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All-On-4 Dental Implant Cost

In recent years, my partner, Dr. Giovanni Castellucci, and I have seen a resurgence of the use of the "hybrid" prosthesis with the "All-On-4" Immediate Dental Implant (Teeth in a Day) protocol. Now, we successfully restore fully edentulous arches on four implant fixtures on the same day that the hopeless teeth are removed, oftentimes without the need for bone grafts. Our patients are thrilled with the results, and the functional and esthetic benefits are instant.

The cost of the All-On-4 procedure varies based upon the type of final restoration that is made.  The traditional and least expensive prosthesis is typically made with acrylic teeth, similar to that of a regular denture, that are "permanently" fixed to the underlying dental implants.  Fees for this prosthesis range from $25,000 to $30,000.  The fee may vary for a variety of reasons including management of severe disease, infection, and number of extractions.  Many patients choose to have the final teeth made out of ceramic zirconia such as Procera which provides superior esthetics, strength and durability.  Due to increased dental laboratory costs, these more sophisticated restorations can cost between $35,000 and $40,000. 

It is critical for patients to seek the care of experienced and expert surgeons and restorative dentists.  After all, this is a big investment for most people.  Patients need and deserve to have it done right the first time.  There are no substitutes for experience and expertise!  In our practice, with offices in Newton and Framingham, MA, we take great pleasure in knowing that we have consistently improved the quality of life for thousands of our patients by restoring ideal dental health and function, and creating beautiful smiles for the past three decades.



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After 33 years in private practice in periodontics, dental implants, and bone regeneration, I am constantly looking for ways to tweak the treatment protocols to achieve faster treatment turnaround times while maintaining ideal functional and esthetic outcomes for our patients; all with a success rate that approaches 98%. My partner and I have many implant systems in our office to accommodate the needs and desires of our restorative colleagues. Most recently though, we have been attracted to implants with 3 specific design features that help us to realize our treatment goals.

1. Tapered implant body (roughened surface to the top) with an aggressive thread design. This allows for maximum initial stability which is especially important in our Teeth in a Day and All on 4 immediate implant placement and restoration cases.

2. "Platform switch" design for connection of the permanent abutment to the implant. This has been proven to help preserve crestal bone which, in turn, helps to maintain the overlying soft tissue levels thereby enhancing the esthetic outcome.

3. Internal conical connection of the permanent abutment to the implant. This connection has also been proven to eliminate or significantly reduce micromovement of the abutment. Abutment micromovement due to poor fit or inherent engineering design can contribute to bacterial invasion. The inflammatory infiltrate which ensues may contribute to bone loss and soft tissue alteration.

Three examples of implant fixtures which incorporate these design features are listed below:

Nobel Biocare NobelReplace CC 

Astra Tech OsseoSpeed TX

Straumann Bone Level Tapered 

We all have great outcomes in the past with traditional implant design. However, we work so hard to re-build bone and soft tissue so that our patients have beautiful results which mimic natural teeth. Doesn't it make sense to try to preserve these structures? What do you think?

Photo Credits: NobelBiocare, Dentsply, Straumann

For more information, contact:
Cary Feuerman, DMD
Periodontal Associates

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I came across an interesting article by Laura Landro in the Wall Street Journal.

A sharp rise in a type of throat cancer among men is increasingly being linked to HPV, the sexually transmitted human papillomavirus that can cause cervical cancer in women.  A new study from the National Cancer Institute warns that if recent trends continue, the number of HPV-positive oral cancers among men could rise by nearly 30% by 2020. At that rate, it could surpass that of cervical cancers among women, which are expected to decline as a result of better screening.  The study was recently presented at the annual American Society of Clinical Oncology meeting. 

Between 1988 and 2004, the researchers found, the incidence of HPV-positive oropharynx cancers—those that affect the back of the tongue and tonsil area—increased by 225%. Anil Chaturvedi, a National Cancer Institute investigator who led the research, estimates there were approximately 6,700 cases of HPV-positive oropharynx cancers in 2010, up from 4,000 to 4,500 in 2004, and cases are projected to increase 27% to 8,500 in 2020.

Recent studies show about 25% of mouth and 35% of throat cancers are caused by HPV, according to the Centers for Disease Control and Prevention.

Men account for the majority of cases, and currently the highest prevalence is in men 40 to 55, says Eric Genden, chief of head and neck oncology at Mount Sinai Medical Center in New York. Studies have shown that the cancer can show up 10 years after exposure to HPV, which has become the most common sexually transmitted virus in the U.S.

"We are sitting at the cusp of a pandemic," says Dr. Genden.

