Reaching a compromise
Over recent decades, dental implant therapy has become a major part of restorative dentistry and a number of clinical studies have indicated favourable long-term success rates. To my mind, one of the key elements in the success of implants is careful patient and case selection.
Running a periodontal referral practice involving implant placement, I regularly see patients who could benefit from implant therapy but who are severely periodontally compromised and so set alarm bells ringing. Is this worry justified and what problems do periodontal patients bring with them in view of dental implant therapy?
Implant failure can be divided into early and late failure. Late failure is less well understood and seems to be related to both the peri-implant environment and host parameters. In the periodontal patient who is either considering dental implants or who has them already, there are two microbiological considerations:
• Microbiota associated with peri-implantitis are also observed at sites with advanced periodontitis. However are these organisms the cause of the problem or are they present because of peri-implantitis?
• Periodontal pathogens present in periodontal pockets may colonise newly inserted implants and give rise to tissue breakdown. In partially edentulous patients, periodontal pockets may act as reservoirs for pathogenic organisms. At present, we have to work from the premise that periodontal patients are at more risk of implant failure. However, there is a lack of quality clinical data indicating by how much.
From a periodontal clinical standpoint, my approach has a number of angles and is practical rather than written in hard science:
• Many periodontally compromised patients are smokers. This is a periodontal and implant risk factor and should be controlled
• Patients with tooth loss and poor periodontal health are often uneducated and unmotivated about dental health. This must be changed before considering dental implants
• Oral hygiene and home care must be maintained to an excellent standard
• Active periodontal disease must be controlled on a long-term basis
• Periodontal patients with loss of teeth, or attachment loss around teeth may have occlusal disharmonies. These must be stabilised and the occlusal factors harmonised prior to implant therapy. Once again this must be maintained in the long term
• Don’t forget there are other restorative options that can be considered! There is no exact answer I can give you, but that’s the nature of dentistry.
1. Patient and case selection is vital for implant success
2. Late failure of implants is due to microbiota and pathogens
3. Periodontal patients are at higher risk of peri-implantitis
4. Minimise risk factors as much as possible
5. Good oral health must be maintained.