February 10, 2025 • 50 mins
Unlock the secrets to navigating the complex world of implant dentistry and bisphosphonate medications, especially as they pertain to postmenopausal women's health. Engage with our insightful discussions on the AOMS position paper and its implications for preventing osteonecrosis of the jaws. We'll guide you through the nuances of educating dental residents on managing patients taking bisphosphonates, while revisiting the Women's Health Initiative study and unraveling its misinterpretations that led to a surge in bisphosphonate use.
Join our guest, Dr. Rutkowski, as we explore the intricacies of bisphosphonate-induced osteonecrosis, focusing on drug absorption and potency variations between oral and IV administrations. We highlight the importance of considering dosage, duration, and oral health, and provide a deeper understanding of treatment protocols, including the use of serum CTX and NTX tests and strategic drug holidays. Dr. Rutkowski shares enlightening perspectives on managing dental implants in patients on bisphosphonates and monoclonal antibodies, alongside critical insights for pre- and post-surgery care, including vitamin D supplementation and collaboration with oncologists for radiation therapy cases.
Discover the transformative power of the Waterpik Sonic in maintaining oral health, as illustrated by heartwarming anecdotes from Dr. Rutkowski. Hear about the impact of innovative programs like Jacksonville University's Comprehensive Oral Implantology Program, offering remote residency opportunities. As we close this episode, we celebrate the camaraderie and collective wisdom within the implantology community, with gratitude for the experts who generously share their knowledge, advancing our understanding and enriching patient care.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Tyler Tolbert (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren
Papi and you're listening to theFix Podcast, your source for
all things implant dentistry,absolutely Well, yeah, so I have
a few miscellaneous questionsas well, just kind of based off
of you know what your experienceis and all the different things
that you can, you know, kind ofbring to implant dentistry with
your extensive background.
(00:22):
So you mentioned, you know youhad done some research on
postmenopausal women and issueswith bone formation and things
like that, and so I am kind ofcurious if you have any opinions
on, you know, like the AOMSposition paper on bisphosphonate
medication and relatedosteonecrosis of the jaws and
things like that.
You know what is kind of yourposition and what do you tell
(00:44):
your residents as far aspatients that are taking
bisphosphonates oral or IVdifferent kinds of treatments
that could be used to helpprevent osteonecrosis.
In regards to implant treatment, Okay, that's a great question.
Dr. James Rutkowski (00:58):
It's something I'm very passionate
about, oh good, it's somethingthat I lecture a great deal on
and put a big part of my lifeinto looking at it.
I think the Women's HealthInitiative of 2001 through 2003
was a misinterpreted study thatstudy was based on.
(01:20):
It was sponsored by WyethLaboratories, who had a
medication on the market calledPremarin and another medication
called PremPro.
Premarin was a conjugatedequine estrogen which came from
the urine of pregnant marehorses, which you know.
That was the estrogen we'regoing to go ahead and give these
(01:41):
women.
But it was being done.
Then they had another componentof the drug and they envisioned
that every woman in the worldwould be taking these two drugs.
One of these two drugs eitherPremarin, conjugate equine
estrogen, or PremPro, which wasa conjugate equine estrogen,
plus a synthetic progesteronecalled medroxyprogesterone.
And they just thought this isgoing to be the best study in
(02:04):
the whole wide world.
We're gonna put all these womenin it.
The study was not well definedbut because they wanted to just
get so many massive numbers, wehad women in there that were
smoking and that was a realcompounding factor for blood
clots and for cancer, etc.
Etc.
But they had them in there andthe pharmacologist?
(02:24):
We knew that of all the sexhormones that can cause breast
cancer, the number one issynthetic medroxyprogesterone.
Okay, we knew that before.
That was even there.
I'm sure the pharmacologists atWyeth were probably screaming.
(02:47):
But you have the money managersof these pharmaceutical
companies that are saying wait aminute, we've got to sell drugs
.
You know, somebody's got to payall these salaries.
We've got tremendous overheadand you know.
And what's the instance of it?
Of course, as scientists, we'realways accused of over
exaggerating everything.
And uh, the business people arealways saying you know, it's
(03:09):
not a big deal, you're overexaggerating.
And the pharmacologists aresaying, wait a minute, you're
under exaggerating so there'salways conflict at
pharmaceutical companies betweenthe scientists and the money
people.
Um, and I realize it has to bea balance, you know not, it's
not one right and wrong, butanyway, that study, they got
into it roughly two years andthey found that the group
(03:32):
getting the prem pro had a muchhigher incidence of breast
cancer than did general society,the rest of the women that
weren't taking anything or thegroup just taking premarin.
Okay, so the prem pro study wasstopped abruptly quickly.
It should have been, it was,and they did the right thing and
stopped it.
It's just that the press and,unfortunately, physicians, uh,
(03:58):
they just kind of fell andfollowed in line with what
everybody was saying, becausethere were attorneys and they
were saying that women shouldnot take estrogen because
estrogen causes breast cancerand pharmacologically, that is
not a true statement.
If you have an er positivebreast cancer cell, estrogen
taking it will induce thatcancer to grow.
(04:19):
Okay, sure, so I could go onfor about four hours just on
that topic, but you asked aboutthis.
So since everybody went off alltheir estrogen and all their
estrogen with progesterone, theywent off of it.
Everything was pretty good forabout four or five years,
because when you go off estrogen, whether it be endogenous or
(04:42):
exogenous estrogen, you don'tget a major change in your bone
structure for five years.
So it was.
Things remained pretty goodtill about 2007, 2008
thereabouts don't quote me onthose exact dates, but it's
roughly five years aftereverybody started going off of
it.
Definitely by 2010, everybodywas now moving into something
(05:06):
for osteopenia, osteoporosistreatment or prevention, and
that was bisphosphonates.
So let's go ahead and startgiving them bisphosphonates.
So everybody starts takingbisphosphonates.
Now the thing of it is allpost-menopausal women pretty
much universally start taking it.
And there's some other thingsabout that, just besides dental
(05:28):
but I'll limit the discussion todental for right now that these
drugs.
What they do is they inhibitbone remodeling.
That's what they do.
They inhibit bone remodelingand they do it by preventing
bone resorption.
So when you want to remodelbone, you've gone in there and
(05:51):
you've done a bone graft, you'vedecorticated that bone and
whatnot.
You put that bone graft inthere and you want it to turn
over.
The osteoclasts get activated.
The osteoclasts, they willbreak down the bone in the area
for you and when they do that,they free up BMPs, bone
morphogenetic proteins.
Those BMPs now they go over tomesenchymal stem cells that are
(06:17):
in the area, induce them toproliferate.
So they go from X to 10X or Xto the 10th power Okay, they
just proliferate themtremendously.
Those same BMPs there's lots ofdifferent ones there, but those
same BMPs will then inducethose mesenchymal stem cells
(06:38):
that have been proliferated todifferentiate into osteoblasts.
And then to top it off they'llland on receptors it's all
pharmacology Land on receptorsto induce those osteoblasts to
lay down new bone mineral matrix.
So now your bone graft turnsover your socket graft, your
implant osteo integrates etc.
(06:58):
And so you need bone remodelingto make bone.
And when you take abisphosphonate or monoclonal
antibody you are preventing theosteoclast from freeing up the
BMPs from the bone mineralmatrix yeah, from the very start
You've turned off the switchthat enables bone remodeling.
(07:22):
In other words, if I have an oldhouse and I want to build a
brand new house on that sameproperty, you got to tear the
old house down.
If you don't tear bone down,you can't make bone.
Well now, bisphosphonates.
We have an oral form of thedrug okay, like Fosmex Lindroni
(07:46):
which is 10 to 100 times morepotent than the original
bisphosphonates, which weren'tvery effective at all.
So we came out with all theseoral ones, the pharmaceutical
industry that Beneva, fosmex, etcetera, et cetera.
The only thing is is it's verydifficult for us to predict
where you get ONJ with thosedrugs.
(08:08):
Because if you take abisphosphonate orally and you
take it on an empty stomach, youget 3% absorption.
27% goes out in the fecalmaterial.
But if you take it and once youget it absorbed, of that 3%
that gets absorbed, we'll sayyou took 70 milligrams, so
you've got 2.1 milligramsabsorbed.
(08:29):
10% of it goes to sites ofactive bone turnover.
Well, do you have active boneturnover in your jaws?
If you have no periodontaldisease, a stable occlusion, no
bleeding on probing, you've gotvery little bone turnover going
in the jaws.
You've got very little bit ofthat drug going to the jawbone.
So this jawbone is doingwhatever it normally does
because it's got very littledrug, yeah.
(08:50):
But the spine, the hip, theankle, those have a lot of bone
turnover on it.
The subclinic or the femur,they've got a lot of bone
turnover.
Or if you have periodontaldisease or an unbalanced
occlusion, now you've got a lotof bone turnover.
So then that three percent goesthere.
Am I getting?
This is too much science, isthis?
No, no this is great, we'retracking, all right, thank you,
(09:12):
this is really good.
Okay, you're dumb.
This is this stuff.
Dr. Soren Paape (09:15):
This is the stuff we want to hear.
Dr. James Rutkowski (09:17):
This is good, you gotta lighten this up
jim no this is no, no, no I thisis great I know you can make it
way more complex so Now, whenit starts to go to the bone,
before you ever took the drugyou had no concentration of it
in the jaw bones at all and I'mgoing to say you're missing 19,
18s tilted, 20s tilted, 14sdropped out.
(09:37):
We got bone turnover going overhere.
Over here, man, you brushreally good, you floss this side
really good.
You never lost a tooth.
It, man, you brush really good,you floss this side really good
, you never lost a tooth.
It's stable.
Very little bone turnover, lotsof bone turnover going on that
left side.
So when you first took it youhad no concentration.
You took one pill.
Then you ended up with a 10 tothe minus 500 millionth molar
(09:58):
concentration.
Well, with that lowconcentration, not only did you
inhibit osteoclasts frombreaking the bone down, but get
this and it takes about a year.
But the first year you actuallystimulate the osteoblasts to
lay down new bone.
It's a quirk of pharmacology,but it's well known.
(10:21):
So for the first year you startto make better bone.
This is pretty good.
But then the more you take it,it stays in the bone, it doesn't
come out.
For years you build up aconcentration when you get to
about a mine, a 10 to the minus15th molar concentration.
Now it's toxic to theosteoclast, the osteoblastlast,
(10:45):
the angioblast, the osteocytes.
Every living cell in the bonedies.
Now you can't break bone downand you can't make bone Because
you didn't break bone down.
You can't make bone.
Estrogen, by the way, itstimulated the osteoblast
directly right down bone, but wetook you off estrogen.
(11:05):
We said you got a lot to takeestrogen anymore and I don't
want anybody to get breastcancer.
