The Fixed Podcast

A New Approach to Residency Education with Dr. James Rutkowski: Part 2

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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.

Dr. Tyler Tolbert:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi and you're listening to the Fix Podcast, your source for all things implant dentistry, absolutely Well, yeah, so I have a few miscellaneous questions as well, just kind of based off of you know what your experience is and all the different things that you can, you know, kind of bring to implant dentistry with your extensive background. So you mentioned, you know you had done some research on postmenopausal women and issues with bone formation and things like that, and so I am kind of curious if you have any opinions on, you know, like the AOMS position paper on bisphosphonate medication and related osteonecrosis of the jaws and things like that. You know what is kind of your position and what do you tell your residents as far as patients that are taking bisphosphonates oral or IV different kinds of treatments that could be used to help prevent osteonecrosis. In regards to implant treatment, Okay, that's a great question.

Dr. James Rutkowski :

It's something I'm very passionate about, oh good, it's something that I lecture a great deal on and put a big part of my life into looking at it. I think the Women's Health Initiative of 2001 through 2003 was a misinterpreted study that study was based on. It was sponsored by Wyeth Laboratories, who had a medication on the market called Premarin and another medication called PremPro. Premarin was a conjugated equine estrogen which came from the urine of pregnant mare horses, which you know. That was the estrogen we're going to go ahead and give these women. But it was being done. Then they had another component of the drug and they envisioned that every woman in the world would be taking these two drugs. One of these two drugs either Premarin, conjugate equine estrogen, or PremPro, which was a conjugate equine estrogen, plus a synthetic progesterone called medroxyprogesterone. And they just thought this is going to be the best study in the whole wide world. We're gonna put all these women in it. The study was not well defined but because they wanted to just get so many massive numbers, we had women in there that were smoking and that was a real compounding factor for blood clots and for cancer, etc. Etc. But they had them in there and the pharmacologist? We knew that of all the sex hormones that can cause breast cancer, the number one is synthetic medroxyprogesterone. Okay, we knew that before. That was even there. I'm sure the pharmacologists at Wyeth were probably screaming.

Dr. James Rutkowski :

But you have the money managers of these pharmaceutical companies that are saying wait a minute, we've got to sell drugs. You know, somebody's got to pay all these salaries. We've got tremendous overhead and you know. And what's the instance of it? Of course, as scientists, we're always accused of over exaggerating everything. And uh, the business people are always saying you know, it's not a big deal, you're over exaggerating. And the pharmacologists are saying, wait a minute, you're under exaggerating so there's always conflict at pharmaceutical companies between the scientists and the money

Dr. James Rutkowski :

people. Um, and I realize it has to be a balance, you know not, it's not one right and wrong, but anyway, that study, they got into it roughly two years and they found that the group getting the prem pro had a much higher incidence of breast cancer than did general society, the rest of the women that weren't taking anything or the group just taking premarin. Okay, so the prem pro study was stopped 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, they just kind of fell and followed in line with what everybody was saying, because there were attorneys and they were saying that women should not take estrogen because estrogen causes breast cancer and pharmacologically, that is not a true statement. If you have an er positive breast cancer cell, estrogen taking it will induce that cancer to grow. Okay, sure, so I could go on for about four hours just on that topic, but you asked about this.

Dr. James Rutkowski :

So since everybody went off all their estrogen and all their estrogen with progesterone, they went off of it. Everything was pretty good for about four or five years, because when you go off estrogen, whether it be endogenous or exogenous estrogen, you don't get a major change in your bone structure for five years. So it was. Things remained pretty good till about 2007, 2008 thereabouts don't quote me on those exact dates, but it's roughly five years after everybody started going off of it. Definitely by 2010, everybody was now moving into something for osteopenia, osteoporosis treatment or prevention, and that was bisphosphonates. So let's go ahead and start giving them bisphosphonates. So everybody starts taking bisphosphonates. Now the thing of it is all post-menopausal women pretty much universally start taking it.

Dr. James Rutkowski :

And there's some other things about that, just besides dental but I'll limit the discussion to dental for right now that these drugs. What they do is they inhibit bone remodeling. That's what they do. They inhibit bone remodeling and they do it by preventing bone resorption. So when you want to remodel bone, you've gone in there and you've done a bone graft, you've decorticated that bone and whatnot. You put that bone graft in there and you want it to turn over. The osteoclasts get activated. The osteoclasts, they will break 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 to mesenchymal stem cells that are in the area, induce them to proliferate. So they go from X to 10X or X to the 10th power Okay, they just proliferate them tremendously. Those same BMPs there's lots of different ones there, but those same BMPs will then induce those mesenchymal stem cells that have been proliferated to differentiate into osteoblasts.

