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  • Dr. David Alfaro

Hanging on.....

We give up too easily.

Take a look at this radiograph:

Now please pardon the quality, because it is from before the office was digital, but I am sure that you can clearly make out the extent of bone loss that has occured, particularly in the maxilla. Coupled with the pneumatization of the sinuses, if this patient presented to most offices with this extent of periodontal disease, there would likely be one treatment recommended:


Every implant company is pushing some sort of four-implant, angled, fixed solution, and they are marketing them as an easy, convient option that solves problems quickly, and permanently.

We know that it works. But does that mean that we should give up so easily?

What if we tried to save these teeth? Would that be crazy? Yes, there is loss of bone support. Yes, there is class II mobility throughout the dentition. Yes, there are areas of periodontal pocketing.

But, what if we did not just give up?

Well, in this case, Dr. Ma did not give up. He put the patient through the classical periodontal management for someone with chronic periodontitis, by starting with four quadrants of debridement, re-evaluation, and then periodontal pocket reduction surgeries where indicated. Nothing fancy. Nothing expensive (relative to all-on-four). Nothing new. No grafting.

Most importantly, he was able to implement a change in the patient's behaviour; brushing improved, flossing improved, diet improved, and 4-month maintenance appointments were abided by.

It took a lot of motivation on the patient's behalf to try keep those teeth.

Would you have told the patient to extract everything, or would you have taken the time to give it a shot at saving them?

You know, until I starting seeing the outcomes of a succesful, traditional periodontal maintenance program, I was not a believer that people could actually change their habits. I would have said, "yank em all out". But if you can help people make positive changes, things can work out.

This case is a perfect example of why we should not give up so easily.

That first radiograph was taken over 15 years ago! And this was the patient a couple of years back (again before digital, sorry):

And last week (ok I am not the best photographer)......

Minimal progression of periodontal disease. Yes, the lower jaw required some extractions, but the upper teeth have remained relatively stable.

This patient made a life changing modification to their daily and professional hygiene routine that has allowed them to live another 17 years with what surely most people (including myself) would have deemed to be a failing dentition. Yes, the class II mobility remains and there are exposed roots and areas of mucogingival defects, but the periodontal condition is stable (3-4 mm pockets, crestal cortication on radiographic evalution, minimal BOP), and more importantly, the patient is happy that they have been able to keep their teeth for this long.

Anyone who has worked with all-on-four, or hybrid prostheses in general, knows that, while they work, they are very far from being "successful" treatments. Maintenance is time consuming for both the patient and the dentist. Components are expensive. Lab costs are crazy expensive. Acrylic teeth break and fall off at an extremely high rate. Patients need to know this up front when they are dropping tens of thousands of dollars on a treatment. These treatments are not forever and they cost a lot of money to maintain!

If you haven't worked with hybrids.....they are not as simple as the reps or podium doctors tell you. I have been in many a study club where people have tried this in their general dental practice and have ended up with a very expensive, time consuming mess, sometimes ending up in referral. Not a confidence booster for the patient!

And do you really want to have a hunk of acrylic screwed in to someones mouth who has not been able to implement healthy home hygiene habits? I have seen some horrible, malodourous, hybrid dentures in my day, with very inflamed peri-implant soft tissues because people just do not take the time to clean these the way they have to be. We have to face the fact that patients lose teeth because of poor homecare, and screwing down acrylic and metal into a poorly maintained environment is not a good idea.

Now that I have taken over a periodontal practice and have seen the positive effects that proper home care has on the "failing dentition", I will gladly sit down and scale and debride roots for someone, and help them get on the path to healthy oral habits. This is the first step in any prosthodontic treatment as anything I do in the face of plaque and calculus will surely fail in the future, no matter how smooth my margins are, how clean of an impression I make, or how well the labwork is fabricated.

I guess that is why the reps have stopped coming by my office trying to get me on this is not my treatment of choice and they know that it is my last resort.

Thanks for reading!

Dr. Dave

p.s. I am sure that those following along have noticed that I rarely post any patient photographs or radiographs. Please be assured that I discussed this with my patient and have gratefully received permission to use their photographs and radiographs for this educational purpose. Thanks again for letting me share your experience!

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