We needed to be thinking aboutgenetic testing, familiar
history of breast cancer etc.
But so now, after about a yearand a half or two years of
taking this drug, if you hadbone turnover, you got a toxic
element there.
So if somebody goes in andtakes out 18, you can't turn
(11:29):
that bone over.
You got no blood supply there.
You can't heal that bone andthat whole thing there.
There's about a two hourexplanation that goes to that.
So I'm going to just say justtake that, as that's what
happens there, that happens.
Now over here Somebody elsetakes out number five because
(11:51):
they burnt down a hard nut andbroke it off.
Well, that feels just fine,mm-hmm, here didn't because the
drug was here.
It wasn't here.
Now, to make it worse, though,if you take a bisphosphonate
With food in the stomach,because the drug is very
irritating, it's very acidic.
When you take it, you have toremain upright, you have to
(12:13):
drink eight ounces of water withit.
You can't lay down for an houror two because if you, it will
roll back up your softness andcause the soft, your vertices.
For youophageal varicose.
For you, it can causeesophageal cancer.
For you it's a strong acid.
So what do people do?
They say you know, dr Jim, itbothers.
Dr. Soren Paape (12:35):
How do you take your drug?
Dr. James Rutkowski (12:36):
Well, I take it with some crackers or
some toast.
If you take it with food inyour stomach, you get zero
absorption.
You're never going to have aproblem with O and J, because
they never absorbed any of thedrug.
They never got it to the bone.
What could cause that?
They never interfered at all.
Hey, how's your osteoporosisdoing?
(12:56):
Oh, the doc says it's not doinggood at all.
Dr. Soren Paape (12:58):
Well, that's because you haven't been taking
a drug.
Dr. James Rutkowski (13:00):
You've been taking the drug, but it
never got absorbed.
I You've been taking the drug,but it never got absorbed.
I see when IV though when yougive the drug IV, you guys know,
when you give a drug IV, yourblood level is 100% and the IV
forms of the drug are 10 to 100times more potent than the
Fosamex was.
So now we gave you a much morepotent drug.
(13:21):
You got 100% blood level.
We were giving it to you forcancer treatment.
We gave you that iv treatment,probably once every month or
every three weeks or every twoweeks, a much more potent drug
at a higher concentration tohigher dose.
Well, now, those are the peoplethat get a lot of O and J.
(13:43):
Now the other thing is is whenthey and if I'm getting too
excited, let me just say settledown.
Dr. Soren Paape (13:53):
No, no, no.
Dr. James Rutkowski (13:54):
This is awesome.
Yeah, I really, you know it'sfunny.
Dr. Tyler Tolbert (13:57):
I appreciate that.
You know for a long time I'veunderstood the whole.
You know two years on orals iskind of a cutoff or whatever,
but it's just like, that's justa.
It's very immaterial.
It's like, okay, two years,that's just a reference.
In my mind.
You're really helping usunderstand.
You know where that actuallycomes from and the dynamics of
how that drug was being taken,if it was being taken properly,
and what the local oralenvironment was like during that
(14:19):
time and how it might bedifferent on one side versus the
other, and I had never heardanyone explain that.
So I appreciate that.
Dr. James Rutkowski (14:25):
And in our research company we did
modeling on bisphosphonates andwe came up with 70 milligrams a
week.
Typical, typical.
Typical If you're in an areawith bone turnover.
So that's somebody that's gotsome periodontal disease, not a
balanced occlusion, not 28beautiful pearl white teeth.
You know we're talkingsomething.
(14:46):
You know?
the typical 72 year old ladyyeah, that's got some issues
there and wearing a partial one,etc you know, that those um we
said we found in our modeling itwould take two and a half years
to get to a 10 to the minus15th molar concentration.
Now, a lot of assumptions weremade, man, I gotta admit.
A lot of assumptions were made,yeah, but when we look at these
studies and we say who gets it?
(15:06):
Well, the numerator in thesestudies is who got onj?
Well, we had a thousand casesof onj.
Okay, we had a thousand casesof onj.
People got something done,something happened and they got
ONJ.
And there had to be an incitingeffect.
Somebody had to do surgery,somebody had to take a tooth out
(15:28):
.
You had to cut the gingivaltissue with a fork or you know a
gash from you know crispy foodsor something of that nature.
You had to get that boneexposed.
You had ONJ when you werecovered with all the gingiva,
it's when somebody opened it up.
(15:48):
Now it couldn't heal becausethere was no blood supply in the
bone to help that soft tissueheal over.
So it just opened and opened,and opened, and opened and
greater and greater and greater.
And then you've got actinomycesdown in that bone and now
you've got a bone infection, anosteomyelitis.
But guess what?
You can't cure it becauseyou've got no way of getting the
antibiotic into the bonebecause there's no blood supply.
It has to be debrided.
Yeah, so you know, that's whereit was.
(16:12):
So if somebody, the numerators,everybody who got it, so who do
we put in the denominator?
Well, they put in thedenominator everybody who took
the drug.
Well, you know what?
I don't know?
We had 10 million people, 10million women, in the United
States taking the drug.
(16:33):
There were a thousand peoplethat don't own NJ.
You divide it by 10 million whotook the drug.
Now that is a 0.0001% chance ofit.
You go like well, that's notvery many people.
What are we even worrying about, you know, for those that get
it too bad, too sad, that's notthe attitude we should be taking
(16:54):
.
But that denominator shouldhave been who had an inciting
event, who got a tooth out?
That was in the denominator Isee.
So maybe it's a thousand peoplegot O and J, but only 10,000
people got a tooth out.
That's who should be thedenominator.
Dr. Tyler Tolbert (17:16):
Yeah, now you got more like 110.
Dr. Soren Paape (17:17):
Not the other 9,990,000 people.
Dr. James Rutkowski (17:20):
Yeah, you follow what I'm saying.
Dr. Tyler Tolbert (17:22):
Yeah, I do.
Dr. James Rutkowski (17:23):
So it was like whoa.
And so in Australia they didsome studies and they showed
that the instance of somebodyhaving a tooth out and going
ahead, and they've been taking.
Fosamex and they had to betaking it for over two and a
(17:44):
half years, et cetera.
You know, all these criteriawere met for it.
The incidence of O and J wassubstantially higher.
It went anywhere from 0.34% todepending on what the dose was
like.
In vaginal disease you get ahigher dose and whatnot.
Those individuals, they hadupwards of a 34% incidence of
(18:05):
ONJ.
Wow, wow.
So the dose of the drug, theduration of the drug, the route
of the administration of thedrug, what was the health of the
tissues?
Was there an inciting event ornot?
Yeah, you know.
And now that people have beenon these drugs for multiple
years 8, 10, 15 years it mayhave taken 15 years to get to
(18:28):
where it was toxic, but now theyjust have any little thing
happen to their gingival tissue.
They cut it with a toothbrushand then bingo, all of a sudden
they've got O and J.
I see they had O and J beforeit's just they didn't know they
had it wasn't exposed.
And you look at the x-ray to gohey, hey, your bone looks
pretty good there.
Well, it's not turning over,it's stagnant.
(18:48):
It's it's not living, it's deadbone and dead bone.
You can't take a tooth out ofdead bone and get it healed.
You can't get the genitaltissue co-opted over and expect
it to heal.
It's just not going to happen.
Now the um, when it's iv, thenit is much, much more
predictable.
Those individuals that take theiv form of the drug for cancer
(19:11):
treatment a higher dose morefrequently they get a tooth out.
They found that if you take atooth out and somebody that's
gotten three doses every twoweeks at the doses to treat a um
, a metastasis to the bone, orprevention metastasis to the
bone, um after three doses theystood about a 60 chance of
(19:33):
getting onj.
That's huge.
So it makes a big difference.
As to the dose, the duration,the root of administration of
the drug.
Now there is a study thatshowed that you could reduce the
incidence of ONJ 74%.
(19:53):
And those people that met thecriteria, they took it right,
they had all the things.
So we're taking the realpatient or they were under
cancer treatment.
Okay, prevent metastasis ivwith their frequently higher
doses and whatnot and uhstronger forms drugs.
This was also true withmonoclonal antibodies, by the
way, which are very similar,different but similar to
bisphosphonates uh 74 reduction.
(20:16):
If you could eliminate allbleeding on probing before you
ever did your surgery.
Get rid of all inflammation inthe oral cavity.
Reduce your levels of IL-6,interleukin-6.
If you can reduce thatappreciably and that can be just
demonstrated visually, is whenyou take the periodontal probe
and you probe six readings pertooth, do you have any bleeding?
(20:37):
I got no bleeding.
You know what I stand a 74chance of taking your tooth out,
suturing you up.
I might do a few things inthere to help me heal.
But I'm not going to get onj,most likely even though you were
on this high dose iv form ofthe drug, because I had rid of
the inflammation.
Now the soft tissue itself cantend to heal itself, whether
(21:00):
there was a blood supply comingfrom that periosteum or not, or
from that bone through thatperiosteum.
So and we did a study in ourgroup with it and we reduced it
73%.
Wow, the literature said 74.
Our study showed 73% reductionwith it.
So it's something that wetreated a lot because we were
(21:23):
our clinic.
We were associated with twocancer clinics and they would
send us these patients that weregetting either experimental
monoclonal antibodies, becausethey were one had a huge
clinical trial going on with NIHthat we needed to find out what
they were on, so they wouldbreak the code for us on
patients and we would do theirsurgeries.
(21:44):
But it's a topic I'm verypassionate about.
Dr. Tyler Tolbert (21:49):
Yeah, no, absolutely.
So I want to make sure I don'tbutcher your conclusions there.
So it sounds like that, even inpatients who had IV exposure to
bisphosphonates or monoclonalantibiotics, if you could just
reduce the inflammation in thetissues prior to the exciting
event, you could massivelyreduce the incidence of flossing
(22:10):
necrosis.
Right that?
Dr. James Rutkowski (22:11):
meant good strength, flossing, electric
toothbrush twice a day for twominutes each time, or at least a
minute in the morning and twominutes at night, and then water
irrigation and we put all thosepatients in our clinic on those
, we gave them the and I knowwe're just supposed to tell
commercial product, but whatthat?
It was the water pick, sonic,yeah, the one that's got the
(22:32):
brush in the body.
You know, and I'm telling youwhat.
We did surgery on thosepatients every week and and we
had very, very few complications.
Now I also irrigated the bonetremendously with a lot of
saline.
I would try, and if I had areaswhere it was obviously necrotic
bone, I would remove that bonebefore I would close them.
(22:55):
I got primary closure.
I would use Buffy Coat, prp oncollagen down and then PRF under
the suture lines.
I would use horizontal mattresssutures to keep the tension
away from the suture line.
Then just at the suture line,doing interrupted or continuous,
and that helped a lot.
(23:17):
Now I did order two sets of labtests and it was not to predict
O and J, and the ADA is 100%correct you cannot predict O and
J.