Dr. James Rutkowski :

And then to top it off they'll land on receptors it's all pharmacology Land on receptors to induce those osteoblasts to lay down new bone mineral matrix. So now your bone graft turns over your socket graft, your implant osteo integrates etc. And so you need bone remodeling to make bone. And when you take a bisphosphonate or monoclonal antibody you are preventing the osteoclast from freeing up the BMPs from the bone mineral matrix yeah, from the very start You've turned off the switch that enables bone remodeling.

Dr. James Rutkowski :

In other words, if I have an old house and I want to build a brand new house on that same property, 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 the drug okay, like Fosmex Lindroni which is 10 to 100 times more potent than the original bisphosphonates, which weren't very effective at all.

Dr. James Rutkowski :

So we came out with all these oral ones, the pharmaceutical industry that Beneva, fosmex, et cetera, et cetera. The only thing is is it's very difficult for us to predict where you get ONJ with those drugs. Because if you take a bisphosphonate orally and you take it on an empty stomach, you get 3% absorption. 27% goes out in the fecal material. But if you take it and once you get it absorbed, of that 3% that gets absorbed, we'll say you took 70 milligrams, so you've got 2.1 milligrams absorbed. 10% of it goes to sites of active bone turnover. Well, do you have active bone turnover in your jaws? If you have no periodontal disease, a stable occlusion, no bleeding on probing, you've got very little bone turnover going in the jaws. You've got very little bit of that drug going to the jawbone. So this jawbone is doing whatever it normally does because it's got very little drug, yeah.

Dr. James Rutkowski :

But the spine, the hip, the ankle, 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 periodontal disease or an unbalanced occlusion, now you've got a lot of bone turnover. So then that three percent goes there. Am I getting? This is too much science, is this? No, no this is great, we're tracking, all right, thank you, this is really good. Okay, you're dumb. This is this stuff.

Dr. Soren Paape:

This is the stuff we want to hear.

Dr. James Rutkowski :

This is good, you gotta lighten this up jim no this is no, no, no I this is great I know you can make it way more complex so Now, when it starts to go to the bone, before you ever took the drug you had no concentration of it in the jaw bones at all and I'm going to say you're missing 19, 18s tilted, 20s tilted, 14s dropped out. We got bone turnover going over here. Over here, man, you brush really 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.

Dr. James Rutkowski :

Very little bone turnover, lots of bone turnover going on that left side. So when you first took it you had no concentration. You took one pill. Then you ended up with a 10 to the minus 500 millionth molar concentration. Well, with that low concentration, not only did you inhibit osteoclasts from breaking the bone down, but get this and it takes about a year. But the first year you actually stimulate the osteoblasts to lay down new bone. It's a quirk of pharmacology, but it's well known. So for the first year you start to 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 a concentration when you get to about a mine, a 10 to the minus 15th molar concentration. Now it's toxic to the osteoclast, the osteoblastlast, the angioblast, the osteocytes.

Dr. James Rutkowski :

Every living cell in the bone dies.

Dr. James Rutkowski :

Now you can't break bone down and you can't make bone Because you didn't break bone down. You can't make bone. Estrogen, by the way, it stimulated the osteoblast directly right down bone, but we took you off estrogen. We said you got a lot to take estrogen anymore and I don't want anybody to get breast cancer. We needed to be thinking about genetic testing, familiar history of breast cancer etc. But so now, after about a year and a half or two years of taking this drug, if you had bone turnover, you got a toxic element there. So if somebody goes in and takes out 18, you can't turn that bone over. You got no blood supply there. You can't heal that bone and that whole thing there. There's about a two hour explanation that goes to that. So I'm going to just say just take that, as that's what happens there, that happens. Now over here Somebody else takes out number five because they burnt down a hard nut and broke it off. Well, that feels just fine, mm-hmm, here didn't because the drug was here. It wasn't here.

Dr. James Rutkowski :

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 to remain upright, you have to drink eight ounces of water with it. You can't lay down for an hour or two because if you, it will roll back up your softness and cause the soft, your vertices. For youophageal varicose. For you, it can cause esophageal cancer. For you it's a strong acid. So what do people do? They say you know, dr Jim, it bothers.

Dr. Soren Paape:

How do you take your drug?

Dr. James Rutkowski :

Well, I take it with some crackers or some toast. If you take it with food in your stomach, you get zero absorption. You're never going to have a problem with O and J, because they never absorbed any of the drug. They never got it to the bone. What could cause that? They never interfered at all. Hey, how's your osteoporosis doing? Oh, the doc says it's not doing good at all.

