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Implants


what dentistry calls 'state-of-the-art'

Modern western dentistry takes pride in claiming that titanium implants are the 'state of the art' method of filling the gap after a tooth extraction.  In fact, in Australia, the dental boards frown on a dentist who does not recommend implants to their patients. I state clearly here that I do NOT recommend implants for anyone and call for sound research to be published on the systemic effects of placing titanium implants into the body.  Thankfully there has now been a little of this research done.  Go to the MELISA web site for more information. If you are suffering with an autoimmune disease, this is a MUST READ web site for you.implants in the mouth

Many detrimental health effects are possible from exposure to small amounts of titanium and its oxidizing by-products;

Damage to human bronchial cells(1)
Stimulate bone resorption( 2)
Antibody Mediated immune responses( 3)
Excessive corrosion of Titanium is caused by exposure to fluoride( 4, 5, 6)
Generalized allergic reactions( 7, 8)
Amalgam and Titanium in the same mouth increases corrosion of the amalgam and thus the increased release of mercury9( )
Titanium and amalgam produce dramatic ph changes and a change in taste sensation( 10)
Some are carcinogenic( 11) (it is possible that NiTiSMA particles are directly carcinogenic)
High electrical currents are generated between titanium implants and other metals in the mouth
( 12, 13)
Reduced immune function caused by damage to the spleen( 14)
Titanium found in the root filling cement AH26 has an oestrogenic effect on breast cancer cells.( 15)

From the Holisitic Dental Association website:

“In conclusion, titanium and its oxidizing by-products are not as inert and biocompatible as once believed. Advances in research technology are showing changes to immune reaction cells in the blood, and the lungs. These findings should be taken into consideration when deciding whether or not to remove an implant on a particular patient. The dentist should also take precautions for their own safety when removing an implant, or when adjusting a titanium partial with a high-speed drill.”

The Pros;

1-They do not interfere with the adjacent teeth. 
2-They are solid (most of the time)

The Againsts:

1-The Special Supplement on Endodontics by the Australian Dental Association from March 2007 states the most commonly accepted reasons that dentists would consider that an implant has failed.

“Implant complications may be broadly divided into two categories: biological and technical (mechanical). Biological complications refer to disturbances in the function of the tissues supporting the implant. ... Biological complications also include reactions in the peri-implant hard and soft tissues, which may require adequate clinical and radiographic examination methods for detection.”

In other words success or failure of this treatment is only in regard to the mechanics of the implant itself and also ONLY the local tissue surrounding the implant.  This attitude neglects the wealth of published research which indicates far worse problems.

implants bilateral

2-They are expensive

3-They may cause a loss of fine muscle control of the mandible due to the fact that there is no periodontal ligament and thus all forces are transmitted directly to the bone with no cushioning.

The Special Supplement on Endodontics by the Australian Dental Association from March 2007 states;

“Implants lack a periodontal ligament and therefore the ability to buffer or dampen the forces of occlusal trauma.”

“Patients who lack information from periodontal receptors show an impaired fine motor control of the mandible.”

implant in abscess

4- As there is no fibrous seal between the gingiva (gum) and the post which is emerging from it, there cannot be a seal which prevents bacteria from causing infection in this area and easily entering the bone. 

This supposed tight seal is more like the Champs Elyse to a bacteria. There will always be a minor infection and inflammation in this area.  It is now called ‘peri-implantitis’.  Dentistry is great at making a new language.  If this infection progresses to the bone it is called osteomyelitis.  Such an infection would mean that the implant should be removed and there is a great risk of serious systemic consequences.

5-Most often the implant which is made of titanium will support a metal crown which is usually made from a gold alloy and in some cases completely non-precious alloys. 

Effectively this is an implant of dissimilar metal in the bone.  This can create enormous electrical currents which can have a direct negative effect on the central nervous system.  It is common to find currents as high as 100 micro-amps. 

This situation will also occur if there are any other metals in the mouth, including amalgam or any other crowns or bridges.  The electric currents generated by these devices may also act as a neural interference field.  The galvanic effect will also create an increased rate of corrosion in all of the metals.

6-The increase in currents will drive metal ions from the implant which are then transported around the body, as demonstrated in many published articles.  The spread of titanium from implants is even acknowledged by the Australian Dental Association ( 16). ( 17, 18, 19, 20, 21)

7- I would strongly recommend reading the MELISA website at www.melisa.org, where the following is published:chronic bone infection around titanium implant

“Like all metals, titanium releases particles through normal corrosion. These metals become ions in the body and then bind to body proteins. For those who react, the body will try to attack this structure. This starts a chain reaction which can lead to many symptoms including Chronic Fatigue Syndrome (CFS) or, in the most severe cases, Multiple Sclerosis (MS). The MELISA® test is the only scientifically-proven test which can diagnose titanium allergy and measure its severity.”