I think your biggest predictor,quite honestly, is inflammation
.
And then, looking at theradiographs, if the bone has a
sclerotic appearance, that tellsyou there's not much of a blood
(23:40):
supply.
If it looks rotty, then thatthat really upped the game.
And I always got in a signedconsent forms and I'll share
that with you guys.
Uh, you can share with yourreaders, if you want, in signed
form, please, forbisphosphonates and monoclonal
antibodies.
But I wanted to be able topredict whether you were going
(24:03):
to make bone or not.
So I ordered two lab tests andthe one was a serum ntx, that's
a serum nancy thomas, xavier, nxare the initials, and that
tells me how well theosteoclasts are working.
And I wanted the patient to bein the range of a 40 to
(24:28):
44-year-old premenopausal womanand that because those women
they are breaking bone down,they're remodeling bone, they're
breaking bone down and they'regoing to make bone because they
broke the bone down.
So I want an NTX and I don'tcare whether you're 90 years old
, it is possible for your NTX tobe in that range.
(24:48):
Then I ordered a serum BSAP,that's bone-specific alkaline
phosphatase Serum BSAP that'sbone specific alkaline
phosphatase serum bsap.
And I wanted that in the rangeof a 34 to 44 year old
premenopausal female and thattold me whether the osteoblasts
were working.
(25:09):
Could you build the bone sobefore I went in and did this,
all on x, or this bone graft, uh, or even just a single implant?
you know, maybe, maybe should bedoing the fixed bridge for you.
You know, if we really want toknow, I want to know whether you
can heal that bone or not,whether you can make bone.
(25:31):
Can you osteointegratingimplant and can you do that?
And I realized bob marks uses a.
He used a urine ctx becausewhen he came out with it that's
what was being used here in theUnited States.
The serum NTX started beingused in Japan.
Japan is way ahead of theresearch on postmenopausal women
(25:51):
because Asian women have a muchhigher incidence of osteopenia,
osteoporosis, than does therest of the world.
So they're way ahead in theirresearch.
Now a serum CTX.
I don't personally I don't knowthe ranges on that like they do
the serum NTX.
So I personally have stayedwith the serum CTX excuse me,
(26:11):
serum NTX and didn't go over tothe newer serum CTX.
But that just gave me theconfidence.
Does this look like this has achance of working?
Because now they're universallab tests?
They weren't specific for thejaws, but if the numbers were
bad.
You know what you might not makebone.
If the numbers were good, youmight make bone.
(26:33):
And so what I did is I got youall cleaned up.
Good prophy, good scaling, goodplaning.
I want no bleeding on probing.
You're doing good daily oralhygiene at home.
I would get these tests If thetests were good.
I said I want you to stop takingthe bisphosphonate or the
(26:55):
monoclonal antibody with aphysician's permission for 16
weeks, because I want to put myimplant in or my bone graft and
I want it to turn over.
Okay, so we're not going totake any drug for 16 weeks if
the numbers were good.
If the numbers are bad, I wantyou to take a six-week holiday,
(27:21):
okay, and then we're going torepeat the tests and if the
numbers are good, we're going togo ahead and do your surgery.
You're still signing a consentform and the reason being is you
didn't kill every osteoclastand osteoblast-induced necrosis,
every one of them in the body.
No, you still have some thatare working.
(27:42):
It's just that now you haven'tbeen on the drug for six weeks,
okay.
Or if you want to be a bit moreconservative, you can go three
months, okay, and I think threemonths is probably a better
number than six weeks.
So wait three months, repeatthe tests.
If the numbers are good, goahead and do your surgery, but
(28:02):
don't start to drug up foranother 16 weeks.
Does that make sense?
Yeah, it does.
Yeah, it does.
Dr. Soren Paape (28:09):
Okay, so I got a couple questions.
First, is this just forpatients taking IV
bisphosphonates, or oral andoral?
Dr. James Rutkowski (28:14):
I had everybody that took a
bisphosphonate and monoclonalantibody.
That's what they did.
I had everybody that took abisphosphonate and monoclonal
antibody.
That's what they did If they'dbeen on for two years.
Dr. Soren Paape (28:21):
Okay, so good.
Lab tests 16-week holiday, thenyou place your implant.
Can they jump back on it rightaway?
Dr. James Rutkowski (28:29):
No, once I do my surgery, I want to give
them another 16 weeks.
Dr. Tyler Tolbert (28:35):
So holidays after the procedure.
Dr. Soren Paape (28:38):
Once you place the implant wait 16 weeks.
Dr. James Rutkowski (28:41):
Once you've got the implant in and
it's also integrated, now theycan go back into drug.
Dr. Soren Paape (28:45):
Got it, got it, okay.
So if good tests and we'll tryto put these numbers in a show
notes so people can look.
But if they have good numbers,you'll place the implant right
away and then have them take adrug holiday for 16 weeks after
the after integration.
Right, if the numbers are badsix week, or you said six week,
(29:07):
or three month, if you want tobe conservative three months,
yeah, three months retest.
If numbers are good, place theimplant.
Wait another 16 weeks yeah um,does it matter how long they've
been taking the oralbisphosphonates?
Dr. James Rutkowski (29:19):
Yeah, yeah , I mean, you know if they took
it ideally and it was 70milligrams a week, which that's
what everybody took in Fosmex anosteopenia dose was 35
milligrams a week.
Osteoporosis dose was 70, buteverybody got 70 milligrams.
Even when you had a diagnosisof osteopenia, everybody got 70,
seemingly so.
I think in all my years I onlysaw two or three people on 35,
(29:42):
but you know over half thosepeople were just osteopenia.
But um, if it's 70 milligramsevery week and they took it just
as they were supposed to, in anempty stomach, you know, there
there is a report of as early as18 weeks somebody getting L and
(30:03):
J, but that could be just anoutlier.
That could be just an outlier.
They may have had othermorbidities.
Maybe they smoked as well.
Maybe they were takinglong-term steroids, because
there are other comorbiditiesbesides just having that surgery
.
But traditionally we didn't seeit in under two years.
Now, if you didn't take itright, you might have taken the
(30:25):
drug for 10 years.
Yeah, it wouldn't matter, right, right, you weren't at risk.
Yeah, so it was.
How did you take the drug?
The duration, the state of theoral cavity, amount of
inflammation.
So there's just so manycompounding factors.
It's very difficult.
I agree personally with 90% ofeverything that was said in that
(30:47):
ADA paper, in the Amos paper.
I should say the Amos paper.
I agree with 90% of it there.
They did not have onepharmacologist on there, yeah,
that's crucial, yeah it's apharmacology question, it is.
Dr. Tyler Tolbert (31:03):
There's nuances, yeah, for sure so.
Dr. Soren Paape (31:06):
so you have placed implants in patients that
have been I on ivbisphosphonates, on oral
bisphosphonates, as long as theythe protocols are followed
properly, the the tests cameback well and overall you said—
Reduced inflammation.
Yeah, and how long would youhave them?
You talked about the brushingwater, pick flossing.
(31:31):
How long, typically, would ittake your patients to get to a
point where no bleeding onprobing?
Dr. James Rutkowski (31:37):
They would have that in three months.
So between right, many, many ofmy implant patients I'm very um
discriminating about oralhygiene with dental implants
because I came up in the 80swhen nobody understood the
importance of it.
Then we had so muchperi-implantitis uh, you know
that I learned from it the hardway, not by reading papers but
(31:59):
by experiencing it.
So it was usually within threemonths, between three months,
prophylaxis.
You know, you come in, you getyour consult, etc, etc.
This is what you need to do.
We need to get this all cleanedup.
You're gonna come in, you'regonna get your teeth all cleaned
up here.
Scale and replaning, whateverwe're going to do with that.
If there was paranormal disease,we've got the paranormal
disease eradicated the best wecould before we ever did it.
(32:21):
And even if I was going to takeout all their teeth and when I
was doing this in the in the 90swe weren't doing all on exits,
we were doing fp1s oroverdentures or things of that
nature um, that we would uh, westill followed that protocol and
that helped us tremendously bygetting no smoking.
(32:42):
We didn't want any bleeding andprobing but within three months
just about everybody could beto the point where we did not
have any bleeding and probingand I thought that was a huge.
That was a huge factor for it?
Dr. Tyler Tolbert (32:53):
And yeah, I'm curious to do you sponsor any
other like adjunctivetherapiesctive therapies prior
to the procedure?
So obviously you know peopletalk about hyperbaric dives.
Some people are fans ofadministering pentoxyfilene and
vitamin E for some time prior tothe procedure and after the
procedure.
Do you feel one way or anotherabout those?
Could they hurt?
Dr. James Rutkowski (33:14):
You know, the literature is not.
I try to do everything in mylife based on what does
literature say, and I realizethat the literature is flawed
and the literature is incomplete.
Sure, okay, so just know that.
I'm very much aware of that.
That.
I think that it is veryimportant for these patients to
(33:36):
go on vitamin D, yeah, ahead oftime, and I like them to be on
that for at least a month, ifnot two months.
And I like it best when we havevitamin D levels on those
patients from their lab testsand whatnot, because that can
help us prescribe mostaccurately.
(33:56):
But if, for whatever reason, wedon't have that, then I put them
on vitamin d3 5000 units a dayone month pre-surgery and then I
keep them on vitamin d3 5000.
It's vitamin d3 5000 units onemonth prior to surgery, then
vitamin d3 5000 units daily forum two months afterwards.
(34:18):
But it is a lipid-solublevitamin D3 that you can get
toxicity, but it would take youa long time at 5,000 units a day
to get the toxicity.
So if you're in the northeastor if you're north of the
Mason-Dixon line, even if you'renorth-central or um northwest
(34:39):
united states, where you getvery little sunshine, uh, and
even though the people that arein phoenix, arizona, they're all
wearing long sleeves andsunscreen now, they're not
getting much vitamin d right youknow, technically we should
have the blood levels.
But if we don't 5 000 units aday for that criteria a month
ahead of time, two monthsafterwards, you're not going to
(34:59):
get in trouble.
Then go to 2 000 units a dayfor that criteria a month ahead
of time, two months afterwards,you're not going to get in
trouble.
Then go to 2 000 units a day,you will not get in trouble with
vitamin d toxicity.
Okay, could you go vitamin d 5000 units longer than that?
Yeah, you could, but without alab test we don't know that
definitively.
I'm just saying saying thosenumbers 30 days before, 60 days
after and then 2,000 units a daythereafter, particularly in the
(35:23):
populations beyond the age of70, most of them have some
vitamin D deficiencies anyway.
Dr. Soren Paape (35:32):
That was really good.
Dr. Tyler Tolbert (35:33):
That was awesome.
Dr. James Rutkowski (35:35):
And our listeners will really appreciate
that.
