A Nuanced View on Peri-implantitis

One of the most quoted scientists in dental implantology, Professor Tomas Albrektsson, MD, PhD, ODhc, worries peri-implantitis is increasingly used as an alarming label for benign marginal bone loss around implants. On a recent visit to Zurich, he took questions from Stefan Holst, DDS, Nobel Biocare’s Vice President of Implant Systems and Research, on this controversial topic.

Stefan Holst, DDS: Peri-implantitis is currently a prominent discussion topic at various events and congresses. Is the nature of these discussions beneficial for the implantology community, or could it be a threat to our reputation?

Tomas Albrektsson, MD, PhD, ODhc: When incorrect biological reasoning is done, it is always a threat. When we look at the clinical outcomes in long-term studies, they are so much better than many of those that we are hearing and reading about. I’m very critical of this. It is trying to make problems of things that may not be that problematic. The frequency of peri-implantitis has been grossly exaggerated in the literature. All bone loss that happens in the first year is definitely not peri-implantitis. We see bone remodeling and bone loss for very different reasons. This bone loss is benign in that it doesn’t threaten the implant. Then we have a disease called peri-implantitis, which, with controlled (clinically documented) implants placed by properly trained individuals, is a rare disease, but still one of some magnitude. With 1% to 2% of modern controlled implants showing clear signs of disease at 10 years or more of follow-up, we can’t ignore it. But we are not helped by the exaggeration of the figures. There are 13 different definitions available for peri-implantitis, and we can be without the great majority of those.

Holst: How does a clinician determine whether bone loss is a natural physiological reaction or that caused by disease?

Albrektsson: From the clinician’s stand-point, we should take all types of marginal bone loss seriously even if most implants with some bone loss never develop peri-implantitis. The problem is that we don’t know which ones won’t. For example, one reason for problems with bone loss is cement remnants in the soft tissue. If you remove that in time, the bone loss stops. The implant can function happily ever after, without any problems. But there is also the possibility that, were you to leave the cement remnants in place for 10, 15, or 20 years, then peri-implantitis may develop with the same implant. A clinician should always take action when he or she sees marginal bone loss or rather the preface of it, which is called mucositis. Mucositis is only the first sign of an immunological reaction; it has nothing to do with anything else but immunology, which is unfortunately not understood by many of our clinical colleagues.

Holst: Recent studies based on the Swedish population imply that implant brand plays a role in peri-implantitis. Is this not misleading given that so many factors influence treatment outcomes?

Albrektsson: Many of the figures that are being quoted, be that in the recent Swedish publication or others, are lamentably unrealistic. They have used the most liberal definitions they can find of what they call a disease when, in reality, it is no such thing. Our own studies of long-term follow-up on implants demonstrate very clearly a similar, small percentage of implants that are affected by peri-implantitis, between 1% and 2%, whether you prefer one of the major implant systems or the other makes no difference. But implant systems that say they need no documentation of their own because they are similar to another company’s documented implants are not to be trusted. Clinicians need to pick an implant system that has its own documentation published in peer-reviewed publications. If that doesn’t exist, don’t buy it. Never forget that buying a cheap implant that is undocumented can prove to be very expensive.

Holst: Based on your clinical experience, what are the factors that play a role?

Albrektsson: It is complications to treatment that cause bone loss. We call it the Triad of Poor. First, poor implant systems. As mentioned, these exist and are sold at a cheap price. Again, you should avoid these implant systems. Second is poor clinical handling by clinicians without the right skills. Finally, there is what we can term poor patients; those patients who are difficult to treat. These are the causes of bone loss that, in some rare cases, may in the long term lead to peri-implantitis, but not in most cases.

Holst: So what can we as dental implant professionals do to prevent the proliferation of misinformation about peri-implantitis?

Albrektsson: I’m increasingly irritated with people calling benign bone loss a disease. Those who are doing so have to read the new research that’s out and realize they are wrong. The profession must, in a united manner, protest against alarming reports in a much stronger way than we have done to date. But at the same time we must, of course, continue to take patients very seriously. We cannot ignore bone loss, even if it proves to be benign. We have to be active all the time and work to the best of our knowledge for our patients.

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