Comparing implant outcomes of healthy and compromised patients
Are patients with periodontal disease at a higher risk for implant failure? Some clinicians assume they are. That’s because a similar bacterial flora forms around diseased teeth and diseased implants.
Swedish scientists conducted a systematic review to explore whether patients susceptible to periodontitis also show an elevated risk for peri-implantitis. They compared three outcomes — the survival rate of dental implants, postoperative infection and marginal bone loss in two groups — periodontally healthy patients (PHPs) and periodontally compromised patients (PCPs) who received implants. They published their findings in the December 2014 issue of the Journal of Dentistry.
Scientists evaluated 10 controlled clinical trials and 12 retrospective analyses from 2,768 initially identified studies in their electronic search of PubMed, Web of Science, the Cochrane Oral Health Group Trials Register and a manual search of journals, reference lists and clinical trials. The studies, dating from 1996 to 2014, included those for any group of patients receiving dental implants in which PCPs and PHPs were compared. They included subjects of different ages with different numbers of implants, different follow-up times and smoking status, as well as studies with different thresholds for the definition of periodontitis.
Results showed significant disparities in implant failure rates between PCPs and PHPs. From the 10,927 implants inserted in periodontally compromised patients, 587 failed, or 5.37 percent. Periodontally healthy patients received a total of 5,881 implants and experienced 226 failures, or 3.84 percent.
Scientists performed additional analysis to adjust for the type of research methodology used. They found a statistically significant difference in implant failure outcomes between the two groups whether retrospective studies and controlled clinical trials were considered together or separately. They also found significantly higher occurrences of postoperative infections and marginal bone loss in the PCP group.
They called for more research on the history of bone tissue loss prior to implant placement in PCP patients.
“Due to the multifaceted aspects of any infectious disease such as periodontitis, any correlations between this disease and peri-implantitis need not necessarily indicate that bone loss around teeth and implants is dependent on the same type of disease,” authors surmised.
Authors said results should be interpreted with caution because the analyzed studies include uncontrolled confounding factors.
“Within the limitations of the existing investigations, the present study suggests that an increased susceptibility for periodontitis may also translate to an increased susceptibility for implant loss, loss of supporting bone and postoperative infection,” they said.
Consulting Editor: Eros Chaves, DDS
Professor and Chair,
Department of Periodontics
University of Oklahoma Health Sciences Center
College of Dentistry
The Consulting Editor assists in the selection of scientific editorial content. Neither he nor the American Academy of Periodontology has a connection with or input into any product mentioned or any advertising that appears in this newsletter.
Evaluating implant therapy after treatment
An article in the January 2015 Journal of Dental Research described effectiveness of implant therapy in a large patient population and up to nine years after treatment.
Scientists in Gothenburg, Sweden, used the national data register to inspect the files of 2,765 patients from more than 800 clinicians. In addition, 596 of those patients received follow-up examinations nine years after therapy.
Scientists analyzed information about patients, clinicians, treatment procedures and outcomes. Two periodontists carried out most of the follow-up examinations. Implant failures were divided into early (before abutment connection) and late (later occurring loss) according to the timing of the failures.
“Implant loss is not an uncommon event, and patient and implant characteristics influence outcomes,” authors said about the results, which showed that 7.6 percent of the patients had lost at least one implant nine years after therapy. Early implant loss occurred in 4.4 percent of the patients (1.4 percent of implants). Some 4.2 percent of the patients who were examined nine years out experienced late implant loss (2.0 percent of implants).
Scientists detected higher odds ratios for early implant loss in study populations including smokers and patients with an initial diagnosis of periodontitis. They found no associations between late implant loss and patients with an initial diagnosis of periodontitis.
All results were based on subjects who received implants in 2003.
Keynote speaker Randall Wolcott MD, Director of the Southwest Regional Wound Care Center, discusses chronic biofilm infections and the shortcomings of antibiotics at Perio Protect¹s Annual Meeting in Las Vegas on April 17-18. Additional speakers include Duane Keller DMD, John Chao DDS, Lou Graham DDS, and Janet Press RDH. Come to energize your team and improve treatment results.