Dr. Soren Paape:

Well, that's because you haven't been taking a drug.

Dr. James Rutkowski :

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 you give the drug IV, you guys know, when you give a drug IV, your blood level is 100% and the IV forms of the drug are 10 to 100 times more potent than the Fosamex was. So now we gave you a much more potent drug. You got 100% blood level. We were giving it to you for cancer treatment. We gave you that iv treatment, probably once every month or every three weeks or every two weeks, a much more potent drug at a higher concentration to higher dose. Well, now, those are the people that get a lot of O and J. Now the other thing is is when they and if I'm getting too excited, let me just say settle down.

Dr. Soren Paape:

No, no, no.

Dr. James Rutkowski :

This is awesome. Yeah, I really, you know it's funny.

Dr. Tyler Tolbert:

I appreciate that. You know for a long time I've understood the whole. You know two years on orals is kind of a cutoff or whatever, but it's just like, that's just a. It's very immaterial. It's like, okay, two years, that's just a reference. In my mind. You're really helping us understand. You know where that actually comes from and the dynamics of how that drug was being taken, if it was being taken properly, and what the local oral environment was like during that time and how it might be different on one side versus the other, and I had never heard anyone explain that. So I appreciate that.

Dr. James Rutkowski :

And in our research company we did modeling on bisphosphonates and we came up with 70 milligrams a week. Typical, typical. Typical If you're in an area with bone turnover. So that's somebody that's got some periodontal disease, not a balanced occlusion, not 28 beautiful pearl white teeth. You know we're talking something. You know?

Dr. James Rutkowski :

the typical 72 year old lady yeah, that's got some issues there and wearing a partial one, etc you know, that those um we said we found in our modeling it would take two and a half years to get to a 10 to the minus 15th molar concentration. Now, a lot of assumptions were made, man, I gotta admit. A lot of assumptions were made, yeah, but when we look at these studies and we say who gets it? Well, the numerator in these studies is who got onj? Well, we had a thousand cases of onj. Okay, we had a thousand cases of onj.

Dr. James Rutkowski :

People got something done, something happened and they got ONJ. And there had to be an inciting effect. Somebody had to do surgery, somebody had to take a tooth out. You had to cut the gingival tissue with a fork or you know a gash from you know crispy foods or something of that nature. You had to get that bone exposed. You had ONJ when you were covered with all the gingiva, it's when somebody opened it up. Now it couldn't heal because there was no blood supply in the bone to help that soft tissue heal over. So it just opened and opened, and opened, and opened and greater and greater and greater. And then you've got actinomyces down in that bone and now you've got a bone infection, an osteomyelitis. But guess what? You can't cure it because you've got no way of getting the antibiotic into the bone because there's no blood supply.

Dr. James Rutkowski :

It has to be debrided. Yeah, so you know, that's where it was. So if somebody, the numerators, everybody who got it, so who do we put in the denominator? Well, they put in the denominator everybody who took the drug. Well, you know what? I don't know? We had 10 million people, 10 million women, in the United States taking the drug. There were a thousand people that don't own NJ. You divide it by 10 million who took the drug. Now that is a 0.0001% chance of it.

Dr. James Rutkowski :

You go like well, that's not very many people. What are we even worrying about, you know, for those that get it too bad, too sad, that's not the attitude we should be taking. But that denominator should have been who had an inciting event, who got a tooth out? That was in the denominator I see. So maybe it's a thousand people got O and J, but only 10,000 people got a tooth out. That's who should be the denominator.

Dr. Tyler Tolbert:

Yeah, now you got more like 110.

Dr. Soren Paape:

Not the other 9,990,000 people.

Dr. James Rutkowski :

Yeah, you follow what I'm saying.

Dr. Tyler Tolbert:

Yeah, I do.

Dr. James Rutkowski :

So it was like whoa. And so in Australia they did some studies and they showed that the instance of somebody having a tooth out and going ahead, and they've been taking.

Dr. James Rutkowski :

Fosamex and they had to be taking it for over two and a half years, et cetera. You know, all these criteria were met for it. The incidence of O and J was substantially higher. It went anywhere from 0.34% to depending on what the dose was like. In vaginal disease you get a higher dose and whatnot. Those individuals, they had upwards of a 34% incidence of ONJ. Wow, wow. So the dose of the drug, the duration of the drug, the route of the administration of the drug, what was the health of the tissues? Was there an inciting event or not? Yeah, you know. And now that people have been on these drugs for multiple years 8, 10, 15 years it may have taken 15 years to get to where it was toxic, but now they just have any little thing happen to their gingival tissue. They cut it with a toothbrush and then bingo, all of a sudden they've got O and J.