 

This is the main issue regarding the implantation of Titanium.  The potential risk of creating an autoimmune disease is HIGH!  There are few doctors who would recognize metal intolerance as a cause of autoimmune diseases and even fewer dentists who would have a clue.  I do NOT recommend implants.  I DO recommend that you read the information at www.melisa.org.  Sorry for repeating myself but this really is critical information if you are contemplating this treatment.

8-In the presence of fluoride there is a dramatic increase in the release of titanium form the implant. 
So where is the rational of fluoridating the water, having fluoride in toothpaste, having a regular fluoride treatment every six months and then having titanium implanted into your jaw?  “The ion release increases extreme (up to 500 microg/(cm2 x d) in the presence of fluoride.”( 22)

9-In terms of the evidence which supposedly supports the great success of this treatment, it appears that there is not very much of it. 

Also from the Special Supplement on Endodontics by the Australian Dental Association from March 2007, we read a citation from the Journal of Evidence Based Medicine,( 23)

“White et. al., ( 24) in a recent evidence-based review of the outcomes of both treatment modalities, noted that if evidence-based principles are applied to the data available for both treatment modalities, few implant or endodontic outcome studies can be classified as being high in the evidence hierarchy.”

If there is little evidence supporting these treatments
than what are they based on?

Implant and rct

10-Even the Australian Dental Association has published warnings against placing an implant near to a root treated tooth.  The reason is that the bacteria which remain in the dead tooth, whether there is an abscess showing on the x-ray or not.  They even suggest that it may be better to extract the dead tooth before placing the implants.( 25)

“….the importance of evaluating and possibly retreating or extracting adjacent endodontically treated teeth before placing implants.”
“It has been reported that implant failure may occur when the implant is positioned adjacent to teeth that are clinically symptomatic of periapical pathology.”
“An asymptomatic tooth that appears normal on a periapical radiograph usually indicates that endodontic treatment has been successful.”
“It has been shown, however, that even if a periapical area seems to have been resolved on a radiograph, microorganisms may persist indefinitely.”
“Dentists are unable to test the sterility of a tooth’s apex. Therefore, an asymptomatic endodontically treated tooth may be harboring a chronic infection, which may be the cause of implant failure.”

Perhaps the cost of an implant
may be far higher
than the $ cost of having the work done!

Multiple Titanium implants with other metals and root therapies

 

A quick glance at the literature clearly shows
that these problems are well known
and have been for quite some time. 
Are patients ever informed of this information
when having implants recommended? 

 

Following are some abstracted references:

Ultrafine titanium dioxide particles in the absence of photoactivation can induce oxidative damage to human bronchial epithelial cells. Gurr JR, Wang AS, Chen CH, Jan KY. Toxicology. 2005 Sep 15;213(1-2):66-73. Department of Tourism, Hsing Wu College, No. 11-2 Fen-Liao Road, Linkou, Taipei, Taiwan 24452, ROC.

Ultrafine titanium dioxide (TiO(2)) particles have been shown to exhibit strong cytotoxicity when exposed to UVA radiation, but are regarded as a biocompatible material in the absence of photoactivation. In contrast to this concept, the present results indicate that anatase-sized (10 and 20 nm) TiO(2) particles in the absence of photoactivation induced oxidative DNA damage, lipid peroxidation, and micronuclei formation, and increased hydrogen peroxide and nitric oxide production in BEAS-2B cells, a human bronchial epithelial cell line. However, the treatment with anatase-sized (200 and >200 nm) particles did not induce oxidative stress in the absence of light irradiation; it seems that the smaller the particle, the easier it is for the particle to induce oxidative damage. The photocatalytic activity of the anatase form of TiO(2) was reported to be higher than that of the rutile form. In contrast to this notion, the present results indicate that rutile-sized 200 nm particles induced hydrogen peroxide and oxidative DNA damage in the absence of light but the anatase-sized 200nm particles did not. In total darkness, a slightly higher level of oxidative DNA damage was also detected with treatment using an anatase-rutile mixture than with treatment using either the anatase or rutile forms alone. These results suggest that intratracheal instillation of ultrafine TiO(2) particles may cause an inflammatory response.

