Preserving Smiles, Improving Lives: Unmasking the Dr. Medha Gupta's Magic (Part-3)
Welcome to part 3 of our conversation with Dr. Medha Gupta
How frequently do you encounter cases that require full mouth rehabilitation in your practice?
Dr. Medha Gupta: In a setup like Bangalore, I wouldn't say the number of cases is very low, but on average, if you inquire at my clinic, I will estimate that there are not more than a couple of cases in a month. Sometimes, there might even be none. This is because there is a significant client journey involved in convincing the patient to undergo full mouth rehabilitation. For someone to commit to dedicating that much time and effort, they need to be highly committed to their appointments. If they miss appointments, the entire process can be negatively affected. Considering the amount of time, patience, punctuality, and financial investment required, the process can be somewhat demanding for patients.
This is particularly true when dealing with cases where some teeth are severely decayed while others have been well-maintained. It can be quite challenging for patients. Only those who are educated about the process, or those we can successfully educate, tend to become candidates for full mouth rehabilitation.
Which type of crown do you typically recommend or prefer to use after the placement of a dental implant?
Dr. Medha Gupta: I neither have a specific preference for crowns, nor do I entirely prioritize patient preference, as each type of crown has its own advantages and disadvantages. Consider a patient with bruxism, for instance. Giving them a ceramic crown might actually harm the opposing natural tooth due to the higher modulus elasticity of ceramics, which can negatively impact the teeth in contact. In cases like this, especially for posterior teeth, I tend to lean towards full metal crowns. I make an effort to educate the patient that metal is softer than glass or porcelain in such scenarios.
In situations involving anterior teeth with a deep bite, I aim to educate and motivate the patient to avoid chewing primarily with their front teeth. Instead, I encourage them to chew with their posterior teeth and use their canines for biting, as this can help preserve their front teeth. In terms of crown materials, nothing can beat eMax crowns (lithium disilicate crowns). Zirconia is also a preferred option for both anterior and posterior teeth. There are good commercial options for zirconia available in the market, such as Bruxir. Although it's marketed as being specifically suitable for patients with bruxism, I have encountered cases of fractures even with this type of crown.
Zirconia is a much better choice, especially for root canal treated teeth. It offers greater opacity, making it effective at covering darkened teeth. When aiming for a smile makeover to close gaps, veneers can be a suitable choice, and full ceramic crowns can also be preferred. For posterior teeth, porcelain-fused-to-metal (PFM) crowns work well, although crowns made entirely of metal are also effective. However, the finish tends to deteriorate over time, becoming noticeable within 3-4 years, with issues like metal hue becoming apparent.
What is the current failure rate associated with dental implants in your practice?
Dr. Medha Gupta: The number of studies on this topic is quite substantial, and it's primarily theoretical. A well-planned and effectively executed dental implant, coupled with a highly motivated patient, is unlikely to fail. Several key factors come into play:
Thorough Planning: Have you meticulously planned the procedure? This step is crucial as it sets the foundation for success.
Skillful Execution: Was the procedure carried out skillfully? The actual implementation is as important as the planning stage.
Post-Procedure Care: Equally important is how well the patient follows post-procedure care instructions. Proper maintenance significantly contributes to the success of the implant.
From a layperson's perspective, if you're consulting with an implantologist, it's essential to ask a few critical questions. First, gain an understanding of the X-rays and the pros and cons the doctor has already discussed in terms of your bite and habits such as clenching, as well as potential concerns like a deep bite.
Second, inquire about the type of implant being used. The choice of implant depends on factors such as bone thickness. For instance, if there's a sufficient amount of bone, a standard implant might suffice. Implant companies offer various types, from smoother options to more aggressive ones.
When selecting a doctor, consider whether you've opted for a comprehensive package or if you're assessing the doctor's profile based on their previous cases. A proficient doctor prioritizes understanding the patient's profile before determining the suitable implant. With a multitude of implant manufacturers, a doctor should discern which implant type suits specific conditions. It's worth noting that there isn't a single implant company with an absolute failure rate. Success depends on the patient's individual profile, bone thickness, CBCT (cone beam computed tomography) reports, clinical examination, and economic feasibility for the patient.
For instance, if Nobleactive is the ideal choice for a patient but their budget doesn't allow it, opting for European or Israeli-made implants with similar quality could be a practical alternative. The success or failure rate of implants involves several variables. Yet, keeping in mind the three key factors I've mentioned, implant failure can be significantly minimized.