Dr. James Rutkowski :

I see they had O and J before it's just they didn't know they had it wasn't exposed. And you look at the x-ray to go hey, hey, your bone looks pretty good there.

Dr. James Rutkowski :

Well, it's not turning over, it's stagnant. It's it's not living, it's dead bone and dead bone. You can't take a tooth out of dead bone and get it healed. You can't get the genital tissue co-opted over and expect it to heal. It's just not going to happen. Now the um, when it's iv, then it is much, much more predictable.

Dr. James Rutkowski :

Those individuals that take the iv form of the drug for cancer treatment a higher dose more frequently they get a tooth out. They found that if you take a tooth out and somebody that's gotten three doses every two weeks at the doses to treat a um, a metastasis to the bone, or prevention metastasis to the bone, um after three doses they stood about a 60 chance of 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 that showed that you could reduce the incidence of ONJ 74%. And those people that met the criteria, they took it right, they had all the things. So we're taking the real patient or they were under cancer treatment. Okay, prevent metastasis iv with their frequently higher doses and whatnot and uh stronger forms drugs. This was also true with monoclonal antibodies, by the way, which are very similar, different but similar to bisphosphonates uh 74 reduction.

Dr. James Rutkowski :

If you could eliminate all bleeding on probing before you ever did your surgery. Get rid of all inflammation in the oral cavity. Reduce your levels of IL-6, interleukin-6. If you can reduce that appreciably and that can be just demonstrated visually, is when you take the periodontal probe and you probe six readings per tooth, do you have any bleeding? I got no bleeding. You know what I stand a 74 chance of taking your tooth out, suturing you up. I might do a few things in there to help me heal. But I'm not going to get onj, most likely even though you were on this high dose iv form of the drug, because I had rid of the inflammation.

Dr. James Rutkowski :

Now the soft tissue itself can tend to heal itself, whether there was a blood supply coming from that periosteum or not, or from that bone through that periosteum. So and we did a study in our group with it and we reduced it 73%. Wow, the literature said 74. Our study showed 73% reduction with it. So it's something that we treated a lot because we were our clinic. We were associated with two cancer clinics and they would send us these patients that were getting either experimental monoclonal antibodies, because they were one had a huge clinical trial going on with NIH that we needed to find out what they were on, so they would break the code for us on patients and we would do their surgeries. But it's a topic I'm very passionate about.

Dr. Tyler Tolbert:

Yeah, no, absolutely. So I want to make sure I don't butcher your conclusions there. So it sounds like that, even in patients who had IV exposure to bisphosphonates or monoclonal antibiotics, if you could just reduce the inflammation in the tissues prior to the exciting event, you could massively reduce the incidence of flossing necrosis. Right that?

Dr. James Rutkowski :

meant good strength, flossing, electric toothbrush twice a day for two minutes each time, or at least a minute in the morning and two minutes at night, and then water irrigation and we put all those patients in our clinic on those, we gave them the and I know we're just supposed to tell commercial product, but what that? It was the water pick, sonic, yeah, the one that's got the brush in the body. You know, and I'm telling you what. We did surgery on those patients every week and and we had very, very few complications. Now I also irrigated the bone tremendously with a lot of saline. I would try, and if I had areas where it was obviously necrotic bone, I would remove that bone before I would close them. I got primary closure. I would use Buffy Coat, prp on collagen down and then PRF under the suture lines. I would use horizontal mattress sutures to keep the tension away from the suture line. Then just at the suture line, doing interrupted or continuous, and that helped a lot.

Dr. James Rutkowski :

Now I did order two sets of lab tests 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 the radiographs, if the bone has a sclerotic appearance, that tells you there's not much of a blood supply. If it looks rotty, then that that really upped the game. And I always got in a signed consent forms and I'll share that with you guys. Uh, you can share with your readers, if you want, in signed form, please, for bisphosphonates and monoclonal antibodies.

Dr. James Rutkowski :

But I wanted to be able to predict whether you were going to make bone or not. So I ordered two lab tests and the one was a serum ntx, that's a serum nancy thomas, xavier, nx are the initials, and that tells me how well the osteoclasts are working. And I wanted the patient to be in the range of a 40 to 44-year-old premenopausal woman and that because those women they are breaking bone down, they're remodeling bone, they're breaking bone down and they're going to make bone because they broke the bone down. So I want an NTX and I don't care whether you're 90 years old, it is possible for your NTX to be in that range. Then I ordered a serum BSAP, that's bone-specific alkaline phosphatase Serum BSAP that's bone specific alkaline phosphatase serum bsap. And I wanted that in the range of a 34 to 44 year old premenopausal female and that told me whether the osteoblasts were working. Could you build the bone so before I went in and did this, all on x, or this bone graft, uh, or even just a single implant?

