Approximately three million Americans already have dental implants. This figure is estimated to increase by half a million each year.
Over the past few years, the quality of dental implants has significantly improved, with success rates generally estimated around 95%. However, complications are more likely to arise when dental implants are placed by clinicians who have minimal surgical experience or who have a lack of training in the planning of treatments. Although implants are usually a highly successful treatment, a small percentage of dental implants will fail, even when planned and placed correctly. This may be due to mechanical problems, a failure of the implant to osseointegrate, or rejection or infection. Peri-implantitis is also a particular problem. Generally, when an implant begins to fail there is little choice but to remove it.
Often implant complications are due to several different factors, making it tricky to identify the reason as to why an implant may fail. A multidisciplinary approach towards treatment is essential. Prior to recommending dental implants, it’s important to thoroughly assess the patient’s medical history and to complete a thorough intraoral examination.
Minimizing Complications during the Planning Phase
Before implant surgery, any existing dental conditions should be treated, especially concerning the management of periodontal disease. Next, a restorative treatment plan can be developed using x-rays and a CT scan and possibly a diagnostic wax-up. Using implant simulation software will help you to evaluate all anatomical structures and to determine all possible implant positions. If required, bone augmentation should be completed to help improve the success of implant therapy, allowing dental implants to be optimally positioned. Peri-implantitis is thought to be more prevalent in poorly positioned dental implants. Additionally, good positioning is required to achieve a functional and esthetic outcome.
Another factor that must be considered is whether to use a screw-retained or cement-retained restoration. There are several advantages to using a cement-retained restoration in terms of ease of use, cost, and the ability to change the angulation of the implant access through using angled abutments. However, a screw-retained restoration may have a slightly lower risk of complications, which is mainly due to the problem of subgingival residual cement. It’s thought residual cement can act as a bacterial reservoir, potentially contributing to peri-implantitis.
Behavioral and Biological Risk Factors
Given the initial cost of implant treatment, patients have high expectations regarding its success, but may fail to understand the importance of their role during and after treatment. Often their understanding of dental implant treatment is limited. Helping patients to recognize potential risks, developing and discussing a suitable treatment plan, and providing good ongoing maintenance care will help minimize complications, improving the long-term treatment outcome for the patient.
When discussing dental implant treatment with patients, there are several important steps you can take to ensure they understand the importance of adhering to a proper ongoing maintenance plan. Patients may need to modify behaviors to reduce their risk and to help improve the long-term outcome of treatment, but this is often easier said than done. Other risk factors are related to the patient’s dental history and their medical history. It’s also important to consider nutrition and even stress.
Many patients may have lost teeth due to a history of periodontal disease. When this is the case, it’s important that they realize the increased risk of peri-implantitis and implant loss. One common assumption among patients is that a dental implant is resistant to infection, but implants are equally as susceptible to the pathogens in biofilms as natural teeth. Good adherence to a dental hygiene routine is particularly essential for patients in this position. They should understand that regular maintenance visits and ongoing oral care at home are extremely important. You can recommend the frequency of their maintenance visits and treatment based on their risk factors. Patients who have an acceptable oral hygiene routine may only need maintenance visits every six months, but others might need to see a hygienist more frequently.
Peri-implantitis is a major cause of implant failure, where inflammation can destroy the hard and soft tissues around the implant. It can develop when pathogenic microbes are incorporated into biofilms, encouraging their growth. These pathogenic microbes are little different from periodontal disease and are dominated by gram-negative bacteria. When biofilms are allowed to develop on dental implants it can lead to peri-implantitis.
Smoking is a major risk factor for implant failure and for periodontal disease. Patients who continue to smoke during and after treatment have a higher risk for peri-implantitis, and may have more problems with marginal bone loss and increased pocket depth compared to non-smokers. Many people will find it difficult to quit smoking, but it’s vital that patients realize the risks to the long-term survival of dental implants.
There is a bidirectional relationship between diabetes and periodontal disease, and diabetics with poorly controlled glucose levels will generally have a less favorable long-term prognosis after implant treatment. They are at greater risk of peri-implantitis and inflammation around implant sites. It is a difficult risk factor to assess, as research into the impact of this disease on dental implants is minimal. If a patient with well controlled diabetes is considering implant treatment, you might think they are a reasonable risk, provided they are aware of the potential complications.
Healthy nutrition is essential for optimal wound healing. If you suspect a patient has a poor nutritional status, you might wish to assess their vitamin and mineral levels and discuss strategies for increasing the nutritional value of their diet before surgery.
Stress can affect implants in two different ways. After implants have placed, stress can slow down wound healing. When a patient is particularly stressed, it’s worth discussing stress reduction techniques with them to help improve wound healing. Stress may also cause bruxism which could affect the long-term survival of a dental implant. Excessive loading can cause bone loss or even implant fracturing. Ideally, bruxism should be treated prior to implant surgery and patients should be provided with a suitable night guard.
By carefully selecting patients who are suitable for implant-supported restorations, you can reduce risk factors to acceptable levels, especially when combined with careful treatment planning utilizing a multidisciplinary approach. Patients must understand there is always a small risk associated with any type of surgery, but good education combined with an individualized and long-term maintenance care plan can help to minimize implant complications.
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