Dear friends, we're now reaching the end of the second exciting week in the course, and I want to thank you again for your motivation and participation to all interesting discussions. This week we read more than 350 mission statements. Most of them evolving around the patient and the patient's needs and wishes. So I'm sure Professor Lang would be very pleased with the impact of his lectures. We also saw the clinical examination of our three patients, and a lot of discussions evolving around them. I’d like to tell you that Gina, Mary, and Justin are actual patients of our department treated by students and staff in our clinic. At times, you may see that the documentation may not be optimal, or conditions not perfect. We discussed a lot among our staff to decide what cases to use for that purpose. Our aim is to introduce you to the practice of implant dentistry under highest quality conditions, but using actual treatments which could be performed in any good clinical practice settings. As with every treatment process, there is hardly a right or wrong approach, and we can achieve our objectives following many different pathways. The reason we shared these patient treatments with you is to stimulate discussion and to help all reflect on the different ways one can apply the treatment planning principles to the individual patient. One very lively discussion was about bisphosphonates and the actual risks they pose for candidates of implant treatment. This is fully understandable, as especially with regards to bisphosphonates, we have a lot of hypotheses, but very little actual evidence to help us understand the pathogenesis of osteonecrosis. Some people discussed whether the use of prophylactic antibiotics is indicated in such patients. The truth is that there is no evidence, or known biological mechanism, to suggest any benefit from prophylactic antibiotics. Some experimental studies have indicated possible microbial involvement in the pathogenesis of osteonecrosis, but that remains a hypothesis. Some people also discussed the interruption of the bisphosphonates treatment for a certain period before the implant placement, what we would call, a “drug holiday”. Few professional bodies have in the past recommended a three-month interruption of the oral bisphosphonates prior to implant placement. The truth is that there is no evidence that any interruption would lower the risks for osteonecrosis. In addition, when we look at the pharmacokinetics of bisphosphonates, one could not easily see how an interruption of three months would make any significant difference. Some experimental studies have indicated the concentration of bisphosphonates in the blood as being involved in the pathogenesis of osteonecrosis. But even so, a “drug holiday” of a few days would achieve the same outcomes as this of a few months. To complete the discussion about bisphosphonates, we recommend you to read the paper by the American Dental Association Council on scientific affairs. This paper estimates the highest reliably reported prevalence of osteonecrosis to be 0.1%. In addition, it states that the “drug holiday” might not reduce the risk of osteonecrosis, while as of today, there is no validated test in order to predict the risk of osteonecrosis of a patient. Luckily, Mary has only taken oral bisphosphonates for a period of three years. This means Mary has an elevated risk as compared to a healthy person, nevertheless, on the basis of the evidence we have discussed, the likelihood of an osteonecrosis is very low. This is well reflected in your response to this week's tasks as well. At the same time, as most of you have pointed out, Mary is a bruxer. Although bruxism is not a contraindication for dental implants, it certainly poses challenges, as it might subject reconstructions to adverse loading, and increase the risk for technical complications. We have to take this into consideration in our planning. How to best counter parafunction is something that we can discuss further in Modules 4 and 5. Justin and Gina, on the other hand, are young and healthy without any systemic compromise. Does this make them easy cases to treat with dental implants? Certainly not. As they're both young and significantly focused on aesthetics, they might have very specific expectations from our treatment. Dental implants in the aesthetic zone pose significant challenges, and therefore risk assessment, patient communication and treatment planning must be very careful. As most of you correctly observed, Gina has quite some way to go before she's ready to receive implants, as we need to ensure the perfect gingival health and oral hygiene conditions. On the other hand, Justin seems to be already in a good periodontal condition. This fact, together with the location of his fractured tooth, might have encouraged many to see him as a good candidate for an immediate implant. I think patients like Justin could certainly value the immediate aesthetics that would come from a flapless implant with an immediate temporary crown. At the same time, however, the local anatomic conditions are extremely important for the predictability of our aesthetic outcomes. The presence of periodontal inflammation in the site of 21, and the fact that part of the interdental and buccal bone was lost, suggested an increased risk for aesthetic complications, and therefore we decided to follow the more predictable approach of early placement six weeks after the extraction, of which we will discuss more next week. From mission statement, to patients' assessment and treatment planning, we have now discussed many of the fundamental keys to success in implant dentistry. Next week, it is time to get into specifics and see how we can take the critical step from optimal planning to an optimal execution. I wish you all a nice weekend and I'm looking forward to see you more in action next week.
