTVD ABC 11 News TroubleShooter Diane Wilson, says Durham dentist Dr. David M. Haas Lambert, DDS.  Ms. Wilson was contacted because local Raleigh residents wanted help in disposing of unwanted YellowPage telephone directories.  Local refuse collectors will not pick up these books and apparently they are to be disposed at a special drop-off center, which residents feel is unrealistic.  Search engine technology is obviously replacing the need for the Yellow Pages.

WTVD ABC News 11 TroubleShooter Video:  click here


Pradaxa (Dabigatran)…the new anticoagulant…

May 18, 2011 § Leave a comment

Durham Oral Surgeon David M. Haas Lambert, DDS says Pradaxa (Dabigatran – Boehringer Ingelheim) promises to potentially replace Coumadin (warfarin) for one of it’s most common indications – atrial fibrillation.  Dabigatrin is a direct inhibitor to thrombin, the enzyme that catalyzes the conversion of fibrinogen to fibrin, the last phase of the coagulation cascade.  The drug has very few dietary restrictions and drug interactions – yes, you can drink all the grapefruit juice, eat all the leafy greens, and just about take any medication, Rx or OTC, without any further consideration.  Dabigatrin is also safer than warfarin as it causes less than half the number of intracranial bleeds – the most significant morbidity associated with warfarin.  Furthermore the drug requires less, if any, monitoring, dosing is simple, and for invasive surgery may be terminated 48 hours before theater.  Stay tuned for more information on Dabigatran.

A Quick Way To Enter The Social Marketing Arena…

March 23, 2011 § Leave a comment

Most of us have a private network in our offices.  If not, better get one!  As part of your overall security routine, you should have a firewall to prevent outward intrusion – and most firewalls these days are also dual-purpose as a wireless access point.  Your network specialist probably has WEP password protection to your wireless office network, however most firewalls have an option to allow “guest access” to your network – much like you see in hotels and restaurants.

Typically when someone in your office attempts to access the internet, their smartphone or computer will detect the guest access, and they’ll be presented with a page, where you will then supply complimentary log-in info.  You can however customize that login to point to another webpage upon successful registration.  This webpage, for example, could be a site likeFourSquare where you can encourage folks to geotag their location, write comments, etc.
Go ahead, give it a try.  At the very least, you’ll certainly have a lot of fun with it!

Idiopathic Peri-Implant Alveolar Resorption

March 12, 2011 § Leave a comment

Big word eh?  I think so too but we gotta call it something.

We like to promise patients the world – in a well meaning way.  That is, we like to tell patients, yes we should be able to put an implant in here or there and it should work.  It should work for a long time.

But it doesn’t always work out that way.  An implant surgeon’s worst nightmare is unexplained, or idiopathic, resorption around an implant, leading to a symmetric vertical type of bone loss defect.  There’s not much that can be done about it really.  You place an implant in what appears to be an ideal site, the implant integrates, and it’s restored.  Then you watch it slowly over time, and the bone just gradually disappears.  At first it’s very, very slow, then it progressively increases, probably as the implant loses stability, develops micro-movement, and ultimately fails.

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The more we learn, the less we find we know…

There are other situations that can be more readily explained – an implant placed in a multiply-operated site, or a site previously exposed to trauma, etc.  While the resorption here is similar, the likely culprit is most likely a relative loss of vascularity.  But with this particular issue, there’s no explaining it – other than it appears to happen most frequently in post-menopausal women.  It can occur in the maxilla or the mandible, anterior or posterior.  Perhaps chronic disease plays into it (diabetes, etc), but often times there are no issues with osteoporosis/osteopenia of the skeleton.  So, it appears to be a mystery.

I have no explanation other than to say it frustrates me.  I would however be interested in the possible role of bisphosphonates in possibly preventing this problem.  I know that sounds somewhat counter-intuitive, but I have a sneaking suspicion it just might help.

Either way we constantly remain humbled as practitioners.  The more we learn, the less we find we know.