What are the common complications that can arise from dental implant procedures?
Dr. Medha Gupta: Complications after implant surgery can sometimes be unforeseen. Immediately following the procedure, as it is a minor surgery, you should expect mild swelling, slight pain, and a slight difficulty in opening your mouth. During this time, adhering to a soft diet is recommended. Regular check-ups and cleanings are necessary during the three-month period of implant healing. These are the immediate complications.
Long-term complications can encompass various issues. These include the potential for implant crown or implant fractures, alterations in your bite, and the development of teeth grinding over time. Beyond fractures, there's a possibility of experiencing peri-implantitis, which involves an infection in the gums surrounding the implant. Notably, advancements in dentistry now offer effective methods to salvage implants even in cases of peri-implantitis. Laser treatments, potent antibiotics, and thorough cleaning procedures contribute to successful treatment.
While an implant isn't susceptible to cavities like a natural tooth, gum infections can occur and extend to the bone, leading to infection around the implant. These local complications are among the primary concerns. However, it's important to recognize that implants don't have the potential for cavities or requiring root canals.
Furthermore, if a patient has a history of cardiac or kidney issues, it's crucial to be aware that implant surgery, being a surgical procedure, carries a risk. Infections that develop at the surgical site could potentially spread to the heart, lungs, or kidneys, causing secondary infections. Although the chances are present, they can be managed through proper care.
Localized complications might involve ecchymosis, particularly visible in lower implants and more prevalent in older patients who have undergone multiple implant procedures. Ecchymosis results from local bleeding into the tissues, often leading to the appearance of blood clots or bruises on the skin. However, with the application of ice packs and controlled pressure, these hematomas typically diminish within a week to 10 days.
What are the typical post-operative instructions you provide to patients after a dental implant procedure?
Dr. Medha Gupta: The general instructions after the surgical procedure are quite similar to those you receive after an extraction. Even with a secure suture, I prefer using a tight pack for about 30 minutes. After removing the pack—please don't spit it out, use your hand to remove it—consume something cold, ideally chilled like an ice drink or ice cream. Also, take the pain medication we've prescribed. Anticipate mild swelling, pain, and discomfort while eating for the next 24 hours.
During this initial period, avoid vigorous brushing, rinsing, or gargling. Opt for room temperature foods—nothing too hot, hard, or spicy. It's worth noting that due to the implant being in the bone, patients might experience a tickling or prickly sensation. Refrain from touching the wound site, which is crucial for proper healing.
For patients with same-day prosthetics, such as a denture or crown, a soft diet and antiseptic mouthwash are recommended since cleaning the implant site could be challenging initially. Once the crown or cap is placed, there are fewer dietary restrictions, but caution is advised for very crunchy or hard foods. Items like Muruku or chewy candies should be broken into small pieces before consumption, as the forces exerted by the human mouth can damage ceramics or titanium.
Your daily oral hygiene routine needs to be intensified after any prosthetic procedure, including implants. Effective flossing, use of interdental brushes, and mouthwash are essential. A simple saltwater rinse with warm water can replace chemical-based mouthwash—rinse, but don't gargle. Brush twice daily and after consuming sugary items, rinse well.
It's vital to visit your dentist regularly, ideally every six months or at least once a year, for implant check-ups, cleaning, and addressing any potential issues or treatments needed.
In essence, the instructions are straightforward.
Do you have a preference for immediate loading or delayed loading of implants after their initial placement, and what factors contribute to your decision?
Dr. Medha Gupta: Once again, it's important to emphasize that the approach is highly specific to each case and patient. Nowadays, I'd even say it's patient-specific because some patients are quite insistent on receiving their prosthetic restoration on the same day as the implant procedure. However, I address this by explaining the process. I typically start by thoroughly reviewing the CBCT scans to assess the bone condition. Then, I match this with the clinical placement of the implant.
For instance, if I've handled full mouth cases involving all-on-four or all-on-six procedures and I've encountered challenges with patients who have fewer than fifty teeth remaining, I need to adapt. In such scenarios, rather than opting for a hybrid denture, I might suggest transitioning to a removable denture. This provides the patient with teeth, albeit not in a fixed manner to implants. This approach allows the implants to heal properly. Immediate loading, in situations like these, isn't always the optimal choice. Instead, I would assess the specific circumstances and make an informed decision.
