Preserving Smiles, Improving Lives: Unmasking the Dr. Medha Gupta's Magic
Welcome to part 2 of our conversation with Dr. Medha Gupta
What approach do you take to differentiate and manage the implant procedure for younger adults versus older ones?
Dr. Medha Gupta: For a young adult who has a missing tooth, getting an implant might seem relatively straightforward for both the patient and the dental professional. However, nowadays, certain habits like smoking can pose issues. Apart from these factors, from a clinical health perspective, there are usually no major concerns. Yet, when dealing with geriatric patients, typically aged 70 and above, several factors come into play.
Firstly, it's important to assess whether an older patient is suitable for an invasive procedure like an implant. Many older patients may have pre-existing heart or cardiovascular disorders, as well as kidney issues, leading them to be on anticoagulant medications or blood thinners. The presence of blood thinners can raise significant concerns during any surgical procedure, particularly in the oral cavity, as the mouth cannot be fully immobilized. After an implant procedure, patients need to continue eating and performing daily activities, making it challenging to control bleeding. Thus, for older individuals, it's crucial to ensure that cardiovascular and kidney health is optimal or obtain clearance from their general physician to temporarily halt blood thinners for a few days without adverse effects.
Secondly, the condition of the bone plays a vital role. When geriatric patients seek dental implants, their bone loss levels are often substantial due to factors like osteoporosis, deficiencies in calcium and vitamin D, or simply the effects of aging. Evaluating whether an implant is a viable long-term solution becomes imperative. Presently, patients in their late 40s to 50s are educated extensively about the benefits of implants over more traditional procedures like post and core treatments or lengthy span bridges. The rationale behind this approach is that, down the line, when a bridge, crown, or denture fails after a decade or more, and the patient is in their mid-60s to 70s, they might not be medically fit for an implant procedure. Opting for a solution that can endure for the next four decades without necessitating constant adjustments becomes a more pragmatic choice.
In essence, while implants might be straightforward for younger adults, addressing the complexities associated with geriatric patients requires a comprehensive evaluation of their cardiovascular health, bone status, and potential long-term implications. Educating patients about the advantages of implants over time-sensitive alternatives can contribute to more effective and enduring dental solutions.
What is the timeline for the entire implant placement process, starting from consultation to the completion of the placement?
Dr. Medha Gupta: When it comes to advising both patients and doctors, my suggestion would be to invest a substantial amount of time. Often, practitioners might propose options like six implants, four implants, or even a smile design, yet the crucial backstory is frequently overlooked. It's essential to ensure that the consultation process is extensive and comprehensive. Pay close attention to the patient's bite, a critical aspect. There are instances were placing an implant or providing a cap, crown, or denture that facilitates proper biting and chewing becomes challenging due to an inadequate bite assessment. Verify the bite thoroughly. Have a clear vision of the kind of bite you intend to achieve, especially in cases involving full-mouth implants. This vision is crucial.
A meticulous consultation and clinical examination are imperative. You should possess the ability to envision the outcome. Alternatively, you can use available AI tools to scan and predict post-implant procedure results. Precisely record the vertical dimension to understand the plan or compare it after the implant procedure. Conduct an exhaustive clinical examination. Additionally, prioritize a comprehensive medical assessment for the patient. This is of paramount importance, including evaluating sugar levels, bleeding and clotting times, and platelet levels. I encountered a case where a patient's implant failed three months after placement due to undiagnosed diabetes resulting from PCOS. This underscores the significance of comprehensive pre-planning and patient assessment. Occasionally, it's essential to assess the patient's overall health beyond oral concerns.
Following a thorough clinical assessment, the next step is acquiring a CBCT report, which might take a few days. If everything aligns with the plan within a week, you can proceed with the surgical phase of the implant. With advancements like same-day implants and crowns, you can have a full set of teeth within days. Alternatively, for cases requiring longer healing periods, implants are placed, and after three to four months of healing, the preparation for crowns begins. The entire rehabilitation process might span a few weeks, especially for a full mouth reconstruction. While it might be time-consuming, the result is a permanent solution. The investment in time should be viewed in light of the lasting benefits.