Dr. Soren Paape (35:39):
You know we don't have a ton of time left,
but I'd love like a quick recapon your thoughts for patients
who like radiation levels.
You know my understanding istypically under 60 grays.
You're a lot, you know, in amuch better place for implant
placement.
So I'm curious on your thoughtson that better place for
implant placement.
(35:59):
So I'm curious on your thoughtson that.
And then I'm curious yourthoughts on um a1c levels, uh,
and and where you're comfortableplacing implants with patients
if you have time to answer thoseyeah, 55 to 60 grays is should
be the cutoff.
Dr. James Rutkowski (36:12):
Okay, that should be the cutoff.
But the more important thing isthat you get with the
oncologist and you look at themapping when was the radiation
given, what was shielded andwhat was not shielded.
And they are very good atshielding.
So if that radiation treatmentis probably in the last eight
(36:35):
years, 10 years, they probablyhad excellent shielding
techniques.
Even if it was head and neckradiation, they probably had
excellent shielding techniquesand if that bone was shielded
then you probably don't havemuch of an issue whatsoever.
But you've got to talk withthat oncologist.
They are very willing to talkwith you.
(36:55):
Many physicians they get verybusy and they have bigger fish
to fry than talking to thedentist about their patient and
so many times talking to thenurse practitioner or their head
nurse in the office and whatnot.
They are more relatable manytimes just because they don't
(37:17):
have as many things going oninside their head that maybe
that head doctor does.
But I will say the oneexception that is every time
that I have had to talk to anoncologist and when we worked
with the cancer clinics wetalked with them all the time.
Those individuals they werereally.
(37:37):
They knew the consequences oforal surgery in somebody with
radiation and they didn't wantthose patients to have a problem
.
And so I found if there's onegroup of physicians that'll give
you everything to lay it allout there, it is the oncologist,
the radiologist, who does thattreatment for them.
(38:00):
Uh, so one, make sure you do aconsult, make sure you get the
number of grades, make sure youget the mapping, and again, make
sure there's no inflammation inthe mouth, because we believe
we believe we don't have theliterature support it, but we
believe we would probably havesomething similar with that lack
of inflammation allowing us tohave better healing force there.
(38:21):
Then, depending on what it is,then we may have to talk about
hyperbaric oxygen and things ofthat nature.
Dr. Soren Paape (38:27):
I have a.
Yeah, the reason I was askingin particular is I have a.
I try to stay away frombisphosphonate patients and
radiation patients just to beconservative, right, but I did
have one patient that I did anupper lower all on six on
probably a month and a half agoand he had some neck radiation.
(38:48):
But I met with the oncologist,we went over all the mapping and
I ensured that he was under 55degrees in all areas that I was
placing implants and he had alsodone full hyperbaric oxygen
therapy.
So he's in the healing processright now and everything seems
like it's healing great.
But you know, it's always thatthing that I'm thinking about.
(39:09):
I'm always like, until he'sfully healed, I'm always just
going to be like all right,hopefully everything goes okay.
But that's great to hear fromyou.
Dr. James Rutkowski (39:18):
What about your A—oh?
Go ahead, you might let thoseimplants integrate just a little
bit longer and then do yourISqs on there to to see what
kind of readings they've got,before you do look and um, you
know, because the implants willgo in that, that bone and I.
I think you've done everythingjust exactly right.
(39:39):
You did everything right.
You talked to the oncologistthere and the diaper berry
auction you did all those thingsjust exactly right.
But if the bone is not turningover quickly or at all for you
when they first go in, yeah,they can be nice and stable, but
then do they truly osseomantic,right um on.
But you did everythingabsolutely right as far as I'm
(40:00):
concerned, from my vantage pointhere um ha1c's.
Um I lecture, I try to keepeverybody from having trouble.
I don't want them to havetrouble and the literature
strongly supports that.
An HA1C above seven.
You probably shouldn't be doingelective surgery on them Now
(40:23):
that's not to say that a 7.1, a7.2, you can't sweep by, you
know.
And where did they start out?
Did they start out at a 14,?
And they've been working fornine months with their
endocrinologist and the bestthey can get them is 7.2.
Well, okay, that's aconsiderable amount of
improvement.
Well, 7.2 is not 7.0, so, jim,you mean the guy you know.
So what I'm saying is you knowwe have to make everything
(40:45):
realistic in this world too.
But if you want to play, it'sconservative 7-0.
You never do an electivesurgery about that.
If you said I'm willing tostretch, I know the patient,
they're going to do best hygienethat they can possibly do.
I'm going to be careful.
Um, we're going to get them inevery three months.
(41:07):
They're going to do everythingthey can possibly do.
All right, and you're not alitigious patient.
I'll go to seven and a halfwith you.
Okay, I think anybody that doesanything beyond eight is why
don't you just go out and takemoney and burn it in the streets
Because you're going to see anice fire.
(41:30):
Otherwise, all you're going todo is see those implants again
and you're going to do themagain and again and again, and
that's going to cost you money.
So just burn the money thefirst time.
You'll be just further, youknow.
Dr. Tyler Tolbert (41:42):
Save yourself time, save yourself time Okay.
Dr. Soren Paape (41:45):
So nothing above an eight.
Dr. James Rutkowski (41:46):
If it is between.
If it's below seven, great.
And sometime we'll talk aboutmaybe steroids and things of
that nature, because there'ssteroid doses in what we do.
Dr. Soren Paape (41:57):
But if it's below seven.
Dr. James Rutkowski (41:58):
yeah, I go ahead and I do implants,
grafting, whatever has to bedone there with it, Great, great
.
Dr. Soren Paape (42:04):
Are there any other?
Any other?
I mean, those are kind of thethree big ones that I feel like
people talk about the most.
Right a diet, uncontrolleddiabetes, head and neck,
radiation, bisphosphonates.
Is there anything else that youthink that our listeners should
be really um aware of as likean absolute contraindication,
then?
Dr. Tyler Tolbert (42:23):
like protonics, and antidepressants
as well to some degree not notan absolute contraindication,
but people are talking aboutyeah, yeah, those those.
Dr. James Rutkowski (42:29):
Those are less.
Uh, you know, if it's an ssriright?
I suggest you let thoseimplants integrate for longer
and maybe, when you do load them, you load them with an acrylic
based tooth um or an acrylicocclusal surface.
I should say that's going towear form um, because I I wanted
(42:50):
to wear, realizing full wellyou're going to have to replace
them more frequently than youare, maybe zirconia or something
of that nature but they need ashock absorber because that bone
, those drugs, they interferewith bone remodeling.
They put them in a negativeremodeling state where they're
going to break bone down morethan they're going to build the
bone up With an SSRI.
(43:12):
Of the 25 top drugs prescribedin the United States in 2022,
that's the latest data I have,it's 22.
I don't have 23 data and 24data yet that comes off the
pharmaceutical industry.
But the top 25 drugs prescribedin 2020, through, every single
(43:34):
one of them had an effect onoral health or healing of oral
surgical procedures.
So some of them were positive,some of them were negative.
But you know, I think thebiggest factor as I can say from
what I've gleaned from theliterature in just about
everything, in confoundingfactors 44 years of clinical
(43:59):
experience is you want to makesure they've got good oral
hygiene.
I think that Waterpiksonicevery single patient got
implants in my practice.
They got a waterpiksonic, theygot one implant, you got a
waterpiksonic.
Great, I was retired for 14months.
(44:21):
One of my patients whom, um, uh,I was friends with and he had
my um, my cell number he textedme.
He says jim, I just came backfrom the people that took over
my practice.
He said and I had a perfectcheckup, and I gotta tell you,
jim, I want to thank you for allthe things you ever did for me,
and that included implants,restorative, etc, etc.
(44:44):
He said the best thing you everdid for me, though, was give me
that electric toothbrush thatputs the water out.
Oh, that's great, you know?
I I thought that was that wasunsolicited.
He just called out, in fact.
He called me at christmas time,and he said all my grandkids,
for christmas, got a sonic, awaterpik sonic.
(45:09):
That's good.
He said.
If I were to have him when Iwas a kid, I would have needed
all that work from you.
I might?
Dr. Soren Paape (45:14):
I don't.
I don't have a waterpik sonicand I'm I might be getting.
I know I can see him searchingamazon right now.
Dr. Tyler Tolbert (45:20):
Which are these things like?
Dr. Soren Paape (45:23):
we give.
We give all of our patientswater picks but not water
picksonics.
So I'll definitely have to lookinto that and I appreciate the
advice.
Dr. James Rutkowski (45:33):
I've enjoyed my time with you guys.
Hopefully I didn't wear out mywelcome.
No, oh no, not at all.
Dr. Soren Paape (45:40):
Before you go, though, please let everyone know
what the best way to um findfind the residency program, to
get more info on the residencyprogram, to maybe reach out if
they want more info.
Dr. James Rutkowski (45:52):
Uh, that'd be, that'd be really helpful
okay, uh, you want to um uh,google jacksonville university
comprehensive oral implantologyprogram.
So again, jacksonvilleUniversity, comprehensive oral
(46:14):
implantology program.
If it's okay with you guys,I'll give my phone number,
please.
Yeah, and I'm going to just askthat you text me, because I got
a spam blocker and it's not inmy phone it doesn't ring so I
tried to call you.
You never know my phone number.
Text me, Send me your card andthen I'll put your card in there
(46:34):
and put in there that you wantinformation on Jacksonville
University program and thatnumber is 803-415-4838.
Again, 803-415-4838.
(46:56):
Again, 803-415-4838.
And for those of you that havea great deal of clinical
experience, you are oralsurgeons, perio pros greet, or a
diplomate of the ICOI or adiplomate of the ABOI ID or a
fellow of the American Academyof Implant Dentistry.
It's just that all those theyhave been assessed as to having
some competencies in implantdentistry.
(47:19):
If you're those, we do have aremote residency program for you
where, if you own your ownpractice, you stay in your
practice.
You still work with EPAs, butyou have a remote director who
you report to, and so you neverhave to leave your practice.
You stay there, you get it all.
You do all the didactic work,you do all the EPAs, you get the
(47:41):
same master's degree and it's atwo-year program as well for
them.
So we have a handful of thosein our program now.
Dr. Tyler Tolbert (47:49):
Very cool, excellent, very cool.
Well, dr Rakowski, this hasbeen an absolute pleasure, and I
think both of us can.
I speak for Swarm when I saythat we learned way more than we
ever even expected to with thisinterview.
You know, we were we alreadyjazzed about learning about the,
about the, about the residency,of course, but we got schooled
on all kinds of pharmacologystuff, which has been an
absolute pleasure, and these arethings that we talk about all
(48:10):
the time.
Um, so really, thank you somuch for sparing your time and
and I hope that the fans of ourshow will be reaching out to you
about their interest in theprogram and we hope to use you
as a resource in the future aswell for all of our burning
questions about implantology,because you have an incredibly
deep and broad knowledge andkudos to the two of you for what
you're doing.
