35-Year Old Woman with Bone Loss: thoughts?

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I am writing in desperation, as I have seen over 7 specialists in the past 3 months trying to address my condition. I have (what I’ve been told is significant) bone loss for a woman in her mid 30s. I have seen orthodontists, perios, my general, implant specialists/prosthodontists, and more recently a TMJ expert to help me. I have notoriously had impeccable hygiene since a young age, but no matter, I have experienced bone loss and recession. I have pain along the gum lines and a slight cross bite and open bite. I grind heavily at night and wear a nightguard. As I approach my 40s, this pain has increased.

Some things I am considering/have been suggested to me: orthodontic work to correct the malocclusion (however, he is hesitant given the bone loss), gum or bone grafting (although I have horizontal, not vertical, bone loss, so perio thinks that could be a problem), and I am now deeply considering a full mouth extraction with All on 4s for both arches. I saw a prosthodontist who asked me to rate my quality of life, which I can honestly state is very poor. He said All on 4s is an option that is still viable at this point. He would not do bone grafting, as he feel it leads to less predictable results.

I have attached a Pan from 5 years ago and more recent bitewings (whole mouth). Can anyone please tell me what you would do if you were presented with a patient such as myself? Recommend extraction and implants to salvage what bone is left and improve my quality of life? Or, should I continue to hold on to these teeth at whatever expense and pain?






