Fall 2018

The New Face of Dentistry

The School of Dental Medicine is leading the way into a bold, new future for implantology.

By Helene Ragovin

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Illustration: Eva Tatcheva

An unfortunate encounter with a cherry pit did in Hans-Peter Weber’s molar. Even a dental school professor emeritus is not immune from the kind of accident that can claim a tooth. Today, some 178 million American adults are missing at least one tooth, the result of trauma, decay, or gum disease, and roughly 40 million have lost all of them in one or both jaws. The club of people missing teeth is enormous, and it’s one that many more people will inevitably join as they age.

After a sleepless night, a trip to the oral surgeon, and a subsequent extraction of the molar, Weber now finds himself waiting for a bone graft to heal, so that his dentist can place an implant. Even just a generation ago, he might have gone with a different prosthetic. But now, an implant is the only solution he considered. And with about half a million dental implants placed in the US last year, Weber is hardly alone in making the choice (although he’s likely to be the only person in the waiting room to have coauthored a textbook on the subject).

Following decades of research that has led to highly successful outcomes, implants are increasingly the preference for patients. Between 1999 and 2016, the number of patients with missing teeth who opted for implants increased 14 percent a year, on average, according to a recent study drawing on data from the National Health and Examination Survey (NHANES).

To best serve their patients, more dentists and dental students are understandably eager to acquire and perfect their implantology skills. New technology, such as advanced imaging and robotic-assisted equipment, is enabling them to plan and place implants and restorations with ever increasing ease and precision. Meanwhile, Tufts School of Dental Medicine is responding with its own innovative research, paired with changes in curriculum and new facilities for patient care. “Implant dentistry gives us different ways to think about cases, and to treat cases: A whole different tool box to help our patients,” said Nadeem Karimbux, associate dean for academic affairs.

It’s not that implants, which can be costly, have replaced dentures and other types of restorations. But start adding up some of the potential benefits—they let patients chew and speak more easily, they don’t have to be taken out to be cleaned, and they don’t require alterations to existing teeth the way a bridge does—and it’s easy to see why the age of dental implants is now upon us. “I have two implants myself, for congenitally missing laterals, and it’s been a life-changing experience,” said Ekaterini Antonellou, DG98, MSD01, DI04, associate professor of prosthodontics and the director of the dental school’s growing implant clinic. “I say that as a dental practitioner and an actual patient.”

Judging by the archaeological record, humans have been experimenting with ways to replace their missing teeth for millennia. Evidence of attempts to use stones or pieces of shell have been found in ancient Mayan and Egyptian remains. By the time of George Washington, the materials for false teeth had evolved to ivory and animal bone; later, so-called “Waterloo teeth” gathered from the corpses of fallen soldiers came into use. Comfortable, affordable dentures—fitted with porcelain teeth—finally went mainstream in the mid-19th century, following Charles Goodyear’s breakthroughs with vulcanized rubber.

Top: A radiograph of a patient who required extraction of all remaining teeth. Bottom: The digitally designed implants and provisional restorations were all placed on the same day. Radiographs: Courtesy Wael Att

Dentures reigned in dental medicine for more than a century. Although the first modern implants, with metal or ceramic posts or threaded screws that fuse with the jawbone and support a crown, date to the post-WWII period, it wasn’t until the early 1980s that titanium implants as we know them emerged. That’s when an effective system developed by Swedish researcher Per-Ingvar Branemark began to be taught widely, and when the FDA approved the use of titanium dental implants in the U.S.

In the years since, the use of implants has only grown. A study in the Journal of Dental Research published in August reported that in the period 1999-2000, 0.7 percent of people missing a tooth had an implant. By 2015-2016, the figure had increased more than eight times, to 5.7 percent—and the researchers estimated implant use could reach as high as 23 percent by 2026. The most substantial increases in adoption have taken place over the last decade, in concert with declines in healing time and implant failures, and the aging of the Baby Boomer generation.

Seniors are not the only candidates for implants, however. Prosthodontics Chair Wael Att, who previously taught in Germany, said the large proportion of cyclists in Europe led to many younger patients who’d left a tooth on the roadside. But aging takes its toll on dentition, and NHANES data showed people ages sixty-five to seventy-five getting implants at a much faster clip than younger adults. Market research firms predict the global implant market will grow at a rate of about 7 percent a year, reaching as much as $6.5 billion by 2024.

Compared to other forms of restoration, implants can offer patients a more natural look and ease of use because they remain permanently affixed. From an oral-health perspective, they can help maintain bone, and don’t require work on the existing teeth alongside them. Yet implants are not right for everyone. Sufficient bone is still needed to hold the implant in place, and bone augmentation is not always possible. Peri-implantitis—inflammation and infection of the gum and bone surrounding the implant—is a risk. Smokers, people with diabetes, and others with slow healing face the most challenges. And contrary to what many patients believe, implants are not maintenance-free, and consistent follow-up is needed. Ultimately, 5 percent to 10 percent of implants fail.

And fear of dental surgery can still be off-putting for patients. “Not all patients flock to the treatment,” said Weber, the former chair of prosthodontics at Tufts. “For a patient like me, who cracked and lost a tooth that can successfully be replaced with an implant and a crown or a three-unit bridge for about the same expense, many patients and dentists will still opt for the bridge.”

Not too long ago, implant placements were the sole purview of specialists, primarily oral surgeons and periodontists, and there are many situations where specialists are necessary. For example, said Karimbux, a periodontist, if you want to place an implant in an area where too much bone has been lost, a bone graft will likely be needed. Sometimes, a sinus elevation is necessary. “Those in specialty programs have spent time learning those techniques,” he said. “If you don’t have adequate training, or don’t know your limits, you can get in trouble.”

For straightforward cases, however, general dentists have been increasingly offering surgical placement of implants. More than half the roughly 500,000 implants placed in the U.S. in 2017 were done by general dentists, according to the American Academy of Implant Dentistry, with training coming primarily from continuing education courses and implant manufacturers. And dental educators well understand that implantology skills will be in demand for new dentists, which is why Tufts is deepening its investment in resources and teaching.

If anything is slowing the rise of implants, it’s cost. Because every case is different, numbers are hard to come by, but estimates suggest the price of implants can range from about $1,000 to $3,000 for a single replacement, and reach into tens of thousands of dollars for a full mouth. At the same time, public insurance programs do not cover implants, and many private insurance plans cover only a portion of the cost for the restorations, and don’t pay anything for the surgical placement. According to demographic research in the JDR study, implant recipients are more likely to be white, have more than a high school education, and have private dental insurance.

To broaden access, Antonellou believes the dental community needs to improve its efforts at advocating for expanded insurance coverage. “Everything in implants costs a lot,” she said. And she’s hopeful changes in insurance coverage, together with improvements in technology and training, will help in driving the costs down. (In the meantime, one cost-effective option can be treatment at an academic clinic like the dental school. Tufts recently offered a “two-for-one” package for patients who needed multiple implants.)

For patients with the means to afford implants, however, Antonellou says to think of them as a sound investment in something they will be using every day. Research suggests even if implants cost more upfront, their permanent nature can make them a more inexpensive option over the long term. “The benefit you get out of implant restorations is tremendous,” she said. “Implants are changing the face of dentistry forever.”

Keep reading about how the School of Dental Medicine is leading the way in the field of implantology in these articles:

Looking Forward at Tufts
Beyond Science Fiction
Hands-On Learning

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