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QUESTION: Hi, I have read about your credentials and your answers are also very informative which is why I decided upon you to answer my question.  My daughter had two abscesses and in both the instances had an apicoectomy performed, both occasions in hospital under anaesthetic.  The last apicoectomy about four years ago.  During 2013 the abscess recurred (every time the same spot).  She was advised to have a dental implant.  She was on antibiotics for approximately four months and then she had the abscess (apparently) removed, bone grafting (augmentation) was done and the first step of implant was also done, ALL SIMULTANEOUSLY.  This was not done under anaesthetic.  Within three days she was taken to a another dentist who referred her once again to a dental surgeon as it seemed as if the abscess was still there.  Within a weeks she went to a different dental surgeon (as the surgeon who did the work the first time was on holiday overseas) who placed her on antibiotics for two weeks;  after two weeks she went back and the abscess was removed as well as the dental implant.  Bone grafting was done once again which failed and after three months bone grafting was again done which once again failed.  Eventually one year after the (apparent) initial removal of the abscess, bone grafting and dental implant, it was decided that she will rather get a bridge, which should have been advised initially before the dental implant as she has a heart condition and is smoking as well.  After about nine months she is so happy with the bridge, never had any problem and smiles all the time.  I would like to know, taken her history about abscesses and two apicoectomies into account, when the abscess was (apparently) removed the third time, should there not rather have been a waiting period (say three to four months time) before the bone grafting and dental implant take place, mostly in order to make sure that infected area (abscess) has completely healed?  If any infection was left behind obviously it would spread  and bone grafting would not succeed which then leads to taking out just about everything.  I thank you in anticipation.  Regards.

ANSWER: Hi Rencey and thanks for your question and very kind words.

Firstly, let me express my sadness with what your daughter has endured to date, but I am relieved that it has all ended well.  The truth is that there are many different schools of opinions when it comes to bone grafting and implant placement - should one wait or is it viable to place the implant immediately...And the reality is that most clinicians follow a protocol which works best in their hands and which give them the most predictable and long-term results.  There are guidelines which should always be followed, but due to the great diversity one finds in patient healing times and the degree to which the bone graft is accepted by the body, there are patients, like your daughter, where the bone graft is not successful and hence the implant fails.  For this reason, the greatest majority of oral surgeons, periodontists and prostodontists would never consider placing an implant in a patient who smokes, as this greatly affect healing and proper knitting of bone.  Her existing heart condition is less of a risk factor for the treatment performed, but the overall condition and wellness of any patient if a vital indicator of how their body will tolerate any surgical procedure.

I also feel that the persistent intentions of the respective clinician could only be viewed as inherently good, attempting to redo the bone graft 3 times in the hope of attaining success.  But sadly, this was not the result for your daughter.  Every good clinician is concerned about their patients and their professional reputation is held in very high regard - no one I know would attempt a bone graft 3 times without the belief that each one would fail.

Yes, the history of recurrent abscesses in the area is a factor to take into account during the treatment planning and more time could have been left between treatments, but given the rate of treatment failure in your daughter, this would not have necessarily ensured overall success - it merely would have reduced the odds thereof.  Smoking would have a much bigger contribution to the failure rate for the reasons mentioned.

I hope this helps and wish you and your daughter all the very best further, and just hope this incident in no way affects your regard of the dental profession in general.  Take care.

Kind regards
Dr Craig Peck

---------- FOLLOW-UP ----------

QUESTION: Hi Dr Craig,  I read your answer cautiously.  I most certainly agree that smoking is not advisable when having an implant.  If the implant failed because of smoking, fine and accepted.  BUT the fact that there was no waiting period when the abscess was (apparently) removed before bone grafting and implant was done bothers me more.  She was taken to a dentist three days after the implant and then to a dental surgeon within two weeks who then had to remove the implant AND the abscess, which tells me that the abscess was either not removed or was only partially removed when the bone graft and implant was done.  Had there been a waiting period when the abscess was removed (say three months)then surely when bone graft was done (and once again to make sure) another period of three months given for healing of bone graft, and it then failed by all means blame it on smoking.  I am aware that anything and everything in one's mouth is very sensitive, hence, why not TOTALLY remove abscess and make sure that there are no further infection before starting with bone grafting?  Just for interest sake;  when she had her second apicoectomy in 2009 in hospital, she was left with seven stitches as the dental surgeon by then removed so much as it was already spreading to the rest of her teeth (gums) and almost no bone was left.  Sorry to "second guess", but to a layperson waiting periods makes sense to me.  On a total different note:Your paintings are great, had a look on Internet.  Regards.

