Dental implants are considered the gold standard for replacing missing teeth. But nothing can last forever, and with increasing numbers in service, modern dentists are starting to understand the limitations of these devices. Here, periodontics specialist Edward Sammut highlights the two main implant problems that can be faced.

The desire to avoid wearing removable false teeth, together with the psychological and social connotations that this brings about has resulted in a global explosion in the use of dental implants, a trend also noticeable in Malta.

Treatment with dental implants relies on the ability of the bone tissue to form a biological bond to the titanium surface of the implant. The development of this bond is a predictable event seen in the overwhelming majority of dental implants placed (97 per cent).

As with everything else, nothing lasts forever, and with increasing numbers of implants in service, dentists are starting to understand the limitations of these devices.

Significant bone loss may threaten the implant’s ability to support the implant teeth

Mechanical issues with an implant reconstruction, such as breakage or loosening of parts, are usually fairly easy to remedy.

However, there are biological processes, similar to gum disease affecting natural teeth, which can affect the attachment of implants to the jawbone. The two main problems are called peri-implant mucositis and peri-implantitis.

Peri-implant mucositis is a term used to describe redness, swelling and/or bleeding of the gums around dental implants.

It is generally agreed this is caused by bacterial plaque building up on the implant surfaces similar to how gum inflammation starts around natural teeth.

The gum tissue may detach from the implant surface, allowing the bacteria and inflammatory products to penetrate more deeply, causing damage to the bone immediately around the implant.

At this point, the disease is called peri-implantitis, which is similar to peri-implant mucositis, except for the possibility of discharge from the gums and bone loss evident on X-ray images of the implant. Significant bone loss may threaten the implant’s ability to support the implant teeth. Therefore, peri-implantitis is a serious threat to an implant’s longevity.

Some estimates suggest in implants that have been in function for more than five years, up to 80 per cent may have some degree of peri-implant mucositis and up to 43 per cent may have peri-implantitis.

At the other extreme, in the ideal conditions of a Swiss University clinic, where patients were treated by implant experts and had meticulously maintained oral hygiene, only 1.8 per cent of implants developed peri-implantitis after 10 years.

Causes and risk factors

The causes and risk factors for peri-implantitis are similar to those for periodontitis (gum disease around teeth). The main cause is bacterial plaque on the implants, and this problem is typically aggravated by the fact that fixed implant restorations can be more difficult for the patient to keep clean when compared to natural teeth.

Individuals who have had gum disease or lost their teeth thanks to gum disease have an increased risk of developing peri-implantitis. This risk may be even greater if these patients still have gum disease around the remaining natural teeth.

Smoking has been clearly shown to be a significant risk factor for development and aggravation of both periodontitis and peri-implantitis.

How is peri-implantitis treated?

Unfortunately, peri-implantitis appears to be harder to treat than periodontitis. Part of the problem is that once bacteria get into the implant threads, they are very difficult to remove. Mild situations only, where inflammation is limited to the gum tissue and the superficial bone, may be successfully treated with professional cleaning and application of antiseptic agents.

Deeper damage almost certainly requires peri-implant surgery to reflect the gum tissue away from the implants to allow direct cleaning of the contaminated threads. The tissue is stitched back on but typically recedes over a period of time, exposing some of the implant metal. In general, the outlook for severely affected implants is poor, with treatment failing in just over 50 per cent of cases.

The strategy must be on careful preventative regimes to avoid developing this problem at all!

What should I do to prevent this?

Firstly, before you set out on implant treatment, the environment needs to be ideal. Make sure any gum disease around the natural teeth is identified and treated.

Establish good day-to-day tooth-cleaning habits, which should include twice-daily brushing, as well as using interdental cleaning aids like floss or interdental brushes.

If you smoke, then quit, and if you can’t, try to reduce your smoking as much as possible.

If you already have dental implants, have the implants and the gums around them checked at least once a year by your dentist. Most implant manufacturers recommend periodic X-rays to check on the bone level around the implants.

Get your teeth and implants cleaned professionally at least twice a year. Ensure you know how, and routinely keep the implant reconstruction clean and free from plaque on a day-to-day basis.

Tell your dentist immediately if you notice gum bleeding, swelling, or discharge from near the implant(s). Early treatment may prevent the situation from worsening.