Several opinions-collapsed arch, jaw, bite. Osteoporosis Implants

@tmtm4 I am a patient with dental implants, and yes, the success of dental implants depends on bone growth around the implant to hold it in place. Another thing they don't tell you is that they make the implant anchored teeth so there is no contact with the opposing tooth on the other arch. The reason for that is that the shock of bashing an implant with your other teeth causes problems like bone loss. Another problem is if food debris can be trapped up under the gums around the implant. These are things my oral surgeon said recently because I just went through oral surgery around one of my implants. I have good bone quality and a lot of bone in my jaw, and I got Zirconium implants because I have had reactions to metals in my body, and suspected that titanium implants could cause immune issues for me. That hunch turned out to be right, because when I broke my ankle and became the owner of titanium surgical plates, they did cause pain, and I had chronic hives for months and an escalation of my asthma symptoms.

We did everything right, after extraction, there was bone graft placed in the empty sockets and we waited 5 months for healing before the implants were placed. Then we waited extra time for my bone to fully integrate with the implants. I got my new bridge also made of Zirconium last summer, and a month ago, I developed a fistula that formed on my gum over the implant because of an infection there. My oral surgeon had to cut open the gums to figure out what was wrong, and it was just at the lower end where the teeth attach, I had bone loss and degradation. The rest of my bone is fully integrated and a lot of solid bone around the implants. He debrided away the dead bone, and replaced it with bone graft. I will see him next week to follow up from the surgery.

I see all these commercials on TV for implant supported dentures, and I have to think that those could be a recipe for disaster if they are taking all the pounding of chewing and are under the denture that can trap food debris. I was being careful with my oral care, and still got in trouble. In my case, it may be a defect in the abutment which is the go-between between the implant and the teeth on the bridge. There was a notch that showed on the X-ray, and perhaps that tiny defect was trapping food debris that caused an infection causing done loss. The oral surgeon should have something to say about this at the next appointment.

The other thing about implants is they are very expensive, and you don't want to spend money experimenting on something that may not be a good solution in your case with osteoporosis. There is a lot of money to be made doing them, so income for the dentist and surgeon may influence their decision to do them. It is a tough question to answer as to what is right for you. You definitely need an opinion that is honest and not biased by potential income to be made. I will try to remember to ask if osteoporosis is disqualifier for dental implants.
I did search for some research that wasn't an ad for a practice and found this:
https://meridian.allenpress.com/joi/article/41/5/550/6748/Low-Skeletal-Bone-Mineral-Density-Does-Not-Affect

Your rheumatologist makes a good point about your teeth falling out. One of the problems leading to this is receding gums because it is the blood supply in the gums that keeps the bone alive in the jaw holding onto the teeth. I have had a few gum graft procedures for just this purpose where they take a slice of gum from the roof of the mouth and insert it into the gums above the teeth on the outside of the arch. If this is a problem that you have, that will affect your bone quality in your jaw in addition to osteoporosis.

In my case, the oral surgeon is in a practice for just oral surgery and dental implants. He does not do the restorative work or make new teeth. That is done through my dentist and the dental lab. I think this gives a more objective opinion. It is not a "one stop shopping" practice to pull the teeth and replace them all at a great cost to you as outlined in a fancy brochure or commercial full of smiling people who are happy with their new smiles. You definitely need an unbiased opinion from a good oral surgeon and facial surgeon and perhaps that of a good periodontist about the health of the gums in relationship to the jaw bone.

Have you been evaluated by a periodontist about tooth loss?

Thank you for your insight. No, but I do have periodontal disease. I still have all but one tooth on my bottom arch but I grinded them down due to stress from all the surgeries and then relationships on top of that. The last ten years have completely changed me. I used to be healthy, walked 2/3 miles a day, lifted free weights, etc.
So many failed surgeries, chronic pain, fear of what will happen w/my back, stenosis, and now this. It's making me cry just thinking about it. Since I am a retired teacher in MO, I cannot get SS disability even though I qualify in five areas. I paid into the teacher retirement system instead of SS so I don't have enough work credits. The teacher system does not have disability benefits after you retire. I taught for 25 years. I make too much from my monthly teacher benefit to qualify for low income even though I have to pay close to $1000 per month for insurance..not counting the $2800 deductible. I added a pic of my foot after the first surgeon didn't put my big toe on "the ridge" and it fell off breaking/dislocating six joints. I taught for two more years with this foot and the three smashed discs in my back. Thank our Lord I found an excellent foot surgeon who did the best she could but it still hurts every day, although nothing like it used to. Scary, sad, frustrating, overwhelming. This is really getting old.

