PSYCHOLOGIC, ESTHETIC AND FUNCTIONAL CONSEQUENCES OF TOOTH LOSS

A COMPREHENSIVE REPORT BY JAMES J. KHAZIAN DMD. AFAAID

FACIAL BONE LOSS AND PREMATURE AGING CAN LOSING TEETH MAKE YOU LOOK OLDER?

Hi, my name is Dr. James J. Khazian. I am excited and happy to provide this valuable report to my patients and the general public. The very important issue of facial bone loss following tooth extraction has been grossly neglected in dentistry. The devastating consequences of this kind of bone loss are multifaceted and complex, and severely affect many aspects of an individual’s life.

This report is designed to motivate awareness by dentists and the general public equally about the effects of tooth loss, the resulting bone loss in the jaw, and consequential facial collapse and premature aging. This has historically been grossly ignored by professionals in the field, due to a lack of knowledge about the relationship between tooth and bone volume and how volume is decreased after tooth loss.

Replacement of missing teeth in traditional dentistry focused on restoring the lost tooth with dentures and bridges to provide chewing function. This approach however did not address the bone condition and prevent future bone loss. Now dentists and patients have another option. Dental implants are considered a permanent replacement of tooth loss. It works, looks, and acts like a natural tooth. But before we go any further, we need to understand why loosing bone is bad.

To answer this very important question, let’s discuss the importance of the jawbone and the whole skeletal system. As every one knows our skeletal system is the framework for our body, it holds all of our organs together. Muscles and skin drape over this framework and any change in this framework directly reflects through skin. Athletes are not able to create beautiful muscles and shape if they do not have a sufficiently strong skeletal and bone structure. Strong and well-shaped muscles simply would not have a framework to hold on to.

WHAT IS THE RELATIONSHIP BETWEEN TEETH AND THE SUPPORTING FACIAL BONE?

Development of the jawbone starts in the fetus stage and is primarily initiated by presence and development of tooth buds, which develop into baby and adult teeth. The jawbone does not develop in the absence of baby or adult teeth. This close relationship between teeth and facial bone continues throughout life. The maintenance of the volume and density of facial bone is highly dependant upon teeth and the stimulating forces transmitted to the bone through functioning teeth. Every time these forces are modified, a definite change occurs in the internal architecture and external configuration. Bones need proper chewing forces to maintain their form and density. Teeth transmit compressive and tensile forces to the surrounding bone. When a tooth is lost, the lack of stimulation to its supporting bone causes a decrease in bone volume and density. According to credible research, 25% of bone loss occurs during the first year after tooth loss and continues into the years to come.

A tooth is necessary for the development of facial bone, and stimulation of this bone by chewing forces is vital for maintenance of its volume and density. This issue, of utmost importance, has been ignored in the past and is currently being ignored by traditional dentistry. Dentists most often overlook facial bone loss that occurs after tooth extraction. The general public is often not educated about the anatomic, the potential esthetic, and functional consequences of continued bone loss. The bone loss often accelerates when the patient wears a removable denture. Yet patients do not understand that the bone loss occurs over time, and at a greater rate with removable dentures.

Traditional dentistry has emphasized preventive measures to decrease tooth loss. But unfortunately it has not addressed the issue of bone loss after tooth extraction. Tooth loss causes remodeling and shrinkage (resorption) of the supporting jawbone and eventually leads to atrophic facial bone and collapse of overlying muscle and skin. Although the patient is often not aware or informed of potential consequences, over time they will occur. Today, this issue should be prioritized and dentists must take it upon themselves to educate the public about the serious functional, psychological, and aesthetic consequences of bone loss.

FUNCTIONAL CONSEQUENCES

Continued loss of facial bone, especially in multiple extractions, compromises the ability of upper and lower arches to support dentures. In advanced phases of bone loss, certain nerves that are otherwise enclosed and protected by the bone are exposed and only protected by the gum tissue. This condition makes the use of dentures extremely painful since the pressure of the dentures is placed directly onto these exposed nerves. As a result, acute pain and/or transient to permanent numbness (paresthesia) could occur. If the denture is supported by a few remaining natural teeth (partial dentures), lack of support from atrophied bone will cause excessive load and force on those teeth. This will result in shifting and eventual loss of additional teeth, which in turn will lead to even more bone loss. Because these consequences are not sudden and occur gradually over a period of years, patients often learn to tolerate and adapt.

The difference in chewing forces in a person with natural teeth and one who wears dentures is dramatic. In the molar region of a person with natural teeth, the average force has been measured at 150-250 psi. Certain patients who grind or clench their teeth may exert a force of up to 1000 psi. The maximum force in denture patient is reduced to less than 50 psi. The longer an individual wears dentures, the less force they are able to generate. Individuals wearing dentures for more than 15 years may have a maximum chewing force of 5.6 psi.

