When Perio, When Implants?

Periodontal treatment mainly focuses on the treatment of periodontally compromised tooth. The primary objective of periodontal treatment is regeneration of periodontium. Complete regeneration is still a distant dream for periodontist. For both patients and practitioners, tooth extraction is a last resort when all other treatment options fail. However, the marketing strategies of dental implant companies have changed the scenario. Many dentists won’t have an intention of saving the periodontally weakened tooth. Despite saving the tooth, they focus on dental implant treatment. Therefore a clear demarcation line should be drawn to decide at which conditions we require periodontal therapy or implant. The above is the objective of this review.

“The only constant in life is change” – Heraclitus. Mankind has been making persistent attempts to replace natural body parts that are either congenitally absent or lost subsequent to disease or injury, so as to maintain a perfect combination of form and function. For decades, the underlying objective of preserving natural dentition has provided the foundation for clinical decision making in dentistry. To both patients and practitioners, tooth extraction is a last resort when all other treatment options fail. However, the marketing strategies of dental implant companies have changed the scenario. Despite saving the tooth, many dentists focus on dental implant treatment. This is particularly true while treating periodontally compromised patients. In this article, we will discuss how to choose between periodontal treatment and dental implants as strategies in the management of periodontally compromised patients.

Hugoson 2008 in his long term study showed that with increase in age there was an increase in prevalence of periodontitis of which advanced stage of periodontitis accounted for only 10% [12]. Therefore most of the periodontitis patients belong to mild to moderate periodontitis category, which can be successfully managed with periodontal therapy. In untreated or non-compliant individuals with advanced stage of periodontitis, both bone destruction and tooth loss are inevitable.

In some individuals with advanced stage of periodontitis, the severity of a periodontal problem is such that tooth extraction should be considered as one of the treatment modalities to resolve the problem. This can be evaluated through complete periodontal and radiographic examination. These cases might include deeper pockets with complex anatomy such as furcation’s and deep infrabony defects which show progressive attachment loss and symptoms. Teeth with increasing bone loss on radiographs and increasing mobility or fremitus in function, or progression to a complex perio/endo lesion, should be extracted. We should be aware that in cases with severe periodontal bone loss, grafting techniques may be required to facilitate implant placement later.

In aggressive periodontititis patients showing extensive bone loss, comprehensive periodontal treatment should be attempted first. Refractory cases pose a problem in decision making, where elimination of the pocket flora coupled with maintenance of remaining bone for future implants may be the correct early treatment in extreme cases. However, in such refractory cases not all implants and their superstructures last forever.

Recent reports indicate that implants may follow the same survival rate as natural teeth. Thus, the risk for loss of bone support over time seems to be roughly the same for an implant as the loss of periodontal support for a natural tooth. On an average, root length of a tooth is about 20 mm while the most commonly used implant is 10 mm long. Longitudinal studies on random samples of Swedish populations have demonstrated that there is a gradual interproximal bone height reduction of about 0.1 mm per year around teeth [13-15]. Adell 1990 reported annual bone loss around dental implants (after the first year with 1 mm of bone loss) to be between 0.1 and 0.2 mm. Thus, a tooth will have a prognosis better than an implant with normal length if we simplify the assessments to amatter of distances [16].

Long-term follow-up studies have clearly demonstrated that advanced forms of periodontal disease can be successfully treated for arresting disease progression and minimizing or even preventing tooth loss, provided that the patient is enrolled in a high-quality maintenance care program after completion of active treatment and refrains from smoking [17-19]. Wennstrom in 1990, suggested that with adequate oral hygiene, regular dental check-ups and preventive care, any patient should have a bone score of at least 50% at 70 years of age, which is more than sufficient for support [20].

Lundgren and Nyman 1975 gave a periodontal–prosthodontic concept of bridgework for prosthetic rehabilitation of dentitions with markedly reduced periodontal support. The above concept contradicted the generally accepted principles for bridgework by Ante (1926). It implies that fixed bridges can be placed and successfully maintained on a minimal number of abutment teeth with significantly reduced periodontal support, provided that the prosthodontic treatment is (i) preceded by adequate periodontal treatment and (ii) followed by an effective maintenance program to prevent recurrence of periodontitis. Therefore, before considering implant supported dentures in periodontally compromised patients we have to evaluate the option of tooth supported fixed partial dentures [21].

Four decades ago, the first implant was placed in human jaws for treating complete edentulism. The scenario has gradually changed and now we are using implants for the treatment of partially edentulous patients as well, with single tooth replacement being most common. This is thanks to the strategies initiated by dental implant companies, who market them as invincible treatment options for edentulous patients. The primary question to be asked here is, “Are all dentists trained in placing implants?”. The answer sadly, is, ‘no.’ Implant companies cannot depend on limited specialties practicing Implantology, as this limits their market. To overcome this, these companies offer short term courses as a way of encouraging all dentists to pursue implant placements. Ultimately, the patients suffer. This is because in short term courses, one cannot expect an instructor to explain the pros and cons of implant treatment in detail. They are obliged to focus on success and avoid discussing failures, in order to promote implant placement.

This incomplete knowledge can be detrimental. The focus should be on implant placement and restoration of the dentition and not just the placement of implants for monetary gain. For this reason, implants should be placed by dentists who are well versed in prosthodontic concepts. The implant placing dentist should also be equipped with sufficient knowledge on how to identify and manage complications such as peri-implantitis. These factors are all crucial to ensure that dental implants are successful.

Lost teeth can be replaced with tooth-supported or implant-supported reconstructions. The latter is a treatment modality that is gradually increasing in incidence and sometimes leads to premature extraction of teeth. However, there is significant evidence to indicate that periodontally involved teeth can be maintained and used to provide function for a long time. Unlike the data on teeth, our knowledge on implant survival beyond 10 years is limited and is based on implant systems that are no longer available. Risk factors for peri-implant diseases have been identified and include smoking, poor oral hygiene and a history of periodontitis. Therefore, if implant treatment is considered in patients with periodontitis, a combined patient and site risk profile assessment, together with a cost–benefit analysis based on patient’s expectations, should always be performed following an extended observation period after completion of periodontal therapy.

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