It's crucial to highlight that the concept of immediate loading, just like delayed loading, comes with its own advantages and disadvantages. Both methods have their rightful place and can be justified in different contexts. I refrain from declaring one as better than the other since both are valid. The decision between immediate and delayed loading hinges entirely on the specific case and patient at hand.
What recent advancements have you encountered in terms of implant companies or other relevant developments that are impacting the field of dental implants?
Dr. Medha Gupta: When it comes to the surgical aspect of implants, I might not be well-versed in the latest emerging companies. However, in the realm of prosthetics, our focus is on embracing a comprehensive digital workflow. Our clinic has already adopted this approach, with an in-house iTero scanner at the forefront. While iTero was initially associated with Invisalign, it now extends significantly into rehabilitative and prosthetic applications.
Our digital workflow commences with implant planning. We either scan the patient directly or take casts and impressions, which we forward to the lab. Here, a digital guide is crafted, often using materials like peak or carbon fiber for its lightweight nature. This guide is pivotal, facilitating a flapless implant surgery. This means no incisions, no sutures—just a guided, minimally invasive procedure. Concurrently, the CBCT image is overlaid onto our scans, granting us a volumetric view of the bone structure. With this, we can virtually plan the implant's placement, ensuring it avoids interfering with nerves and blood vessels. This preoperative virtual planning guides us throughout the process.
After the digital planning, we proceed to the guided surgery. If immediate loading is suitable, we proceed accordingly. Otherwise, we await the three-month healing period. At this point, we move to the second stage. For submerged implants, the procedure is investigative. However, if the implants are not submerged, we can directly place digital scan bodies. This simplifies the process since the gingiva has already healed well.
We employ digital scan bodies and send the scans to the lab, accompanied by specific lab components such as a UCLA abutment. Using the digital information, the lab prints a 3D model. This model becomes the foundation for milling the crown directly from the implant replica or working with the specified abutment. This digital process eliminates the potential for human errors that were commonplace with traditional putty impressions, pickup impressions, and multiple metal trials.
This approach negates the need for a jig trial and multiple adjustments. The digitally fabricated crown is then ready for placement. Fixing the crown or bridge onto the patient takes around 30 minutes, with minimal high points due to the precision of the digital bite data we have acquired.
In cases of congenital missing lateral incisors where there's a lack of bone, such as minimal D3 bone, how do you typically approach treatment and implant placement?
Dr. Medha Gupta: Certainly, there are various augmentation methods available, particularly in the surgical realm. These techniques can be considered when a patient is open to the idea and willing to undergo additional surgery. Augmentation procedures involve adding bone to the area, essentially creating a more favorable environment for implant placement. However, it's important to note that augmentation is an additional surgical step in the process.
Some augmentation methods include block bone grafting and split bone grafting. These procedures aim to increase the amount of available bone in the target area. Alternatively, there are approaches like Bicortical implants, where we can utilize regions such as the nasal floor or the zygoma to anchor the implant. This can provide a solution without being too invasive, as we're not affecting other bones in the skull.
There are two potential approaches. One involves the surgical augmentation of the existing bone, followed by the placement of a traditional endosteal implant. This route, however, requires the patient to undergo two separate surgeries. While it isn't overly invasive as it doesn't involve other skull bones, it still adds an extra phase to the treatment.
The second approach entails engaging the nasal floor or zygoma directly during a single surgical phase. This method is more direct, potentially involving less bone grafting. However, it can be somewhat more invasive, especially for younger patients.
Both approaches have their merits and considerations. Augmentation methods can effectively rehabilitate cases with compromised bone, but the choice between the two strategies depends on the patient's condition, preferences, and overall health.
How does the level of lab work and overall demands of your current dental practice compare to your experiences during your post-graduation in prosthodontics?
Dr. Medha Gupta: Absolutely, the term "hectic" truly captures it. When it comes to prosthodontics, it's a realm that not all practitioners delve into. In my case, I still prefer to mix my own alginate because I've found that the commercially available mixtures don't meet my standards. Even when it comes to assistants, colleagues, junior colleagues, interns, or BDSs, I've maintained the practice of preparing my own alginate mix. For cases that hold immense significance to me, and where there's zero room for error, I continue to pour my own casts.
As for lab work, I've been fortunate to work with exceptional labs, which has spared me from the hands-on tasks like trimming and other detailed work. I've been fortunate that clients have been willing to pay for quality work, and my practice doesn't involve significant overheads.
