METH MOUTH - EFFECTS OF CRYSTAL METH ON TEETH

Methamphetamines or "meth" is one of the most powerful and addictive illegal drugs. According to a former addict during his trial, meth makes you feel no pain and you can go for days without sleep. He explains how he went for a week without sleeping, just staying high as a kite. During his tale of meth addiction, he looked over at his former friend (now defendant) then removed his dentures and said he lives with the reminder of his drug addiction every day.

Depending on the amount of the drug used and frequency, a typical healthy person with pearly whites can end up with a mouth of rotting teeth within a year. Use of meth causes the teeth to blacken, rot, chip and fall apart which ultimately lead to the teeth having to be extracted. A variety of factors contribute to the tooth decay including the dry-mouth caused by meth use, cravings for sugary foods and beverages, tooth grinding, and poor hygiene. While meth does cause cravings of sugary foods, it also acts as an appetite suppressant and users can go days without wanting to eat meals. A meth user's ultimate goal is to get the next high, not brush their teeth or care for their overall health.

The dry-mouth leads to meth users drinking more and because of their sugar craving, they opt for sodas. Meth is also a stimulant that increases motor activities causing the user to grind their teeth or clench their jaws tightly. Some experts contradict the common belief that meth mouth is caused by acids or corrosives that comprise the actual drug. However, common ingredients in meth include muratic and sulfuric acids which may cause burning of the inside of the mouth when meth is smoked.

Meth addicts are often referred to as "tweakers". Tweakers are known to act impulsively and unpredictable. They will have a need to fulfill their body with the meth and sometimes resort to violence to get that next rush. Their movements are often jerky and their eye reaction is quick and erratic. Unfortunately, users began their addiction thinking that it was only a one-time occurrence.

The abuse of methamphetamines has a lasting effect on the body, not just the mouth and teeth. Sometimes viewing graphic pictures of this condition isn't enough to stop an individual from getting a cheap high. And one young 23 year-old boy sits on Florida's death row living with the affects he caused himself and that of the family of an innocent man he killed.

DENTAL IMPLANTS - PART 4

CONSIDERATIONS.....

For dental implant procedures to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation. In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

In all cases careful consideration must be given to the final functional aspects of the restoration, such as assessing the forces which will be placed on the implant. Implant loading from chewing and parafunction (abnormal grinding or clenching habits) can exceed the biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone.

The dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reverse engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist may consult with the oral surgeon, periodontist, endodontist, or another trained general dentist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the implant surgeons request, and are used as physical aids to treatment planning. If not supplied, the implant surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CT scan to achieve the proper treatment plan.

Computer simulation software based on CT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or sterolithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis' occlusion and aesthetics.

Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides. Specialized software applications such as "simplant" (simulated implant) or "NobelGuide" use the digital data from a patient's CBCT to build a treatment plan. A data set is then produced and sent to a lab for production of a precision-in-mouth drilling guide.

SUCCESS RATES....

Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and the patient's oral hygiene. The consensus is that implants carry a success rate of around 95%.

One of the most important factors that determine implant success is the achievement and maintenance of implant stability. The stability is presented as an ISQ (Implant Stability Quotient) value. Other contributing factors to the success of dental implant placement, as with most surgical procedures, include the patient's overall general health and compliance with post-surgical care.

FAILURE....

Failure of a dental implant is often related to failure to osseointegrate correctly. A dental implant is considered to be a failure if it is lost, mobile or show peri-implant (around the implant) bone loss of greater than 1.0mm in the first year and greater than 0.2mm a year after.

Dental implants are not susceptible to dental caries but they can develop a condition called peri-implantitis. This is an inflammatory condition of the mucosa and/or bone around the implant which may result in bone loss and eventual loss of the implant. The condition is usually, but not always, associated with a chronic infection. Peri-implantitis is more likely to occur in heavy smokers, patients with diabetes, patients with poor oral hygiene and cases where the mucosa around the implant is thin.

Currently there is no universal agreement on the best treatment for peri-implantitis. The condition and its causes is still poorly understood.