Dr. James Rutkowski :

you know, maybe, maybe should be doing the fixed bridge for you. You know, if we really want to know, I want to know whether you can heal that bone or not, whether you can make bone. Can you osteointegrating implant and can you do that? And I realized bob marks uses a. He used a urine ctx because when he came out with it that's what was being used here in the United States. The serum NTX started being used in Japan. Japan is way ahead of the research on postmenopausal women because Asian women have a much higher incidence of osteopenia, osteoporosis, than does the rest of the world. So they're way ahead in their research. Now a serum CTX. I don't personally I don't know the ranges on that like they do the serum NTX. So I personally have stayed with the serum CTX excuse me, serum NTX and didn't go over to the newer serum CTX. But that just gave me the confidence. Does this look like this has a chance of working? Because now they're universal lab tests? They weren't specific for the jaws, but if the numbers were bad.

Dr. James Rutkowski :

You know what you might not make bone. If the numbers were good, you might make bone. And so what I did is I got you all cleaned up. Good prophy, good scaling, good planing. I want no bleeding on probing. You're doing good daily oral hygiene at home. I would get these tests If the tests were good.

Dr. James Rutkowski :

I said I want you to stop taking the bisphosphonate or the monoclonal antibody with a physician's permission for 16 weeks, because I want to put my implant in or my bone graft and I want it to turn over. Okay, so we're not going to take any drug for 16 weeks if the numbers were good. If the numbers are bad, I want you to take a six-week holiday, okay, and then we're going to repeat the tests and if the numbers are good, we're going to go ahead and do your surgery. You're still signing a consent form and the reason being is you didn't kill every osteoclast and osteoblast-induced necrosis, every one of them in the body. No, you still have some that are working.

Dr. James Rutkowski :

It's just that now you haven't been on the drug for six weeks, okay. Or if you want to be a bit more conservative, you can go three months, okay, and I think three months is probably a better number than six weeks. So wait three months, repeat the tests. If the numbers are good, go ahead and do your surgery, but don't start to drug up for another 16 weeks. Does that make sense? Yeah, it does. Yeah, it does.

Dr. Soren Paape:

Okay, so I got a couple questions. First, is this just for patients taking IV bisphosphonates, or oral and oral?

Dr. James Rutkowski :

I had everybody that took a bisphosphonate and monoclonal antibody. That's what they did. I had everybody that took a bisphosphonate and monoclonal antibody. That's what they did If they'd been on for two years.

Dr. Soren Paape:

Okay, so good. Lab tests 16-week holiday, then you place your implant. Can they jump back on it right away?

Dr. James Rutkowski :

No, once I do my surgery, I want to give them another 16 weeks.

Dr. Tyler Tolbert:

So holidays after the procedure.

Dr. Soren Paape:

Once you place the implant wait 16 weeks.

Dr. James Rutkowski :

Once you've got the implant in and it's also integrated, now they can go back into drug.

Dr. Soren Paape:

Got it, got it, okay. So if good tests and we'll try to 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 a drug holiday for 16 weeks after the after integration. Right, if the numbers are bad six week, or you said six week, or three month, if you want to be conservative three months, yeah, three months retest. If numbers are good, place the implant.

Dr. Soren Paape:

Wait another 16 weeks yeah um, does it matter how long they've been taking the oral bisphosphonates?

Dr. James Rutkowski :

Yeah, yeah, I mean, you know if they took it ideally and it was 70 milligrams a week, which that's what everybody took in Fosmex an osteopenia dose was 35 milligrams a week. Osteoporosis dose was 70, but everybody got 70 milligrams. Even when you had a diagnosis of osteopenia, everybody got 70, seemingly so. I think in all my years I only saw two or three people on 35, but you know over half those people were just osteopenia.

Dr. James Rutkowski :

But um, if it's 70 milligrams every week and they took it just as they were supposed to, in an empty stomach, you know, there there is a report of as early as 18 weeks somebody getting L and J, but that could be just an outlier. That could be just an outlier. They may have had other morbidities. Maybe they smoked as well. Maybe they were taking long-term steroids, because there are other comorbidities besides just having that surgery. But traditionally we didn't see it in under two years. Now, if you didn't take it right, you might have taken the 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 the oral cavity, amount of inflammation. So there's just so many compounding factors. It's very difficult. I agree personally with 90% of everything that was said in that ADA paper, in the Amos paper. I should say the Amos paper. I agree with 90% of it there. They did not have one pharmacologist on there, yeah, that's crucial, yeah it's a pharmacology question, it is.

