EDWARD J. ZUCKERBERG, DDS, was a private practitioner from 1981 to 2013 in Dobbs Ferry, New York, where he created painless techniques and focused on implementing cutting-edge technology. He authored the chapter on social media in The ADA Practical Guide to Internet Marketing. Today, he maintains a part-time practice in Cupertino, California, while advocating for the advancement of the dentist as a primary care practitioner through his work as chief dental officer at Viome and advising numerous other oral health start-ups.
Inside Dentistry (ID): You've long been a proponent of incorporating technology into the dental practice. What are some of the most exciting advancements in dental implant technology that you've seen recently?
Edward J. Zuckerberg, DDS (EJZ): The robotic influence and the AI influence are obviously making implant placement more accurate and safe for the patients and more efficient for the practitioners. Lately, my general focus has been on the oral-systemic connection. I'm a lot more focused on the role that bacteria play in not only periodontal disease and diseases of the mouth but also diseases of the body as well. Peri-implantitis is well documented as one of the leading causes of implant failure, and research has shown that Porphyrmonis gingivalis, which is the main driver of periodontal disease, is also the main driver of peri-implantitis. So, I think that in the ounce of prevention school, one technology that dentists should be paying more attention to is salivary diagnostics. Before embarking on implant cases, dentists should be acquiring a full salivary microbiome analysis, and there's a number of ways to do that. But by identifying at-risk patients before the implant, we can eliminate a lot of our post-placement failures.
(ID): What role do you think robotics and dynamic navigation will play in the future of implant dentistry? Are we close to mainstream adoption?
(EJZ): About 8 years ago, I was on the diligence team for a venture capital company who was considering an investment in Neocis, the manufacturer of the Yomi robotic surgery system. We flew down to Miami, Florida, to get firsthand experience using it to work on a mannequin mouth, and I can tell you, it was really easy. I mean, I could not place an implant at an incorrect angle. The robot would not allow me to do it. And then once I started placing an implant, if the treatment plan called for a 10-mm sink, the robot would not go deeper than 10 mm. It would hit a hard stop, and that would be the end.
I think that this technology may not be a great fit for clinicians who already place a lot of implants, but it's perfect for those who only occasionally place implants because the robot is going to provide the ultimate in safety for patients. When it comes down to it, a robot is going to make fewer errors. It's not going to slip and accidentally cut a lip or a tongue or anything like that. It's going to be more precise and exact and do better dentistry. I think that patients trust robots to be very precise surgically.
(ID): How are magnetic and piezoelectric technologies being employed to advance healing and osseointegration?
(EJZ): The developments in these technologies are really exciting, not just for implants but also for periodontal disease. Various forms of electric fields, such as magnetic and piezoelectric, are being used to expedite care. This is certainly an exciting field in terms of both improving the quality of bone that we're placing our implants into, which will lead to lower failure rates, and shortening the time interval between extraction and grafting and when the bone is fully healed. Faster bone growth and healing reduces the overall time to get that final implant result for the patient. The studies are all very positive in terms of showing bone growth that is faster and denser, and when it comes to piezoelectric, a company called Oral Biolife has done some early work on dogs that has demonstrated the ability to actually regrow bone in the furcations.
When it comes to periodontal treatment, until now, the goal of therapy has always been to halt, arrest, or slow down the progress of periodontal disease. Regarding the regeneration of bone, we may be able to fill in a three-wall defect, but the ability to regrow vertical bone is something that's never been in our armamentarium. When Oral BioLife's piezoelectric hydrogel is injected subgingivally after scaling and root planting and then light cured, normal function (ie, chewing, clenching) stimulates it to release piezoelectric energy into the tissues. It is hypothesized that this creates an antibacterial effect, lysing the cell membranes of pathologic bacteria, and also stimulates bone growth, overcoming the main obstacles to osteoblastic activity. So, looking at these studies in dogs, the early line here is that there could be a use case for piezoelectric energy to regrow and regenerate bone. Currently, Oral BioLife is focusing on periodontal applications, but they're also planning to look at implant applications for the gel.
(ID): What innovations can help patients improve at-home oral care following implant placement, especially for those who required implants due to their preexisting poor oral hygiene habits?
