Wagner Oral Surgeon & Dental Implant Specialists

WHICH IS BETTER; PRGF OR PRF?

 I have written on this in the past, and was reintroduced to the subject in a recent article in our journal (J Oral Maxillofac Surg 76:1823.e1-1823.e12, 2018).

PRGF (platelets rich in growth factors) and PRF (platelet rich fibrin – also called L-PRF) are terms used to describe products of blood fractionation used in surgical procedures. Unfortunately they do not have a specific definition from a procedure standpoint medically/surgically. The original descriptor for PRGF was “plasma rich in growth factors” which is also an appropriate term, but I feel falls short of showing that we are using a platelet concentrate, not just plasma. There is an importance in that some techniques that other practitioners use to separate the component parts include additional cells which may adversely affect the desired result. Some include the white blood cells (leukocytes) and others include some red cells (erythrocytes) and/or additional plasma and components. I feel strongly that there is a difference in results and in our practice we stick to using primarily the platelet–growth factor portion where we can, which is the vast majority of cases.

Historically we used the patient’s own bone harvested locally, from the jaw, or from a distant area such as the hip or rib as examples. This works well especially for large defects and especially with vascularized grafts (bone grafts including the grafting of associated blood vessels and tissue such as muscle). The problem with your own bone is the necessity of a donor surgical site and also that our bodies absorb our own bone easily – so a graft such as an onlay graft using your own bone, which might be performed for implant reconstruction, will absorb easily during the healing process resulting in the loss of the graft.

In comes materials such as ceramics, animal bone products, and human bone products. Of these the human bone product (deproteinated and irradiated for sterilization) has shown to be the best received and very stable for grafting of smaller defects as might be used in typical oral surgical procedures. The ceramics and animal bone products have their uses and we find them to be excellent for certain applications, however they may show a more difficult “take” or acceptance and they tend to stay on forever in their present state (which is technically not usually a problem – but can be). The human bone product is essentially completely reabsorbed and replaced by your own native bone during the healing process. This result is more desirable to me.

When you mix PRGF and the human bone product (and in some cases the other bone substitutes) I call it a “super-charged” graft with not only a bony scaffold (the bone graft material), but also a very cellular accelerant which “induces” bone growth (the PRGF). This has been a quantum leap for our grafting procedures and gives great results. The cited article backs up the idea that the PRGF works better than just PRF to induce tissue regeneration and growth.

We have been using these techniques for about 10 years. Again, we have been performing implants and grafting procedures for over 30 years and we have trained in and tried all of the reasonable techniques. We stick with what works best and keep looking for new and better materials and methods.

In our hands, PRGF works better than PRF for grafting techniques.

DIRECT ORAL ANTICOAGULANTS AND MEDICAL COMORBIDITIES

Patients who are taking oral anticoagulant drugs such as Coumadin or Plavix (as examples) can be divided into about 10,000 groups based on their medication, age, medical problems, history, genetics, dosage, the treatment needed (to name a few). In other words there is no simple one-size-fits-all answer to this question/problem of how do you manage a patient on oral anticoagulants who needs an oral surgery procedure. (J Oral Maxillofac Surg 77:463-470, 2019).

There are some simple rules-of-thumb that we follow and they all boil down to the idea that we need to “know” our patient as much as possible and then use good judgement and tried surgical techniques to control bleeding as much as possible. Along with that, a well-informed patient and family/support personnel as to how to deal with problems as they arise, goes a long way to head off problems. Some very basic fact-finding with the patient, patient’s family, and patient’s primary care doctor will usually answer the questions required to make good decisions for an experienced, well-trained surgeon.

The article that I site discusses the effect of comorbidities such as diabetes as predictors. Frankly, I have found that trying to predict based on comorbidities has a limited use. Clearly, a patients’ other medical problems as a list is good to have – but these need to be assessed as they relate to how they are affecting “this” patient. We see patients with multiple serious medical concerns who know their own health well and have good control. They will have a much lower risk than someone who does not understand their own disease such as hypertension and who has poor control.

Again, these are complicated issues and proper discernment, follow through, and responsible surgical care work best to save us from having problems.

3 Benefits of Dental Implants

3 Benefits of Dental Implants

Missing a tooth? Meet your new best friend—dental implants. Before choosing to opt for a dental implant, it’s important that you understand the in’s and out’s of these replacement teeth and how they will benefit your smile. When replacing a tooth or a gap with a dental implant, you are not only giving your smile the perfect finishing touch, but also allowing yourself the normalcy of a full set of teeth. Below are three reasons as to why dental implants are the best tooth replacement option.