Dr. Tyler Tolbert:

There's nuances, yeah, for sure so.

Dr. Soren Paape:

so you have placed implants in patients that have been I on iv bisphosphonates, on oral bisphosphonates, as long as they the protocols are followed properly, the the tests came back well and overall you said— Reduced inflammation. Yeah, and how long would you have them? You talked about the brushing water, pick flossing. How long, typically, would it take your patients to get to a point where no bleeding on probing?

Dr. James Rutkowski :

They would have that in three months. So between right, many, many of my implant patients I'm very um discriminating about oral hygiene with dental implants because I came up in the 80s when nobody understood the importance of it. Then we had so much peri-implantitis uh, you know that I learned from it the hard way, not by reading papers but by experiencing it. So it was usually within three months, between three months, prophylaxis. You know, you come in, you get your consult, etc, etc. This is what you need to do. We need to get this all cleaned up. You're gonna come in, you're gonna get your teeth all cleaned up here. Scale and replaning, whatever we're going to do with that.

Dr. James Rutkowski :

If there was paranormal disease, we've got the paranormal disease eradicated the best we could before we ever did it. And even if I was going to take out all their teeth and when I was doing this in the in the 90s we weren't doing all on exits, we were doing fp1s or overdentures or things of that nature um, that we would uh, we still followed that protocol and that helped us tremendously by getting no smoking. We didn't want any bleeding and probing but within three months just about everybody could be to the point where we did not have any bleeding and probing and I thought that was a huge. That was a huge factor for it?

Dr. Tyler Tolbert:

And yeah, I'm curious to do you sponsor any other like adjunctive therapiesctive therapies prior to the procedure? So obviously you know people talk about hyperbaric dives. Some people are fans of administering pentoxyfilene and vitamin E for some time prior to the procedure and after the procedure. Do you feel one way or another about those? Could they hurt?

Dr. James Rutkowski :

You know, the literature is not. I try to do everything in my life based on what does literature say, and I realize that the literature is flawed and the literature is incomplete. Sure, okay, so just know that.

Dr. James Rutkowski :

I'm very much aware of that. That. I think that it is very important for these patients to go on vitamin D, yeah, ahead of time, and I like them to be on that for at least a month, if not two months. And I like it best when we have vitamin D levels on those patients from their lab tests and whatnot, because that can help us prescribe most accurately.

Dr. James Rutkowski :

But if, for whatever reason, we don't have that, then I put them on vitamin d3 5000 units a day one month pre-surgery and then I keep them on vitamin d3 5000. It's vitamin d3 5000 units one month prior to surgery, then vitamin d3 5000 units daily for um two months afterwards. But it is a lipid-soluble vitamin D3 that you can get toxicity, but it would take you a long time at 5,000 units a day to get the toxicity. So if you're in the northeast or if you're north of the Mason-Dixon line, even if you're north-central or um northwest united states, where you get very little sunshine, uh, and even though the people that are in phoenix, arizona, they're all wearing long sleeves and sunscreen now, they're not getting much vitamin d right you know, technically we should have the blood levels.

Dr. James Rutkowski :

But if we don't 5 000 units a day for 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 for 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 5 000 units longer than that? Yeah, you could, but without a lab test we don't know that definitively. I'm just saying saying those numbers 30 days before, 60 days after and then 2,000 units a day thereafter, particularly in the populations beyond the age of 70, most of them have some vitamin D deficiencies anyway.

Dr. Soren Paape:

That was really good.

Dr. Tyler Tolbert:

That was awesome.

Dr. James Rutkowski :

And our listeners will really appreciate that.

Dr. Soren Paape:

You know we don't have a ton of time left, but I'd love like a quick recap on your thoughts for patients who like radiation levels. You know my understanding is typically under 60 grays. You're a lot, you know, in a much better place for implant placement. So I'm curious on your thoughts on that better place for implant placement. So I'm curious on your thoughts on that. And then I'm curious your thoughts on um a1c levels, uh, and and where you're comfortable placing implants with patients if you have time to answer those yeah, 55 to 60 grays is should be the cutoff.