The “Immediate Implant Placement Bubble”…

February 19, 2011 § Leave a comment

There has been an increasingly disturbing trend for some surgical specialists to market  implants placed “immediately”to their restorative colleagues and to the public at large.  To the lay person this means that an implant is placed immediately after a tooth is extracted as opposed to the more traditional “staged” approach where a tooth is removed, the site is grafted – allowed to heal for several months – then re-evaluated for implant placement.

What is the benefit?  Really, it’s not that implants *can’t* be placed immediately…just not *all* of them!! The selling pitch, of course, is time.  Time to the patient supposedly means fewer appointments, less pain, etc.  Time to the implant teams also means fewer appointments but with the added bonus that revenue streams associated with treatment occur more rapidly.  This of course would be well and good provided that both approaches consistently yielded the same results.

So why all the fuss?  The problem is truly predictability; predictability in the sense that bony resorption, or remodeling, is itself unpredictable.  When a tooth is removed, there are two opposing processes…one is bony resorption, or break-down, and the other is bony deposition, or bone growth.  Taken together the net result of these two processes defines bony remodeling or healing.

Here’s the problem; when an implant is placed “immediately”, i.e. at the time of tooth removal, a best guess estimate is made to determine where the height of bone relative to the top of the implant will ultimately reside – meaning the implant is “countersunk” or placed below the top of the jaw bone to account for anticipated bone remodeling resulting in the height being lower than it’s original position after a tooth is removed.  If more bone loss occurs than is compensated for in the placement of the implant, then there is a portion of the implant that becomes exposed above the level of the bone.

So, why is this an important issue?  Teeth normally have an attachment to the surrounding gum tissue which prevents food, debris, and bacteria from gaining access below the gumline, leading to further bone loss and possibly even outright infection.  However, implants have no attachment to soft tissue whatsoever…in fact they rely upon the gum tissues natural adherence to the jaw bone to produce a “seal” around the implant.  If he top of the implant is level with the crest of the surrounding bone, then the gum tissues attachment terminates at the margin between the implant and the jaw bone itself…creating a very desirable and stable seal around the implant.  However, if an implant is placed immediately, and there is more bone resorption than anticipated – and there is no way to know this for sure in any situation – then parts of the implant will become exposed above the level of the jaw bone – and the interface between the implant and gum tissues leaves very little resistance for debris and bacteria to become displaced along the side of the implant, potentially resulting in inflammation and more bone loss.

Many people may have heard of a type of implant treatment referred to as “teeth in a day”.  The original “teeth in a day” paradigm was primarily a marketing ploy on the part of Nobel Biocare to transform completely edentulous patients to implant supported complete dentures “in a day”…the “all on 4” technique… because the dentures are supported “all on 4” implants in each arch.  Teeth may be removed and implants placed in the same day, but the implants are not placed in the same orientation as the natural tooth roots – this particular facet is a very important distinction and very significant difference between “teeth in a day” via the “all on 4” technique and “immediate implant placement”.  This does not readily translate the notion that just because the “teeth in a day” and “all on 4” paradigm do have some validity to it, that likewise all teeth can always be removed singly and have implants placed immediately in extraction socket that will still enjoy a long life of comfort and function.  This premise is the major component of the fallacy.

As with all things, it comes down to case selection.  What is disturbing to this surgeon is that there is an ongoing marketing extravaganza with the intent of “selling” patients that most, if not all, implants can be placed immediately – and which will enjoy the same long duration of life commonly observed when implants are placed in the more conventional and predictable “staged” manner.

Unfortunately, the unstable and unpredictable economics of the day appear to be displacing better judgement and driving this marketing tactic.  I don’t know about you, the reader, but if I’m about to undergo costly treatment to replace missing teeth in my mouth, I’m willing to sacrifice expedience for predictability in almost every case.  Rome wasn’t built in a day and it is truly important for the lay public to be aware that their expectations should be appropriately tempered.

Implants can be placed immediately after tooth extraction in some cases, but not all. Do not be misled by the marketing tactics of the day that any implant can be placed immediately.  It simply is not true.