Titanium particles stimulate bone resorption by inducing differentiation of murine osteoclasts. Bi Y, Van De Motter RR, Ragab AA, Goldberg VM, Anderson JM, Greenfield EM. J Bone Joint Surg Am. 2001 Apr;83-A(4):501-8.

CONCLUSIONS: The present study showed that titanium particles stimulate in vitro bone resorption primarily by inducing or survival.

Immunohistochemical study of the soft tissue around long-term skin-penetrating titanium implants. Holgers KM, Thomsen P, Tjellstrom A, Bjursten LM. Biomaterials. 1995 May;16(8):611-6. Department of Anatomy and Cell Biology, University of Goteborg, Sweden.

"The data suggest that there is an immunological compensation for the mechanical loss in barrier function at these implants and that an antibody-mediated response is present at clinical signs of irritation."

In vitro corrosion of titanium. Strietzel R, Hosch A, Kalbfleisch H, Buch D. Biomaterials. 1998 Aug;19(16):1495-9. BEGO, Bremer Goldschlagerei, Bremen, Germany.

Titanium is used in dentistry for implants and frame work because of its sufficient chemical, physical and biological properties. The corrosion behaviour is from high interest to value biocompatibility. A static immersion test was undertaken with a titanium test specimen (30 mm x 10 mm x 1 mm, immersion time = 4 x 1 w, n = 3 for each series). The following parameters were investigated: specimen preparation, grinding, pH-value, different casting systems, comparison with CAD/CAM, influence of: chloride, thiocyanate, fluoride, lactate, citrate, oxalate, acetate. Atomic absorption spectroscopy was used to analyse the solutions weekly. The course of corrosion was investigated photometrically. Titanium reveals ion releases [(0.01-0.1) microg/(cm2 x d)] in the magnitude of gold alloys. There is little influence of grinding and casting systems in comparison with organic acids or pH value. The ion release increases extreme (up to 500 microg/(cm2 x d)) in the presence of fluoride. Low pH values accelerate this effect even more. Clinically, no corrosion effects were observed. Nevertheless it is recommended that it is best to avoid the presence of fluoride or to reduce contact time. In prophylactic fluoridation of teeth, a varnish should be used.

(This is another good reason to avoid fluoride toothpastes)

Sensitivity to titanium. A cause of implant failure? Lalor PA, Revell PA, Gray AB, Wright S, Railton GT, Freeman MA. London Hospital Medical College, England J Bone Joint Surg Br. 1991 Jan;73(1):25-8 

Abstract:
Tissues from five patients who underwent revision operations for failed total hip replacements were found to contain large quantities of particulate titanium. In four cases this metal must have come from titanium alloy screws used to fix the acetabular component; in the fifth case it may also have originated from a titanium alloy femoral head. Monoclonal antibody labelling showed abundant macrophages and T-lymphocytes, in the absence of B-lymphocytes, suggesting sensitisation to titanium. Skin patch testing with dilute solutions of titanium salts gave negative results in all five patients. However, two of them had a positive skin test to a titanium-containing ointment.

A case of allergic reaction to surgical metal clips inserted for postoperative boost irradiation in a patient undergoing breast-conserving therapy Tamai K, Mitsumori M, Fujishiro S, Kokubo M, Ooya N, Nagata Y, Sasai K, Hiraoka M, Inamoto T. Breast Cancer. 2001;8(1):90-2

Abstract:
We report a case of a 28-year-old woman with right-sided breast cancer. The patient had been treated for atopic dermatitis since her infancy. She underwent breast-conserving surgery (BCS) in July 1998, and three titanium clips were placed at the margin of the excision cavity at the time of surgery. Two months after surgery, the patient exhibited a rapid exacerbation of atopic dermatitis. Various drugs were suspected to be the cause of the allergic reaction, but the results of a bi-digital O-ring test (BDORT) suggested an allergic reaction to titanium clips. In August 1999, the patient underwent a second operation to remove the titanium clips under local anesthesia. Allergy to surgical titanium clips is a rare complication, but in patients with a history of severe allergic diseases, a preoperative immunologic examination should be performed and the patient's history of metal allergy should be investigated.

Biocompatibility of dental casting alloys Geurtsen W Department of Conservative Dentistry and Periodontology, Medical University Hannover, D-30623 Hannover, Germany. Crit Rev Oral Biol Med. 2002;13(1):71-84.

