West Palm Beach Dentist Carlos Boudet, DDS DICOI
Cosmetic Implant and Laser Dentistry
Phone (561) 968 6022
Located at 1840 Forest Hill Blvd Suite 204
West Palm Beach, Florida. 33406
A patient presented to my office seeking help for a loose anterior bridge on implants. He goes to another dentist, but had come to my office previously for another implant related problem.
A visual inspection and a periapical x-ray showed a 4 unit bridge retained by implants placed in the maxillary central incisor positions 8 and 9 respectively (the two upper front teeth). The implants were placed extremely deep under the bone and needed 7 mm long standard abutments (posts) to bring the connection to the correct revel about 1 mm subgingivally. The bridge was loose, and the radiograph showed that the screw that attached to the left implant was broken inside the implant. The abutment had fallen out and the patient brought it in his hand.
This is a rare occurrence with today's dental implants, but these implants were the original Branemark implants and had been placed 23 years ago in 1989, and were more prone to screw loosening and fracture than the implants we have today.
Fortunately for the patient, the screw was not threadlocked and was fairly easy to remove, allowing the patient to repair the bridge with a new screw, which I was surprised it was still available from the manufacturer.
Below is a video of the procedure taken through the surgical microscope:
Carlos Boudet, DDS DICOI
1840 Forest Hill Blvd Suite 204
The article discusses the importance of propper treatment planning in dental implant cases to avoid situations where the patient is given a prosthesis that is problematic and how upgrading from a removable overdenture that kept breaking to a fixed partial denture supported by implants provided the patient with a solution that was both durable and comfortable.
A link to the digital edition of the article can be viewed on page 113 here:
The latest edition of Chairside Magazine (digital version) has just been posted, and in it is my new article on Digital Impressions For Implants Using Scannable Abutments.
Digital impressions using intraoral scanners are going to be the way impressions will be done in the future. They are here today, but due to the high cost of equipment and training, it is difficult for most dentists to afford them.
We have had digital impression systems since 1987 when the first Cerec machine became available, but we have not had the ability to scan implants the same way until recently.
The article explains the simplicity of the process using the Cerec red cam system of digital impressions.
The Relationship Between Snoring, Sleep Apnea And Your Health
I have been suddenly awoken more than once by my wife’s gentle nudging saying that I am snoring loudly and the noise wakes her up or doesn’t let her go to sleep.Luckily it only happens when I have a problem with nasal congestion and I end up breathing through my mouth at night. Sometimes snoring is so severe that it affects relationships and your sleeping partner chooses to go to another room in order to get a good night's sleep.
It is estimated that about half of the population in the states snore, and that percentage increases with age and obesity, so this is a very common problem.
So what! You might say, what is a little noise during sleep, it is only an annoyance that my wife (or husband)has been able to accept about me and does not complain about it any more.Well, it is well documented in the medical literature that a percentage of those of us that snore, do so because of a condition called Sleep Apnea.In Sleep Apnea the individual stops breathing during sleep at frequent intervals, and this causes lack of oxygen to all parts of the body.Over time the circulation to the brain is affected and leads to narrowing of blood vessels that can cause a stroke and even death.This is not a minor nuisance anymore.
Sleep Apnea is diagnosed with a Sleep Study or polysomnogram requested by your physician that records the number of times that you stop breathing during the night, and how long your breathing stops.Signs that may indicate that you suffer from sleep apnea are sleepiness during the day, irritability, lack of focus and decreased libido to name a few.If you are diagnosed with sleep apnea, your physician will recommend a CPAP machine.It looks like a small reversible vacuum cleaner and has a hose with a mask that attaches to your nose and forces air under pressure to keep your airway from closing so you can breathe without interruptions.
Those persons that have severe sleep apnea, need that machine and CPAP works great for them,however, those with mild to moderate sleep apnea find the machine cumbersome and difficult to tolerate.It is those individuals that can benefit from oral appliance therapy.The appliance is made by your dentist, and moves the jaw forward opening up the airway to prevent an obstruction.Many persons that tried and stopped using the CPAP machine resort to and do well with the oral appliances.
The purpose of this writing will be fulfilledif I have made you aware of the fact that snoring may be an indication that you, your friend or relative have an undiagnosed condition called sleep apnea that may lead to serious and even life threatening health problems, and that this condition can be easily treated by your physician and dentist and result in an improved quality of life.
Please talk to your physician or dentist if you think you are at risk.
The recent publicity given to the subject of radiation exposure in dentistry and the new CBCT scan technology prompted the ADA's Council on Scientific Affairs to come up with a statement and principles for the safe use of CBCT scans in dentistry.