Risk of failure is increased in smokers. For this reason implants are frequently placed only after a patient has stopped smoking as the treatment is very expensive. More rarely, an implant may fail because of poor positioning at the time of surgery, or may be overloaded initially causing failure to integrate. If smoking and positioning problems exist prior to implant surgery, clinicians often advise patients that a bridge or partial denture rather than an implant may be a better solution.

Failure may also occur independently of the causes outlined above. Implants like any other object suffers from wear and tear. If the implants in question are replacing commonly used teeth, then these may suffer from wear and tear and after years may crack and break up, although this is a very rare occurrence. The only way to minimize the risk of this happening is to visit your dentist for regular reviews.

In the majority of cases where an implant fails to integrate with the bone and is rejected by the body the cause is unknown. This may occur in around 5% of cases. To this day we still do not know why bone will integrate with titanium dental implants and why it does not reject the material as a "foreign body". many theories have been postulated over the last five decades. A recent theory argues that rather than being active biological tissue response, the integration of bone with an implant is the lack of a negative tissue response. In other word for unknown reasons the usual response of the body to reject foreign objects implanted into it does not function correctly with titanium implants. It has further been postulated that an implant rejection occurs in patients whose bone tissues actually react as they naturally should with the "foreign body" and reject the implant in the same manner that would occur with most other implanted materials.

CONTRAINDICATIONS....

There are few absolute contraindications to implant dentistry. However, there are some systemic, behavioral and anatomic considerations that should be assessed.

Particularly for mandibular (lower jaw) implants, in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above the mandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN).

Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the fum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling.

Uncontrolled type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement.

There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates.

The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamaz and Boniva) may sometimes be advised to stop the administration prior to implant surgery, then resume several months later. However, current evidence suggests that this protocol may not be necessary. As of January, 2008, an oral bisphosphonate study reported in the February 2008 Jornal of ORal and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms.

DENTAL IMPLANTS - PART 3

SURGICAL TIMING:

There are different approaches to place dental implants after tooth extraction. The approaches are:

1. Immediate post-extraction implant placement
2. Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction).
3. Late implantation (3 months or more after tooth extraction).


According to the timing of loading of dental implants, the procedure of loading could be classified into:

1. Immediate loading procedure.
2. Early loading (1 week to 12 weeks).
3. Delayed loading (over 3 months)

IMMEDIATE PLACEMENT:

An increasing common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site. In addition, immediate loading is becoming more common as success rates for this procedure are now acceptable. This can cut months off the treatment time and in some cases a prosethetic tooth can be attached to the implants at the same time as the surgery to place the dental implants.

Most data suggests that when placed into single rooted tooth sites with healthy bone and mucosa around them, the success rates are comparable to that of delayed procedures with no additional complications.

USE OF CT SCANNING:

When computed tomography, also called cone beam computed tomography or CBCT (3D-X-ray imaging) is used preoperatively to accurately pinpoint vital structures including the inferior alveolar canal, the mental foramen, and the maxillary sinus, the chances of complications might be reduced as is chairtime and number of visits. Cone beam CT scanning, when compared to traditional medical CT scanning, utilizes less than 2% of the radiation, provides more accuracy in the area of interest, and is safer for the patient. CBCT allows the surgeon to create a surgical guide, which allows the surgeon to accurately angle the implant into the ideal space.

COMPLEMENTARY PROCEDURES:

Sinus lifting is a common surgical intervention. A dentist or specialist with proper training such as an oral surgeon, periodontist, general dentist or prosthodontist, thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance. This results in more volume for a better quality bone site for the implantation. Prudent clinicians who wish to avoid placement of implants into the sinus cavity pre-plan sinus lift surgery using the CBCT X-ray, as in the case of posterior mandibular implants discussed earlier.

Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width. Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone height - which is very difficult to achieve - is particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth.

Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone. This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or more cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability.