Lasts A Lifetime: Dental implants are made with a combination of titanium (yes, the same titanium used in airplanes and spacecrafts!) and jawbone that creates a sturdy foundation for the replacement tooth. This replacement tooth is able to withstand numerous years of regular wear and tear when paired with a proper oral hygiene routine that is consistent and thorough. This powerful replacement tooth (or teeth) is permanent—so you won’t have to worry about getting a new one anytime soon. To ensure that you keep your dental implants in tip top shape, take the initiative to clean your implants after enjoying any foods or drinks—just as you would with your natural teeth.

Can Prevent Gum Disease: By having a dental implant in place of a gap, you are able to prevent any debris or bacteria from being trapped within the crevices between your teeth and gums. In fact, a dental implant can give you the appropriate amount of space you need to maintain a daily brushing and flossing ritual, reducing the risk of irritation of your gums, like periodontitis.

Restores Chewing Power: One of the biggest advantages of dental implants is being able to fully chew and eat again! In fact, studies show that many patients fail to even find a difference between a natural tooth and a dental implant, as they look and feel just the same. With the ability to chew properly, you’re able maintain a normal and healthy balanced diet (and life) by being able to eat a variety of your favorite foods.

When looking for a replacement tooth option, consider dental implants. Need more information or want to learn more? Give us a call at Racine Office Phone Number 262-634-4646 to explore the next steps to regain not only your smile back, but your confidence too.

THE VAZIRANI-AKINOSI NERVE BLOCK

This technique has been around since the 70s and is a technique that I use often. (J Oral Maxillofac Surg 77:489-492, 2019). I must confess that I go back and forth with the techniques and often use the Gow-Gates technique as well. When I went through my training in the 80s we were taught multiple techniques with a prejudice toward a variation of the Halstead’s technique. The sited article suggests, that in training, alternative techniques are not shown. I did not find this to be true. At all of my training sites including Marquette Dental School multiple techniques were taught and shown. I am guessing that the experience could vary from person to person depending on their interests and basic skills. Certainly in my various residency experiences the different techniques were actually stressed and encouraged as it is not uncommon to run into special circumstances and special patient populations in a surgical practice requiring one to “think outside of the box.”

Anecdotally, I would make the observation that many patients are difficult to gain satisfactory local anesthetic for more invasive procedures and especially in the face of infections or other factors which normally reduce the effectiveness of the local anesthesia agents. In these patients, short of performing the treatment with sedation or general anesthetic agents, knowledge of and trying multiple local anesthetic techniques is often necessary.

MEDICATION RELATED OSTEONECROSIS OF THE JAWS

Medication related osteonecrosis of the jaws (MRONJ) is a disorder with bone maturation that occurs as a result of taking certain medications (historically bisphosphonate drugs such as Fosamax; more recently with antiangiogenic drugs such as Denosumab; and mainly from injectable forms of these drugs used in chemotherapy such as Zometa) where dental related disease processes or dental procedures result in a dead-bone disease (osteonecrosis of the jaws). This disease process typically just affects the tooth bearing areas of the jaws, although I have seen cases involving the palate, sinuses, and nasal structures as well.

Simply put, these drugs cause a blockage of the natural re-uptake of bone in what would be the normal bone apposition and re-uptake process that our skeletons go through. The result is to get a net increase in bone mass. The technical problem is that the resultant bone is a buildup of “old bone” which may be more prone to healing problems.

The prescribers of these medications, especially the oncologists, are doing a much better job of dosing these than even 10 years ago. We saw the biggest problem in the first years of this century when less was known and greater doses were given. Fortunately it has become a rarer problem.

The oral surgery association here in America has put out a “white paper” on MRONJ which was last updated in 2014 suggesting that the disorder has not changed much in the past 5 years. I have put the link below and I recommend looking at this if you have an interest. I follow their guidelines in general when faced with these cases. Because these are now more-rare cases I might suggest referral to regional medical centers with oral surgery services such as oral surgery residency programs if that is available. This facilitates best-care practices and usually helps to add to the knowledge base in the study of these problems. Again, fortunately, improvement in the dosing regimens has reduced the number of cases we are seeing.

 

https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/mronj_position_paper.pdf

 

COMPLETE IMPLANT TEETH – ALL ON FOUR – TEETH IN A DAY

I am excited to announce that we have taken the All on Fourä concept to a new level. There are many ways to say it: Teeth in a Dayä, Same Day Teethä, Smile in a Dayä, etc, etc. These have all been coined to illustrate the immediacy of this technique. We have refined our technique and taken a process which was tedious, and sometimes difficult to predict and made it much more predictable, easier, and fun.