Researchers: standardized protocols needed for laser disinfection therapy
Between 12 to 43 percent of dental implants will develop clinical signs and symptoms of peri-implantitis and crestal bone loss at five or more years, according to research cited by authors publishing in the November 2014 issue of Clinical Advances in Periodontics. The complication often is treated effectively with surgically guided bone regeneration (GBR), they noted.
Laser therapy is among treatments considered to improve implant surface decontamination and used adjunctively with both surgical and nonsurgical therapy. Scientists at the University of Alabama at Birmingham interested in its effectiveness on implant survival rates conducted a PubMed search of the evidence.
Finding 96 abstracts and 19 full-text articles that met their criteria, they published a report and summarized their findings by highlighting four of the articles. The research covered a total of 86 implants treated with GBR and laser implant surface decontamination. Follow-up periods ranged from 0 to 60 months.
Results showed an improvement in clinical and/or radiographic outcomes from baseline to follow-up for ailing implants treated with both laser and GBR protocols. Furthermore, the two studies that demonstrated comparative results for implants treated with GBR but without laser debridement showed improved outcomes in the laser decontamination group when compared with implants treated with standard decontamination.
Although the scientists also questioned whether implant survival rates differed based on laser treatment modality, reviewed articles used varied laser protocols, making conclusions about the effectiveness of individual laser types unfeasible.
One highlighted article demonstrated to authors that adjunctive laser disinfection improvements may be short-term. They also noted potentially adverse events associated with laser treatment, particularly elevated temperature of implants.
“It is very important to note the time, wavelength, presence of cooling and power of lasers used for peri-implantitis treatment when adapting a published laser treatment protocol for clinical application,” authors cautioned.
Treatment costs compared
Scientists publishing in the November 2014 issue of the Journal of Clinical Periodontology say success or survival rates of treatments should be balanced against the costs of initial and follow-up therapies.
Doctors in Germany performed a study comparing strategies for treating molars affected by bone loss. Their aim was to assess the cost-effectiveness of retaining such furcation-involved molars via periodontal treatments versus replacing them with implant-supported crowns.
Scientists simulated a 50-year-old male with a modified Markov design decision model and calculated cost estimates in the context of the German health care system. They assumed that the tooth would have been previously restored and compared further tooth-retaining strategies — scaling and root planing, flap debridement, root resection, guided tissue regeneration and tunneling — with tooth replacement using implant-supported crowns. The model simulated the natural history of a periodontally affected tooth or an implant-supported crown in six monthly cycles. The sequence of events was constructed according to current evidence and the consensus of experienced clinicians, authors reported.
Among results, authors found that while implant-supported crowns required re-treatments later than other strategies, retaining teeth was less costly than removing and replacing them.
Authors noted that cost effectiveness was assessed as costs per retention year of tooth or implant. They cautioned that retaining periodontally affected teeth and retaining implants might not be identical — “… retention does not necessarily mean similar functional rehabilitation or quality of oral life,” authors said.
They proposed that clinical decision making will be guided not only by cost-effectiveness, but by setting patients’ or providers’ priorities, such as predictability, access, treatment time per visit and number of visits, surgical or nonsurgical approach and available equipment.
Quarterback dentistry: what’s your call?
A new patient enters your practice with generalized periodontitis. The comprehensive exam reveals generalized, moderate bone loss, gingival recession, and pocket probing depths of 4-6 millimeters throughout the mouth. Tissues around the upper posteriors and around every tooth on the lower arch are bleeding on probing, with extensive heavy bleeding in the lower anteriors. The patient understands the need for immediate treatment and long-term maintenance care. What do you recommend?
This case scenario is more common than ever as patients who have avoided dental care during the long recession are now returning to dental offices. When the patient described above entered Dr. Greg Gist’s practice in Southlake, Texas, Jan. 28, 2013, it had been more than four years since his last dental exam. Dr. Gist’s protocol, outlined below, resulted in long-term successful treatment as well as an Orkos Award honoring his excellence in treatment for gum disease with this case study report.