Introduction:
Most cast dental restorations are made from alloys or commercially pure titanium (cpTi). Many orthodontic appliances are also fabricated from metallic materials. It has been documented in vitro and in vivo that metallic dental devices release metal ions, mainly due to corrosion. Those metallic components may be locally and systemically distributed and could play a role in the etiology of oral and systemic pathological conditions. The quality and quantity of the released cations depend upon the type of alloy and various corrosion parameters. No general correlation has been observed between alloy nobility and corrosion. However, it has been documented that some Ni-based alloys, such as beryllium-containing Ni alloys, exhibit increased corrosion, specifically at low pH. Further, microparticles are abraded from metallic restorations due to wear. In sufficient quantities, released metal ions-particularly Cu, Ni, Be, and abraded microparticles-can also induce inflammation of the adjacent periodontal tissues and the oral mucosa. While there is also some in vitro evidence that the immune response can be altered by various metal ions, the role of these ions in oral inflammatory diseases such as gingivitis and periodontitis is unknown. Allergic reactions due to metallic dental restorations have been documented. Ni has especially been identified as being highly allergenic. Interestingly, from 34% to 65.5% of the patients who are allergic to Ni are also allergic to Pd. Further, Pd allergy always occurrs with Ni sensitivity. In contrast, no study has been published which supports the hypothesis that dental metallic materials are mutagenic/genotoxic or might be a carcinogenic hazard to man. Taken together, very contradictory data have been documented regarding the local and systemic effects of dental casting alloys and metallic ions released from them. Therefore, it is of critical importance to elucidate the release of cations from metallic dental restorations in the oral environment and to determine the biological interactions of released metal components with oral and systemic tissues.

Corrosion of titanium and amalgam couples: effect of fluoride, area   size, surface preparation and fabrication procedures.   Johansson BI  Bergman B   Dent Mater (1995 Jan) 11(1):41-6

OBJECTIVES. The aim of this investigation was to study the effect of surface treatments and electrode area size on the corrosion of cast   and machined titanium in contact with conventional and high-copper   amalgams in saline solutions with and without added fluoride ions.   METHODS. The potentials and the charges transferred between amalgam   and titanium couples were registered using standard electrochemical   methods. RESULTS. Conventional amalgam corroded more than high-copper   amalgams in contact with titanium in saline solutions. Adding   fluoride to the solution made the titanium potential more active and   enhanced the corrosion of titanium in combination with high-copper   amalgams. The amalgam corrosion increased with a five-fold   enlargement of the titanium area. The increase was significant for   one titanium-amalgam combination. Surface preparations affected the   electrochemical behavior, and surface alterations were occasionally   observed on wet-ground titanium specimens. No significant differences   were found in comparisons of cast and lathe- cut titanium.   SIGNIFICANCE. Surface preparations and fluoride affect the    electrochemical activity of titanium.

Galvanic corrosion and cytotoxic effects of amalgam and gallium alloys coupled to titanium. Bumgardner JD  Johansson BI   Eur J Oral Sci (1996 Jun) 104(3):300-8

Results of this study indicated that before connecting the high-copper amalgams to titanium, the amalgams exhibited more positive potentials which resulted in initial negative charge transfers, i.e. corrosion of titanium. However, this initial corrosion appeared to cause titanium to passivate, and a shift in galvanic currents to positive charge transfers, i.e. corrosion of the amalgam samples. ... significant   cytotoxic effects were observed when the dispersed-type high-copper amalgam and the gallium alloy were coupled to titanium. Even though the corrosion currents measured for these couples were less than gold alloys coupled to amalgam, these results suggest there is the potential for released galvanic corrosion products to become cytotoxic. .

Corrosion current and pH rise around titanium coupled to dental alloys. Ravnholt G  Scand J Dent Res (1988 Oct) 96(5):466-72

Corrosion reactions around titanium, usually considered biologically inert, might be provoked by coupling it galvanically with more corrodible dental alloys. Experiments in vitro simulating the conditions of a titanium dental implant or root canal post coupled to an amalgam filling, demonstrated corrosion current densities up to 31 microA/cm2, anodic pH values around the amalgam down to 2, and cathodic pH values around the titanium up to 10. The amounts of tin released by the enhanced corrosion of amalgam might contribute measurably to the daily intake of this element; the corrosion current   generated reached values known to cause taste sensations. If the buffer systems of adjacent tissues in vivo are not able to cope with the high pH generated around the titanium, local tissue damage may   ensue; this relationship is liable to be overlooked, as it leaves no evidence in the form of corrosion products.