A wide range of grafting materials and substances may be used during the process of bone grafting/bone replacement. They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft); bovine bone or coral (xenograft); or artificially produced bone-like substances (calcium sulfate with names like Regeneform; and hydroyapatite or HA, which is the primary form of calcium found in bone). The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason, although the bone forming properties of many of these substances is a hotly debated topic in bone research groups. Alternatively the bone intended to support the implant can be split and widened with the implants placed between the two halves like a sandwich. This is referred to as a "ridge split" procedure.

Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavitity. Then the mucosa is carefully sutured over the site. Together with a course of systemic antibiotics and topical mouth rinses, the graft site is allowed to heal (several months).

The clinician typically takes a new radiograph to confirm graft succes in width and height and assumes that positive signss in these two dimensions safely predict success in the third dimension; depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam radiograph may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same radiographic data set can be employed for the preparation of computer-designed placement guides.

Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.

Part Two....SURGICAL PROCEDURE

SURGICAL PLANNING....

Prior to commencement of surgery, careful and detailed planning is required to identify vital structures such as the inferior alveolar nerve or the sinus, as well as the shape and dimensions of the bone to properly orient the implants for the most predictable outcome. Two-dimensional radiographs, such as orthopantomographs or periapicals are often taken prior to the surgery. Sometimes, a CT scan will also be obtained. Specialized 3D CAD/CAM computer programs may be used to plan the case.

Whether CT-guided or manual, a "stent" may sometimes be used to facilitate the placement of implants. A surgical stent is an acrylic wafer that fits over either the teeth, the bone surface or the mucosa (when all the teeth are missing) with pre-drilled holes to show the position and angle of the implants to be placed. The surgical stent may be produced using stereolithography following computerized planning of a case from the CT scan. CT guided surgery may double the cost compared to more commonly accepted approaches.

BASIC PROCEDURE:

In its most basic form, the placement of an osseointergrated implant requires a preparation into the bone using either hand osteotomes or precision drills with highly regulated speed to prevent burning or pressure necrosis of the bone. After a variable amount of time to allow the bone to grow on to the surface of the implant (osseointegration) a tooth or teeth can be placed on the implant. The amount of time required to place an implant will vary depending on the experience of the practitioner, the quality and quantity of the bone and the difficulty of the individual situation.

DETAIL PROCEDURE:

At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid the vital structures (in particular the inferior alveolar nerve or IAN and the mental foramen within the mandible). Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline or water spray keeps the temperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit). The implant screw can be self-tapping, and is screwd into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone). Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.

SURGICAL INCISIONS:

Traditionally, an incision is made over the crest of the site where the implant is to be placed. This is referred to as a "flap". Some systems allow for "flapless" surgery where a piece of mucosa is punched-out from over the implant site. Proponents of "flapless" surgery believe that it decreases recovery time while its detractors believe it increases complication rates because the edge of bone cannot be visualized. Because of these visualization problems, flapless surgery is often carried out using a surgical guide constructed following computerized 3D planning of a pre-operative CT scan.

HEALING TIME:

The amount of time required for an implant to become osseointegrated is a hotly debated topic. Consequently the amount of time that practitioners allow the implant to heal before placing a restoration on it varied widely. In general, practitioners allow 2-6 months for healing but preliminary studies show that early loading of implant may not increase early or long term complications. If the implant is loaded too soon, it is possible that the implant may move which results in failure. The subsequent time to heal, possibly graft and eventually place a new implant may take up to eighteen months. For this reason many are reluctant to push the envelope for healing.

ONE -STAGE, TWO-STAGE SURGERY:

When an implant is placed either a "healing abutment", which comes through the mucosa, is placed or a "cover screw" which is flush with the surface of the dental implant is placed. When a cover screw is placed the mucosa covers the implant while it integrates then a second surgery is completed to place the healing abutment.

Two-stage surgery is sometimes chosen when a concurrent bone graft is placed or surgery on the mucosa may be required for esthetic reasons. Some implants are one piece so that no healing abutment is required.

In carefully selected cases, patients can be implanted and restored in a single surgery, in a procedure labeled "Immediate Loading". In such cases a provisional prosthetic tooth or crown is shaped to avoid the force of the bite transferring to the implant while it integrates with the bone.


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