The statement explains that although CBCT scans produce a higher radiation dose that routine dental x-rays, this dose is significantly lower than the one produced by a medical CT scan.
The dental CBCT units are also capable of further reducing radiation exposure by reducing the area exposed ( also called FOV or field of view).
There have been many measures taken to provide guidance in the safe use of CBCT in dentistry, such as position statements6,7 and professional guidelines for CBCT use.4,8 Recommendations for adequate operator education have been published.1,6
The guidelines state that children are more sensitive to radiation so "Additional considerations should be weighed prior to the exposure of children and adolescents". Also that CBCT scans should be prescribed only when the diagnostic yield will benefit patient care, enhance patient safety, and significantly improve clinical outcomes.
Another term you may have heard is the ALARA Principle which means “as-low-as-reasonably-achievable” , so the radiation dose for dental patients should be optimized to achieve the lowest practical level for a specific image.
In our dental office, as it should be in general, we try to taylor the recommendations for radiographic images to each individual patient's needs, and patient safety.
HornerK, et al. Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology. Dentomaxillofac Radiol 2009;38(4):187–195.
PauwelsR, et al SEDENTEXCT Project Consortium. Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol 2012;81(2):267–271.
LudlowJB, IvanovicM.Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(1):106–114.↵
The SEDENTEXCT Project. Radiation Protection: Cone Beam CT for Dental and Maxillofacial Radiology: Evidence Based Guidelines 2011 (v2.0 Final). www.sedentexct.eu/files/guidelines_final.pdf. Accessed May 11, 2012.
LudlowJB, Davies-LudlowLE, WhiteSC.Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. JADA 2008;139(9):1237–1243.
CarterL, et al.American Academy of Oral and Maxillofacial Radiology. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(4):561–562.
Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology. Use of cone-beam computed tomography in endodontics. www.aaomr.org/resource/resmgr/Docs/AAOMR-AAE_postition_paper_CB.pdf. Accessed July 10, 2012.
Academy of Osseointegration. 2010 guidelines of the Academy of Osseointegration for the provision of dental implants and associated patient care. Int J Oral Maxillofac Implants 2010;25(3):620–627.
ScarfeWC“All that glitters is not gold”: standards for cone-beam computerized tomographic imaging (published online ahead of print Feb. 3, 2011). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(4):402–408.doi:10.1016/j.tripleo.2011.01.006.
National Council on Radiation Protection & Measurements. Radiation Protection in Dentistry (Report No. 145). Bethesda, Md.: NRCP Publications; 2003.
National Research Council of The National Academies, Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, Board of Radiation Effects Research, Division on Earth and Life Studies. 2006. Health Risks From Exposure to Low Levels of Ionizing Radiation: BEIR VII phase 2. Washington: National Academy of Sciences, National Academies Press; 2006.
International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on Radiological Protection (publication 103). Ann ICRP 2007;37(2–4):1–332.
National Council on Radiation Protection & Measurements. Structural Shielding Design for Medical Imaging Facilities (Report No. 147). Bethesda, Md.: NRCP Publications; 2004.
The FDA has recently published a recommendation and warning against the use of Benzocaine topical anesthetic ointments that could result in a rare condition called methemoglobinemia.Since their original report in 2006 there have been 29 cases of methemoglobinemia reported and of those, 19 were children, 15 were under two years old.
Benzocaine is a local anesthetic and can be found in such over-the-counter (OTC) products as Anbesol, Hurricaine, Orajel, Baby Orajel, and Orabase.
Mothers with babies that are teething may resort to some of these gels or ointments in an effort to soothe their babies gums, but this can result in the rare but almost always fatal condition.
The FDA recommends that parents and caregivers not use benzocaine products for children younger than 2 years, except under the advice and supervision of a health care professional.
The symptoms can be confused with other problems, here is a list of the signs of methemoglobinemia:
• pale, gray, or blue-colored skin, lips and nail beds
• shortness of breath
• fatigue
• confusion
• headache
• light-headedness • rapid heart rate
If your child has any of these symptoms after using benzocaine discontinue using it and call 911.
As an alternative to ointments, you can use a chilled teething ring or gently rub your child’s gums with a clean finger.
Children present a higher risk, but adults can be affected also.
For the original article by the FDA please see the link below:
• store any products containing benzocaine out of the reach of children.
• use benzocaine gels and liquids sparingly and only when needed. Do not use them more than 4 times a day.
