In Conversation with Dr. Sofia Karapataki

In Conversation with Dr. Sofia Karapataki

The dental implant community currently works under the assumption that titanium intolerance and corrosion aren’t real risks to the patient. If there’s a complication or negative reaction, it’s often blamed on the implant technique, prosthetic work, or the patient’s health and lifestyle. There’s an emphasis on selecting the “ideal” patient for dental implants, but only a handful of patients can actually meet the requirements necessary to be “ideal,” and there’s a growing need to focus on dental implants with long-term stability in the “average” patient.

Our team at Zircon Medical recently hosted Dr. Sofia Karapataki, a world-renowned dentist, periodontologist, and implantologist, on our podcast series to discuss the myth of the “ideal” dental implant patient and the need to shift from titanium to zirconia implants.

Introducing Dr. Karapataki, world-renowned dentist, periodontologist, and implantologist

Dr. Sofia Karapataki is the owner of a private practice in Athens, Greece. After graduating from the Athens School of Dentistry in 1989, she specialized in periodontal and dental implant policy. She received her specialty degree in Periodontics - Implantology at the Institute for Postgraduate Dental Education of Jönköping University in Sweden. She is a world-renowned speak on various subjects related to health and dentistry, including the importance of shifting from titanium implants to zirconia implants.

Dr. Karapataki says she “accidentally” stumbled into dentistry rather than making a conscious decision at an early age. Her primary goal was to take care of people in general, and so she went ahead with her examinations and entered dentistry school. She attributes her desire to enter the field of healthcare to her naturally curious personality. Besides her desire to help people, she feels compelled to understand the mechanisms behind everything. In the beginning, she says she was fascinated by the gurus of dentistry and voraciously consumed information.

However, after the first couple of years, she says she stopped actively thinking. She believes all of her combined experience and knowledge made her complacent. It took an unfortunate accident, which she describes as a slam on her face, for her to really awaken her curiosity again. That accident compelled her to start thinking again and to start investigating everything she knows all over again, propelling her into the current phase of her career.

Waking up to the possibility of titanium corrosion

When asked about the inciting incident that fueled her epiphany, Dr. Karapataki describes a titanium implant-related incident with a patient. She describes herself as a “titanium child” — she was proud of only introducing the best companies for titanium implants to her patients. She was keen and extremely careful with her patients, accurately following all the instructions and protocols.

Dr. Karapataki had placed two implants in the molar regions for a patient who happened to be a family friend. She was proud of her work because the situation had been complex, but she perfectly placed the implants. She followed up with the patient every year according to standard protocol, and everything was fantastic — there was osseointegration up to the neck.

For the prosthetic, Dr. Karapataki had placed two implants with two crowns connected two each other, not individual crowns. She used gold-platinum crowns because she wanted to treat the patient well. On the opposite jaw, the patient already had an old gold acrylic bridge, so the patient was really happy with the world — it was an exemplary case situation.

When the patient returned for a follow-up after nine-and-a-half years, Dr. Karapataki had to change the little gold screws that were used commonly back in those days to secure the prosthetics on the abutment. During the nine-year follow-up, she had to change the gold screws to titanium ones because the golds ones were no longer available.

Approximately six months later, the patient returned with the complaint that they had a little bit of movement on the tooth. Dr. Karapataki took an X-ray on the more distal implant and found a crater up to the second thread. She was stunned and initially assumed the patient was suffering from peri-implantitis, but upon further investigation, it was revealed that the second implant and abutment screw were cutting “like a salami into the bone.”

Dr. Karapataki says she was naturally freaked out and shocked because she couldn’t understand why this happened. Five years later, the first implant also broke at the same level and in the exact same manner. She was stunned because she had initially assumed this was a perfect situation, and she had done everything according to protocol. She contacted the implant company, and they said the prosthetics may have been wrong, but that didn’t seem feasible — not after 15 years!

Dr. Karapataki had all the information and data recorded. The patient was extremely angry and consulted many other doctors before returning to her, asking her to sue the implant company. However, Dr. Karapataki didn’t believe they stood a chance against a billionaire company, and they couldn’t do much else. She says the mystery of this situation followed her, and she only realized why the implant failed after five years.

Over the years, Dr. Karapataki found some documents and research with the information she found concerning. The World Health Organization published a paper in 2010 about the effects of titanium dioxide, and she was shocked by its revelations. Soon after, she finally understood why the implant had failed — she had connected one metal with another metal in a wet environment with electrolytes. She says she felt stupid because she had failed to combine her knowledge of simple chemistry and physics.

As if to sprinkle salt on her wounds, it so happened that her apartment flooded in that same period. And the reason for the flood? Her plumber matched the copper with an iron pipe in an environment with warm water temperature, leading to metal corrosion. Basically, the same principles that lead to titanium corrosion in her patient also lead to her apartment being flooded. She says these two incidents taught her a valuable lesson in dealing with metal.