After my Dexa scan, the Endo nurse practitioner called me with my test results. She asked me how my teeth are doing. I have never been asked that before. I told her I have jaw pain and she told me there is no such thing as osteoporosis of the jaw. After reading your post I am wondering about the tooth connection because I am on Reclast.

Several surgeons will not touch me because I took Reclast. You also cannot get a tooth pulled unless it has been months since your infusion. Now I am on Tymlos which is supposed to build back bone in my mouth. IDK Good luck.

How do you get an unbiased opinion?

Thank you that explains a lot. My dentist was very negative when I told him I am on Reclast. However, I recently had foot surgery and not a word was said about it.

Foot and shoulder surgeries never said anything either, except the shoulder surgeon kept saying I had thin bones. I didn't think about it but he should have told me to get tested for Osteoporosis then. The back surgeon is the one who questioned why I haven't been tested/treated for Osteo, That's when I was treated. Water under the bridge.

@tmtm4 I don't have periodontal disease, but because of gun recession, my gums have thinned and the roots of my teeth are exposed a bit. Stress affects this a lot. This is likely from tension in my neck and jaw and it has been going on for years. It started when I was younger and dentists would ask if I was brushing too hard or using a hard toothbrush. Well, maybe I did. I was quite upset as a child getting cavities and didn't want it to happen again. The gums have to seal around the teeth roots, and if you have tension pulling on the gums through the jaw (as can happen with grinding teeth and stress), it can affect it. Even grinding teeth, or having a tooth that is "taller" than the others puts stress on that tooth and can start blunting the roots of the tooth from pressure and can loosen that tooth leading to possible loss. My dentist showed me an x-ray demonstrating this, and had me have my bite adjusted by filing down (very slightly), the teeth that were "too tall", so that it evened out the pressure of biting over the whole mouth.

For grinding at night, having a bite guard made and wearing it helps with the pressure. I had one for awhile, but after my implants and new bridge and bite adjustment, it no longer fits, and they say I don't need it now.

My mom has similar issues with her feet and deformity due to arthritis along with severe osteoporosis. It is good that you are treating the thin bones. My mom had a spontaneous compression fracture in her spine because of the severe osteoporosis because she had a problem with a parathyroid gland that was malfunctioning and causing calcium to be pulled out of her bones. If that is the situation, it's best to be seen by an endocrinologist because some medications for osteoporosis don't help enough in that situation. My mom was on Fosamax for 10 years before the spine fracture happened, and now is receiving injections of Evenity instead.

What brings you joy? You may wonder why I asked this, but you can find ways to distract yourself from the stress and health problems that you live with. Fear increases pain a lot, and finding something creative to do can take your mind away from it all. This is a lesson I had to learn myself because I was very fearful of pain and surgeries, and when I needed to choose between surgery for cervical stenosis and loosing the coordination of my arms, I decided to face my fear and embrace the surgery that changed my life. I had the voice of a small powerless child inside influencing me who had not resolved the past fearful issues. I worked through all of that, and left that fear behind. I realize your experience is different, but you can control the voice in your head and how it talks to you about your life. You can choose to occupy your mind with something that brings you joy. I say these words with kindness, not criticism. Mayo Clinic does have a pain management program that teaches people how to re-frame their thinking about pain, and all the artwork everywhere at Mayo speaks to this need to be inspired by beauty as part of healing. There is also a great discussion on Art and healing here on Connect.
https://connect.mayoclinic.org/discussion/art-for-healing/