Dr. James Rutkowski (48:29):
thank you know.
Uh, we're, we're, we're, youknow, we're all brothers and
sisters in implant dentistry andum, we all have the same joys,
we all have the same anxieties,um, and we, all of us, I truly
believe we really want what isbest for our patients.
I truly believe that, and it'sexemplified so clearly by the
(48:53):
things that the two of you aredoing.
So, thank you very much forinviting me, thank you for being
who you are in the work thatyou're doing.
So hats off to you guys.
Likewise.
Dr. Tyler Tolbert (49:02):
Thank you, have a nice day.
Bye.
My name is Dr Tyler Tolbert and I'm Dr Soren
Papi and you're listening to theFix Podcast, your source for
all things implant dentistry,absolutely Well, yeah, so I have
a few miscellaneous questionsas well, just kind of based off
of you know what your experienceis and all the different things
that you can, you know, kind ofbring to implant dentistry with
your extensive background.
(00:22):
So you mentioned, you know youhad done some research on
postmenopausal women and issueswith bone formation and things
like that, and so I am kind ofcurious if you have any opinions
on, you know, like the AOMSposition paper on bisphosphonate
medication and relatedosteonecrosis of the jaws and
things like that.
You know what is kind of yourposition and what do you tell
(00:44):
your residents as far aspatients that are taking
bisphosphonates oral or IVdifferent kinds of treatments
that could be used to helpprevent osteonecrosis.
In regards to implant treatment, Okay, that's a great question.
Dr. James Rutkowski (00:58):
It's something I'm very passionate
about, oh good, it's somethingthat I lecture a great deal on
and put a big part of my lifeinto looking at it.
I think the Women's HealthInitiative of 2001 through 2003
was a misinterpreted study thatstudy was based on.
(01:20):
It was sponsored by WyethLaboratories, who had a
medication on the market calledPremarin and another medication
called PremPro.
Premarin was a conjugatedequine estrogen which came from
the urine of pregnant marehorses, which you know.
That was the estrogen we'regoing to go ahead and give these
(01:41):
women.
But it was being done.
Then they had another componentof the drug and they envisioned
that every woman in the worldwould be taking these two drugs.
One of these two drugs eitherPremarin, conjugate equine
estrogen, or PremPro, which wasa conjugate equine estrogen,
plus a synthetic progesteronecalled medroxyprogesterone.
And they just thought this isgoing to be the best study in
(02:04):
the whole wide world.
We're gonna put all these womenin it.
The study was not well definedbut because they wanted to just
get so many massive numbers, wehad women in there that were
smoking and that was a realcompounding factor for blood
clots and for cancer, etc.
Etc.
But they had them in there andthe pharmacologist?
(02:24):
We knew that of all the sexhormones that can cause breast
cancer, the number one issynthetic medroxyprogesterone.
Okay, we knew that before.
That was even there.
I'm sure the pharmacologists atWyeth were probably screaming.
(02:47):
But you have the money managersof these pharmaceutical
companies that are saying wait aminute, we've got to sell drugs
.
You know, somebody's got to payall these salaries.
We've got tremendous overheadand you know.
And what's the instance of it?
Of course, as scientists, we'realways accused of over
exaggerating everything.
And uh, the business people arealways saying you know, it's
(03:09):
not a big deal, you're overexaggerating.
And the pharmacologists aresaying, wait a minute, you're
under exaggerating so there'salways conflict at
pharmaceutical companies betweenthe scientists and the money
people.
Um, and I realize it has to bea balance, you know not, it's
not one right and wrong, butanyway, that study, they got
into it roughly two years andthey found that the group
(03:32):
getting the prem pro had a muchhigher incidence of breast
cancer than did general society,the rest of the women that
weren't taking anything or thegroup just taking premarin.
Okay, so the prem pro study wasstopped abruptly quickly.
It should have been, it was,and they did the right thing and
stopped it.
It's just that the press and,unfortunately, physicians, uh,
(03:58):
they just kind of fell andfollowed in line with what
everybody was saying, becausethere were attorneys and they
were saying that women shouldnot take estrogen because
estrogen causes breast cancerand pharmacologically, that is
not a true statement.
If you have an er positivebreast cancer cell, estrogen
taking it will induce thatcancer to grow.
(04:19):
Okay, sure, so I could go onfor about four hours just on
that topic, but you asked aboutthis.
So since everybody went off alltheir estrogen and all their
estrogen with progesterone, theywent off of it.
Everything was pretty good forabout four or five years,
because when you go off estrogen, whether it be endogenous or
(04:42):
exogenous estrogen, you don'tget a major change in your bone
structure for five years.
So it was.
Things remained pretty goodtill about 2007, 2008
thereabouts don't quote me onthose exact dates, but it's
roughly five years aftereverybody started going off of
it.
Definitely by 2010, everybodywas now moving into something
(05:06):
for osteopenia, osteoporosistreatment or prevention, and
that was bisphosphonates.
So let's go ahead and startgiving them bisphosphonates.
So everybody starts takingbisphosphonates.
Now the thing of it is allpost-menopausal women pretty
much universally start taking it.
And there's some other thingsabout that, just besides dental
(05:28):
but I'll limit the discussion todental for right now that these
drugs.
What they do is they inhibitbone remodeling.
That's what they do.
They inhibit bone remodelingand they do it by preventing
bone resorption.
So when you want to remodelbone, you've gone in there and
(05:51):
you've done a bone graft, you'vedecorticated that bone and
whatnot.
You put that bone graft inthere and you want it to turn
over.
The osteoclasts get activated.
The osteoclasts, they willbreak down the bone in the area
for you and when they do that,they free up BMPs, bone
morphogenetic proteins.
Those BMPs now they go over tomesenchymal stem cells that are
(06:17):
in the area, induce them toproliferate.
So they go from X to 10X or Xto the 10th power Okay, they
just proliferate themtremendously.
Those same BMPs there's lots ofdifferent ones there, but those
same BMPs will then inducethose mesenchymal stem cells
(06:38):
that have been proliferated todifferentiate into osteoblasts.
And then to top it off they'llland on receptors it's all
pharmacology Land on receptorsto induce those osteoblasts to
lay down new bone mineral matrix.
So now your bone graft turnsover your socket graft, your
implant osteo integrates etc.
(06:58):
And so you need bone remodelingto make bone.
And when you take abisphosphonate or monoclonal
antibody you are preventing theosteoclast from freeing up the
BMPs from the bone mineralmatrix yeah, from the very start
You've turned off the switchthat enables bone remodeling.
(07:22):
In other words, if I have an oldhouse and I want to build a
brand new house on that sameproperty, you got to tear the
old house down.
If you don't tear bone down,you can't make bone.
Well now, bisphosphonates.
We have an oral form of thedrug okay, like Fosmex Lindroni
(07:46):
which is 10 to 100 times morepotent than the original
bisphosphonates, which weren'tvery effective at all.
So we came out with all theseoral ones, the pharmaceutical
industry that Beneva, fosmex, etcetera, et cetera.
The only thing is is it's verydifficult for us to predict
where you get ONJ with thosedrugs.
(08:08):
Because if you take abisphosphonate orally and you
take it on an empty stomach, youget 3% absorption.
27% goes out in the fecalmaterial.
But if you take it and once youget it absorbed, of that 3%
that gets absorbed, we'll sayyou took 70 milligrams, so
you've got 2.1 milligramsabsorbed.
(08:29):
10% of it goes to sites ofactive bone turnover.
Well, do you have active boneturnover in your jaws?
If you have no periodontaldisease, a stable occlusion, no
bleeding on probing, you've gotvery little bone turnover going
in the jaws.
You've got very little bit ofthat drug going to the jawbone.
So this jawbone is doingwhatever it normally does
because it's got very littledrug, yeah.
(08:50):
But the spine, the hip, theankle, those have a lot of bone
turnover on it.
The subclinic or the femur,they've got a lot of bone
turnover.
Or if you have periodontaldisease or an unbalanced
occlusion, now you've got a lotof bone turnover.
So then that three percent goesthere.
Am I getting?
This is too much science, isthis?
No, no this is great, we'retracking, all right, thank you,
(09:12):
this is really good.
Okay, you're dumb.
This is this stuff.
Dr. Soren Paape (09:15):
This is the stuff we want to hear.
Dr. James Rutkowski (09:17):
This is good, you gotta lighten this up
jim no this is no, no, no I thisis great I know you can make it
way more complex so Now, whenit starts to go to the bone,
before you ever took the drugyou had no concentration of it
in the jaw bones at all and I'mgoing to say you're missing 19,
18s tilted, 20s tilted, 14sdropped out.
(09:37):
We got bone turnover going overhere.
Over here, man, you brushreally good, you floss this side
really good.
You never lost a tooth.
It, man, you brush really good,you floss this side really good
, you never lost a tooth.
It's stable.
Very little bone turnover, lotsof bone turnover going on that
left side.
So when you first took it youhad no concentration.
You took one pill.
Then you ended up with a 10 tothe minus 500 millionth molar
(09:58):
concentration.
Well, with that lowconcentration, not only did you
inhibit osteoclasts frombreaking the bone down, but get
this and it takes about a year.
But the first year you actuallystimulate the osteoblasts to
lay down new bone.
It's a quirk of pharmacology,but it's well known.
(10:21):
So for the first year you startto make better bone.
This is pretty good.
But then the more you take it,it stays in the bone, it doesn't
come out.
For years you build up aconcentration when you get to
about a mine, a 10 to the minus15th molar concentration.
Now it's toxic to theosteoclast, the osteoblastlast,
(10:45):
the angioblast, the osteocytes.
Every living cell in the bonedies.
Now you can't break bone downand you can't make bone Because
you didn't break bone down.
You can't make bone.
Estrogen, by the way, itstimulated the osteoblast
directly right down bone, but wetook you off estrogen.
(11:05):
We said you got a lot to takeestrogen anymore and I don't
want anybody to get breastcancer.
We needed to be thinking aboutgenetic testing, familiar
history of breast cancer etc.
But so now, after about a yearand a half or two years of
taking this drug, if you hadbone turnover, you got a toxic
element there.
So if somebody goes in andtakes out 18, you can't turn
(11:29):
that bone over.
You got no blood supply there.
You can't heal that bone andthat whole thing there.
There's about a two hourexplanation that goes to that.
So I'm going to just say justtake that, as that's what
happens there, that happens.
Now over here Somebody elsetakes out number five because
(11:51):
they burnt down a hard nut andbroke it off.
Well, that feels just fine,mm-hmm, here didn't because the
drug was here.
It wasn't here.
Now, to make it worse, though,if you take a bisphosphonate
With food in the stomach,because the drug is very
irritating, it's very acidic.