Dr. James Rutkowski :

Okay, that should be the cutoff. But the more important thing is that you get with the oncologist and you look at the mapping when was the radiation given, what was shielded and what was not shielded. And they are very good at shielding. So if that radiation treatment is probably in the last eight years, 10 years, they probably had excellent shielding techniques. Even if it was head and neck radiation, they probably had excellent shielding techniques and if that bone was shielded then you probably don't have much of an issue whatsoever. But you've got to talk with that oncologist. They are very willing to talk with you.

Dr. James Rutkowski :

Many physicians they get very busy and they have bigger fish to fry than talking to the dentist about their patient and so many times talking to the nurse practitioner or their head nurse in the office and whatnot. They are more relatable many times just because they don't have as many things going on inside their head that maybe that head doctor does. But I will say the one exception that is every time that I have had to talk to an oncologist and when we worked with the cancer clinics we talked with them all the time. Those individuals they were really. They knew the consequences of oral surgery in somebody with radiation and they didn't want those patients to have a problem.

Dr. James Rutkowski :

And so I found if there's one group of physicians that'll give you everything to lay it all out there, it is the oncologist, the radiologist, who does that treatment for them. Uh, so one, make sure you do a consult, make sure you get the number of grades, make sure you get the mapping, and again, make sure there's no inflammation in the mouth, because we believe we believe we don't have the literature support it, but we believe we would probably have something similar with that lack of inflammation allowing us to have better healing force there. Then, depending on what it is, then we may have to talk about hyperbaric oxygen and things of that nature.

Dr. Soren Paape:

I have a. Yeah, the reason I was asking in particular is I have a. I try to stay away from bisphosphonate patients and radiation patients just to be conservative, right, but I did have one patient that I did an upper lower all on six on probably a month and a half ago and he had some neck radiation. But I met with the oncologist, we went over all the mapping and I ensured that he was under 55 degrees in all areas that I was placing implants and he had also done full hyperbaric oxygen therapy. So he's in the healing process right now and everything seems like it's healing great. But you know, it's always that thing that I'm thinking about. I'm always like, until he's fully healed, I'm always just going to be like all right, hopefully everything goes okay. But that's great to hear from you.

Dr. James Rutkowski :

What about your A—oh? Go ahead, you might let those implants integrate just a little bit longer and then do your ISqs on there to to see what kind of readings they've got, before you do look and um, you know, because the implants will go in that, that bone and I. I think you've done everything just exactly right. You did everything right. You talked to the oncologist there and the diaper berry auction you did all those things just exactly right. But if the bone is not turning over 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 everything absolutely right as far as I'm concerned, from my vantage point here um ha1c's.

Dr. James Rutkowski :

Um I lecture, I try to keep everybody from having trouble. I don't want them to have trouble and the literature strongly supports that. An HA1C above seven. You probably shouldn't be doing elective surgery on them Now that's not to say that a 7.1, a 7.2, 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 for nine months with their endocrinologist and the best they can get them is 7.2.

Dr. James Rutkowski :

Well, okay, that's a considerable 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 know we have to make everything realistic in this world too. But if you want to play, it's conservative 7-0. You never do an elective surgery about that. If you said I'm willing to stretch, I know the patient, they're going to do best hygiene that they can possibly do. I'm going to be careful. Um, we're going to get them in every three months. They're going to do everything they can possibly do. All right, and you're not a litigious patient. I'll go to seven and a half with you. Okay, I think anybody that does anything beyond eight is why don't you just go out and take money and burn it in the streets Because you're going to see a nice fire. Otherwise, all you're going to do is see those implants again and you're going to do them again and again and again, and that's going to cost you money. So just burn the money the first time. You'll be just further, you know.

Dr. Tyler Tolbert:

Save yourself time, save yourself time Okay.

Dr. Soren Paape:

So nothing above an eight.

Dr. James Rutkowski :

If it is between. If it's below seven, great. And sometime we'll talk about maybe steroids and things of that nature, because there's steroid doses in what we do.

Dr. Soren Paape:

But if it's below seven.

Dr. James Rutkowski :

yeah, I go ahead and I do implants, grafting, whatever has to be done there with it, Great, great.

Dr. Soren Paape:

Are there any other? Any other? I mean, those are kind of the three big ones that I feel like people talk about the most. Right a diet, uncontrolled diabetes, head and neck, radiation, bisphosphonates. Is there anything else that you think that our listeners should be really um aware of as like an absolute contraindication, then?

Dr. Tyler Tolbert:

like protonics, and antidepressants as well to some degree not not an absolute contraindication, but people are talking about yeah, yeah, those those.