Dr. Chaturvedi says more studies are needed to evaluate whether a vaccine now used to prevent HPV for genital warts and genital and anal cancers can prevent oral HPV infections.

The HPV vaccine, Gardasil, made by Merck & Co., was approved in 2006 for girls and young women up to age 26, but while it is routinely recommended, only about 27% of girls have received all three doses needed to confer protection.

The FDA in 2009 approved the vaccine for males ages 9 through 26 to reduce the risk of genital warts, and in 2010 approved it for both sexes for the prevention of anal cancers. However, the CDC has only a "permissive" recommendation for boys, rather than a routine recommendation, meaning doctors generally will only administer it if parents or patients ask for it, says Michael Brady, chairman of the American Academy of Pediatrics infectious disease committee.

Lauri Markowitz, a CDC medical epidemiologist, says the CDC advisory committee that sets vaccine recommendations will review new data related to the issue at a meeting next month. However, at present there aren't any clinical-trial data showing the effectiveness of the vaccine against oral infections, she says.

A Merck spokeswoman says the company has no plans to study the potential of Gardasil to prevent these cancers.

Researchers say it isn't clear why men are at higher risk for HPV-positive oral cancers. But for both men and women a high lifetime number of sex partners is associated with the cancer.

Changes in sexual behaviors that include increased practice of oral sex are associated with the increase, but a 2007 New England Journal of Medicine article also said engagement in casual sex, early age at first intercourse, and infrequent use of condoms each were associated with HPV-positive oropharyngeal cancer. Mouth-to-mouth contact through kissing can't be ruled out as a transmission route.

Most infections don't cause symptoms and go away on their own. But HPV can cause genital warts and warts in the throat, and has been associated with vaginal, vulvar and anal cancers.

Anna Giuliano, chairwoman of the department of cancer epidemiology at the Moffitt Cancer Center in Tampa, Fla., who studies oral HPV infections of men in several countries, says the rise in cancers among men shows it is important for males, as well as girls, to be vaccinated.

Doctors typically don't test for HPV-positive oral cancers. But Jonathan Aviv, director of the voice and swallowing center at New York's ENT and Allergy Associates, says his group looks through a miniature camera inserted through the nose at the back of the throat and tongue, and can biopsy suspicious warts or tumors.

In addition to being asked about symptoms such as hoarseness, difficulty swallowing, a neck mass or mouth sore that won't heal, patients are asked to fill out a risk-assessment sheet that includes the number of lifetime oral-sex partners. "People do get upset sometimes, but if your sexual history puts you at an increased risk for HPV, you should go and see an ear, nose and throat doctor," says Dr. Aviv.

Fortunately, says Mount Sinai's Dr. Genden, those with HPV-positive oral cancers have a disease survival rate of 85% to 90% over five years, higher than those with oral cancers that aren't linked to HPV, but are more commonly linked to alcohol use, tobacco, and radiation exposure.


Source:  WSJ Online

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Another great All-on-4 dental implant case with computer guided surgery in partnership with Ira and Brandon Dickerman of Dickerman Dental Prosthetics The patient was scanned in a Carestream CS 9300 CBCT scanner while wearing a surgical/diagnostic guide with radiopaque teeth.  With that information, the virtual implants and other components are located within the prosthesis and bone during an online treatment planning conference session with the doctor and lab technician.  The locking pins are also located which will stabilize the guide on the arch during surgery. 

This case was set up for the use of Nobel Biocare NobelReplace Conical Connection implants which provide maximum stability due to the tapered body design, and crestal bone preservation due to the horizontal "platform shift" of the restorative table.  Of course, the proprietary NobelBiocare surgical kit must be used for the implants in this particular case.  However, any dental implant that is designed for guided surgery may be used, per the choice of the surgeon, as long as that manufacturer's guided surgery kit is utilized.

The surgery typically involves minimal discomfort for the patient and can be completed in significantly less time than conventional implant surgery.

These cases are cost-effective, durable, and esthetic, which vastly improves the quality of our patients' lives.

Cary Feuerman, DMD

Periodontal Associates

Newton and Framingham, MA

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My partner, Giovanni Castellucci, and I have been placing dental implants in our periodontal practice for over 27 years. In the early days, the Branemark "hybrid" prosthesis was the standard of care for restoration of fully edentulous patients with five or six implant fixtures. We followed the traditional two-stage protocol and our patients enjoyed tremendously successful outcomes which have improved their quality of life. However, as time progressed, the hybrid prosthesis became less popular as more conventional PFM fixed restorations were fabricated on custom abutments.