Morphological transformation of BHK-21 cells by nickel titanium shape memory alloy particles encapsulated by titanium oxide Qin R  Peng S  Jiang X  Chung Hua I Hsueh Tsa Chih (1995 Nov) 75(11):663-5, 708-9

Therefore, it is possible that NiTiSMA particles are directly carcinogenic and that NiTiSMA particles encapsulated by titanium oxide are not potentially carcinogenic.

Evaluation of restorative and implant alloys galvanically coupled to titanium. Venugopalan R  Lucas LC   Dent Mater (1998 Jun) 14(3):165-72

RESULTS: Noble restorative (Au-, Ag-, and Pd-based) alloys coupled to titanium were found to be least susceptible to galvanic corrosion. Co-Cr-Mo, Ni-Cr and Fe-based alloys coupled to tatanium were found to be moderately susceptible to galvanic corrosion due to mechanical-electrochemical interaction. Ni-   Cr-Be alloy coupled to titanium was found to be highly susceptible to galvanic corrosion. The in vitro test results for the titanium/Disperalloy combination does not concur with the published clinical performance of this combination, and thus warrants further investigation.

Corrosion of coupled metals in a dental magnetic attachment system.  Iimuro FT  Yoneyama T  Okuno O Dent Mater J (1993 Dec) 12(2):136-44

Corrosion of titanium and ferromagnetic stainless steel seemed to be accelerated by coupling with gold alloys or gold-silver-palladium alloys.

Polymetallism and osseointegration in oral implantology: pilot study on primate. Foti B  Tavitian P  Tosello A  Bonfil JJ     Franquin JC   J Oral Rehabil (1999 Jun) 26(6):495-502

After 2 months, the presence of a precious alloy superstructure lead to titanium   migration towards the area around the cervical region of the implant   (10-50 microm ). This phenomenon did not occur with a titanium   implant. It can therefore be presumed that polymetallism leads to   detectable corrosion after 2 months but without apparent modification of osseointegration.

On electric current creation in patients treated with osseointegrated dental bridges. Nilner K  Lekholm U Swed Dent J Suppl (1985) 28:85-92

Electric currents are created when metals or metal alloys are   immersed and make contact with each other in an electrolyte. ...The mean   potential difference between the two metallic systems was found to be 73 mV and the mean generated maximum electric currents was in the magnitude of 26 microA at oral contacts between titanium and dental gold alloy.

In vivo corrosion behavior of gold-plated versus titanium dental retention pins. Palaghias G  Eliades G  Vougiouklakis G  J Prosthet Dent (1992 Feb) 67(2):194-8

Two types of titanium dental retention pins and a gold-plated
  stainless steel pin were tested for their in vivo corrosion behavior.
 ... Traces of Hg, Sn, Cu, S, Zn,  Ca, K, Cl, P, and S were detected at the gold-plated pin/amalgam
  interface, while Cl and P were found at the gold-plated pin/composite resin interface.

Influence of fluoride on titanium in an acidic environment measured by polarization resistance technique. B oere, G. J Appl Biomater, 6(4):283-8, 1995.

Abstract:  The effect of sodium fluoride on the polarization resistance of titanium was investigated.  ...
The results showed a large decrease in polarization resistance with increasing fluoride concentration at pH 4. The polarization resistance at pH 7 remained constant after a slight decrease at a very high value, even with a high fluoride concentration.  The results clearly confirm that titanium is attacked by fluoride in an acidic environment.  The clinical implications are that fluoride rinses or fluoride gels must have a neutral pH if there is a titanium containing device in the oral environment despite the less prophylactic effectiveness.

References

1 Ultrafine titanium dioxide particles in the absence of photoactivation can induce oxidative damage to human bronchial epithelial cells. Gurr JR, Wang AS, Chen CH, Jan KY. Toxicology. 2005 Sep 15;213(1-2):66-73.

2 Titanium particles stimulate bone resorption by inducing differentiation of murine osteoclasts.
Bi Y, Van De Motter RR, Ragab AA, Goldberg VM, Anderson JM, Greenfield EM. J Bone Joint Surg Am. 2001 Apr;83-A(4):501-8.

3 Immunohistochemical study of the soft tissue around long-term skin-penetrating titanium implants.
Holgers KM, Thomsen P, Tjellstrom A, Bjursten LM. Biomaterials. 1995 May;16(8):611-6.