Good morning, @tmtm4 I’ve taken the past few days to give your post a lot of consideration before replying. Just to clarify, I have a strong dental background but I’m not a dentist so I’m not in a position to offer treatments or tell you to do.
I’d like to help you sort through a few things and narrow your options. I know this is a lot to take in all at once so I think the best way is to break this down into steps and with more than one conversation.
From what you’ve written, you have quite a long history of health, bone and dental concerns. Not having a healthy mouth can cause inflammation and potentially serious health issues in the rest of the body too. So, the goal is to get your mouth healthy again and have a smile return to your face. ☺️

Are you looking to have all your teeth extracted and replaced with dentures? Your current dentist nailed it by saying you’d need to have adhesive (goop) to keep them held in place. However, it is possible and is probably the least expensive option. Generations of grandparents lived that way. The upper would stay in place reasonably well, but the lower denture would have no where to rest solidly, even with adhesive, without a ridge. Do you still have your lower eye teeth? Are they solid? Sometimes those can be used as anchors for a lower denture.

Implants might be the way to go in your case, as I’ll explain further. I know there’s a hesitancy because of the Reclast, osteoporosis and cost. But they might give you a more permanent and fixed dental prosthetic. Implant replacements come in many sizes and options from individual teeth, to full mouth ‘bridges’ (with no palate) to anchors for removable dentures with a palate.
There are different types of implant anchors as well. Mini implants are short, not as long as standard, making them usable in people with diminished jaw bone. They can be used to hold dentures in place. Another option is bone grafting for dental implants if the patient’s bone loss is significant. That’s what’s used in the All on 4 technique.

I think to begin with, talking about bone support in your jaws is a good place to start. Jawbone loss is a common consequence of tooth loss. Physical stimuli such as biting and chewing strengthen the jawbone. Just like weight bearing exercises strengthen our body’s bones. Every time you eat or chew, the biting or chewing force travels through your teeth to the jawbone, stimulating the jawbone to grow and rebuild. After tooth extraction, the jawbone loses its stimuli, causing the jawbone to lose width, height, and volume. After while the upper and lower jaw bones shrink to the point where there is little ridge left on the top for a denture to grip and the lower jaw ridge becomes none existent.

Replacing missing teeth with bridges and dentures won’t solve the problem of bone loss because they don’t transmit the chewing and biting force to the jawbone. Dental implants can prevent jawbone loss because they act like natural teeth roots, and transmit the biting and chewing force directly into the jawbone.

One of the concerns of having dental implants with someone taking bisphosphonates for bone support, such as Reclast, has do with the natural regeneration of bone. Bisphosphonates slow down the deterioration process while reducing bone thinning to a substantial extent.
One concern for discussion is whether or not people who are taking bisphosphonates tend to have a worse prognosis compared to those who are not taking the medication. The reason for this is due to the constant bone renewal process referred to as “bone turnover.” This turnover is only accomplished when the bone has two types of cells – the first type eats up the old bone (osteoclasts) and the second lays new bone in its place (osteoblasts).

Well, because bisphosphonates interfere with the effectiveness of cells that eat up the bone (osteoclasts) it tends to increase bone density. But it isn’t allowing for old bone to be ‘eaten up’ or resorbed. It’s not a natural process of renewal.
Because implants need the bones to heal, the new bone around a newly placed dental implant must be ‘eaten up’ by osteoclasts before new bone can be formed. Because of bisphosphonates, this may be less effective and the area may not heal as well. In some cases, your dentist will recommend a blood test procedure called a serum CTX, which evaluates how your osteoclasts are being affected by Bisphosphonates.

However, you are now on Tymlos, which is another mechanism altogether. It actually allows for both parts of the natural bone building process which, in my opinion, makes you potentially a much better candidate for some implants.

May I ask how your tooth loss journey began? Did you have a history of gum disease/periodontal disease? That is generally how bone support in the mouth begins to fail. How many teeth do you have remaining on each arch that your current dentist feels are solid and could remain?

There definitely is such a thing as busphosphonate-related osteonecrosis ("dead bone") of the jaw so the nurse might not have the correct word. One endocrinologist wrote an article arguing that BRONJ is actually a form of osteomyelitis and needs to be rethought. But the end result is pretty much the same with respect to treatment.