Some patient cases just stick with you, particularly when there is extreme damage to the teeth, gums, and mouth. With hard work, you can dramatically improve the patient’s mouth and smile. I’d like to share the story of one patient who both challenged my skills and made me proud.
A new patient, let’s call him “Steve,” came into our office in 2021. He was referred to me by an existing patient who was so ecstatic about his results that he referred several other patients to us, including Steve. At the time, Steve was 25 years old, had a history of crystal meth use, but had been clean for about nine years. He had a long list of oral problems and complaints, including gum disease, tooth pain, food getting stuck between his teeth, jaw pain, difficulty chewing, grinding his teeth, and an unpleasant taste and odor in his mouth. He was embarrassed by his smile and felt it was preventing him from furthering his career. His main concern was “getting back to healthy.”
When I looked into his mouth, cavities were on every tooth. Most of his teeth were broken and worn down to the gums. There was tartar build up and red and inflamed gums which bled just by touching them. The only teeth still intact were the two he had crowns on, but even those teeth had cavities underneath the crowns. Looking at him, he appeared tired and older than his actual age, which is common when people start to lose teeth or when teeth get worn down. He even had to force his muscles to smile just to show me his teeth, which made his eyes look strained. He needed an intervention to re-create a healthy mouth and give him a normal appearance.
For background, I have specific experience working with people who suffer from substance abuse. After I graduated in 2008 from The University of Tennessee Health Science Center, I completed several different implant programs. My first one was a year-long comprehensive implant residency in Alabama. The facility was part of a ministry that specialized in treating the underserved and those in recovery from substance abuse. We often had to perform big surgeries without being able to prescribe narcotics to patients. Part of the training was learning how to manage these situations, keep our patients pain-free, and cause the least amount of discomfort during the healing process. This specific aspect of my training has served thousands of patients well over the years, including Steve.
Many treatment options are available to patients in this situation—upper and lower dentures, removable implant dentures, fixed implants, or any combination of these. Fixed implants can be made of many different durable materials (such as acrylic with metal or zirconia), which generally makes them the strongest and most aesthetically-pleasing option. But they are also the most costly. Let’s refer to the fixed implant as a “prosthesis.”
When it comes to using dentures for the lower teeth, there’s usually no way for the denture to stay in place without using a lot of adhesive. Even then, lower dentures tend to flop up, move when eating or talking, or, worse yet, fly out of the patients’ mouths when sneezing. Within the dental profession, lower dentures are considered below clinical standards and are not advisable if other options are available. That’s why most patients prefer a fixed option for their lower teeth.
Depending on the patient’s needs, either an upper removable denture or a fixed prosthesis works well. A removable implant denture often offers more lip support, fills out wrinkles, and is generally more economical on the front end, but it often needs additional replacement and maintenance over time. A fixed upper implant-supported prosthesis is stronger, more aesthetic, and needs less maintenance, but again, it is more costly.
After several conversations with Steve, we mutually agreed the best course of action at the time was a combination option. We would remove all his teeth and make him a removable denture for the upper teeth and a premium fixed implant prosthesis for the lower teeth. We decided on this treatment based on what we thought would give him the best “bang for his buck,” what would give him effective chewing capability, and what would look the best, all within his budget limits. Depending on how things went, he could consider changing to implants for the upper teeth at a later time. Fortunately, Steve was lucky to have his treatment paid for by a family member.
Based on our 3D images, I planned out where I wanted Steve’s implants to be located, along with their length and width. We worked with our lab to precisely locate the optimum areas for placing the implants. After several meetings and adjustments, the lab rendered the placements on their computer software and fabricated a computer-generated guide. We used this guide to determine precisely how much bone to shape and remove to allow for permanent placement of the implants. The guide also accurately replicated my proposed implant positions.
On the day of surgery, we sedated Steve, took all his natural teeth out, shaped the bone, and inserted the implants. We did some bone grafts in the areas where we didn’t place implants to preserve as much bone as we could. We also used platelet-rich fibrin (PRF), a blood-derived substance that facilitates healthy bone and tissue growth and promotes healing. Steve walked out that day with an entirely new set of teeth! The uppers were regular, removable dentures, and the lowers were a screwed-in, temporary prosthesis that he could chew on immediately. This temporary prosthesis had natural-looking teeth and pink gums.
At his 24-hour post-op visit, Steve was in remarkably good spirits and presented with minimal pain and discomfort. We followed up with him periodically during the healing process, and he was so happy that he couldn’t wait to get his final prosthesis. He already got a new job with better pay, which was also more customer-facing. Steve now looked his age and was able to smile effortlessly. Six months later, we inserted Steve’s final prosthesis. He is extremely happy with his mouth and smile, which has been fully restored for two years. He is now considering getting implants on the upper teeth.
Steve’s transformation was a deeply emotional journey, not just for Steve but also for me and my team. Witnessing the dramatic change, not only in his oral health but in the overall quality of his life, brought tears and smiles to everyone involved in his care. These cases remind me of my privilege as a dentist and the immense satisfaction I gain from my ability to change lives. I would encourage anyone interested in implants to talk to their dentist about their options, ask for pictures of past cases, research the practice’s experience, and look at their reviews.
Dr. Raj Kshatri believes every patient is unique and requires a customized treatment plan to restore their oral health for the best outcome. He spends as much time as needed answering all his patients' questions and believes in giving back to the community. He regularly volunteers time at the Interfaith Dental Clinic, providing much-needed dental care to those in need. Donated Dental Services is another organization where he provides dental care to those in extreme need.
Dr. Kshatri is a lifelong learner, always seeking to enhance his knowledge and the quality of service he provides. His dedication has led him to maintain a license in Comprehensive IV Sedation, ensuring safe sedation for apprehensive patients. He has also completed advanced training in placing Implants at the Alabama Implant Institute and completed the Comprehensive Implant Residency Program and the American Association of Implant Dentistry MaxiCourse. He lives in Nashville with his wife, Anita, and enjoys playing golf and traveling. Visit his WEBSITE for more information.
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