Implant indications

The speaker outlined four questions which would be addressed in his presentation:

1. What are the rates of tooth survival in the general population and in people with periodontitis?
2. How can periodontal treatment change the trajectory of a patient’s prognosis?
3. What can be done for tooth preservation?
4. What are the key differences with implants in terms of prevention?

A recent systematic review of the rate of tooth loss in the general population found that 0.1–0.3 teeth are lost per patient per year (with some variation between continents) (Needleman et al. 2018). From this figure, it is remarkable that only a minority of people lose teeth.

“Only a minority of people lose teeth: 0.1–0.3 teeth are lost per patient per year”

Another systematic review reported on tooth loss in patients who had received periodontal treatment and proper maintenance (Chambrone et al. 2010). The results showed a mean tooth loss of 0.05–0.1 per patient per year, most of which occurred in a small fraction of patients and was caused mostly by reasons other than periodontitis.

From this evidence, we can see that well-maintained periodontal patients are four times less likely to lose teeth than the general population. Periodontal therapy is very powerful and effective.

“Well-maintained periodontal patients are four times less likely to lose teeth than the general population.”

The speaker went on to discuss what can be done for long-term preservation of teeth in cases involving extremely compromised conditions and treated with regenerating intrabony defects (Cortellini & Tonetti. 2004). Tooth survival was 96% at 10 years.

The 20-year results of an RCT comparing periodontal regeneration in compromised teeth with access flap surgery were recently published (Cortellini et al. 2017). They showed better tooth retention and cost-effectiveness for the regenerative approach.

The speaker also discussed the 5 and 10-tear follow-up of a study comparing periodontal regeneration at teeth compromised by periodontal defects beyond the apex with their extraction and replacement with implants or bridges (Cortellini et al. 2011). The regenerated group showed tooth retention of 88% at 10 years (all these teeth should have been extracted according to current standard practice because of the deep lesions). Furthermore, the cost for treatment and management of 10-year complications was much lower for the cases in which teeth were retained.

“Periodontal regeneration has been proven to be effective even in compromised cases”

The aim of periodontal treatment is generally to make the case maintainable in the long-term. This involves controlling the risk profile and keeping pocket depth shallow in order to control inflammation. It is an attainable goal.

Is the previous data gathered from teeth also applicable to implants?

A clinical study showed that the inflammatory response to experimental plaque accumulation at teeth and implants was reversible (Salvi et al. 2012). A recently performed study (Chan et al. 2019), however, shows that plaque-induced inflammation at implants is only reversible if the implant is not placed too deeply into the soft tissues (which is something clinicians frequently do to mask the metal components in the soft tissue mucosal tunnel). A retrospective clinical study on patients with peri-implant mucositis reported that only a third of the cohort returned to normal after following a hygiene programme (Costa et al. 2012).

“It seems that it is harder to resolve inflammation in implants than in teeth, due to the deeper peri-implant sulci”

This less favourable peri-implant soft tissue response may have been due to the fact that implants with a deeper sulcus than natural teeth may not allow proper plaque control.