Following the comprehensive initial exam, Dr. Gist began the first of four debridement and scaling procedures. After mechanical therapy, he delivered prescription periodontal trays (Perio Trays®, Perio Protect LLC, St. Louis, MO) to the patient to be used twice a day for 10 minutes to deliver 1.7 percent hydrogen peroxide gel (Perio Gel®, QNT Anderson, Bismarck, ND) and 3 drops of an antibiotic (Vibramycin®, Pfizer, New York, NY) deep into periodontal pockets.
At the end of March, about 2 months after the initial visit, the patient exhibited three sites that were bleeding on probing, and pocket probing depths measuring more than 3 mm were just 7 percent, down from 100 percent at pretreatment. A periodontal maintenance visit on June 26, 2013, confirmed the improvements with no bleeding on probing. At the patient’s most recent dental appointment on Sept. 9, 2014, inflammation remained under control with no bleeding on probing exhibited. All pocket probing depths measured 3 mm or less. Recession had also decreased with reported improvements in the lamina dura.
Dr. Gist attributes the long-term success of this case study to his focus on both the destructive symptoms and bacterial causes of the disease. “So much medicine today focuses on what has happened, not how to fix a problem. I am concerned with comprehensive treatment and prevention that addresses the sources of disease.”
Dr. Gist describes the prescription tray delivery used for this patient, and for many in his practice, as his “secret weapon” and “therapeutic silver bullet” for effective biofilm treatment. “The unique way in which the trays are fabricated,” Dr. Gist explains, “enables us to force the medication deep into the periodontal pockets where most of the bacteria reside and where most patients have a problem cleaning.”
The simplicity of this treatment system is also relevant. According to Dr. Gist, “The prescription tray is so easy for our patients to use that it allows patients to have a high degree of compliance, especially when patients are educated to the incredible systemic and lifestyle benefits of keeping their mouths infection free.”
Dr. Gist prescribes the Perio Tray® for more than just periodontal disease. “We have developed a pre-operative treatment regimen that gets our patients ready to be restored, and a post-operative regimen that protects my patient’s investment in their health after their restorative work is complete. We have actually built a niche Perio Protect practice within our restorative/cosmetic practice that is improving our patients’ health while serving as a great profit center for the practice as well.”
For more information on Dr. Greg Gist and his dental practice, visit www.GregGistDDS.com. Details on the Orkos Award are available at www.theorkosaward.com. For more information on the prescription Perio Tray® and how to become a prescriber, visit www.perioprotect.com.
Save on ADA periodontal maintenance brochure
The ADA is offering a 15 percent discount on its newly revised patient education brochure, “Periodontal Maintenance: Stay Ahead of Gum Disease.”
Dentists can use the updated eight-panel brochure to encourage periodontal patients to stick with their treatment for healthy gums. The brochure also addresses the oral-systemic connection and cautions against tobacco use. It features reader-friendly text, new illustrations and before-and-after photos of periodontal treatment.
“Periodontal Maintenance” is available in packs of 50 from the ADA Catalog. Call 1-800-947-4746 or go to adacatalog.org. The brochure also is available personalized or in Spanish. Readers who use the code 15408E before Jan. 30 can save 15 percent on all ADA Catalog products.
Perio Protect CE Training
Perio Protect offers several training options including live seminars, live webinars, personalized training, and online self study program. The trainings review the science behind prescription Perio Tray® delivery of peroxide, case study presentations, and treatment protocols. To register visit http://www.perioprotect.com/trainingOptions.asp. If you prefer one-on-one presentation, Personalized Trainings can be scheduled Monday through Friday from 9AM to 5PM Central. Simply call 877-434-GUMS (4867) to schedule today.
What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on periodontics, the first in the series on this topic for 2015. Other Specialty Scan issues are devoted to endodontics, orthodontics, oral and maxillofacial radiology and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own divisions of Science and Legal to assist with these newsletters. We welcome your feedback on this and all Specialty Scan issues.
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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.
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