When you take it, you have toremain upright, you have to
(12:13):
drink eight ounces of water withit.
You can't lay down for an houror two because if you, it will
roll back up your softness andcause the soft, your vertices.
For youophageal varicose.
For you, it can causeesophageal cancer.
For you it's a strong acid.
So what do people do?
They say you know, dr Jim, itbothers.
Dr. Soren Paape (12:35):
How do you take your drug?
Dr. James Rutkowski (12:36):
Well, I take it with some crackers or
some toast.
If you take it with food inyour stomach, you get zero
absorption.
You're never going to have aproblem with O and J, because
they never absorbed any of thedrug.
They never got it to the bone.
What could cause that?
They never interfered at all.
Hey, how's your osteoporosisdoing?
(12:56):
Oh, the doc says it's not doinggood at all.
Dr. Soren Paape (12:58):
Well, that's because you haven't been taking
a drug.
Dr. James Rutkowski (13:00):
You've been taking the drug, but it
never got absorbed.
I You've been taking the drug,but it never got absorbed.
I see when IV though when yougive the drug IV, you guys know,
when you give a drug IV, yourblood level is 100% and the IV
forms of the drug are 10 to 100times more potent than the
Fosamex was.
So now we gave you a much morepotent drug.
(13:21):
You got 100% blood level.
We were giving it to you forcancer treatment.
We gave you that iv treatment,probably once every month or
every three weeks or every twoweeks, a much more potent drug
at a higher concentration tohigher dose.
Well, now, those are the peoplethat get a lot of O and J.
(13:43):
Now the other thing is is whenthey and if I'm getting too
excited, let me just say settledown.
Dr. Soren Paape (13:53):
No, no, no.
Dr. James Rutkowski (13:54):
This is awesome.
Yeah, I really, you know it'sfunny.
Dr. Tyler Tolbert (13:57):
I appreciate that.
You know for a long time I'veunderstood the whole.
You know two years on orals iskind of a cutoff or whatever,
but it's just like, that's justa.
It's very immaterial.
It's like, okay, two years,that's just a reference.
In my mind.
You're really helping usunderstand.
You know where that actuallycomes from and the dynamics of
how that drug was being taken,if it was being taken properly,
and what the local oralenvironment was like during that
(14:19):
time and how it might bedifferent on one side versus the
other, and I had never heardanyone explain that.
So I appreciate that.
Dr. James Rutkowski (14:25):
And in our research company we did
modeling on bisphosphonates andwe came up with 70 milligrams a
week.
Typical, typical.
Typical If you're in an areawith bone turnover.
So that's somebody that's gotsome periodontal disease, not a
balanced occlusion, not 28beautiful pearl white teeth.
You know we're talkingsomething.
(14:46):
You know?
the typical 72 year old ladyyeah, that's got some issues
there and wearing a partial one,etc you know, that those um we
said we found in our modeling itwould take two and a half years
to get to a 10 to the minus15th molar concentration.
Now, a lot of assumptions weremade, man, I gotta admit.
A lot of assumptions were made,yeah, but when we look at these
studies and we say who gets it?
(15:06):
Well, the numerator in thesestudies is who got onj?
Well, we had a thousand casesof onj.
Okay, we had a thousand casesof onj.
People got something done,something happened and they got
ONJ.
And there had to be an incitingeffect.
Somebody had to do surgery,somebody had to take a tooth out
(15:28):
.
You had to cut the gingivaltissue with a fork or you know a
gash from you know crispy foodsor something of that nature.
You had to get that boneexposed.
You had ONJ when you werecovered with all the gingiva,
it's when somebody opened it up.
(15:48):
Now it couldn't heal becausethere was no blood supply in the
bone to help that soft tissueheal over.
So it just opened and opened,and opened, and opened and
greater and greater and greater.
And then you've got actinomycesdown in that bone and now
you've got a bone infection, anosteomyelitis.
But guess what?
You can't cure it becauseyou've got no way of getting the
antibiotic into the bonebecause there's no blood supply.
It has to be debrided.
Yeah, so you know, that's whereit was.
(16:12):
So if somebody, the numerators,everybody who got it, so who do
we put in the denominator?
Well, they put in thedenominator everybody who took
the drug.
Well, you know what?
I don't know?
We had 10 million people, 10million women, in the United
States taking the drug.
(16:33):
There were a thousand peoplethat don't own NJ.
You divide it by 10 million whotook the drug.
Now that is a 0.0001% chance ofit.
You go like well, that's notvery many people.
What are we even worrying about, you know, for those that get
it too bad, too sad, that's notthe attitude we should be taking
(16:54):
.
But that denominator shouldhave been who had an inciting
event, who got a tooth out?
That was in the denominator Isee.
So maybe it's a thousand peoplegot O and J, but only 10,000
people got a tooth out.
That's who should be thedenominator.
Dr. Tyler Tolbert (17:16):
Yeah, now you got more like 110.
Dr. Soren Paape (17:17):
Not the other 9,990,000 people.
Dr. James Rutkowski (17:20):
Yeah, you follow what I'm saying.
Dr. Tyler Tolbert (17:22):
Yeah, I do.
Dr. James Rutkowski (17:23):
So it was like whoa.
And so in Australia they didsome studies and they showed
that the instance of somebodyhaving a tooth out and going
ahead, and they've been taking.
Fosamex and they had to betaking it for over two and a
(17:44):
half years, et cetera.
You know, all these criteriawere met for it.
The incidence of O and J wassubstantially higher.
It went anywhere from 0.34% todepending on what the dose was
like.
In vaginal disease you get ahigher dose and whatnot.
Those individuals, they hadupwards of a 34% incidence of
(18:05):
ONJ.
Wow, wow.
So the dose of the drug, theduration of the drug, the route
of the administration of thedrug, what was the health of the
tissues?
Was there an inciting event ornot?
Yeah, you know.
And now that people have beenon these drugs for multiple
years 8, 10, 15 years it mayhave taken 15 years to get to
(18:28):
where it was toxic, but now theyjust have any little thing
happen to their gingival tissue.
They cut it with a toothbrushand then bingo, all of a sudden
they've got O and J.
I see they had O and J beforeit's just they didn't know they
had it wasn't exposed.
And you look at the x-ray to gohey, hey, your bone looks
pretty good there.
Well, it's not turning over,it's stagnant.
(18:48):
It's it's not living, it's deadbone and dead bone.
You can't take a tooth out ofdead bone and get it healed.
You can't get the genitaltissue co-opted over and expect
it to heal.
It's just not going to happen.
Now the um, when it's iv, thenit is much, much more
predictable.
Those individuals that take theiv form of the drug for cancer
(19:11):
treatment a higher dose morefrequently they get a tooth out.
They found that if you take atooth out and somebody that's
gotten three doses every twoweeks at the doses to treat a um
, a metastasis to the bone, orprevention metastasis to the
bone, um after three doses theystood about a 60 chance of
(19:33):
getting onj.
That's huge.
So it makes a big difference.
As to the dose, the duration,the root of administration of
the drug.
Now there is a study thatshowed that you could reduce the
incidence of ONJ 74%.
(19:53):
And those people that met thecriteria, they took it right,
they had all the things.
So we're taking the realpatient or they were under
cancer treatment.
Okay, prevent metastasis ivwith their frequently higher
doses and whatnot and uhstronger forms drugs.
This was also true withmonoclonal antibodies, by the
way, which are very similar,different but similar to
bisphosphonates uh 74 reduction.
(20:16):
If you could eliminate allbleeding on probing before you
ever did your surgery.
Get rid of all inflammation inthe oral cavity.
Reduce your levels of IL-6,interleukin-6.
If you can reduce thatappreciably and that can be just
demonstrated visually, is whenyou take the periodontal probe
and you probe six readings pertooth, do you have any bleeding?
(20:37):
I got no bleeding.
You know what I stand a 74chance of taking your tooth out,
suturing you up.
I might do a few things inthere to help me heal.
But I'm not going to get onj,most likely even though you were
on this high dose iv form ofthe drug, because I had rid of
the inflammation.
Now the soft tissue itself cantend to heal itself, whether
(21:00):
there was a blood supply comingfrom that periosteum or not, or
from that bone through thatperiosteum.
So and we did a study in ourgroup with it and we reduced it
73%.
Wow, the literature said 74.
Our study showed 73% reductionwith it.
So it's something that wetreated a lot because we were
(21:23):
our clinic.
We were associated with twocancer clinics and they would
send us these patients that weregetting either experimental
monoclonal antibodies, becausethey were one had a huge
clinical trial going on with NIHthat we needed to find out what
they were on, so they wouldbreak the code for us on
patients and we would do theirsurgeries.
(21:44):
But it's a topic I'm verypassionate about.
Dr. Tyler Tolbert (21:49):
Yeah, no, absolutely.
So I want to make sure I don'tbutcher your conclusions there.
So it sounds like that, even inpatients who had IV exposure to
bisphosphonates or monoclonalantibiotics, if you could just
reduce the inflammation in thetissues prior to the exciting
event, you could massivelyreduce the incidence of flossing
(22:10):
necrosis.
Right that?
Dr. James Rutkowski (22:11):
meant good strength, flossing, electric
toothbrush twice a day for twominutes each time, or at least a
minute in the morning and twominutes at night, and then water
irrigation and we put all thosepatients in our clinic on those
, we gave them the and I knowwe're just supposed to tell
commercial product, but whatthat?
It was the water pick, sonic,yeah, the one that's got the
(22:32):
brush in the body.
You know, and I'm telling youwhat.
We did surgery on thosepatients every week and and we
had very, very few complications.
Now I also irrigated the bonetremendously with a lot of
saline.
I would try, and if I had areaswhere it was obviously necrotic
bone, I would remove that bonebefore I would close them.
(22:55):
I got primary closure.
I would use Buffy Coat, prp oncollagen down and then PRF under
the suture lines.
I would use horizontal mattresssutures to keep the tension
away from the suture line.
Then just at the suture line,doing interrupted or continuous,
and that helped a lot.
(23:17):
Now I did order two sets of labtests and it was not to predict
O and J, and the ADA is 100%correct you cannot predict O and
J.
I think your biggest predictor,quite honestly, is inflammation
.
And then, looking at theradiographs, if the bone has a
sclerotic appearance, that tellsyou there's not much of a blood
(23:40):
supply.
If it looks rotty, then thatthat really upped the game.
And I always got in a signedconsent forms and I'll share
that with you guys.
Uh, you can share with yourreaders, if you want, in signed
form, please, forbisphosphonates and monoclonal
antibodies.
But I wanted to be able topredict whether you were going
(24:03):
to make bone or not.
So I ordered two lab tests andthe one was a serum ntx, that's
a serum nancy thomas, xavier, nxare the initials, and that
tells me how well theosteoclasts are working.