In recent years, we have seen a resurgence of the use of the hybrid prosthesis with the "All-On-4" Immediate Dental Implant (Teeth in a Day) protocol. Now, we successfully restore fully edentulous arches on four implant fixtures on the same day that the hopeless teeth are removed, oftentimes without the need for bone grafts. Our patients are thrilled with the results, and the functional and esthetic benefits are instant.

When speaking with many of our restorative colleagues in Boston, Newton, Framingham, and the Metrowest communities, I occasionally hear them say "my practice doesn't have edentulous patients", or "we don't make dentures". This would imply that the demographic profile of these practices does not include a major component of the general population. Yet, we know that millions (if not billions) of dollars are spent annually on denture adhesives, and that the national dental clinics that focus on denture fabrication are thriving. And, let us not forget that many people with hopeless teeth due to severe gum disease or decay oftentimes avoid treatment because of fear of having to wear a complete removable denture. The "All-On-4" treatment is the perfect solution for these patients as they can have their natural teeth replaced by non-removable, fixed implant-supported teeth on the same day in one dental appointment.

In our practice, we see "All-On-4" patients from all communities, even the most affluent. After all, dental and periodontal diseases do not discern one community from another. With this in mind, we urge all clinicians to "open their eyes" to the benefits of immediate dental implant restorations as another tool to help enhance the lives of our patients.

Have any of you had similar experiences? Please share them with the community.

Cary Feuerman, DMD
photo credit:

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My partner, Giovanni Castellucci, and I have been placing dental implants in our periodontal practice for over 27 years. Every day, we see an ever increasing amount of requests from our restorative colleagues and patients from Boston, Newton, Framingham, and the surrounding metrowest communities for extraction of a compromised tooth, followed by immediate dental implant placement and restoration (Teeth in a Day). Years ago, this was a very challenging proposition for a variety of reasons, and we oftentimes had to decline these requests and follow a more traditional treatment protocol. However, with the current advances in dental implant design (including surface technology, thread pattern, and restorative connection), we can confidently and predictably deliver immediate dental restorations in one dental appointment. One of our favorite dental implants for "teeth in one day" is the NobelActive fixture from NobelBiocare. We have been impressed by the tremendous stability at insertion (70 Ncm), platform switch - bone preservation design, surface technology to maximize bone-implant contact and osseointegration, and ease of restoration.

Case selection is paramount to assure a successful outcome, and not every patient is truly a candidate for these procedures. Every case has to be thoroughly evaluated on its own merits. And, there is no substitute for clinical experience and surgical expertise. In the end, our mission is to have a happy and healthy patient with normal function and a beautiful smile.

Have any of you had similar experiences? Please share them with the community.

Cary Feuerman, DMD

photo credits:

Dental Implant #9 - Cary Feuerman, DMD

NobelActive Graphic:

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An interesting article by Pamela Babcock.

To make your teeth last a lifetime, don't do these things.

Teeth are tough -- their enamel is the hardest part of the body -- but they're no match for neglect, misuse, or abuse. Here are some surefire ways to find out how vulnerable your teeth are -- trust us, you don't want to do this:

1. Don’t Brush After Every Meal.

The ideal is to brush your teeth three times a day: after breakfast, lunch, and dinner. But if you do it too soon, you can scrub away tooth enamel that becomes softer in the acidic environment created in your mouth when you eat.

“Make sure you wait 30 to 60 minutes after each meal, which gives the acidity time to neutralize and the teeth time to remineralize," says Debra Gray King, DDS, FAACD, of the Atlanta Center for Cosmetic Dentistry.

Brushing too much, too hard, or with a hard-bristle brush can also erode your enamel. Brush gently, using circular strokes and a soft brush.

2. Forget About Flossing.

Flossing stimulates gum health by cleaning between the teeth and under the gum line. Gums bleed when you brush vigorously? That’s a sign of mild gingivitis, or inflammation of the gums, which can lead to tooth loss.

“You need to brush and floss your teeth every time you eat,” says Jeffrey Gross DDS, FAGD, a Cleveland dentist. “The longer food stays in contact with the teeth and the gums, the easier it is to create problems.”

3. Skip checkups.

Dentists recommend every six months, but most patients fail to comply. This allows plaque to form tatar, which attracts more plaque on its surface, carrying the plaque deeper within the gums. This can weaken supporting structures, such as bone.

“The sooner you find issues, the easier and a lot less expensive they will be to address,” King says.

4. Use Your Teeth as Tools.

Chomping ice and hard candy, not to mention popping off bottle caps and ripping open potato chip bags, can crack or break your teeth.

