Dental implants are one of the great success stories of modern dentistry, offering unparalleled comfort as well as aesthetic and functional results to partially and fully edentulous patients. With long-term (10 years+) success rates routinely reported to be in excess of 95%, some may come to view implants as near infallible.[i], [ii] However, such success rates are built upon good case selection, accurate assessment, careful planning and surgical skills, reliable implant systems and other factors like perfect host condition and compliance. The dental clinician’s knowledge of risk assessment and management is absolutely integral to achieving and maintaining long-term successful outcomes.
When assessing a patient’s suitability for dental implants, there are numerous risk factors that must be considered.[iii] Bruxism, poorly controlled diabetes, smoking and defects of supporting bone structure are not necessarily contraindications to treatment, but have been associated with a greater risk of failure. Success rates for patients with these risk factors could be much less than routine implant cases if the risks are not analysed and mitigated by careful planning and meticulous delivery of the surgical and restorative treatment stages. Notably, the co-presence of risk factors can substantially increase the chance of failure. For example, failures purely attributable to bone augmentation procedures, are comparatively rare – 1.6%. Meanwhile smoking, as a lone factor, significantly increases the failure rate to almost 13%. However, when a patient requires bone augmentation and another risk factor is present (smoking, periodontal disease, diabetes) a much higher failure rate of 40% + has been recorded.[iv] Being aware of potential risk factors is essential to safe provision of dental implants, and in supporting patients throughout their rehabilitation. Where these risks are modifiable behaviours (such as smoking), if at all possible, the patient should be informed and encouraged to implement changes. Long-term success starts with and depends on a meticulous maintenance and support programme for the implant patient, under clinical supervision.
Research into how various risk factors effect long-term dental implant survival is on-going, which may highlight new risks over time, or demonstrate that a known risk factor is more complicated in its action than previously understood. For example, Selective Serotonin Reuptake Inhibitors (SSRIs), which are commonly prescribed for depression, post-traumatic stress, anxiety and other mental health disorders, have been suggested as presenting a risk to osseointegration. Recent studies have indicated that implant failure among SSRI users, is three times more likely than for non-users. However, these studies were small in scale and the results did not reach statistical significance.[v], [vi] Further research will help establish if, and to what degree, SSRIs represent a risk to the osseointegration process. As always, obtaining as complete a picture as possible is beneficial. Emotional disorders, including anxiety and depression which SSRIs are typically a frontline treatment for, have been identified as potential risk factors for chronic periodontitis.[vii] Depression can influence other factors that impact implant success and survival, such as reducing the patient’s commitment to maintaining oral hygiene, impairing the healing process and increasing the likelihood of hypertension (calcium channel blockers used to treat hypertension can cause gingival hyperplasia around teeth or implants).[viii], [ix], [x], [xi] Maintaining an ongoing, up-to-date awareness of risk factors and their complicated interactions, can aid clinicians in their decisions to acheive satisfactory results and to satisfy increasing patient expectations in the long-term.
Knowledge is key
Some members of the public, encouraged by occasional tabloid sensationalism, may believe that dental practitioners deliberately recommend implants too readily.[xii] This, of course, runs counter to the responsibility, standards and duty of care of dental professionals. In fact, there has been an observed trend that those with less training in periodontology and implant dentistry are substantially more likely to move towards extraction at an earlier stage.[xiii] Those with postgraduate training in periodontology and implant dentistry have been observed to invest significantly more time and effort into retaining compromised teeth, before moving to extraction (and implants) where appropriate.[xiv] The research into this does not provide insight into why this pattern occurs. However, we might infer that such findings indicate that those with greater knowledge and experience in this area – knowing precisely what is required and what can be achieved with dental implants – are responsible with that knowledge, aware of the value of conservative dentistry, and more able to distinguish between optimal treatments for a given patient. Modern dental implantology offers so many options and choices for the rehabilitation of edentulous patients. These range from root form removable or fixed full arch reconstructions supported by root form implants (all on 4 or 6), complex pre-prosthetic bone grafting to Zygomatic implants with different advantages, disadvantages and complexities. Put simply, just because we can, does not mean we should – and more knowledge helps one make the right decisions for the benefit of the patient.
Acquiring necessary knowledge takes quality education. Ucer Education’s Postgraduate Certificate (PG Cert) in Implant Dentistry (EduQual Level 7) is a one-year dental implant course that will empower clinicians to safely and confidently use reliable and well-documented implant systems. Proven over a quarter century, Ucer Education has a reputation for excellence, and provides learners with the theoretical and practical skills to perform dental implant procedures to the very highest standard. Whether your interest is surgical, restorative or both – this course will enable you to develop the knowledge and skills you need.
Practitioners becoming more versed in periodontology, implant dentistry, or other areas, is not simply a case of adding that particular capability. The expanded knowledge brings with it a more holistic awareness, facilitating better treatment. There is a saying, known as the law of the instrument or Maslow’s hammer, that addresses this cognitive bias, “When all you have is a hammer, every problem looks like a nail”.[xv] While no clinician is so singular, by investing further in their education, dental practitioners metaphorically and literally give themselves more tools to work with – enabling them to better discern which methodology is best suited to the case in question.