23 Comments on 35-Year Old Woman with Bone Loss: thoughts?

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Mark Sheklian DMD
6/27/2018
I can't imagine , looking at your xrays, why anyone would extract all your teeth. The bone level now compared to what your saying is five years ago, does not look a whole lot different. People live fine with minor malocclusions, so unless the orthodontist thinks aligning your teeth will reduce occlusal trauma, why do it. Having sad that, minor tooth movement with stable controlled forces is not contraindicated for someone with stable perio andbsome bone loss. I like clear aligners for the reason that I feel the movement is very controlled and with light forces. If I had your teeth I would try to keep them as long as possible and figure out how to control your periodntal condition. Thats my opinion.
Alejandro Berg
6/27/2018
My dear, there is no way we could give you any kind of advise without at least a cbct, images that you provided are simply not enough. But as a rule of thumb, we never do this aggressive treatments before finding out the real reason for such bone loss. Implants are not immune to it so that needs fixing before jumping into long and expensive treatments. So sorry
Jeffrey Ganeles
6/27/2018
In my opinion, anyone that wants to extract all your teeth does not have an understanding of dental biology or an appreciation for potential complications with Implants. While it appears you have some problems with your natural teeth, they do not yet rise to the level of “hopeless”. Find yourself a treatment team that includes a periodontist with a long term view of you and your dentition and a restorative dentist that understands occlusion. You should try to delay implant placement for a couple of decades at a minimum as long as treatment is reasonable. Remember that complications or bone loss around teeth is infinitely easier to address than bone loss on Implants.
Dr. Francis G. Serio
6/27/2018
You appear to have what I refer to as “Dad’s teeth in Mom’s jaw.” Your teeth are broad in a bucco lingual (outside to inside) direction probably with the buccal root surfaces outside the bone. You can see that in some of the photos. You also have very thin gingiva (gum tissue). With your over enthusiastic hygiene, you have been causing micro trauma with your toothbrush and paste. Over time, since the gums are thin and have no bone underneath for support, the gums retreat down the root surface. This can carry over in between the teeth. I have a couple of patients with this exact same problem. My suggestions- 1. Ease up a bit in the hygiene. Get an extra soft tooth brush. 2. This may be a case for what used to be called Periostat, really a low dose doxycycline that may slow this process. 3. Stay away from anyone with extraction forceps. You don’t have a titanium deficiency. You may not have an ideal dentition, but Dr. Geneles hit the nail on the head. Especially at your age, the last thing you want is implants and the potential challenges that can manifest particularly in patients with thin bone.
Dorian Hatchuel
6/27/2018
Please don't extract your teeth. Your problem is multifactorial. It is not only periodontal disease. You have in addition what is termed Occlusal Disease. This is poorly understood by the majority of dentists. Look up Dr. Louis Ruiz in Burbank California and go and see him. Here is a link to his site. https://www.ruizdentalseminars.com I would treat with a combination of non-surgical periodontal therapy for bacterial control as needed, orthodontic therapy to create an ideal occlusion as best as possible (be sure to get CT's prior to treatment to check underlying bone), finalize the occlusion with mimimally invasive restorative dentistry and life long use of an occlusal guard (Michigan-type splint) that creates point contacts on all teeth, immediate posterior teeth disclussion in excursions (lateral and anterior). Lastly if necessary I would perform gingival grafts to improve the so called gingival phenotype. What I have written here may be controversial but it is based on experience as well as literature. Most important will be continued periodontal and occlusal maintenance. There is no quick fix. The treatment must be with light orthodontic forces, focused on occlusion. I believe you should find an orthodontist that will treat you using the Roth technique i.e. starting from a position of centric relation and not centric occlusion. Wow that's a lot to digest, and many dentists nevermind a private individual will not understand what I have written, but I am convinced after many years of experience that it is the treatment of choice. There are many controversial statements in what I have written. Best wishes, and I hope your quality of life improves. Invest in a flight to Burbank California. By the way, as a disclaimer, I have no connection to Dr. Ruiz in any way. I simply believe in his treatment philosophy.
Dale Gerke - BDS, BScDent
6/27/2018
What has been said above is excellent advice. Especially it is important to realise that clinical opinions cannot be properly given without a clinical examination. That said I must emphasise that the advance of dental implants as a treatment option over the last 30 years has been a wonderful things for patients. BUT (and it is a very big BUT), you should understand the implants are a fantastic way to solve many problems (not in all cases) if there are teeth missing or have to be extracted (ie definitely not restorable). However in almost all cases, retaining natural teeth is definitely a better option than implants for a variety of reasons which most clinicians will understand. As best I can see from the limited information you presented, you would be most unwise to have teeth extracted and implants placed. While you have some problems, your situation is not hopeless and can be managed. My sincere advice is to find a competent dentist (possibly a specialist) who will work with you to control your undesirable symptoms and at the same time maintain your teeth. By doing this, I would think you should be able to keep your teeth for a lifetime.
Dr. Alex Galo
6/27/2018
Make sure you get a night guard that has canine rise and anterior disclussion. Any dentist that is experienced in making night guards will know what that means. Having that will greatly reduce the strain on your TMJ (if you wear it). Your bone loss appears to be quite related to your heavy grinding and class III bite. That in itself is a contraindication for implants. But with a good night guard, continued excellent oral hygiene and minimal sugar, , you can probably keep most of your own teeth for the rest of your life.
SunnyDayz
6/27/2018
I appreciate the counsel. This information does help me in at least putting a halt to full mouth extraction. I will profess that the prosthodontist I visited was at one of the "teeth in a day" shops, a reputable one nevertheless. He is a licensed oral surgeon, but I would imagine there is a quota component tied to the establishment. I am following up with my third perio visit for the summer (I'm a teacher, so time has been afforded for me to condense my course of action in 2 months). The first one basically gave me no hope in terms of bone or soft tissue grafting, and the second one was the antithesis, so I figured a third opinion might help me reach a consensus. I originally thought it would be as simple as doing some GTR and I poured through a number of studies on Emdogain...although, that doesn't seem like a viable option either. My main concern and reason why I want to go the route of implants is the sensitivity, and I just simply want root coverage at this point. I just don't know why it's difficult to find a specialist in the Milwaukee (WI) market who can assist me. It might be worth the 50 minute drive to Chicago. On another note, I also poured through studies on the promising perspectives of orthodontists who operate under the notion that torquing could produce bone in a new direction and that correction of my malocclusion (if you notice in the pics, I have abfractions and significant root exposure all along the right side, but not so much the left) could lead to less bruxing and even forces that could perhaps end the bone destruction. In sum, it's just all this information that at times I "get" and at times I don't "get" that leaves me confused. Alas, I'm about gathering different points of view to make an informed decision. Osseous surgery was no joke and rendered me utterly terrified of even so much as a dental cleaning for years thereafter. The paranoia will dissipate someday, but until then.... Thanks again for the professional perspective!