As a result of this decreased force and instability of dentures, chewing efficiency is severely compromised. Many patients with dentures will avoid most hard food, some are only able to eat soft or mashed food, and some claim they eat more efficiently without their dentures. Lower intake of fruits, vegetables, and vitamin A in these individuals leads to digestive and other systemic disorders. As a result, these individuals take more drugs/supplements compared to those with natural teeth and better chewing ability.

Also, the reduced consumption of high fiber foods could induce digestive problems in denture wearing individuals with deficient chewing performance. Credible research and reports provide proof suggesting that a compromised dental function causes poor chewing and swallowing ability and digestive disorders, which in turn may favor systemic changes favoring illness, debilitation, and shortened life expectancy.

Several reports correlate individuals’ health and life spans to their dental health. These reports point to significant relationship between dental disease and cardiovascular disease, the latter being a major cause of death today. It is therefore easy to believe that restoring the dental function of these individuals to a more normal function may indeed enhance the quality and length of their lives.

Several studies concluded that the use of partial dentures deteriorates the health of the gums and remaining natural teeth. Individuals wearing partial dentures often exhibit loosening of the retaining natural teeth, heavier plaque retention, increased gingivitis and gum bleeding, more tooth decay, and accelerated bone loss. Dentists and patients should study all these issues of tooth and bone loss more carefully and look at other available options for a long-term solution rather than a quick fix.

Dental implants should be seriously considered as the first option at the time of tooth extraction. Dentists should discuss the benefits of implants with their patients and inform them about the consequences of not having dental implants.

PSYCHOLOGICAL CONSEQUENCES

The psychological effects of tooth and bone loss are complex and varied, and range from minimal to a state of neuroticism. Most denture wearers feel their social life is significantly affected. They are concerned about kissing and romantic situations, especially if the partner is unaware of their oral handicap. Surveys indicate that not all patients are able to use their dentures. Some individuals are even reluctant to use their dentures for social occasions. Individuals with severe bone loss are not able to use their dentures at all. They rarely leave their home environment and when they feel forced to venture out, the thought of meeting and talking to people when not wearing their teeth is unsettling.

Majority of denture wearers complain of some speech difficulties, some having severe speech problems. It is easy to understand how this will affect an individual’s social activities. Awareness of movement of dentures, especially the lower one, severely affects the emotional and psychological state of individual. These people often avoid eating in public. Even at home, most denture wearers limit their diet to soft food and avoid fruits and vegetables.

The use of denture adhesives is a clear indication of the instability of dentures, especially during advanced bone loss. The annual sale of denture adhesives in the U.S. is in the hundreds of millions of dollars. The patient is willing to accept the unpleasant taste, need for recurrent application, inconsistent denture fit, and continued expense for the sole benefit of increased retention of the denture.

It is not difficult to imagine the psychological impact of dentures on an individual’s self image. It can gradually change an individual’s behavior from an outgoing social person to one who prefers solitude, who is constantly aware of her/his dentures, and one who avoids any social situations.

Such dental problems can be avoided or corrected if dentists and/or patients look beyond a quick replacement of one or several missing teeth. Rather, plan a sound treatment option that prevents bone loss and the debilitating consequences. With advances in the field of implant dentistry, such solutions are very well within reach of any one who has lost teeth or is about to.

Patients treated with dental implants have shown significant improvement in psychological health compared with their previous state wearing traditional, removable dentures, and perceive the implant supported teeth as an integral part of their body. Clearly the lack of retention and psychological risk of embarrassment in the denture wearer with removable denture is a concern the dental profession must address.

ESTHETIC CONSEQUENCES

A well-shaped, symmetrical face with healthy looking facial skin needs an intact and healthy underlying bone structure. This is demonstrated well in young adults with intact boney structures. The same is observed in middle aged or even old individuals who have been able to maintain their facial structure. It might be called graceful aging but it is not an accidental phenomenon or due to luck. It is directly related to the state of their oral and dental health. A 65-year-old individual who has been able to maintain all his or her teeth looks much younger than the same age individual who has lost teeth and wears dentures.

The facial changes that naturally occur in relation to the aging process can be accelerated by the loss of teeth and the resulting facial bone loss. A decrease in facial height from a collapsed vertical dimension (distance between tip of the nose and chin) causes several facial changes. The immediate and most prominent change is creation of wrinkles around the mouth. Of equal importance is the thinning of lips. Upper and lower lips loose their fullness. As the vertical dimension progressively decreases, the chin will move forward and create a prognathic facial appearance.

