1. What is
the longevity of implant therapy? Are implants for life?
All
panelists agreed here that dental implants are not meant to last for life, despite
being the most successful implantable materials in medicine. Studies have shown
that approximately 90% of the patients maintain their implants at 10 years time
point, but there is a very wide individual variation that makes it very difficult
to give a reliable estimation for each patient. The panel suggested colleagues
to conduct a thorough risk assessment of each patient and communicate the
limitations to the patient, while emphasizing on the importance of attending a regular
maintenance scheme. Mario Rocuzzo mentioned that he offers a free replacement
if an implant is to be lost within 10 years, but only to patients who adhere to
the recommended maintenance scheme, an idea however that was not adopted by the
prosthodontist of the panel, Prof. Thoma. All authors stressed that it is
important not to convey the message to patients that “implants last for life”, something
that is actually not the case with any other medical device. Maybe not
surprisingly however, the attitude that “implants last for life” was still very
widespread among colleagues, as the audience poll showed..!
An online poll with the congress attendants showed that 36% of dentists believed that "implants are for life, but the prosthesis can be replaced", 28% believed the life expectancy to be 10-20 years and 22% admitted to "not have a good answer".
2. What can
we expect from the surgical treatment of Peri-implantitis? What to do if our surgery
fails to arrest disease progression?
Mario Rocuzzo
the basis of their 2021 study (reconstructive surgery) mentioned that he would expect
around 2/3 of the patients to maintain success after 5 years, with success defined
as the absence of deep pockets around the implants and absence of additional
bone loss. At the same time around 17% of patients may lose an implant in the same
period. Lisa Heitz Mayfield added that if one year after surgery after we
maintain pretty shallow probing depths and a fairly good stability of the bone
levels, we can anticipate a pretty good chance to still maintain success after
3 or 4 years. Recurrence of the disease can occur however at any stage. If deep
pockets and marginal bone loss persist or reappear at some point in time, she
will be not inclined to repeat the surgery, but rather consider explantation of
the implant. Actually, removal of the implant is something that we should consider
discussing with the patient, as one option or potential outcome to be aware of
in any case of peri-implantitis.
3. What to
do with implants which are placed in sub-optimal position?
Implants referred
to the prosthodontist might be at times placed in more or less compromised
position. Daniel Thoma acknowledged that this can be at times the case in
particular in full arch restorations, therefore he always aims to discuss the
treatment plan with the surgeon beforehand. In cases however where he ends up
with a referral of malpositioned implants,
he will discuss the risks first with the referring colleagues as well as the
patients. There were cases where he ended up choosing other restorative options
than implant born restorations in such situations.
4. What
about prosthesis modification in patients with Peri-implantitis?
This is a
situation that is occurring often, especially in large and full arch reconstructions.
When the prosthesis predisposes to plaque accumulation and peri-implantitis
would discuss with the referring dentist and explain the need for modification.
As however many patients are no longer followed by the dentist who placed the
restoration or do not wish to return for further care, he often has to
undertake such modifications himself or in collaboration with his lab, after a
thorough explanation to the patient. In some cases prostheses cannot be easily
modified and at times he had to remake them or resort to replace fixed with removable
prostheses.
5. How do
you decide between surgical treatment or explantation?
Here we
have to use multiple levels. First of course the patient behavioural and systemic
risk level. Obviously no surgery will be meaningful for a patient who is unable
or unwilling to apply the proper oral hygiene. Then come several local
parametres that can direct us to one or the other option. It is very important if
the implant is properly positioned or in a compromised place. If there is an
aesthetic involvement or not. Furthermore, added Mario Rocuzzo, the surface and geometry of the implant, the
familiarity of the operator to the implant and how easy it is to decontaminate it.
The prosthesis type and accessibility to the defect, the amount of bone and tissue
remaining, the presence and condition of neighbouring teeth, the overall
rehabilitation plan and the strategic aspects of possible alternative solutions
or not, all these might be important determinants in a case-by-case assessment.
6. Do systemic
antibiotics help in the surgical treatment of peri-implantitis?
Maybe
surprisingly to many, Lisa Heitz Mayfield acknowledged that the evidence in
support of the use of systemic antibiotics as a supplement to peri-implantitis
surgery is very weak. In very few randomized controlled trials a small benefit
is shown in favour of systemic antibiotics which is limited in the first year.
In the light of recent evidence about the potential harmful role of antibiotics,
it is today debatable whether systemic antibiotoics should be used with
peri-implantitis treatment. On the other hand she admitted that her studies
with surgical treatment of peri-implantitis were conducted in conjunction with
systemic antibiotics, mainly Amoxicillin and Metronidazole.
7. Which
are the main risk factors for peri-implantitis?
Lisa Heitz
Mayfiend identified 3 major risks for
peri-implantitis, based on the current evidence:
-
Deficient
plaque control
-
History
of severe periodontitis
-
Lack
of compliance with maintenance care
Surprisingly
maybe, the evidence against smoking and diabetes is less robust, although both
have been traditionally considered as major risks. The good news is then that 2
of the major risks are controllable with proper interventions. Proper design to
ensure cleanability of the prosthesis and professional maintenance care
delivered at least twice a year together with patient administered oral hygiene
could minimize the risks for peri-implantitis. Finally, she presented a recently
published instrument (IDRA) for the assessment of the patients’
peri-implantitis risk based on 8 parametres: a) prosthesis design b) supportive
care frequency, c) bleeding on probing d) number of deep pockets e) Perio susceptibility and f) Bone Loss in relation to age.