What do the term 'Bi-cortical implants' refer to?
Dr. Medha Gupta: Bicortical implants come in various types and find extensive application, particularly in older patients with significant bone loss. The choice to use them depends on the remaining bone volume observed in maxilla and mandible x-rays. When addressing the upper jaw or maxilla, we consider the utilization of zygomatic and pterygoid plate engagement within the skull. Similarly, for mandibular implants, engagement at the base of the mandible is contemplated. While bicortical implants are commonly employed, we exercise caution before opting for them.
Do you recommend implants for patients with complete attrition?
Dr. Medha Gupta: As a prosthodontist, I would never recommend replacing a natural tooth with implants. From a prosthetic perspective, I can successfully restore a severe attrition case without resorting to extraction or altering your natural teeth. I would always advise considering root canal procedures, which are less invasive alternatives, coupled with an increase in your vertical dimension. This can be followed by the placement of high-quality ceramic or porcelain-fused-to-metal (PFM) crowns. In cases where natural teeth are not infected and aren't causing discomfort—just suffering from attrition—there exist prosthetic solutions that are far more advantageous than opting for implants.
In cases of severe attrition with missing teeth, do you consider using implants for replacement?
Dr. Medha Gupta: In cases involving multiple missing teeth, such as complete posterior edentulous situations, it's essential to adopt a cautious approach. Even in distal extension cases, the recommendation is to refrain from extracting any anterior teeth. Instead, focus on elevating the bite and carefully assessing the anterior guidance. Providing a robust prosthetic rehabilitation for both the anterior and posterior segments is advised. Only after ensuring stability and functionality in the anterior region should implants be considered for the posterior areas.
For scenarios where there are gaps between teeth or a mix of attrition, mobility, and severe decay in the remaining dentition, implants can indeed be a viable option. In such situations, the decision to pursue implants should be carefully evaluated based on the overall condition of the teeth, the patient's oral health, and the potential benefits of implant-supported prosthetics.
What is your protocol for full mouth rehabilitation?
Dr. Medha Gupta: The protocol for full mouth rehabilitation is known to vary, and while various textbook methods exist, implementing these methods can extend the process to over six months. Given the constraints of time, patience, and financial considerations, a more practical approach is advisable. When undertaking a full mouth rehabilitation, I recommend focusing on one side at a time. You can begin with either the upper or lower anterior segments. Begin by assessing the vertical dimension (VD) and planning the anterior guidance. Subsequently, proceed to address the posterior portion.
In cases where starting with the posterior teeth is preferred, it's crucial to keep the temporomandibular joint (TMJ) in mind. Whenever the bite is raised, it's wise to place the patient on soft acrylic crowns for about a month. This allows the patient to acclimate to the changes and enables you to monitor for the development of temporomandibular disorders (TMD) or discomfort. Ensuring patient comfort and TMJ adjustment is paramount. Once the patient is well-adjusted, you can transition from acrylic crowns to porcelain and then proceed to address the anterior aspect.
While a month and a half are a reasonable timeframe for comprehensive full mouth rehabilitation, meticulous planning is essential. This entails precise impression-taking, preliminary casts, and well-executed wax-ups. Collaborating with dental labs equipped with proficient Hanau articulators or virtual articulators is essential. Furthermore, performing a face bow transfer ensures accurate case execution.
It's crucial not to favor starting with the anterior or only addressing the upper teeth solely because they are more visible. While these approaches might seem patient-friendly initially, they can lead to substantial TMJ discomfort down the line. To avoid such complications, a comprehensive and balanced approach, focusing on both functional and aesthetic aspects, is recommended. This strategy ensures patient satisfaction and minimizes the risk of post-rehabilitation issues.
Stay tuned for the third part of this interview!