These conditions result in a decreased upward curvature of lips (seen more prominently in a smiling face) and dropping of the corners of the mouth, giving the patient an unhappy facial appearance when the mouth is at rest. The thinning of the lips from lost vertical dimension, underlying bone loss, and loss of tonicity of the muscles involved in facial expression is more pronounced in women. They often use one of two techniques to hide this cosmetically undesirable appearance: either no lipstick or minimum make-up, so that little attention is brought to this area of face or application of lipstick over the vermilion border to give the appearance of fuller lip. Collapse of upper lip due to underlying bone loss and loss of fullness will make the nose appear larger than if the upper lip had more support.

Even though facial muscle tone decreases as we age, this process is accelerated in patients with tooth and bone loss. This loss of tonicity causes lengthening of the lips. Since facial muscles are attached to facial bone, the bone loss severely affects these muscles and their function. The facial skin begins to sag. The combination of a prognathic chin, sagging muscles and skin, long lips, and a large looking nose makes the individual appear prematurely aged.

Since these changes occur gradually, patients are unaware that these changes are from the loss of teeth. Therefore it is the dentist’s responsibility to explain these consequences to patients before extracting teeth and providing all other options at this time. The best time to plan and do implant placement is at the time of extraction and not after. The amount of bone loss in the early months after extraction, will make implant placement much more complicated. It is strongly recommended to plan tooth extractions very carefully and seriously consider the resulting bone loss from tooth extraction and dire esthetic, functional, and psychological consequences.

ADVANTAGES OF DENTAL IMPLANTS

The use of dental implants to replaces missing teeth or as a support for dentures offers a multitude of advantages.

The primary reason to consider dental implants to replace missing teeth is the maintenance of valuable facial bone. The dental implant placed into the bone serves not only as an anchor for the new teeth or to stabilize dentures, but it also serves as one of the best preventive procedures in dentistry. The chewing forces are transmitted to the bone surrounding the dental implant that stimulate bone growth and maintain density and volume. Implants should be placed at the time of extraction to immediately stop bone loss. Delaying implant placement, after extraction, will only cause significant bone loss and eventual complications resulting in the need for bone graft. Research has concluded that most bone loss occurs in the first year following extractions.

Today, replacing a tooth with dentures or bridges is no longer the best option or even an acceptable one. Dental problems associated with these kinds of restorations are not few.

Bridges are anchored to adjacent natural teeth (abutment teeth), and in the process of making them they are drilled to almost half their size. This will obviously weaken them. Often abutment teeth become sensitive and might require root canal treatment. Bridges fail due to weakness and decay of the abutment teeth, which leads to more tooth loss. Therefore we can only consider bridges as a temporary solution for tooth loss.

Dentures are even worse. These removable restorations are bulky, uncomfortable, catch food particles, interfere with speech, are often painful, etc. Both dentures and bridges cause facial bone loss, which is the primary cause of facial collapse and premature aging.

In today’s modern dentistry, the best acceptable solution for tooth loss is dental implant. From the replacement of single missing tooth to extensive reconstruction and replacement of several or even all teeth, dental implants offer the healthiest and most intelligent solution.

Some of the advantages of dental implants include:

• Maintenance of facial bone. As previously discussed, dental implants prevent bone loss. This is due to stimulation of the jawbone by the chewing forces transmitted by inserted implants.
• Improved chewing ability. Dental implants provide a solid and stable foundation for new teeth. Patients are able to eat without worrying about moving or loose dentures.
• Improved phonetics. Eliminating bulky, loose dentures, improves phonetics significantly. Dental implants feel like natural teeth and patients actually forget they have missing teeth.
• Improved psychological health. Having dental implants is like having a new set of natural teeth. With all the comfort of eating, talking, and socializing without the fear of embarrassment, the individual’s self image is tremendously enhanced.
• Improved esthetics. By preventing bone loss, often through bone repair and replacement, implant procedures significantly improve facial esthetics.
• Regained chewing awareness. Chewing forces are directly transmitted to the jawbone, which helps patient’s chewing awareness. With dentures, the roof of the mouth (palate) and all gum surfaces are covered, which prevents taste and chewing reception.
• Maintenance of muscles of chewing and facial expression. A sound, healthy bone structure is vital for intact overlying facial muscles. By preventing facial bone loss, dental implants maintain the integrity of facial muscles.
• Increased retention and stability of dentures. Loose, instable dentures can effectively be anchored to jawbone and provide stability and retention.

These are the main, but not the only, advantages of dental implants.

The goal of modern dentistry is to return patients to a level of oral health that they are accustomed to. Patients who lose teeth and use fixed or removable dentures may be unable to recover normal function, esthetics, comfort, or speech with these traditional restorations.

However, an implant restoration can return the function to near normal. An implant stimulates the bone and maintains its dimensions in a manner similar to healthy natural teeth. As a result, the facial features are not compromised by lack of support. In addition, implant supported restorations are positioned in relation to esthetics, function, and speech to mimic natural teeth. Because implant teeth are not bulky and take only as much space in the mouth as natural teeth do, facial muscles and tongue do not undergo changes.