Interestingly, having an understanding of lab work has provided me with unique advantages. I'm able to detect potential issues in the lab work before the patient even steps in for their appointment. This has allowed me to inform the patient in advance if there are problems and that their work needs to be corrected. This way, I can save the patient an unnecessary visit, which they surely appreciate.
Being familiar with both the clinical and lab aspects has proven beneficial in other ways as well. There have been instances where the lab has approached me for guidance. They might say, "There's no clearance here, what should we do?" Given my combined knowledge, I can suggest solutions. Whether it's suggesting minimal clearance or understanding that even a metal thickness of 0.3 millimeters is sufficient, I can guide the lab effectively.
Common challenges on the prosthetic side often revolve around bite issues and deciding whether a cantilever crown is appropriate. While I'm not directly involved in hands-on lab work anymore, my ability to guide the process based on clinical and technical insights has proven invaluable. Ideas flow from me, and the lab executes them with precision.
On average, how many appointments does a patient need to attend for the placement of a single dental implant?
Dr. Medha Gupta: Certainly, when it comes to the implant journey, the minimum number of appointments I would typically consider is four. Let me break down these appointments:
Consultation and Initial Investigation: This includes the consultation session where I discuss the treatment plan and gather essential background information. I prefer to keep consultation separate from other stages.
Implant Placement: The second appointment involves the surgical placement of the implant. If I'm also placing the crown on the same day, this step is crucial.
Three Months Post-Placement: The third appointment occurs around three months after the implant placement. This period allows for healing. During this appointment, I take impressions to transition the temporary crown or acrylic prosthesis to a permanent one.
Final Crown Placement: The fourth appointment centers around fixing the final crown in place, completing the restoration process.
However, the maximum number of appointments could vary significantly. The implant journey can encounter hurdles and unexpected challenges, which might necessitate multiple appointments beyond the minimum. These additional appointments might be due to adjustments, unexpected healing concerns, or other factors.
Of these appointments, at least two tend to occur within a relatively short span of about 10 days. The remaining two appointments are typically scheduled after a gap of 3 to 4 months, allowing for proper healing and progression in the treatment plan.
What differences have you noticed in the healthcare systems between Kolkata and Bangalore based on your experience of shifting between the two cities?
Dr. Medha Gupta: My journey has encompassed quite a lot, especially considering my path from Kolkata to Ludhiana and then to Bangalore. Each location has offered a unique experience. Let me elaborate:
Coming from Kolkata and transitioning to Ludhiana, a smaller town, and subsequently arriving in Bangalore, a large city, has marked significant growth. While Kolkata is classified as a metropolitan city, there is substantial room for growth in terms of healthcare. While the practitioners are indeed excellent, the city tends to lean towards more traditional and conservative approaches when it comes to adopting new methods and technology in healthcare. While I appreciate and respect the conservative nature, I also recognize that there are instances where incorporating technology could simplify processes. This distinct difference between Kolkata and Bangalore lies in their openness to embracing digitization and medical technology. Patients in Bangalore are generally more receptive to experimenting with technological advancements throughout their healthcare journey. This includes aspects ranging from scheduling appointments to receiving dental restorations. Bangaloreans are willing to invest in these advancements and are comfortable with the changes.
In contrast, Kolkata still holds onto a more conservative approach, and there's a slower adoption of new technologies. This isn't necessarily negative, but rather reflective of the city's mindset at the moment. Over time, this could change and become more aligned with newer trends. This difference is likely influenced by Bangalore's position as a tech-savvy city with advanced technological infrastructure.
Ludhiana was another phase in my journey. Here, the focus wasn't just on embracing technology; it was about educating the community about the importance of certain treatments. Even before considering digital advancements, there was a need to enlighten the population about healthcare needs and options.
Overall, these three cities have provided me with a comprehensive perspective on healthcare. I've observed the spectrum, ranging from primary care to embracing digital innovations. This diverse experience has equipped me to adapt and manage healthcare situations across various contexts globally.
What methods do you use to stay current with the latest advancements and research in your field?
Dr. Medha Gupta: Even though I'm an avid reader now, I wasn't particularly inclined towards scientific reading in the past. Even writing my own dissertations and thesis posed challenges for me, which deterred me from venturing into scientific writing extensively. Thus, I wouldn't claim to immerse myself in a plethora of journals. However, I do keep up with and follow the works of accomplished dentists who have made significant contributions to the field. Their insights are invaluable to me.