4 Corrosion of titanium and amalgam couples: effect of fluoride, area   size, surface preparation and fabrication procedures.   Johansson BI  Bergman B   Dent Mater (1995 Jan) 11(1):41-6

5 In vitro corrosion of titanium. Strietzel R, Hosch A, Kalbfleisch H, Buch D. Biomaterials. 1998 Aug;19(16):1495-9.

6 Influence of fluoride on titanium in an acidic environment measured by polarization resistance technique. B oere, G. J Appl Biomater, 6(4):283-8, 1995.

7 Sensitivity to titanium. A cause of implant failure? Lalor PA, Revell PA, Gray AB, Wright S, Railton GT, Freeman MA. London Hospital Medical College, England J Bone Joint Surg Br. 1991 Jan;73(1):25-8

8 A case of allergic reaction to surgical metal clips inserted for postoperative boost irradiation in a patient undergoing breast-conserving therapy  Tamai K, Mitsumori M, Fujishiro S, Kokubo M, Ooya N, Nagata Y, Sasai K, Hiraoka M, Inamoto T. Department of Therapeutic Radiology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan Breast Cancer. 2001;8(1):90-2

9 Effects of titanium-dental restorative alloy galvanic couples on   cultured cells.  Bumgardner JD  Johansson BI   J Biomed Mater Res (1998 Summer) 43(2):184-91

10 Corrosion current and pH rise around titanium coupled to dental   alloys. Ravnholt G  Scand J Dent Res (1988 Oct) 96(5):466-72

11 Morphological transformation of BHK-21 cells by nickel titanium shape memory alloy particles encapsulated by titanium oxide Qin R  Peng S  Jiang X  Chung Hua I Hsueh Tsa Chih (1995 Nov) 75(11):663-5, 708-9  it is possible that NiTiSMA particles are   directly carcinogenic 

12 On electric current creation in patients treated with osseointegrated   dental bridges. Nilner K  Lekholm U Swed Dent J Suppl (1985) 28:85-92

13 In vivo corrosion behavior of gold-plated versus titanium dental retention pins. Palaghias G  Eliades G  Vougiouklakis G  J Prosthet Dent (1992 Feb) 67(2):194-8

14 Ferreira ME, De Lourdes Pereira M, Garcia e Costa F, Sousa JP, de Carvalho GS. (2003) Comparative study of metallic biomaterials toxicity: a histochemical and immunohistochemical demonstration in mouse spleen. J Trace Elem Med Biol. 2003; 17(1): 45-9.

15 Pulgar R, Segura-Egea JJ, Fernandez MF, Serna A, Olea N. 2002. The effect of AH26 and AH Plus on MCF-7 breast cancer cell proliferation in vitro. Int Endod J. 2002 Jun; 35(6): 551-6

16Australian Dental Journal  (Aust. Dent. J.)  ISSN 0045-0421  002, vol. 47, no3, pp. 214-217 FRISKEN K. W. ; DANDIE G. W. ; LUGOWSKI S. ; JORDAN G. ;

17 Journal of the Indian Prosthodontic Association 2005 Vol 5 Iss 3 P126-131

18 Meachim G, Williams DF. Changes in nonosseous tissue adjacent to titanium implants. J Biomed Mater Res 1973;7:555-72.  

19 Solar RJ, Pollack SR, Korostoff E. In vitro corrosion testing of titanium surgical implant alloys: an approach to understanding titanium release from implants. J Biomed Mater Res 1979;13:217-50. 

20 Merrit K, Brown SA. In Compatibility of Biomedical Implants, Kovacs P., Istephanous NS. Editors, Proc.-Vol.94-15, The Electrochemical Society: Pennington NJ; 1994. p. 14.  

21 Ferguson AB, Jr, Laing PG, Hodge ES. "The ionization of metal implants in living tissue". J Bone Jt Surg 1960;42:76-89. 

22 In vitro corrosion of titanium. Strietzel R, Hosch A, Kalbfleisch H, Buch D. Biomaterials. 1998 Aug;19(16):1495-9.

23 White SN, Miklus VG, Potter Ks, Cho J, Ngan AYW,.  Endodontics and implants, a catalogue of therapeutic contrasts. J Evid Based Dent Pract. 2006;6:101-109

24 White SN, Miklus VG, Potter Ks, Cho J, Ngan AYW,.  Endodontics and implants, a catalogue of therapeutic contrasts. J Evid Based Dent Pract. 2006;6:101-109

25 Implant Failures Associated With Asymptomatic Endodontically Treated Teeth David L. Brisman, D.M.D.; Adam S. Brisman, D.M.D.; Mark S. Moses, D.D.S. JADA February 2001, page 191