In the past 15 years implant dentistry has evolved into a predictable treatment model for replacement of missing teeth. Advantages of implants over traditional dentures and bridges make them the best choice for this purpose. Fortunately, the awareness in the general public about dental implants and their advantages has increased significantly. This has motivated many dentists to become more knowledgeable and offer this treatment to their patients. This is very promising and will undoubtedly improve the oral health in the U.S.

Our office provides the most comprehensive implant services. Both surgical and restorative phases of your treatment are done by Dr. Khazian. For you, this means a more consistent treatment process and less confusion. There will be no referrals back and fourth to other offices and doctors. This means a smooth and fast treatment process and better results. We offer the following:

Single tooth replacement: Quite often this is done using a flapless procedure and immediate loading. This means, no stitches are placed and a tooth is placed on the implant right after surgery. Flapless procedure ensures the most esthetic result and creates gum tissue around the implant that resembles that of natural teeth.

Multiple teeth replacement: The goal of modern dentistry is to restore patients to normal esthetic, comfort, function, speech, and health. However, the more teeth a patient is missing, the more challenging this goal becomes with traditional dentistry and the use of dentures and bridges. By using advanced implant designs, materials, and techniques, predictable success is now a reality for the treatment of many challenging clinical situations.

Replacement of all teeth: We provided this amazing service to our patients. If you have lost all your upper or lower teeth or even both, it is possible to effectively replace them with dental implants. Patients who have had this service, did not have to use dentures any more, and felt a sense of freedom, joy, and improved self-esteem. They noted, eating, speaking, and socializing was more enjoyable.

Bone Grafts and Reconstruction: If you have suffered bone loss and need bone grafting in preparation of implant placement, we offer the cutting edge techniques, materials, and 16 years of advanced education and experience. You will receive these treatments in the most comfortable setting and will see only the best results.

Denture stabilization, using implants: If you have dentures that are loose and unstable, hurt your gum and do not chew your food properly, implants can help. Dentures can be anchored to implants to provide better stability. With new techniques this can be achieved in a short, one-hour visit, with minimal flapless surgery.

Whether you have one, two, or more teeth missing, have suffered bone loss or have denture problems, call or visit our offices. We will help you learn more about all your options.

SAN DIEGO OFFICE

3969 Fourth Avenue, Suite 205
San Diego CA. 92103
Telephone: (866)4my-smile

ESCONDIDO OFFICE

727 East Grand Avenue
Escondido CA. 92025
Telephone: (760)738-7000

ABOUT DR. KHAZIAN

During the past 16 years, Dr. Khazian has been striving to offer the best of dentistry to his patients. In order to be on the cutting edge of dentistry, he has attended numerous hours of advanced education in all aspects of dentistry, including surgical and restorative implant dentistry, cosmetic dentistry, neuromuscular dentistry and TMJ, orthodontics and principles of full mouth reconstruction. Being knowledgeable and adept in all these aspects enable Dr. Khazian to treat the most complicated dental problems, often times helping patients who have been turned away by other dentists.

Because of the experience and skill he has demonstrated in surgical and restorative implant dentistry, Dr. Khazian was awarded “Associate Fellow of the American Academy of Implant Dentistry,” a distinction awarded to less than 1% of all dentists. He has been surgically placing and restoring dental implants for the past 15 years and has extensive experience in single tooth, multiple teeth or full mouth implant reconstruction, with special attention to esthetic considerations. He has been performing immediate load implants with a success rate of 99%. Implants placed and restored by Dr. Khazian in the esthetic zone (upper and lower front of mouth) are practically indistinguishable from natural teeth. He has been performing and mastering flapless procedures that require no stitches. He offers sedation or general anesthesia for patients who prefer to have those services. He provides implant services to his patients in the most comfortable manner, in a modern, high-tech office. Because of his strict sterilization protocols and adhering to the most advanced and innovative surgical techniques, almost all procedures are done with minor or no post-operative discomfort.

Dr. Khazian has been providing his patients with the most advanced cosmetic dental care since 1990. His cosmetic work has been recognized as the best by the American Academy of Cosmetic Dentistry and featured on the cover of it’s Journal. His smile creations are beautiful, healthy, and above all, natural looking.

He has appeared in several TV programs as guest speaker including MDTV medical news and Heartbeat of America.

He has offered this exceptional, comprehensive dental care to over 10,000 patients.

Because he strongly believes in organized dentistry and exchange of knowledge and technology, he is actively participating and is a member of the following distinguished dental organizations:

• American Academy of Implant Dentistry
• American Academy of Cosmetic Dentistry
• International Congress of Oral Implantology
• American Dental Association
• California Dental Association

TELEPHONE: SAN DIEGO (866)4my-smile ESCONDIDO (760)738-7000