“People tend to do some wild things with their teeth,” King says. She recalls a patient in her 50s who habitually gripped the ropes of her sailboat’s mast between her teeth. 

Over time, the woman’s natural teeth had worn to the point she needed porcelain veneers. Find a bottle opener or pair of scissors. And if you’re sailing, use your hands.

5. Ditch the Mouthguard.

The Academy of General Dentistry (AGD) recommends mouthguards for many athletes. 

“Anytime there is a strong chance for contact with other participants or hard surfaces, it is advisable to wear a mouthguard. Players who participate in basketball, softball, football, wrestling, soccer, lacrosse, rugby, in-line skating, and martial arts, as well as recreational sports such as skateboarding and bicycling, should wear mouthguards while competing,” the AGD’s web site states. 

6. Grind Away.

Some people clench or grind their teeth when bored, lifting something heavy or stressed; others do it while they sleep. Tooth-to-tooth clenching can wear down teeth and “make you look 10 to 20 years older,” King says.

Grinding also paves the way for cavities. “Aside from causing pressure and fractures, grinding wears away the top layer of enamel and the lower levels of enamel beyond the dentin, which can lead to decay,” Gross says. Can’t stop? Get fitted for a mouthguard.

7. Guzzle Soda, Sports Drinks, and Fruit Juices.

Soda and sports drinks often have either too much sugar or, in the case of diet soda, too much acid. Fruit juices often contain sugar but compared to soda and sports drinks, are “a healthier choice” and water is even better yet, Gross says. 

8. Drink Lots of Red Wine, Coffee, or Tea.

The surface of stained teeth is like sandpaper and attracts more bacteria, which can indirectly lead to tooth decay.

As wine editor for Dish magazine, Yvonne Lorkin of Christchurch, New Zealand, tastes thousands of wines each year. At 37, she spends more on dental upkeep than people twice her age.

“The constant onslaught of acid on my enamel is an occupational hazard, I guess, as we're swilling the wines around in our mouths rather than just swallowing,” Lorkin tells WebMD in an email interview. 

Aside from cutting back, Gross recommends using a straw, when possible, so staining liquids bypass your teeth.

9. Whiten Too Often.

Chronic whitening or failing to follow instructions can lead to gum irritation and increased tooth sensitivity. Desensitizing toothpaste can help. 

If you have very sensitive teeth, gum disease, or worn enamel, “your dentist may discourage whitening,” says Charles H. Perle, DMD, FAGD, a dentist in Jersey City, N.J. and a spokesman for the AGD. Check before starting any whitening treatment.

10. Drink Bottled Water.

Most bottled water has little or no fluoride and most home filtration systems filter much of it out. Stick with fluoridated tap water since it’s “the most cost-effective way to prevent cavities and fight tooth decay,” Perle says. If your water isn’t fluoridated, your dentist may prescribe fluoride supplements.

11. Get Your Tongue Pierced.

When you speak, your tongue moves to make certain sounds and consequently “you’re jamming the metal piercing into your teeth,” Gross says. Fractured teeth may require veneers or crowns in a patient who otherwise doesn’t have other issues.

Jason Lazarus, CEO of Gadgets and Gear in Hauppauge, N.Y., got his tongue pierced and admits he played with it “all the time.” Lazarus says he was shocked when X-rays showed his front teeth “dramatically shaved and chipped” and immediately took his tongue ring out.

“I didn’t want my teeth to get worse,” Lazarus says. He has since spent $2,000 on laminates for his two front upper teeth.

12. Be Bulimic.

Bulimia, which is characterized by bingeing and vomiting, can cause significant dental problems because of the stomach acids. 

“The enamel is usually just kind of worn off, mostly on the front teeth, but even going to the back teeth,” King says. If the damage is done, you may need restorations.

13. Abuse Drugs Such as “Meth."

Crystal methamphetamine, an illegal and highly addictive stimulant, can wreak havoc on your mouth. Users often crave sugary foods and drinks, clench their teeth, and have dry mouth. Telltale signs of “meth mouth” are rampant decay with blackened teeth on the verge of falling out.

“People on methamphetamines are notorious for not taking care of themselves,” Gross says. “By the time the patient is 25 or 30, they are looking at a full set of dentures.”

14. Chronically Use Some Legal Medications.

Oral contraceptives change a woman’s hormonal balance and can lead to chronic gum disease.

“Once they get off the medication, the damage is often done,” Gross says. Some over-the-counter cough medications have lots of sugar, and antihistamines can cause dry mouth, which can lead to decay since saliva protects the teeth.

15. Continue Lighting Up.

Smoking is bad for teeth and gums. Stains make teeth more susceptible to bacteria. It’s also a factor in the development of periodontal or gum and bone disease. 

