August 6, 2019
by Vivian A. Roknian, DMD, DICOI; Joseph P. Mulligan DMD, FACS, FICD*
In the last several years, there has been a noted increase in mysterious cases presented to my practice. These patients seem to have similar oral manifestations – rampant decay, poor healing ability, and an assortment of hopeless teeth. It isn’t uncommon for these patients to be dismissed from a practice, referred to a variety of specialists, or sent to their physician for a possible underlying disease. The experience is frustrating for the patient looking for answers and the practitioner wanting to provide help that will address the patient’s needs.
Last summer alone, a dozen of these patients found their way to my practice. Most notable, was one patient who was dismissed by his former dentist for poor healing after a socket graft. The patient was sent to his physician for a blood panel which resulted in normal results. In fact, the patient’s physician said that the patient had no systemic problems and was completely healthy. After being dismissed from that dental office, the patient went to two other dental offices. While he was clear on wanting an implant to replace a missing tooth, only a fixed bridge was suggested because of a boney defect coupled with dismal healing and normal labs.
For purposes of vanity, the patient did not list any previous surgeries. He thought that since there were no complications and he was otherwise a healthy person, there was no reason for anyone to know that he had weight loss surgery. Interestingly, almost half of my other patients with a history of weight loss surgery also omitted listing weight loss surgery in their health history. Usually, the rampant decay and xerostomia reveal that there is a history of weight loss surgery. The failed socket graft was a new discovery that should be noted.
It is no surprise that there has been a striking increase in the prevalence of obesity worldwide. This can be blamed on a more sedentary lifestyle and higher fat diets. Currently, obesity and being overweight together affect an estimated one sixth of the world population.1,2 Normally, the treatment for obesity is behavioral and clinical. However, these treatments become difficult due to low patient compliance across the span of time needed to obtain more meaningful results.3
Thus, bariatric surgery has emerged as a plausible and successful option for optimizing weight loss in severely obese patients.4 Interestingly, in the United States and throughout Europe, the use of bariatric surgery for cosmetic weight loss purposes is also becoming increasingly popular.5 While bariatric surgery is an effective and increasingly common treatment for severe obesity and its many co-morbidities, it also presents with side-effects. Among the side effects of these procedures are detrimental effects on bone and mineral metabolism.6 These effects on bone and mineral metabolism affect our ability to place implants in a timely manner, perform osseous surgery, provide full mouth reconstructions, or simply count on a successful socket graft.
Current surgeries involve a reduction in stomach size (restriction), delayed mixing of food with bile salts and pancreatic juices (malabsorption), or a combination of both. While the rate of weight loss and resolution of co-morbidities after bariatric surgery varies by procedure, they show similar manifestations intraorally. Some manifestations are due to malnutrition. This is no surprise, since the duodenum and proximal jejunum are main absorption sites for most vitamins. Their subsequent bypass created by surgery leads to nutrient deficiencies of protein, iron, calcium, vitamin D, vitamin B12, vitamin A, vitamin K, zinc, and vitamin C.7 These deficiencies can negatively impact the immune system, bone turnover rate and healing, as well as increase the risk of periodontal diseases. These are all red flags to consider in implant dentistry.
Protein deficiency occurs in 13% to 18% of patients after weight loss surgery.8 Common symptoms include rash and desquamation, lethargy, generalized edema, and delayed healing. Protein also plays an important role in the maintenance of bone structure. Nutritionists suggest supplementing the diet with calcium and vitamin D for most patients who underwent weight loss surgery with the goal of preventing bone resorption. The benefits of this supplementation are efforts in protecting the patient from osteomalacia, secondary hyperparathyroidism and osteoporosis.9,10 This also will help in improving bone healing after extractions, when grafting bone, and placing implants.