At some point in the future, our colleagues will re-learn what we already know – that putting profits ahead of principles only leads to inferior results.  And so thus the characterization of the rush to immediate implant placement as a “bubble”.  Like all bubbles, eventually they do burst.  Until then the public must always remember to be vigilant!  Caveat Emptor! Let the buyer beware!

Women & Cardiovascular Disease…

February 5, 2011 § Leave a comment

Was just watching on ABC 20/20 Barbara Walter’s special on coronary artery disease and open heart surgery.  We all know there are obvious differences between men and women.  However, most women believe their number one health concern to be breast cancer.  Ironically, cardiovascular disease is the greater concern.  We typically think of coronary artery disease manifesting by onset of chest pain…what is referred to as “angina”.  However, this is a gender specific stereotype; men most commonly manifest coronary artery disease as “angina”.  Women on the otherhand manifest coronary artery disease as fatigue, making diagnosis difficult and often times leading to a deferring of appropriate care.

As clinicians, we all need to keep these important differences in mind.  While fatigue may be perceived as being somewhat non-specific; in women, it warrants careful consideration and appropriate disposition.

Oral HPV Cancer Screening

November 23, 2010 § Leave a comment

Human Papillmavirus (HPV) is one of the most common virus groups in the world. There are many different types of HPV, and the health risks vary depending upon the type of virus. While some of the types of HPV are low-risk and may cause skin lesions such as warts, there are other HPV types that are classified as high-risk. These high-risk HPV types may cause a HPV infection that can lead to cancer. For example, medical research shows that certain high-risk types of HPV are linked to approximately 90% of cervical cancers. Similarly, recent studies show that these same high-risk types cause cancers of the mouth, tongue, tonsils, and throat areas. Along with excessive smoking and alcohol consumption, specific types of oral HPV are now considered to be a separate and serious risk factor for developing cancer in the head and neck regions.

HPV transmission of the most common types can be quite simple. With just close contact between people, the infection can be spread. These types of HPV are considered to be low risk. However, the more serious types of HPV (high risk group) that may lead to cervical cancer or oral cancer are known to be sexually transmitted. Other avenues of transmission may also occur. Studies are ongoing to further understand how, in addition to sexual transmission, these viruses are transmitted. Both males and females are at risk when intimate contact is made with HPV-infected indiviuals. Individuals at greatest risk are those that are in intimate relationships with HPV-infected partners.

According to the Centers for Disease Control, approximately 20 million Americans are currently infects with HPV. Another 6 million people become newly infected each year. HPV infections are becoming a source of growing concern.

Clinical signs of oral HPV infections vary depending on the type of HPV that is present in the infection. Low-risk oral HPV types lead to a wart, or “papilloma.” High risk oral HPV may present as a sore that won’t heal, which is a worrisome sign of potential cancer.

Early oral HPV infections do not typically cause any clinical signs or symtoms; thus, a visual exam would not detect people that may already have an infection cause by oral HPV. Today, however, a simple test called Orarisk HPV is available from our dental practice that can detect oral HPV infections very early. The test performed right from our office in Houston, TX can be part of your routine oral health exam. The OraRisk HPV test uses a sterile saline rinse to determine if an oral HPV infection is present and takes about 30 seconds to complete. After the test has been performed, your dental team member will send the coded container to the OralDNA lab for processing. Your oral health care professional will receive your test results and contact you to discuss them.

– Individuals with “traditional” risk factors for oral cancer such as smoking and cancer.
– Males and females are sexually active.
– Individuals with a family history of oral cancer
– According to the Oral Cancer Foundation, “Very recent data lead us to believe that the fastest- growing segment of the oral cancer population is non-smokers under the age of 50.” However, all risk factors should be considered regardless of their age group.

Are you at risk? Come on in and get tested to be certain!!

*information and testing done through Oral DNA Labs. You can find out more information at http://www.oraldna.com and http://www.oralcancerfoundation.org


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