Importance of Optimal Soft Tissue Health in Implant Patients

Introducing Dr. Esha Katyayen, a periodontologist and implantologist in Oslo

Dr. Katyayen is a periodontologist and implantologist currently working at at Oris Dental in Oslo. She completed her master’s in periodontology from Government Dental College in Bangalore, following which she moved to Norway. She says she was driven to pursue a sub-specialization in periodontology and oral surgery because she always wanted to be a surgeon. She says she was fascinated by the surgical aspects of the medical profession since a very young age.

However, she pursued dentistry instead of surgery because her dad cautioned that pursuing a career in surgery would necessitate several additional years of education and training. However, upon embarking upon a career in dentistry, she also realized that the dental field involved considerable potential for oral surgery. As such, pursuing periodontology allowed Dr. Katyayen to fulfil her dream of being a surgeon..

Ignorance: the unknown risk factor for compromised periodontal health in patients

Dr. Katyayen firmly believes that the primary risk factor for periodontal disease is ignorance. Stress, smoking, poor oral hygiene, and diabetes are naturally the most talked-about and studied risk factors for periodontitis. But it’s really ignorance on the part of the patients, dentists, and medical doctors that allows periodontal disease to spread and become a major problem. Even though periodontal tissues are a small part of a person’s body, they play a major role in the patient’s systemic health.

“If a patient has diabetes and you do a random periodontal probe,” Dr. Katyayen says, “you can see pockets that are 6mm and more. I do that, but most dentists don’t do that. If your patient is ignorant about it, it will lead to periodontitis. Other risk factors include irregular dental visits, pregnancy, hormonal factors, diabetes, stress, and more, but ignorance is the primary root problem that allows these other factors to persist.”

If a dentist measured the pockets regularly and guided patients, they could stop periodontal disease at an early stage. In fact, Dr. Katyayen says dentists should measure the periodontal pockets even when making a bridge, during routine checkups, and other procedures. They don’t even have to perform a comprehensive examination, even probing a few areas will help them determine if the patient needs periodontal care.

“Do we build a house if the foundation is weak?” Dr. Katyayen asks. “Is it worth saving a tooth with a root canal if the tooth is mobile or periodontally compromised?” The answer to both these questions is no. Yes, most dentists and patients alike ignore periodontal health until they experience significant problems. And that’s mostly because periodontitis isn’t painful at the early stages, so people allow it to continue unchecked.

“If god granted me one wish,” Dr. Katyayen says, “I would have wished that periodontal problems were painful.It would have been so easy to treat if the pocket was painful. But it doesn’t cause any pain, so people don’t seek the treatment they need.And that’s why the issue gets ignored.”

Systemic health consequences of periodontitis

Periodontal tissues get affected by systemically health problems, and systemic health gets affected by periodontal issues. “If you Google ‘periodontitis and…’,” Dr. Katyayen says, “you’ll see a long list of all possible diseases — cardiovascular disease, diabetes, Alzheimer’s, Parkinson’s, arthritis, respiratory disease, and even pre-term low birthweight in babies. Over 50 diseases are chronic illnesses carry the same inflammatory markers as periodontitis.”

Dr. Katyayen says she can improve a pregnant woman’s chance of giving birth to a healthy baby by simply managing their periodontal health. She also cites the example of a patient suffering from heart conditions and chronic heart pain, who experienced significant relief after her periodontal issues were treated. In that case, Dr. Katyayen agrees that the connection may have been coincidental, but it’s more likely that in treating the periodontal infection, she removed the foci of the bacterial infection responsible for her symptoms.

Because of the obvious links between periodontal health and systemic health, all medical doctors should have a strong understanding of periodontitis. They should also treat periodontal health as a part of the body. After all, the small strip of periodontal tissues in the mouth offer the primary site for bacteria to enter the body and bloodstream. Despite that obvious connection, doctors still don’t treat periodontal health as a part of systemic health. That attitude must change.

According to Dr. Katyayen, every gynecologist must observe their pregnant patient’s mouth for bleeding. And while they don’t need to make a diagnosis, they should send patients with signs of periodontal problems to dentists. The same goes for diabetes. Periodontitis is the 6th complication of diabetes, but physicians rarely refer their diabetic patients to dentists for periodontal checkups. Again, Dr. Katyayen emphasizes that the problem is ignorance on the part of the medical professionals.

Warning signs that doctors must look for

Dr. Katyayen says medical professionals and doctors must look for a few key warning signs in their patients. The primary warning sign is bleeding from the gums upon probing. However, doctors can’t simply rely on their patient’s assessment because they may not floss their teeth. Bleeding on probing is a major sign of periodontal disease. Some of the other indicators are diabetes, smoking, bad odor, halitosis, loose teeth, or even pregnancy. During pregnancy, the body goes through hormonal imbalances that can aggravate periodontitis or lead to gingivitis, which can then turn into periodontitis. 

Dr. Katyayen also says that patients who request Invisalign for shifting teeth and smile should be assessed. If an adult patient’s teeth start shifting out of place, there’s a strong chance that they have periodontitis. In those situations, dentists must assess their oral health, check for periodontal problems, treat underlying periodontitis, and then start the orthodontic treatment. However, most dentists offer Invisalign first and simply ignore the underlying reason for the shifting of teeth. Even dentists who probe on 2 to 3 sites would get a good enough picture of the patient’s overall periodontal health.

Determining a patient’s candidacy for implants

Dr. Katyayen says she only proceeds with dental implants after ensuring the patient is a good candidate. “For example, if there are two teeth with heavy fillings and the middle tooth is missing, a bridge is a better option,” she says. “Butif it’s a young patient with good dental health, and all teeth are healthy with no fillings on neighboring teeth, then implants are better.” Dr. Katyayen also assesses the patient’s general health, including their oral hygiene and whether they have diabetes, to determine if they can proceed with implants.

“The biggest risk factor for peri-implantitis is plaque. If the patient isn’t removing plaque from their teeth, they’re not going to remove it from the peri-implant area either. So bad oral health is a complete disqualifier for implants. If a patient only visits a dentist when there’s pain, then they’re not a good candidate. An implant requires regular care and maintenance. If a patient doesn’t go for regular checkups, they’re not a good candidate.”

“Implants can work for 20 years or more, depending on the patient, surgical technique, the surgeon, the dentist or prosthodontist who rehabilitated it, and then the dentist or dental hygienist who has been taking care of it. If everyone has done the right job, the implant will survive. But if the patient doesn’t maintain good oral hygiene or the surgeon places the implant in the wrong direction, there’s a higher chance of plaque retention. That’s why implantology is complex — it depends on so many factors."

The importance of soft tissue for implants

Everyone understands the importance of checking the bone while placing implants. But few dentists focus on the soft tissue health. Dr. Katyayen says she also checks the gingival area to determine if it’s too thin or thick. Depending on the patient’s condition, she may change the soft tissue quality with grafting. It starts at the planning phase, and the treatment plan can be changed or modified anytime.

Even during the abutment placement, incisions and flap techniques can be used to change the soft tissue type to ensure a good seal. The goal is to ensure there’s sufficient keratinized gingiva around the implant. The importance of keratinized gingiva around the implant is a fairly controversial subject, with some periodontists suggesting that it doesn’t affect the risk of peri-implantitis. However, Dr. Katyayen says she has observed that the gingival health and presence of keratinized gingiva make a major difference in the peri-implant health.

You can contact Dr. Katyayen via Instagram or LinkedIn. You can also listen to her on the latest episode of our Zircon Medical Podcast.