And I wanted the patient to bein the range of a 40 to
(24:28):
44-year-old premenopausal womanand that because those women
they are breaking bone down,they're remodeling bone, they're
breaking bone down and they'regoing to make bone because they
broke the bone down.
So I want an NTX and I don'tcare whether you're 90 years old
, it is possible for your NTX tobe in that range.
(24:48):
Then I ordered a serum BSAP,that's bone-specific alkaline
phosphatase Serum BSAP that'sbone specific alkaline
phosphatase serum bsap.
And I wanted that in the rangeof a 34 to 44 year old
premenopausal female and thattold me whether the osteoblasts
were working.
(25:09):
Could you build the bone sobefore I went in and did this,
all on x, or this bone graft, uh, or even just a single implant?
you know, maybe, maybe should bedoing the fixed bridge for you.
You know, if we really want toknow, I want to know whether you
can heal that bone or not,whether you can make bone.
(25:31):
Can you osteointegratingimplant and can you do that?
And I realized bob marks uses a.
He used a urine ctx becausewhen he came out with it that's
what was being used here in theUnited States.
The serum NTX started beingused in Japan.
Japan is way ahead of theresearch on postmenopausal women
(25:51):
because Asian women have a muchhigher incidence of osteopenia,
osteoporosis, than does therest of the world.
So they're way ahead in theirresearch.
Now a serum CTX.
I don't personally I don't knowthe ranges on that like they do
the serum NTX.
So I personally have stayedwith the serum CTX excuse me,
(26:11):
serum NTX and didn't go over tothe newer serum CTX.
But that just gave me theconfidence.
Does this look like this has achance of working?
Because now they're universallab tests?
They weren't specific for thejaws, but if the numbers were
bad.
You know what you might not makebone.
If the numbers were good, youmight make bone.
(26:33):
And so what I did is I got youall cleaned up.
Good prophy, good scaling, goodplaning.
I want no bleeding on probing.
You're doing good daily oralhygiene at home.
I would get these tests If thetests were good.
I said I want you to stop takingthe bisphosphonate or the
(26:55):
monoclonal antibody with aphysician's permission for 16
weeks, because I want to put myimplant in or my bone graft and
I want it to turn over.
Okay, so we're not going totake any drug for 16 weeks if
the numbers were good.
If the numbers are bad, I wantyou to take a six-week holiday,
(27:21):
okay, and then we're going torepeat the tests and if the
numbers are good, we're going togo ahead and do your surgery.
You're still signing a consentform and the reason being is you
didn't kill every osteoclastand osteoblast-induced necrosis,
every one of them in the body.
No, you still have some thatare working.
(27:42):
It's just that now you haven'tbeen on the drug for six weeks,
okay.
Or if you want to be a bit moreconservative, you can go three
months, okay, and I think threemonths is probably a better
number than six weeks.
So wait three months, repeatthe tests.
If the numbers are good, goahead and do your surgery, but
(28:02):
don't start to drug up foranother 16 weeks.
Does that make sense?
Yeah, it does.
Yeah, it does.
Dr. Soren Paape (28:09):
Okay, so I got a couple questions.
First, is this just forpatients taking IV
bisphosphonates, or oral andoral?
Dr. James Rutkowski (28:14):
I had everybody that took a
bisphosphonate and monoclonalantibody.
That's what they did.
I had everybody that took abisphosphonate and monoclonal
antibody.
That's what they did If they'dbeen on for two years.
Dr. Soren Paape (28:21):
Okay, so good.
Lab tests 16-week holiday, thenyou place your implant.
Can they jump back on it rightaway?
Dr. James Rutkowski (28:29):
No, once I do my surgery, I want to give
them another 16 weeks.
Dr. Tyler Tolbert (28:35):
So holidays after the procedure.
Dr. Soren Paape (28:38):
Once you place the implant wait 16 weeks.
Dr. James Rutkowski (28:41):
Once you've got the implant in and
it's also integrated, now theycan go back into drug.
Dr. Soren Paape (28:45):
Got it, got it, okay.
So if good tests and we'll tryto put these numbers in a show
notes so people can look.
But if they have good numbers,you'll place the implant right
away and then have them take adrug holiday for 16 weeks after
the after integration.
Right, if the numbers are badsix week, or you said six week,
(29:07):
or three month, if you want tobe conservative three months,
yeah, three months retest.
If numbers are good, place theimplant.
Wait another 16 weeks yeah um,does it matter how long they've
been taking the oralbisphosphonates?
Dr. James Rutkowski (29:19):
Yeah, yeah , I mean, you know if they took
it ideally and it was 70milligrams a week, which that's
what everybody took in Fosmex anosteopenia dose was 35
milligrams a week.
Osteoporosis dose was 70, buteverybody got 70 milligrams.
Even when you had a diagnosisof osteopenia, everybody got 70,
seemingly so.
I think in all my years I onlysaw two or three people on 35,
(29:42):
but you know over half thosepeople were just osteopenia.
But um, if it's 70 milligramsevery week and they took it just
as they were supposed to, in anempty stomach, you know, there
there is a report of as early as18 weeks somebody getting L and
(30:03):
J, but that could be just anoutlier.
That could be just an outlier.
They may have had othermorbidities.
Maybe they smoked as well.
Maybe they were takinglong-term steroids, because
there are other comorbiditiesbesides just having that surgery
.
But traditionally we didn't seeit in under two years.
Now, if you didn't take itright, you might have taken the
(30:25):
drug for 10 years.
Yeah, it wouldn't matter, right, right, you weren't at risk.
Yeah, so it was.
How did you take the drug?
The duration, the state of theoral cavity, amount of
inflammation.
So there's just so manycompounding factors.
It's very difficult.
I agree personally with 90% ofeverything that was said in that
(30:47):
ADA paper, in the Amos paper.
I should say the Amos paper.
I agree with 90% of it there.
They did not have onepharmacologist on there, yeah,
that's crucial, yeah it's apharmacology question, it is.
Dr. Tyler Tolbert (31:03):
There's nuances, yeah, for sure so.
Dr. Soren Paape (31:06):
so you have placed implants in patients that
have been I on ivbisphosphonates, on oral
bisphosphonates, as long as theythe protocols are followed
properly, the the tests cameback well and overall you said—
Reduced inflammation.
Yeah, and how long would youhave them?
You talked about the brushingwater, pick flossing.
(31:31):
How long, typically, would ittake your patients to get to a
point where no bleeding onprobing?
Dr. James Rutkowski (31:37):
They would have that in three months.
So between right, many, many ofmy implant patients I'm very um
discriminating about oralhygiene with dental implants
because I came up in the 80swhen nobody understood the
importance of it.
Then we had so muchperi-implantitis uh, you know
that I learned from it the hardway, not by reading papers but
(31:59):
by experiencing it.
So it was usually within threemonths, between three months,
prophylaxis.
You know, you come in, you getyour consult, etc, etc.
This is what you need to do.
We need to get this all cleanedup.
You're gonna come in, you'regonna get your teeth all cleaned
up here.
Scale and replaning, whateverwe're going to do with that.
If there was paranormal disease,we've got the paranormal
disease eradicated the best wecould before we ever did it.
(32:21):
And even if I was going to takeout all their teeth and when I
was doing this in the in the 90swe weren't doing all on exits,
we were doing fp1s oroverdentures or things of that
nature um, that we would uh, westill followed that protocol and
that helped us tremendously bygetting no smoking.
(32:42):
We didn't want any bleeding andprobing but within three months
just about everybody could beto the point where we did not
have any bleeding and probingand I thought that was a huge.
That was a huge factor for it?
Dr. Tyler Tolbert (32:53):
And yeah, I'm curious to do you sponsor any
other like adjunctivetherapiesctive therapies prior
to the procedure?
So obviously you know peopletalk about hyperbaric dives.
Some people are fans ofadministering pentoxyfilene and
vitamin E for some time prior tothe procedure and after the
procedure.
Do you feel one way or anotherabout those?
Could they hurt?
Dr. James Rutkowski (33:14):
You know, the literature is not.
I try to do everything in mylife based on what does
literature say, and I realizethat the literature is flawed
and the literature is incomplete.
Sure, okay, so just know that.
I'm very much aware of that.
That.
I think that it is veryimportant for these patients to
(33:36):
go on vitamin D, yeah, ahead oftime, and I like them to be on
that for at least a month, ifnot two months.
And I like it best when we havevitamin D levels on those
patients from their lab testsand whatnot, because that can
help us prescribe mostaccurately.
(33:56):
But if, for whatever reason, wedon't have that, then I put them
on vitamin d3 5000 units a dayone month pre-surgery and then I
keep them on vitamin d3 5000.
It's vitamin d3 5000 units onemonth prior to surgery, then
vitamin d3 5000 units daily forum two months afterwards.
(34:18):
But it is a lipid-solublevitamin D3 that you can get
toxicity, but it would take youa long time at 5,000 units a day
to get the toxicity.
So if you're in the northeastor if you're north of the
Mason-Dixon line, even if you'renorth-central or um northwest
(34:39):
united states, where you getvery little sunshine, uh, and
even though the people that arein phoenix, arizona, they're all
wearing long sleeves andsunscreen now, they're not
getting much vitamin d right youknow, technically we should
have the blood levels.
But if we don't 5 000 units aday for that criteria a month
ahead of time, two monthsafterwards, you're not going to
(34:59):
get in trouble.
Then go to 2 000 units a dayfor that criteria a month ahead
of time, two months afterwards,you're not going to get in
trouble.
Then go to 2 000 units a day,you will not get in trouble with
vitamin d toxicity.
Okay, could you go vitamin d 5000 units longer than that?
Yeah, you could, but without alab test we don't know that
definitively.
I'm just saying saying thosenumbers 30 days before, 60 days
after and then 2,000 units a daythereafter, particularly in the
(35:23):
populations beyond the age of70, most of them have some
vitamin D deficiencies anyway.
Dr. Soren Paape (35:32):
That was really good.
Dr. Tyler Tolbert (35:33):
That was awesome.
Dr. James Rutkowski (35:35):
And our listeners will really appreciate
that.
Dr. Soren Paape (35:39):
You know we don't have a ton of time left,
but I'd love like a quick recapon your thoughts for patients
who like radiation levels.
You know my understanding istypically under 60 grays.
You're a lot, you know, in amuch better place for implant
placement.
So I'm curious on your thoughtson that better place for
implant placement.
(35:59):
So I'm curious on your thoughtson that.
And then I'm curious yourthoughts on um a1c levels, uh,
and and where you're comfortableplacing implants with patients
if you have time to answer thoseyeah, 55 to 60 grays is should
be the cutoff.
Dr. James Rutkowski (36:12):
Okay, that should be the cutoff.
But the more important thing isthat you get with the
oncologist and you look at themapping when was the radiation
given, what was shielded andwhat was not shielded.