Julian O'Brien
6/27/2018
I love dental implants as a solution to a problem. Trouble is I cannot see that you have a problem. Those are beautiful teeth and a wee bit of bone variation is no cause for catastrophic interventions. Hair lines vary from widow's peak to total baldness. Such is the human manifestation. Daily use of a Waterpik with hot water and bicarb of soda will remove any biofilm or bugs. ( caution: you must wash out the bicarb from the pump circuit). Tread carefully as you could regret any intervention over and above the effective removal of biofilm with the wonderful Waterpik. My comments arise from 44 years of clinical practice and no vested interest in anything other than "keep it simple".
Mark Sheklian DMD
6/27/2018
Sunny, there are ways to reduce your sensitivity such as bonding over hypersensitive abfractions or even root canal if the sensitivity is unbearable or intolerable. All much easier than extraction and implants. Such good advice given in the above comments. Find a dentist and periodontist you trust and wants to save your teeth. Good luck.
Richard Hughes DDS
6/27/2018
I agree with the above. You should keep your teeth. A CBCT would be helpful to determine root position relative to the boney plates. Occlusal control is essential. Perhaps prp/off to stimulate some new bibein the mandibular anterior. An occlusal guard is essential along with an occlusal adjustment. However, start with a comprehensive examination. You are not an implant case at this time. You need to get to the foot cause of the bone loss.
drreshumadan
6/27/2018
In my opinion, you should retain your natural teeth. You might face a similar problem of bone loss with dental implants and then there would be no other choice. Attack the source of the problem first rather than going to the ultimate treatment. If you can go to Boston, Dr. Noshir Mehta may be able to help you at Tufts University.
Dorian Hatchuel
6/27/2018
My comments are going to be somewhat controversial. They are based on literature and experience. Incidentally there is a new classification (one week old) of periodontal diseases based on a staging and grading system (see Journal of Periodontology or Journal of clinical Periodontology. You do not only have periodontal disease which is an infection. In fact it may not even be active. You also have Occlusal Disease. This has some of the following characteristics (signs and symptoms): tooth sensitivity to cold, gingival recession, abfractions (microfractures at the necks of the teeth leading to loss of enamel, dentine and cementum and leaving grooves at the neck of the teeth), spacing between teeth due to drifting, chipping of incisor teeth or thinning of the incisal edges, fremitus (vibration of front teeth when you tap teeth together). You may not have all the features. Occlusal disease occurs when the jaw joints are not in a rest position equal to the fitting together position of the teeth when closed (CR does not equal CO) and this results in interferences in parafunction of the jaws and damage. You may also have airway obstruction leading to the tongue posturing forward and hence an open bite. Your treatment should be: 1. Get an orthodontist who treats using the Roth Technique (Starts by finding CR not from basic desk top study models). 2. Have your teeth moved slowly to a) a position of Point contact between all teeth, b)immediate disclussion of posterior teeth during function and c) no interference in the envelope of function. 3. What the orthodontist cannot achieve finish with minimally invasive dentistry by a competent restorative dentist to create the 3 characteristics mentioned in number 2. 4. Get the help of a myofunctional therapist or speech therapist to control the position of the tongue. 5. Use a Michigan splint for the rest of your life, together with periodontal and occlusal maintenance. For more about this Go to Burbank California and consult with Dr. Louis Ruiz. Incidentally as a disclaimer have no interest in Dr. Ruiz other than I really believe that Occlusal disease is the most under treated aspect of dentistry. Best wishes for a healthy dental life.
Dr Joe Nolan
6/28/2018
Have you had your vitamin D levels looked at? Remove nothing !
Eddie DDS
6/28/2018
Traumatised occlusion due to TMJ Aggressive perio? HIV? Immune issues? Stress related disease and further bone loss in next few years unless TMJ addressed ! MH ? Extractions are madness and this was not a chapter in our training
Comlan M
6/30/2018
Great point here. You nailed it completely. As a board certified periodontist, these teeth will last longer than any implants you will have at your age. Exactly what jeff stated: find a good periodontist and general dentist/prosthodontist who understand occlusion
Sunny
6/30/2018
I appreciate the direction regarding occlusion. I sought out a really great ortho who has recommended closing my bite and reducing the cross bite for equality in forces. He suggests invisalign as a more gentle approach. Given my bone loss, do any of you feel I'm being led in a disastrous direction? Would you recommend for or against invisalign if you were presented with a patient such as myself?
Dr Joe Nolan
7/1/2018
The Damon System in Orthodontics utilizes low force with a bracket design that is more bone friendly . Roth is just one of the protocols invented by Lawrence Andrews, he gave the slot angle pattern free to Roth, who was a student of his. Roth patented Andrew's design and called it his own, made lots of money thereafter. For somebody with a significant bone loss component, there is possibly too high a level of force due to the bracket/wire interface /friction with Roth's brackets....Damon brackets are likely to be far kinder to the bone and soft tissue, especially if not a lot of expansion is required. Keep the periodontist involved.
MP
7/17/2019
Just checking what the original poster decided/where they are at now? I'm in a very similar situation and similar age, and really nervous about losing my teeth.
Sunny
7/17/2019
Hi MP. Original poster here. It has been over a year since I first embarked on my journey. I was scared and I want to see multiple professionals who all had differing opinions. I ignored the individuals who guarantee that I would be toothless by the age of 40 and instead met a great orthodontist and began wearing braces in January. My life has changed night and day. I no longer have the excruciating pain in my teeth and my bone levels have actually started to increase as a result of having braces. This is a disclaimer that I'm not sure this route works for everyone, but it definitely worked for me. I think the biggest thing I learned is to find a group of doctors and dentists who understand your situation and are willing to work with you instead of shutting the door in your face. I wish you the best of luck on your journey
shelly
8/5/2020
HI Sunny thanks for update! Do you think invisalign would have been good for you too? In a similar sitaution due to bad dental work... longs story short....
Kath3939
3/2/2021
Hi reading your comments and am using a waterpik ,I have moderate periodontal disease. Would you not recommend deep scaling and root planing and debridement as treatment ? Thank you . Really need advice..I am 43 and terrified I am loosing my teeth.
Myles
12/9/2021
Hi Sunny. How are things now and have you had any further treatment?