Dr. James Rutkowski :

Those are less. Uh, you know, if it's an ssri right? I suggest you let those implants integrate for longer and maybe, when you do load them, you load them with an acrylic based tooth um or an acrylic occlusal surface. I should say that's going to wear form um, because I I wanted to wear, realizing full well you're going to have to replace them more frequently than you are, maybe zirconia or something of that nature but they need a shock absorber because that bone, those drugs, they interfere with bone remodeling.

Dr. James Rutkowski :

They put them in a negative remodeling state where they're going to break bone down more than they're going to build the bone up With an SSRI. Of the 25 top drugs prescribed in the United States in 2022, that's the latest data I have, it's 22. I don't have 23 data and 24 data yet that comes off the pharmaceutical industry. But the top 25 drugs prescribed in 2020, through, every single one of them had an effect on oral health or healing of oral surgical procedures. So some of them were positive, some of them were negative. But you know, I think the biggest factor as I can say from what I've gleaned from the literature in just about everything, in confounding factors 44 years of clinical experience is you want to make sure they've got good oral hygiene. I think that Waterpiksonic every single patient got implants in my practice. They got a waterpiksonic, they got one implant, you got a waterpiksonic. Great, I was retired for 14 months.

Dr. James Rutkowski :

One of my patients whom, um, uh, I was friends with and he had my um, my cell number he texted me. He says jim, I just came back from the people that took over my practice. He said and I had a perfect checkup, and I gotta tell you, jim, I want to thank you for all the things you ever did for me, and that included implants, restorative, etc, etc. He said the best thing you ever did for me, though, was give me that electric toothbrush that puts the water out. Oh, that's great, you know? I I thought that was that was unsolicited. He just called out, in fact. He called me at christmas time, and he said all my grandkids, for christmas, got a sonic, a waterpik sonic. That's good. He said. If I were to have him when I was a kid, I would have needed all that work from you. I might?

Dr. Soren Paape:

I don't. I don't have a waterpik sonic and I'm I might be getting. I know I can see him searching amazon right now.

Dr. Tyler Tolbert:

Which are these things like?

Dr. Soren Paape:

we give. We give all of our patients water picks but not water picksonics. So I'll definitely have to look into that and I appreciate the advice.

Dr. James Rutkowski :

I've enjoyed my time with you guys. Hopefully I didn't wear out my welcome. No, oh no, not at all.

Dr. Soren Paape:

Before you go, though, please let everyone know what the best way to um find find the residency program, to get more info on the residency program, to maybe reach out if they want more info.

Dr. James Rutkowski :

Uh, that'd be, that'd be really helpful okay, uh, you want to um uh, google jacksonville university comprehensive oral implantology program. So again, jacksonville University, comprehensive oral implantology program. If it's okay with you guys, I'll give my phone number, please. Yeah, and I'm going to just ask that you text me, because I got a spam blocker and it's not in my phone it doesn't ring so I tried to call you.

Dr. James Rutkowski :

You never know my phone number. Text me, Send me your card and then I'll put your card in there and put in there that you want information on Jacksonville University program and that number is 803-415-4838.

Dr. James Rutkowski :

Again, 803-415-4838. Again, 803-415-4838. And for those of you that have a great deal of clinical experience, you are oral surgeons, perio pros greet, or a diplomate of the ICOI or a diplomate of the ABOI ID or a fellow of the American Academy of Implant Dentistry. It's just that all those they have been assessed as to having some competencies in implant dentistry. If you're those, we do have a remote residency program for you where, if you own your own practice, you stay in your practice. You still work with EPAs, but you have a remote director who you report to, and so you never have 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 same master's degree and it's a two-year program as well for them. So we have a handful of those in our program now.

Dr. Tyler Tolbert:

Very cool, excellent, very cool. Well, dr Rakowski, this has been an absolute pleasure, and I think both of us can. I speak for Swarm when I say that we learned way more than we ever even expected to with this interview. You know, we were we already jazzed about learning about the, about the, about the residency, of course, but we got schooled on all kinds of pharmacology stuff, which has been an absolute pleasure, and these are things that we talk about all the time. Um, so really, thank you so much for sparing your time and and I hope that the fans of our show will be reaching out to you about their interest in the program and we hope to use you as a resource in the future as well for all of our burning questions about implantology, because you have an incredibly deep and broad knowledge and kudos to the two of you for what you're doing.

Dr. James Rutkowski :

thank you know. Uh, we're, we're, we're, you know, we're all brothers and sisters in implant dentistry and um, 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 is best for our patients. I truly believe that, and it's exemplified so clearly by the things that the two of you are doing. So, thank you very much for inviting me, thank you for being who you are in the work that you're doing. So hats off to you guys. Likewise.

Dr. Tyler Tolbert:

Thank you, have a nice day. Bye.