Propelled by the revelation, Dr. Karapataki says she couldn’t continue working the same as she had been, knowing there could be a “ticking bomb in the patient’s body.” She says her experiences flew in the face of common dental knowledge — that titanium corrosion didn’t exist. She realized that basic assumption was patently false and that titanium corrosion was a real problem that had to be addressed. She eventually wrote a chapter about titanium corrosion for that very reason.

Dr. Karapataki says her experience with titanium implants propelled her to re-examine everything she had been taught in university. And that set her off on her search for alternative materials, such as zirconia implants.

Zirconia implants lead to healthier patients

In the years and decades since her incident with the titanium implant, Dr. Karapataki has become one of the world’s leading advocates for zirconia implants.

In collaboration with the University of Graz, Austria, Dr. Karapataki is soon to publish a landmark retrospective study on her long-term results with soft tissue health around Patent™ Zirconia implants. She amassed data on over 90 implants with 5-12 years of follow-up — her group included medically compromised patients with a wide spectrum of health profiles, reflective of the “average patient” in the current Greek/Austrian population. Her study concluded that no implants demonstrated peri-implantitis, even after 12 years in function and less than ideal oral hygiene.

Dr. Karapataki says she studies two key indicators to determine if the patient with zirconia implants remains healthy years after the procedure — soft tissue health and bone level.

“First, I see if the soft tissues are embracing and hugging this material (zirconia),” Dr. Karapataki says. “It’s not a new material. We have been using it for ceramic and prosthetic rehabilitation long before implants.” She further elaborates that the soft tissue response to zirconia implants is unbelievable. Next, Dr. Karapataki examines the patient’s bone levels. She says she has tested zirconia implants in really difficult situations and on patients with different health profiles, and the response has always been stunning.

Moving beyond the “ideal patient” to the “average patient” for dental implants

Dr. Karapataki’s retrospective study on the long-term results with Patent™ Zirconia implants is considered groundbreaking because her patient group reflects the “average patient” in the current Greek/Austrian population — not the ideal patient. She is often asked why she places implants on patients not considered ideal, and her answer is simple — there is no such thing as the “ideal” patient. She explains her position with a simple calculation.

Currently, implants are not supposed to be placed on a patient with periodontal concerns. Based on her observation, approximately 12% of all patients have very serious periodontal problems, and 60% more have mild-to-moderate periodontal problems. Once you exclude those patients, only a few patients are left as candidates for dental implants. Next, if you exclude patients with general health problems, the number dwindles even further because most dental implant candidates are at an advanced age with numerous underlying problems.

Furthermore, despite explaining the optimal hygiene protocols to patients, it’s impossible to force all patients to follow those guidelines. All patients follow the aftercare guidelines initially, but their observance of those rules gradually becomes lax. They might go to a party, for example, and then decide they’ll go to bed without brushing because they’re tired, and soon they’re barely following the guidelines. And there’s no way to ensure the patient follows all guidelines for a lifetime.

Dr. Karapataki also highlights that she can’t have her patients sign a contract with a guarantee that they won’t fall sick. Most patients with dental implants are at a fairly advanced age, and they often fall sick, develop underlying health problems, and start taking new medications. Some of them may have been smokers before the procedure, and they might take up smoking again. And so, the patient’s health profile changes with time, even if you start off with the ideal patient.

Dr. Karapataki says if she were to exclude everyone who didn’t meet the requirements for the “ideal” patient, she would be left with less than 5% of her patients. And even those ideal patients can become not-ideal over time. That’s why it’s important to move beyond focusing on the “ideal patient” and focusing more on the “average patient,” i.e., those who are smokers, people with diabetes, periodontitis, and other symptoms.

Dental implants should be suitable and safe for everyone, not just the minutiae of individuals who can be considered “ideal patients.” And since titanium implants can be risky for patients with different health profiles, zirconia implants must become the standards of dental implantology.

Respecting the nature of the implant

Dr. Karapataki says she has placed zirconia implants in practically every kind of situation, but she refuses to place them if the patient desires a few implants with cantilevers. “The nature of the implant is such that we much respect the material,” she says. “If the patient wants just two implants with six cantilevers or something, then I would deny their request because it would jeopardize the nature of the implant. I would be strict and say, either you install more implants, or we find another solution.”

When asked about her goals for the future, Dr. Karapataki says she doesn’t want other colleagues to have bad situations and cases. She says most dentists are isolated behind four walls and don’t communicate a lot with each other beyond conferences. She wants to communicate with more dentists, exchange ideas, and show them how to avoid certain problems. “Nobody’s God,” she says, “Nobody knows everything. We need to make groups and communicate, not only in congresses but also in smaller groups inside the office.”

Dr. Sofia Karapataki can be found in her private practice in Athens or online through her website, Instagram, Facebook, or LinkedIn. You can also listen to Dr. Karapataki at our Zircon Medical Podcast.