(EJZ): There's some really cool new stuff being developed for home care. I'm a venture partner for Revere Partners, and we have invested in a device called the Proclaim Oral Health System. The system utilizes a custom mouthpiece, which is created from a scan of the user's mouth, that has lots of holes in it that are located over each tooth and interproximal area. Similar to a water flosser, the mouthpiece is connected to a water tank with a tube. When the user bites down on the mouthpiece, the system sprays the water through the holes, precisely targeting the user's teeth and interproximal areas. I can't imagine a more effective way to keep the mouth clean. It's our job to explain to patients that implants can suffer from the same periodontal disease that natural teeth can and that it's critical for them to brush and floss their implant-supported restorations, maybe even more so than their natural teeth, because implant restorations may have irregular surface areas and are not as smooth as natural teeth.
(ID): How can dentists best incorporate new innovations into their implant treatment protocols, and if they could only start with one area of technological advancement, what area would you advise them to start with?
(EJZ): If they haven't already incorporated salivary diagnostics, then that is the one area that I'd advise them to start with. That will lead to better oral health in their patients, and patients who start with better oral health are going to have higher implant success rates. Other than that, keeping abreast of the current technology that is being developed is key. The convention scene kind of dried up a little during the COVID-19 era, but it is coming back now, and it's beneficial to get face-to-face with manufacturers and product sales representatives to see stuff and try it out in person. I like getting out of the office for a day or two to attend a meeting, share ideas with colleagues, find out what's working for them, and get really hands-on with new products and ideas. It's also a good idea to keep abreast with the journals and to follow study groups and social media groups like there are on Instagram and Facebook and whatnot to learn what the latest technologies are and how they are working for others.
(ID): What developments are going to help prevent peri-implant disease, and how can clinicians ensure that they're giving their implant patients the best chance for success?
(EJZ): This comes down to evaluating the salivary microbiome and actually measuring the bacteria. There are a couple of companies that are doing work in this area, including Viome, where I'm the chief dental officer. Viome offers a salivary screen with 95% sensitivity for oral and pharyngeal cancer. To me, that alone is a reason why every dentist should be performing one of these on every patient in his or her practice. The ability to detect cancer before we see a white spot, red spot, lump, or anything like that may be a game changer. The 5-year survival rate for oral cancer is still sitting at the same 50% that it was 47 years ago when I began my career as a dentist. Yes, we have some pretty incredible technology that allows us to take parts of an oral cancer patient's tibia to create a jaw and have implants fitted while the patient is having his or her tumor removed so that the patient wakes up with teeth that are in occlusion, but that's not doing anything to help diagnose oral cancer earlier or improve the 5-year survival rate.
Beyond helping with cancer prevention, performing salivary diagnostics is giving us mRNA-based scores that provide information on patients' periodontal health and the role that P. gingivalis is playing in their mouths. There's another company called Integral that has taken this a step further with a test that is geared only at peri-implantitis. After a salivary sample is collected, they do a specific screen and send the dentist a report detailing the patient's risk score for peri-implantitis. This is an excellent proactive step that dentists can take before placing implants.
(ID): Where is AI ready to help with implant cases today, and where do you see it making the biggest impact in the future?
(EJZ): There are a number of companies in the AI imaging market. Overjet and Pearl are well known, and lesser known is a company called VELMENI. Full disclosure, I'm an advisor for VELMENI. They are the first company that has approval from the US Food and Drug Administration for using AI on panoramic radiographs. But, of course, as you probably know, the big prize at the end of the rainbow is being able to apply AI to cone-beam computed tomography (CBCT). Nobody is quite there yet, although I believe VELMENI is the leader of the pack.
When the team at VELMENI first approached me to be an advisor and asked me to guide them regarding the direction that the company should go, I told them that they need to make CBCT easy to understand for everyone, not just for the dentist. We've got to be able to explain this to the patients as well. We know what we can do for patients, but we've still got to convince them that our recommended treatments are the best for them. VELMENI actually has a tool now where patients can put on a Meta Quest headset and look at their jaw and skull in 3D, and then the dentist can kind of overlay an implant treatment plan for them.
Although the patient aspect is important, the true potential for using AI with CBCT is in assessing sites for ample bone width, height, and quality. This can help us to plan and perform sinus lifts and things like that by showing us what's possible as well as highlight anatomic landmarks to help prevent surgical accidents during implant placement.
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Edward J. Zuckerberg, DDS