“The smoke impedes the ability of the gum tissue to maintain a healthy state and fight off disease-creating bacteria,” Gross says. “Almost half of the people who are over 60 who wear dentures are smokers.”


Comments are appreciated!


Cary Feuerman, DMD

Periodontal Associates


Source:  WebMD

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Overuse of Cone Beam CT Scans in Dentistry?

The other day, the New York Times featured an article entitled "Radiation Worries for Children in Dentist's Chairs". The article mainly centers around the increasing use of Cone Beam CT Scans by dentists, including oral surgeons and orthodontists, to aid in the diagnosis and treatment of a variety of common dental problems in children such as malocclusion and impacted teeth. The main issue is that these children are being exposed to much higher doses of radiation as compared to those children who are being evaluated with more traditional diagnostic tools such as conventional panoramic and periapical dental Xrays (both digital and film), photographs, and study casts of the dentition.

The article states that many experts in dental radiation have raised alarms about what they see as their indiscriminate use. They worry that with few guidelines or regulations, well-meaning orthodontists and other specialists are turning to a new technology they do not fully understand, putting patients at risk, particularly younger ones. Some orthodontists now use Cone Beam CT scans to screen all patients, even though a number of dental groups in this country and in Europe have questioned whether the benefit of routine use justifies the added risk. The ADA has already responded and advises that dentists follow the ALARA principle (As Low As is Reasonably Achievable) to determine which diagnostic tools are best for each particular case.

There is no question that Cone Beam CT scans can help dentists and surgeons deal with complex cases involving dental implants, TMJ disorders, jawbone pathology, and other serious dental and medical problems. As a periodontist who has been placing dental implants for over 23 years, we have been using CT scans since the early 1990s to aid in diagnosis and treatment planning for complicated cases. The technology is an extremely valuable tool which helps us to provide our patients with a safe, predictable surgical outcome. But the vast majority of our smaller cases do not require the use of this technology, especially when we have extracted the teeth and repaired the bone with bone graft and guided bone regeneration procedures. These cases may be evaluated by more conventional means outlined above.

With the increasing prevalence of in-office CBCT scanners, usually at a cost of around $140,000, I sometimes wonder if they are being overused by some clinicians just to help pay for the cost of the machines. I would like to believe that this technology would only be used when absolutely necessary to justify the extra radiation exposure, but I have seen instances with patients referred for second opinions where conventional dental Xrays would have been adequate for proper diagnosis and treatment. On the other hand, I completely understand the concept that dentists and surgeons would like to have the best and most complete information available to them prior to treating their patients. In this litigious society, implant surgeons have oftentimes been told that utilizing CT scans in the diagnostic phase is actually the standard of care. So, therein lies a "Catch 22". In the end, we must rely on the judgment, skill and expertise of the treating dentist and surgeon to determine how best to evaluate cases. But, patients do need to be informed of the risks and benefits, especially when concerning children.

Do you think the NY Times article is valid? What are your experiences? Your comments are appreciated.

Cary Feuerman, DMD

Periodontal Associates

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My partner, Giovanni Castellucci, and I have been treating periodontal disease in our periodontal practice for over 29 years. Every day, we see an ever increasing amount of requests from our restorative colleagues and patients from Boston, Newton, Framingham, and the surrounding metrowest communities for Laser Periodontal Treatment as an alternative to more conventional surgical modalities. Dental lasers have been around for many years, and, in my opinion, are here to stay. Several laser devices and treatment protocols exist today including LANAP (laser-assisted new attachment procedure) and LPT (Laser Periodontal Therapy) from Millennium Dental Technologies, WPT (Wavelength-optimized Periodontal Therapy) from Lares Dental Research, and LAPT (Laser-Assisted Periodontal Therapy) from other companies such as Biolase, Kavo, and HOYA ConBio - just to name a few. Benefits include virtually pain-free procedures without surgical incisions and stitches, usually minimal or no bleeding, reduction of bacteria levels, shorter treatment times, and faster recovery. Our patients welcome these possibilities.

It is important to consider that every case must be evaluated on its own merits, and not all cases are best treated with dental lasers. Time-tested conventional periodontal therapy including elimination of bony defects by resection or bone regeneration techniques continues to play an active role in our daily practice.

The number of scientific research studies relating to the use of lasers in dentistry continues to expand. Evidence-based protocols for the treatment of gum disease and associated periodontal problems is of paramount importance for our patients.

What has been your experience? Are your patients requesting laser periodontal treatment? Comments are appreciated.

Cary Feuerman, DMD

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