And they are very good atshielding.
So if that radiation treatmentis probably in the last eight
(36:35):
years, 10 years, they probablyhad excellent shielding
techniques.
Even if it was head and neckradiation, they probably had
excellent shielding techniquesand if that bone was shielded
then you probably don't havemuch of an issue whatsoever.
But you've got to talk withthat oncologist.
They are very willing to talkwith you.
(36:55):
Many physicians they get verybusy and they have bigger fish
to fry than talking to thedentist about their patient and
so many times talking to thenurse practitioner or their head
nurse in the office and whatnot.
They are more relatable manytimes just because they don't
(37:17):
have as many things going oninside their head that maybe
that head doctor does.
But I will say the oneexception that is every time
that I have had to talk to anoncologist and when we worked
with the cancer clinics wetalked with them all the time.
Those individuals they werereally.
(37:37):
They knew the consequences oforal surgery in somebody with
radiation and they didn't wantthose patients to have a problem
.
And so I found if there's onegroup of physicians that'll give
you everything to lay it allout there, it is the oncologist,
the radiologist, who does thattreatment for them.
(38:00):
Uh, so one, make sure you do aconsult, make sure you get the
number of grades, make sure youget the mapping, and again, make
sure there's no inflammation inthe mouth, because we believe
we believe we don't have theliterature support it, but we
believe we would probably havesomething similar with that lack
of inflammation allowing us tohave better healing force there.
(38:21):
Then, depending on what it is,then we may have to talk about
hyperbaric oxygen and things ofthat nature.
Dr. Soren Paape (38:27):
I have a.
Yeah, the reason I was askingin particular is I have a.
I try to stay away frombisphosphonate patients and
radiation patients just to beconservative, right, but I did
have one patient that I did anupper lower all on six on
probably a month and a half agoand he had some neck radiation.
(38:48):
But I met with the oncologist,we went over all the mapping and
I ensured that he was under 55degrees in all areas that I was
placing implants and he had alsodone full hyperbaric oxygen
therapy.
So he's in the healing processright now and everything seems
like it's healing great.
But you know, it's always thatthing that I'm thinking about.
(39:09):
I'm always like, until he'sfully healed, I'm always just
going to be like all right,hopefully everything goes okay.
But that's great to hear fromyou.
Dr. James Rutkowski (39:18):
What about your A—oh?
Go ahead, you might let thoseimplants integrate just a little
bit longer and then do yourISqs on there to to see what
kind of readings they've got,before you do look and um, you
know, because the implants willgo in that, that bone and I.
I think you've done everythingjust exactly right.
(39:39):
You did everything right.
You talked to the oncologistthere and the diaper berry
auction you did all those thingsjust exactly right.
But if the bone is not turningover quickly or at all for you
when they first go in, yeah,they can be nice and stable, but
then do they truly osseomantic,right um on.
But you did everythingabsolutely right as far as I'm
(40:00):
concerned, from my vantage pointhere um ha1c's.
Um I lecture, I try to keepeverybody from having trouble.
I don't want them to havetrouble and the literature
strongly supports that.
An HA1C above seven.
You probably shouldn't be doingelective surgery on them Now
(40:23):
that's not to say that a 7.1, a7.2, you can't sweep by, you
know.
And where did they start out?
Did they start out at a 14,?
And they've been working fornine months with their
endocrinologist and the bestthey can get them is 7.2.
Well, okay, that's aconsiderable amount of
improvement.
Well, 7.2 is not 7.0, so, jim,you mean the guy you know.
So what I'm saying is you knowwe have to make everything
(40:45):
realistic in this world too.
But if you want to play, it'sconservative 7-0.
You never do an electivesurgery about that.
If you said I'm willing tostretch, I know the patient,
they're going to do best hygienethat they can possibly do.
I'm going to be careful.
Um, we're going to get them inevery three months.
(41:07):
They're going to do everythingthey can possibly do.
All right, and you're not alitigious patient.
I'll go to seven and a halfwith you.
Okay, I think anybody that doesanything beyond eight is why
don't you just go out and takemoney and burn it in the streets
Because you're going to see anice fire.
(41:30):
Otherwise, all you're going todo is see those implants again
and you're going to do themagain and again and again, and
that's going to cost you money.
So just burn the money thefirst time.
You'll be just further, youknow.
Dr. Tyler Tolbert (41:42):
Save yourself time, save yourself time Okay.
Dr. Soren Paape (41:45):
So nothing above an eight.
Dr. James Rutkowski (41:46):
If it is between.
If it's below seven, great.
And sometime we'll talk aboutmaybe steroids and things of
that nature, because there'ssteroid doses in what we do.
Dr. Soren Paape (41:57):
But if it's below seven.
Dr. James Rutkowski (41:58):
yeah, I go ahead and I do implants,
grafting, whatever has to bedone there with it, Great, great
.
Dr. Soren Paape (42:04):
Are there any other?
Any other?
I mean, those are kind of thethree big ones that I feel like
people talk about the most.
Right a diet, uncontrolleddiabetes, head and neck,
radiation, bisphosphonates.
Is there anything else that youthink that our listeners should
be really um aware of as likean absolute contraindication,
then?
Dr. Tyler Tolbert (42:23):
like protonics, and antidepressants
as well to some degree not notan absolute contraindication,
but people are talking aboutyeah, yeah, those those.
Dr. James Rutkowski (42:29):
Those are less.
Uh, you know, if it's an ssriright?
I suggest you let thoseimplants integrate for longer
and maybe, when you do load them, you load them with an acrylic
based tooth um or an acrylicocclusal surface.
I should say that's going towear form um, because I I wanted
(42:50):
to wear, realizing full wellyou're going to have to replace
them more frequently than youare, maybe zirconia or something
of that nature but they need ashock absorber because that bone
, those drugs, they interferewith bone remodeling.
They put them in a negativeremodeling state where they're
going to break bone down morethan they're going to build the
bone up With an SSRI.
(43:12):
Of the 25 top drugs prescribedin the United States in 2022,
that's the latest data I have,it's 22.
I don't have 23 data and 24data yet that comes off the
pharmaceutical industry.
But the top 25 drugs prescribedin 2020, through, every single
(43:34):
one of them had an effect onoral health or healing of oral
surgical procedures.
So some of them were positive,some of them were negative.
But you know, I think thebiggest factor as I can say from
what I've gleaned from theliterature in just about
everything, in confoundingfactors 44 years of clinical
(43:59):
experience is you want to makesure they've got good oral
hygiene.
I think that Waterpiksonicevery single patient got
implants in my practice.
They got a waterpiksonic, theygot one implant, you got a
waterpiksonic.
Great, I was retired for 14months.
(44:21):
One of my patients whom, um, uh,I was friends with and he had
my um, my cell number he textedme.
He says jim, I just came backfrom the people that took over
my practice.
He said and I had a perfectcheckup, and I gotta tell you,
jim, I want to thank you for allthe things you ever did for me,
and that included implants,restorative, etc, etc.
(44:44):
He said the best thing you everdid for me, though, was give me
that electric toothbrush thatputs the water out.
Oh, that's great, you know?
I I thought that was that wasunsolicited.
He just called out, in fact.
He called me at christmas time,and he said all my grandkids,
for christmas, got a sonic, awaterpik sonic.
(45:09):
That's good.
He said.
If I were to have him when Iwas a kid, I would have needed
all that work from you.
I might?
Dr. Soren Paape (45:14):
I don't.
I don't have a waterpik sonicand I'm I might be getting.
I know I can see him searchingamazon right now.
Dr. Tyler Tolbert (45:20):
Which are these things like?
Dr. Soren Paape (45:23):
we give.
We give all of our patientswater picks but not water
picksonics.
So I'll definitely have to lookinto that and I appreciate the
advice.
Dr. James Rutkowski (45:33):
I've enjoyed my time with you guys.
Hopefully I didn't wear out mywelcome.
No, oh no, not at all.
Dr. Soren Paape (45:40):
Before you go, though, please let everyone know
what the best way to um findfind the residency program, to
get more info on the residencyprogram, to maybe reach out if
they want more info.
Dr. James Rutkowski (45:52):
Uh, that'd be, that'd be really helpful
okay, uh, you want to um uh,google jacksonville university
comprehensive oral implantologyprogram.
So again, jacksonvilleUniversity, comprehensive oral
(46:14):
implantology program.
If it's okay with you guys,I'll give my phone number,
please.
Yeah, and I'm going to just askthat you text me, because I got
a spam blocker and it's not inmy phone it doesn't ring so I
tried to call you.
You never know my phone number.
Text me, Send me your card andthen I'll put your card in there
(46:34):
and put in there that you wantinformation on Jacksonville
University program and thatnumber is 803-415-4838.
Again, 803-415-4838.
(46:56):
Again, 803-415-4838.
And for those of you that havea great deal of clinical
experience, you are oralsurgeons, perio pros greet, or a
diplomate of the ICOI or adiplomate of the ABOI ID or a
fellow of the American Academyof Implant Dentistry.
It's just that all those theyhave been assessed as to having
some competencies in implantdentistry.
(47:19):
If you're those, we do have aremote residency program for you
where, if you own your ownpractice, you stay in your
practice.
You still work with EPAs, butyou have a remote director who
you report to, and so you neverhave to leave your practice.
You stay there, you get it all.
You do all the didactic work,you do all the EPAs, you get the
(47:41):
same master's degree and it's atwo-year program as well for
them.
So we have a handful of thosein our program now.
Dr. Tyler Tolbert (47:49):
Very cool, excellent, very cool.
Well, dr Rakowski, this hasbeen an absolute pleasure, and I
think both of us can.
I speak for Swarm when I saythat we learned way more than we
ever even expected to with thisinterview.
You know, we were we alreadyjazzed about learning about the,
about the, about the residency,of course, but we got schooled
on all kinds of pharmacologystuff, which has been an
absolute pleasure, and these arethings that we talk about all
(48:10):
the time.
Um, so really, thank you somuch for sparing your time and
and I hope that the fans of ourshow will be reaching out to you
about their interest in theprogram and we hope to use you
as a resource in the future aswell for all of our burning
questions about implantology,because you have an incredibly
deep and broad knowledge andkudos to the two of you for what
you're doing.
Dr. James Rutkowski (48:29):
thank you know.
Uh, we're, we're, we're, youknow, we're all brothers and
sisters in implant dentistry andum, we all have the same joys,
we all have the same anxieties,um, and we, all of us, I truly
believe we really want what isbest for our patients.
I truly believe that, and it'sexemplified so clearly by the
(48:53):
things that the two of you aredoing.
So, thank you very much forinviting me, thank you for being
who you are in the work thatyou're doing.
So hats off to you guys.
Likewise.
Dr. Tyler Tolbert (49:02):
Thank you, have a nice day.
Bye.
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