The typical patient for this procedure is dentate, often phobic, tired of dealing with their avoidance or recurrent dental problems, and ready to transition into a great new technology. Edentulous or dentate, many patients can benefit from this care.

We have improved the technique with more comprehensive treatment planning. Our 3D planning allows us to see and anticipate concerns and provide a treatment plan that transfers seamlessly to the actual surgical procedure. We have a well-equipped lab and our operatories are large and comfortable for these bigger procedures. Our staff is experienced and able to make this an easy technique for you.

I will be looking forward to the opportunity to share our technique with you. We will be offering continuing education on this and if you wish to be involved in a case in the meantime we would have no problem training and seeing you through it one-on-one. I appreciate all referrals. Please consider sending your patients for a consult to consider implant care including complete implant teeth.

The Dos and Don’ts of Good Dental Hygiene

Dos and Don’ts of Good Dental Hygiene

Dental Hygiene is important. Those who practice good oral habits reap the benefits, while the latter… not so much. Most of us have a great deal of control over whether or not we keep our teeth as we age. Those who don’t follow a proper routine, end up losing their teeth, thus requiring the need of tooth replacement (such as dentures, dental implants, etc.). If you want to achieve an optimal level of oral hygiene, all you have to do is follow these do’s and don’ts!

Do…
• Brush your teeth twice a day! Use a soft-bristled brush with a fluoride tooth paste and be sure to brush all surfaces of the teeth, even the hard to reach places.

• Floss your teeth every day! Floss removes food trapped between your teeth and the film of bacteria that forms before it turns into plaque.

• Visit your dentist every 6 months! Regular visits allow your dentist to discover early signs of cavities and gum disease.

• Eat a mouth healthy diet! Indulge yourself in foods such as whole grains, fruits, vegetables, lean meats and of course, water!

Don’t…

• Forget to replace your toothbrush! Tooth brushes should be replaced every 3 month—or after you recover from being sick. If you have an electric toothbrush, replace the head rather than purchasing a whole new one.

• Brush too soon after eating! Brushing immediately after eating acidic food can cause tiny particles of enamel to be brushed away. To be safe, wait at least 1 hour.

• Go overboard with bleaching! Over-bleaching your teeth can make them very sensitive to hot and cold foods, thus causing a variety of other problems.

• Ignore pain or abnormalities! Toothaches can be a sign of a more serious dental issue. See your dentist as soon as you discover changes in your dental health.

• Consume lots of soft drinks and sugary foods! These foods are highly acidic, which wears away your enamel overtime. Frequent consumption of sugary substances allow plaque to grow more rapidly—thus the likelihood of cavities will increase substantially.

When it comes to your dental hygiene—you have the option between keeping your teeth or not. By starting to practice these dental do’s and don’ts, you will be on the right track to a long-lasting smile. Give us a call today Racine Office Phone Number 262-634-4646!

Oral Surgeons Address the Opioid Crisis

Recently opioid abuse and addiction have been a hot story in the news. Dentists were made an early scape goat for prescribing problems with opioids. The truth is that Dentists were identified in questionnaires as being one of the earliest prescriptions for opioids that addicts were exposed to. This may be true. But Dentists write out many thousands of prescriptions for opioids every year and we only see a tiny segment of that population actually having a problem with them. There is a decision that has to be made to abuse prescriptions. And a decision has to be made to take that further and become an addict. I submit that these same individuals were likely to become abusers and addicts, either through their social experiences or by virtue of their genetic / personality predisposition, even without the dental prescription experience.  We can discuss and debate these points.  The truth is that addiction is a complicated process that exists all over the world – whether there is dental care or not.

I was trained about 30 years ago and, oral and maxillofacial surgeons as a specialty, over those years have always stressed high standards for prescribing. This is stressed regularly at our meetings both locally and nationally. We have practiced that here at our office. Over time we have studied and modified our prescribing practices with a goal to provide appropriate coverage for pain and attention to watching out for prescribing problems. The fact is that we perform procedures that cause pain.  Pain control and pain relief are expected by patients as part of quality care and we take it very seriously. We partner with the patient’s physician, healthcare providers and pharmacists in providing proper guidance in the taking of all medications. We employ pain management specialists when we feel it is appropriate.

To stay in front of this subject, our oral surgery association (AAOMS) has published a “white paper” addressing the prescribing of opioids by members of our specialty.  This paper outlines recommended prescribing practices.   In our practice we stand by this paper.  If you have an interest in this subject I encourage you to read this.

https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/opioid_prescribing.pdf