For me, the focus lies in absorbing knowledge and wisdom from these celebrated individuals. I find great value in listening to their perspectives, experiences, and thoughts. Alongside this, I also engage in conversations with my colleagues who are excelling in various parts of the world, including the US, Europe, and Australia.
My approach involves active listening and open discussion. While I don't blindly adopt every idea presented to me, I do take the time to understand new concepts thoroughly. Once I'm acquainted with a novel approach or concept, I embark on further research. I ascertain whether it's practically applicable within the context of India and my professional setup. If it is viable, I enthusiastically incorporate it into my practice.
Could you provide a success story of a patient who achieved life-changing results from your dental implant procedure?
Dr. Medha Gupta: Certainly, I'd be delighted to share a recent patient case with you. Let me tell you about Vaishnavi, a remarkable individual with an interesting journey:
Vaishnavi hails from Karnataka and has quite an illustrious background in the entertainment industry, having acted in numerous Kannada and Tamil movies. However, she transitioned from acting to the tech field and now resides in London, working for a marketing company. One fateful Friday night, after a hectic day, she experienced an unfortunate incident. While asleep, she tripped on her bed and lost one of her front teeth, a central incisor. To make matters more challenging, it was New Year's Eve, and she couldn't locate an available dentist until the following day.
When she did find a dentist, she learned that the tooth couldn't be salvaged due to the elapsed time of 48 hours. Dissatisfied with the options presented to her, Vaishnavi sought assistance back in India. She was already familiar with the clinic where I work, as she had been a patient of the orthodontist there. After returning to India, she explored her choices and decided to proceed with an implant.
My approach involved placing an implant for her, although I didn't provide an immediate crown. Instead, I offered her an immediate removable denture that matched her natural tooth shade. She preferred the removable option to ensure she wouldn't face any emergencies while abroad.
After three months, she returned for the next step. We crafted a crown for her implant. Vaishnavi's smile was successfully restored, allowing her to confidently face life's upcoming milestones, including her impending wedding. Her role in her marketing company involves direct interaction with clients, and her previous celebrity status has resulted in a considerable following on social media platforms like Instagram and Facebook.
In fact, Vaishnavi has been sharing her radiant smiles across her social media channels, and she even expressed her desire to promote the clinic where she received treatment. She enthusiastically shot a reel with her entire team and plans to share it on her platforms as a form of endorsement.
This case is relatively recent, and it truly showcases how dental work can transform lives and restore confidence, even for individuals with an influential presence. If you're interested, I can certainly share a picture collage to accompany this story.
What advice do you have for both patients and fellow dental professionals?
Dr. Medha Gupta: Absolutely, I completely resonate with your sentiments. In my current phase of a career pivot, I find myself engaged in two interconnected yet distinct pursuits. Reflecting on my journey, I'd like to offer guidance to my fellow dentists and to patients as well.
To my fellow dentists, I emphasize the importance of having a clear vision and the means to support it. Dentistry is an exceptional field that can offer abundant rewards, but it also requires substantial financial investment. If you possess both the vision and the means, I urge you to forge ahead without hesitation. Dentistry has vast potential to enrich your life. However, if you find yourself in a situation where the vision is strong but the immediate means are limited, remember that dentistry offers a versatile foundation. As dentists, we are not solely medical practitioners; we are artists in our own right. Our work involves intricate craftsmanship and skillful precision. If your current circumstances necessitate exploring avenues beyond the traditional realm of dentistry, do not hesitate. Our profession equips us with a diverse skill set that can be applied creatively and innovatively.
Turning to patients, I implore you to prioritize education and awareness. The very essence of life resides in the sustenance we consume, and the gateway to that sustenance is our mouths. Teeth, the caretakers of this portal, are entrusted to the dentist's care. This relationship between dentistry and our well-being cannot be overstated. If you identify as a food enthusiast, recognize that your dental health plays an indispensable role in savoring those culinary delights. Moreover, your overall survival and quality of life are deeply intertwined with your oral health. The vitality of your heart is directly influenced by the nourishment you receive through your mouth.
In essence, I encourage patients to empower themselves through education. Your mouth is not just an entry point for sustenance; it's a gateway to health and well-being. Understanding the significance of dental care and its broader implications is a crucial step in embracing a wholesome and fulfilling life.