• read the label to see if benzocaine is an active ingredient when buying OTC products. Labels on OTC products containing benzocaine are not currently required to carry warnings about the risk of methemoglobinemia. If you have any concerns, talk to your health care professional before using them.
Is Oral Bacteria Responsible For Your Failing Joints?
Dentists have been well aware for several decades that patients that have a prosthetic joint need special precautions1.A consultation with the orthopedic surgeon usually results in a recommendation for prophylactic coverage with a large dose of an antibiotic taken one hour before the procedure, and only one dose is necessary2.
The precautionary antibiotic prior to the procedure is given in order to protect the patient from transient bacteremia (bacteria in the bloodstream) as a result of the instrumentation, since the mouth harbors many bacteria, and these bacteria can travel through the circulatory system and end up in the joints.The high level of antibiotic present in the bloodstream reduces the chance of seeding the joints (bacteria creating an infection that will cause damage to the joint that could result in prosthetic joint failure).
A similar recommendation for antibiotic prophylaxis has been used for prevention of bacterial endocarditis3 for decades, but anatomy, microorganisms and mechanisms of infection are different.
Also joints with plates, pins and screws do not need antibiotic prophylaxis, only orthopedic hardware that is bathed by synovial fluid is at risk of developing an infection.
Bacteremias can occur during the course of our daily lives, in the presence of acute infections of the oral cavity, gastrointestinal, urogenital and other systems, and may happen during dental and medical procedures such as dental extractions, colonoscopies, and some urologic and endoscopic procedures.
A recent study shows a possible relation between patients with arthritis and failed prosthetic joints and bacteria found in the oral cavity using sophisticated DNA tests4.The authors conclude that patients with arthritis or failed prosthetic joints should be examined for the presence of periodontal disease and given appropriate treatment if necessary.The results of this article and others like it give support to the increasing evidence of a relationship between oral bacteria in periodontal disease and systemic disease.
It is our responsibility as dentists to make sure that we do not get so involved in the technical and mechanical aspects of our profession that we forget to look at the health status of our patients.
Bibliography:
1 Ching DW, Gould IM, Rennie JA, Gibson PH: Prevention of late haematogenous infection in
major prosthetic joints. J Antimicrob Chemother 1989;23:676-680.
2 Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements. Information statement. http://www.aaos.org/about/papers/advistmt/1033.asp.
3 Guidelines for the prevention of endocarditis with valvular disease. http://circ.ahajournals.org/content/118/8/887.full.pdf.
4Identification of Oral Bacterial DNA in Synovial Fluid of Patients With Arthritis With Native and Failed Prosthetic Joints. Journal of Clinical Rheumatology: April 2012 - Volume 18 - Issue 3 - p 117–121
Chairside Magazine, published by Glidewell dental laboratories Recently published an article by West Palm Beach Dentist Dr. Carlos Boudet in their spring 2012 issue on dental photography.
The article is an introduction to a simple system of intraoral photography that dentists can use to document their cases, show patients their work and promote their practice.
Dr. Boudet also talks a little about camera choices, patient positioning and gives some tips for better pictures.
The system uses a sturdy digital camera from Pentax and describes the basic shots needed for documentation.
Here is a link to the article: An Introduction To Dental Photography .
Dr. Boudet still uses the camera described in the article, but since the article was written, new models of the camera have come out, so look for the new models now.
The Best Hands On Implant Courses In South Florida
Where can I find a course about dental implants where I can get some experience in treatment planning and placing implants that won’t cost me an arm and a leg?
I get that question from fellow dentists very often, and I am very fortunate to be able to provide them with an answer.
For more than a decade I have been a member of the Atlantic Coast Dental Research Clinic in Palm Beach County, Florida. A non-profit organization started by area dentists over fourty years ago to provide continuing education for it’s member dentists. Today the The Atlantic Coast Dental Research Clinic membership has increased to well over a hundred and allows the dental professional the opportunity to participate in accredited, hands-on courses in modern facilities with state of the art technology located at the Palm Beach State College campus. The goals of the Research Clinic are to provide an opportunity for continuing education of dentists, hygienists and assistants, contribute to the clinical education of the Dental Assisting students enrolled at the college, and to provide low cost dental care for the community.
The twelve dental continuing education courses presently offered give the participants up-to-date, state-of-the-art instruction in practical procedures which will enhance the dentist’s skills and experience in areas such as Periodontics, TMD, Endodontics, Oral surgery, Prosthodontics, Pediatric Dentistry, Orthodontics, Dental Marketing and more, including two participation courses in dental implants.
I have taken almost all the courses and they are great, but let me talk a little about the implant courses since that is an area that I have a special interest in.