For more information on the PG Cert in Implant Dentistry from Ucer Education – supported by Geistlich, Megagen, Neoss, TRI Implants and General Medical – click here or call 0161 237 1842
[i] Van Steenberghe D. Diagnosis, avoidance and management of complications of implant-based treatments. European Journal of Oral Implantology. 2018; 11(Suppl. 1) S15-20. https://www.for.org/sites/default/files/consensus/Consensus-on-the-avoidance-and-management-of-complications-of-implant-based-treatment-Foundation-for-Oral-Rehabilitation_rev.pdf June 19, 2019.
[ii] Francetti L., Cavalli N., Taschieri S. Ten years follow-up retrospective study on implant survival rates and prevalence of peri-implantitis in implant-supported full-arch rehabilitations. Clinical Oral Implants Research. 2019; 30(3). https://onlinelibrary.wiley.com/doi/full/10.1111/clr.13411 June 19, 2019.
[iii] Wright SP, Hayden J, Lynd JA, Walker-Finch K, Willett J, Ucer C, Speechley SD. Factors affecting the complexity of dental implant restoration – what is the current evidence and guidance? British Dental Journal 2016; 221(10): 615-622 doi: 10.1038/sj.bdj.2016.855.
[iv] Kandasamy B., Kaur N., Tomar G., Bharadwaj A., Manual L., Chauhan M. Long-term retrospective study based on implant success rate in patients with risk factor: 15-year follow-up. The Journal of Contemporary Dental Practice. 2018; 19(1): 90-93. https://europepmc.org/abstract/med/29358541 June 19, 2019.
[v] Altay M., Sindel A., Özalp Ö, Yildirimyan N., Kader D., Bilge U., Baur D. Does the intake of selective serotonin reuptake inhibitors negatively affect dental implant osseointegration? A retrospective study. Journal of Oral Implantology. 2018; 44(4): 260-265. https://doi.org/10.1563/aaid-joi-D-17-00240 June 19, 2019.
[vi] Chrcanovic B., Kisch J., Albrektsson T., Wennerberg A. Is the intake of selective serotonin inhibitors associated with an increased risk of dental implant failure? International Journal of Oral & Maxillofacial Surgery. 2017; 46(6): 782-788. https://www.ijoms.com/article/S0901-5027(17)30036-X/fulltext June 19, 2019.
[vii] Liu F., Wen Y., Zhou Y, Lei G, Guo Q., Dang Y. A meta-analysis of emotional disorders as possible risk-factors for chronic periodontitis. Medicine. 2018; 97(28): e11434. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6076092/ June 19, 2019.
[viii] Dahl K., Calogiuri G., Jönsson B. Percieved oral health and its association with symptoms of psychological distress, oral status and socio-demographic characteristics among elderly in Norway. BMC Oral Health. 2018; 18: 93. https://link.springer.com/article/10.1186/s12903-018-0556-9 June 19, 2019.
[ix] Jain N., Sharma A., Narang K., Jain A., Sethi M., Thukral H. Systemic factor affecting osseointegration. World Journal of Pharmacy and Pharmaceutical Sciences. 2017; 6(9): 763-775. http://www.wjpps.com/wjpps_controller/abstract_id/7722 June 19, 2019.
[x] Okoro C., Strine T., Eke P., Dhingra S, Balluz L. The association between depression and anxiety and use of oral health services and tooth loss. Community Dentistry and Oral Epidemiology. 2012; 40: 134-144. https://www.ncbi.nlm.nih.gov/pubmed/21883356 June 19, 2019.
[xi] Gouin J., Kiecolt-Glaser J. The impact of psychological stress on wound healing: methods and mechanisms. Immunology and Allergy Clinics of North America. 2011; 31(1): 81-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052954/ June 19, 2019.
[xii] Hoyle A. Could your dentist be destroying your teeth? The Telegraph. January 19, 2015. https://www.telegraph.co.uk/news/health/11350853/Could-you-dentist-be-destroying-your-teeth.html June 19, 2019.
[xiii] Giannobile W., Lang N. Are dental implants a panacea or should we better strive to save teeth? Journal of Dental Research. 2016; 95(1): 5-6. https://doi.org/10.1177%2F0022034515618942 June 19, 2019.
[xiv] Lang-Hua B., McGrath C., Lo E., Lang N. Factors influencing treatment decision-making for maintaining or extracting compromised teeth. Clinical Oral Implants Research. 2014; 25: 59-66. https://onlinelibrary.wiley.com/doi/full/10.1111/clr.12142 June 19, 2019.
[xv] McCullen A. When all you have is a hammer, everything looks like a nail – the Einstellung effect on organisational transformation. Medium. 2018. https://medium.com/thethursdaythought/when-all-you-have-is-a-hammer-everything-looks-like-a-nail-the-einstellung-effect-on-67ee8449f740 June 19, 2019.