The incidence of vitamin D deficiency may be as high as 63% in patients one-year to four years post-bariatric surgery. Vitamin D is essential for calcium absorption, stimulation of osteoblast activity, and normal bone mineralization. Additionally, studies have correlated calcium deficiency to alveolar bone resorption, which may predispose this population to periodontal disease and decreased post-operative healing.11
Many studies have documented increased PTH (Parathyroid hormone) following bariatric surgery. The decline in urinary calcium and rise in PTH that has been reported is consistent with calcium malabsorption, also despite aggressive supplementation. A significant rise in PTH levels, even within the normal range, can still have consequences. The differential effects of PTH on cancellous bone (anabolic) and cortical bone (catabolic), well described in primary hyperparathyroidism and osteoporosis therapy, may be evident after bariatric surgery.13
Patients who undergo bariatric surgery and subsequent weight loss experience both positive and negative effects in the periodontium. The immune systems of overweight and obese people secrete more of the cytokines interleukin-6 and TNF-alpha, raising their risk of periodontal diseases. Patients who have significant weight loss post-surgery experience a decrease in the proinflammatory response and an increase in anti-inflammatory mediators. This results in decreased levels of periodontal inflammation. Although more research is needed, this association between bariatric surgery and positive immunological changes indicates that bariatric surgery, along with professional oral health care, may help resolve obesity-related periodontal disease.14 Because the nutritional deficiencies experienced post-surgery put bone health at risk, this patient population is vulnerable to periodontal diseases within months of the weight loss procedure. This bone loss is attributed to nutrition-related metabolic bone disease, including osteoporosis. Vitamin D deficiency can develop in as little as eight weeks after surgery, putting bone health at risk. As patients lose weight, their parathyroid hormone levels rise and both calcitonin and 25-hydroxyvitamin D levels decrease. This leads to secondary hyperparathyroidism, where parathyroid glands become enlarged and hyperactive. Dietary hyperparathyroidism negatively impacts alveolar bone by increasing bone turnover. An extremely low level of vitamin D and calcium may trigger removal of calcium from bone, including alveolar bone. This results in a weakening of the tooth attachment apparatus and possibly tooth loss.15
Current treatment should be geared toward correcting nutritional deficiencies prior to bone grafting and implant placement. Increased bone resorption, measured by C-Telopeptide (CTX), is evident by six months, and persists for at least 24 months after surgery.16 Thus, a CTX test should also be considered prior to bone grafting or implant placement.17
Patients who have undergone bariatric surgery have special oral health care needs. To reduce the risk of caries, remineralization protocols should be implemented. Dental sealants should be placed in deep pits and fissures that are at risk of decay or incipient lesions. To decrease plaque accumulation, patients need to be educated on effective removal methods.
The daily use of topical fluorides (over the counter or prescription) is extremely helpful in caries protection. Fluoride may be delivered in-office and at-home through customized fluoride trays. Many patients who have undergone bariatric surgery are dehydrated due to the decreased gastric capacity. Patients need to drink one cup of fluid over the course of an hour and swallow beverages slowly. If the patient experiences xerostomia due to dehydration, dry mouth rinses, salivary substitutes, and moisturizing gels should be considered. Behaviors that reduce saliva, such as the consumption of caffeine, alcohol, and/or marijuana, should be avoided.
The patient’s periodontal condition should dictate post-surgical re-care intervals, which are typically every three to four months. The use of a daily antimicrobial agent to control periodontal pathogens and fungal organisms is recommended. Probing depths should be taken at every appointment to monitor changes in bone level. Intraoral and extraoral screening should include monitoring the thyroid and parathyroid and checking for lesions related to xerostomia, low pH, and vomiting.
Patients’ health histories should be reviewed at each appointment with special attention paid to medication usage and any related side effects. We should encourage patients to receive regular examinations, blood work, and bone scans from their primary care physicians – particularly if implants or bone grafting is on the treatment plan. Blood work is recommended preoperatively, and at three-month to six-month intervals postoperatively for the first two years. Aggressive treatment planning of GBR is also suggested – consider two GBR procedures added to the treatment plan instead of one. Use of PRF to help with soft tissue management. Also, due to a slower rate of healing, consider increasing the length of time from bone grafting to implant placement, then from implant placement to implant restoration.
A population of patients is developing who will need implants and bone grafting, yet their needs will be different from our other patients. We need to be prepared for them and provide care which offers outcomes that are predictable and therefore align themselves with the patient’s expectations.
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About the Author
Dr. Roknian Faculty, Misch Implant Institute, Diplomate, ICOI.
Dr. Joseph Mulligan graduated from Temple University School of Dentistry. He completed his residency in Oral and Maxillofacial Surgery at Temple University Medical Center in Philadelphia, Pa. He has achieved diplomate status with the American Board of Oral and Maxillofacial Surgery, the International College of Oral Implantology and The American Dental Board of Anesthesia. He is also a fellow with the American College of Surgeons as well as The International College of Dentists. Dr Mulligan is currently the Chairman of the Department of Oral and Maxillofacial Surgery at Temple University Medical Center.