The first course is Implants: The Surgical and Prosthetic Management of the Endosseous Root Form Patient. This is a one-year course designed to teach the general dentist how to place and restore implants. Because implants should be treatment planned and placed with the best prosthetic result in mind, the course exposes the dentist to the treatment planning, placement and restoration of endosseous root form implants and does not involve complicated implant placements, sinus lifts, etc….
The course is chaired by Dr. Roy Blake, a prosthodontist with over 25 years of experience and a great teacher.
The second course is Oral Implantology. The Oral Implantology course is a comprehensive three year program consisting of a one year prosthetic and two year surgical residency. There are 21 full days of instruction consisting of a morning didactic seminar and an afternoon clinical session where the general dentist or specialist can gain experience performing surgical or prosthetic procedures on patients. It is patterned after the AAID Maxicourse. This program is also designed to prepare the doctor for AAID, ABOI, and ICOI fellow/diplomate exams.
Also if research interests you, this may be an opportunity to publish a paper as a coauthor in your subject of interest.
These two implant courses will give dentists the chance to get some experience with actual patients in treatment planning and placing implants in a supervised environment, allowing the participating dentist to feel more comfortable implementing these modalities in their own private practice.
It hasn’t even been a year since I wrote an article about a statement by Dr. Oz saying that dental x-rays were related to an increase in the incidence of thyroid cancer.
Now a new study is being quoted saying that there is a higher incidence of meningioma, a benign brain tumor, in people that had dental x-rays and the media is running with it.
The study was based on answers to questions in a survey of over a thousand patients with meningioma. One of the questions asked was whether the patients remembered having dental x-rays taken. The implication here is that x-rays can cause cancer.
In my opinion, this type of study should not even be published, since it does not prove anything, and it only serves to fuel concerns in the general public that, although legitimate, they are often fuel for those that take an exaggerated or extremist point of view.
Let me explain why I say that the study is useless as a scientific paper.
The method by which the study was conducted was a survey where the author asked questions to patients diagnosed with meningioma about their recollection of how many dental x-rays they received during their life including childhood. Also what types of x-rays they received. This type of survey is prone to a tendency of overreporting by the participant. Take my office as an example. I routinely ask a new patient if they had recent x-rays done at another office to avoid unnecessary exposure to radiation and they typically say they had a full series of x-rays, but when we request them, it turns out that they only had two or four bitewings taken.
The study also says that the risk of meningioma rises 3 times more with panoramic x-rays compared to bitewings, but in the same article the author states that panoramic equipment and digital x-rays in use today (which significantly reduce the amount of radiation exposure to the patient) were not available for the participants of the study.
Please watch a news report about the study below:
The reporter correctly describes some of the faults in the reasoning behind the study such as asking persons to recollect the types of x-rays in childhood, getting data from memory and not dental records, subjects exposed to radiation from equipment from 30 years ago. I should add that a the author of the study (I read it!) admits that most data on radiation exposure she found was from exposure to nuclear blasts(atomic bomb) and radiation therapy for cancer, both of which are so much higher than the levels of exposure for diagnostic x-rays that it is ridiculous to even mention it.
I could understand the reason to conduct a study for persons exposed to CT scans of the head and neck, as this exposes them to a higher dosage of radiation and includes the brain, but the study does not involve CT scans, instead it focuses on bitewing x-rays that we as dentists rely on to diagnose cavities. These small x-rays are highly collimated (the beam is focused to a small circle in your mouth) and does not expose the brain or tissues around it to any levels of radiation worth worrying about.
As a dentist, I cannot overemphasize the importance of taking periodic x-rays to detect caries. Those small bitewing films allow me to find decay when it is small and has not damaged the tooth to the point where there is pain or other signs. What this means to the patient is that I can fix the tooth before it reaches the point where they may need more extensive work such as a root canal or a crown.
I should also mention that while reading the x-rays for a "routine" initial examination for my patients, I have discovered cancer in the mouth that the patient was never aware of because it was small and in doing so was able to help the patient avoid the radical disfiguring surgery that would have been needed it the tumor had been allowed to grow. Maybe even saved his life...
I try to be optimistic in my thinking and I think that something good can always be found in everything. This publicity should make us (dentists) more aware of the need to tailoring our treatment to the individual patient and not tend to fall in a routine that may lead to unnecessary exposure to radiation. Dentists should use their judgement in determining how often x-rays need to be taken, as dental conditions are different for every person, and recommend these radiographs only as necessary for diagnosis and treatment of their patients.