Answer
Hi Rencey and thanks for your follow up.

For this exact reason, smoking is greatly considered a contra-indication for the placement of implants because it becomes a very unpredictable negative factor which influences all stages of healing - from the resolution of the initial infection, to proper bone knitting after a bone graft and the optimal osseous-integration of the implant. And one of the main reasons for this, is due to the depletion of the body's vit C levels, which greatly diminishes the rate of collagen production, which is so vital during the healing phase of treatment.  I wish I had more encouragement for you, but I believe in open and honest debate and am just pleased the end result was a good one for your daughter.  Take care.

PS:  Many thanks for your very kind words re my art, much appreciated.

Kind regards
Dr Craig Peck

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Dr Craig W Peck ( B.Med.Sc., B.Ch.D., Clin. Botox, Cosmet. Derm.)

Expertise

I am a General Dental Practitioner, with special interests in Cosmetic Dentistry & facial aesthetics and Periodontology, placing a strong emphasis on the establishment and maintenance of a healthy periodontium (the support structure of the tooth) before cosmetic options are considered. I uphold all principles of prevention above interventional treatment and try as far as possible, to remain conservative in my approach. I believe in detailed, open and honest patient discussion, establishing what the patients expectations are and what the reality is of achieving this and involving the patient at every level of the treatment. I have strong principles on ethical treatment and appropriate patient management. I have chosen to treat and rehabilitate many nervous and phobic patients, who, for whatever reason, find it impossible to take part in the very important task of even a routine check-up. I will accept questions relating to general and cosmetic dentistry (in conjunction with the use of facial cosmetic procedures) and dental fears/phobias. I will be more than willing to answer any academic questions in dentistry, biology, physiology, psychology and health sciences in general. As most dentists will tell you, there is often not only one way of dealing with a dental issue - so very often, there is no precise right and wrong way of approaching the problem. All clinicians vary when it comes to treatments and what works best in their hands is often the treatment that is advised. Be understanding of this and bear in mind that nothing lasts forever! Patients are happy to accept only a one-years warrantee when buying a new car, but seem to expect that dental work is going to last them their lifetime.

Experience

I have worked for many years in the UK and RSA as a general dental practitioner - within the NHS, private practice and the government dental health services. I am certificated for the administration of Botox and Dermal Fillers for facial lines and wrinkles as I have attended further courses in minimally invasive facial cosmetic procedures. I started seeing an increasing number of patients who presented with severe to moderate dental fears, even with full-blown phobias, so I started with the slow and patient task of tackling this problem and have successfully rehabilitated many patients. The key is good, effective, concise and understandable communication, shifting control from the dentist to the patient in order to slowly, but confidently, regain their trust back in dentistry, thereby giving them the feeling of achievement and this self-empowerment which drives them to the next level of treatment.

Organizations
Academy of General Dentistry. American Dental Education Association. IAPAM (International Association for Physicians in Aesthetic Medicine). Professional Speakers, Writers and Managements Consultants in Dentistry. The British Dental Association. UK Aesthetics Group. ARC - Aesthetic Professionals. Botox. Aesthetics & Beauty. American Association for Dental Research. FDI - World Dental Federation. SOURCE1uk. World Dental Hygiene Forum. ProDentalCPD. Public Health Dentistry. Dentist Network. LinkedIn. Who's Who of South Africa.

Education/Credentials
B.Med.Sc. Degree (Medical Physiology and Medical Virology; Physiology Cum Laude; Stell 1994). B.Ch.D. Degree (Bachelor of Dental Surgery; Clinical Dentistry Cum Laude; Stell 1997). CPR and CPR-Advanced Courses (2000/2001; UK). Clinical Botox (UK, 2001). Cosmetic Dermatology (Botox and Dermal Fillers; RSA 2011).

Awards and Honors
Placed on the Dean's List at University for academic achievement (1994). Highest achievement in the subject Dental Materials. Medal from 3M and the Radiology Association of South Africa for highest achievement in the subject Dental Radiology and Imaging. Medal from The Periodontal Association of South Africa for highest achievement in the subject Periodontology. Highest achievement for Oral Medicine. Highest achievement in Oral Pathology. Received the DASA (Dental Ass. of South Africa) Gold Medal for highest achieving dental student across the 5 1/2 years of the Degree. Passed the subject, Clinical Dentistry with distinction in final year.

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