616557
research-article2015
JDRXXX10.1177/0022034515616557Journal of Dental ResearchIncreasing Prevalence of Peri-implantitis
Perspective
Increasing Prevalence of Peri-implantitis:
How Will We Manage?
D.P. Tarnow1
Keywords: dental implants, clinical outcomes, peri-mucositis, bone loss, oral implants, osseointegration
In 1982, when I and a large group of specialists from through-
out North America were trained in Toronto by P.I. Branemark
on the concept of osseointegration, we were in total awe of this
new and well-researched technique. In fact, there was very lit-
tle to no discussion about the potential loss of implants due to
peri-implantitis, since all of the discussion was on how to
achieve the miracle of osseointegration. The only way that a
loss of an implant took place was due to poor surgical tech-
nique or occlusal overload. Now 32 years later, this paper from
Derks et al. (2016) highlights some of the critical aspects of
this problem that we are still trying to understand. There are
many reasons for this topic to now be so controversial and even
disputed.
To start with, what is the definition of peri-implantitis
(Mombelli et al. 2012; Tomasi and Derks 2012; Derks and
Tomasi 2015)? How can we as clinicians be sure if a patient is
suffering from a disease when we still don’t all agree on the
clear definition of that disease? That is the first and very real
concern because it allows 2 researchers looking at the same
group of patients to come up with drastic differences in the
prevalence of the disease (Koldsland et al. 2010)—for instance,
47% versus 11% when altering the amount of bone loss from
0.4 to 3 mm.
The key to this specific paper is that even though it is retro-
spective, it gives us some insight into real-life patients who
were treated 9 years ago by various clinicians, with mostly 3
brands of implants, with and without periodontal disease pres-
ent on their remaining natural teeth.
Without question, this highlights, along with the other
papers referenced, that after about 9 years in the mouth, resto-
rations supported by implants are not all perfect. In fact, under
the most conservative estimates, about 10% of all implants
placed today will have some form of peri-implantitis in about
10 years. This fact does not condemn implant use at all.
Implants have been, without question, the most important
modifier of our treatment plans for patients over the past 35
years. However, we cannot just put our heads in the sand and
say that because the implants are still integrated and function-
ing, they are all therefore OK. In fact, “survival rate” versus
“success rate” is really the key discussion. An implant with
70% bone loss may still be able to take on occlusal load well
and may be listed as a “surviving” implant; however, this is
certainly not a “successful” implant (Behneke et al. 2000). This
also means that with the number of implants being placed
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Journal of Dental Research
2016, Vol. 95(1) 7­–8
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DOI: 10.1177/0022034515616557
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increasing every year, the need for periodontal treatment on
implants will go up exponentially.
One of the disturbing results reported in this paper is that
the average amount of bone loss for those implants that had
peri-implantitis was in the range of about 30% of their total
length. If the progress of this disease is not controlled and if the
progression stays at about the same rate, we can see that many
of these implants will be lost over the next 20 to 30 years. This
may become an important discussion that we must have with
our patients as part of our informed consent. It may have to be
clearly stated that without proper restorations and proper main-
tenance by both the dentist and the patient, these implants can
lose bone and may not survive the life of the patient.
I am always amazed at how orthopedic surgeons often tell
their hip replacement patients that their implant will last about
15 years. Then they will have to “revisit” the area again at that
time. We in dentistry must get out of the habit of implying that
all implants will last the lifetime of the patient; although that
may be true for most of them, many may have to be “revisited”
over the years.
In addition, because at least 10% of all implants being
placed this year will have peri-implant disease after 10 years, it
makes us realize how important this is. The estimate that 1 mil-
lion implants were placed last year worldwide should serve as
an eye-opener. If conservatively 10% of all implants will have
this problem, then 100,000 per year will need our attention. It
should also be mentioned that life in the mouth is a hostile
environment for both teeth and implants. We therefore will see
more peri-implantitis on implants as they spend more time in
the mouth. This is just like teeth.
The article showed that there was a difference among the 3
main brands used in the study. However, besides surface tex-
ture differences, there are basic design differences that could
alter the bone loss results. For example, the tissue-level implants
used all had a 1.8- or 2.8-mm polished collar. This, of course, is
very different from the other 2 implants used, which were bone
level. Also, 1 of those 2 systems involved platform-switched
1
Columbia University College of Dental Medicine, New York, NY, USA
Corresponding Author:
D.P. Tarnow, Clinical Professor of Periodontology, Director of Implant
Education, Columbia University College of Dental Medicine, New York,
NY, USA.
Email: dennistarnow@gmail.com
8 Journal of Dental Research 95(1)
implants, which have been shown to also help diminish bone
loss as compared with non-platform-switched ones (Canullo et
al. 2010). This means that the tissue-level implant system
would have less bone loss than the other 2 because there is no
abutment connection near the bone. Therefore, the irritation of
the abutment and/or crown would be less to the bone; in fact,
that was shown in the results of the article.
An area of great concern, and one somewhat politically
charged, is that this paper clearly shows that implants restored
by general practitioners have a much higher rate of peri-
implantitis. This means that we are not spending enough time
teaching generalists how to construct restorations that are
cleansable and easy to manage. This may be important for our
schools to pay more attention to the teaching of implant resto-
rations. Other long-term studies have implied that the con-
struction of the restoration is critical for proper oral hygiene
and that implant loss goes up when this is not done properly
(Block et al. 1996).
This paper obviously dealt with the prevalence of peri-
implantitis after 9 years. However, the other key topic that is of
great concern is how to treat. This is not the topic of this article
or review, but let’s make sure that we know that this is not an
easy, predictable disease to treat once it is passed the mucositis
level into the bone. Therefore, the key is prevention based on
proper implant design, proper placement, and correct contours
for ease of hygiene. This, along with meticulous maintenance
care by both the dentist and the patient, will mean that we won’t
“revisit” these implants. Congratulations to the authors for a
very important paper that helps shed more light into the long-
term concerns about dental implant supported restorations.
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Author Contributions
D.P. Tarnow, contributed to conception, design, and data acquisi-
tion, drafted and critically revised manuscript. The author gave final
approval and agrees to be accountable for all aspects of the work.
Acknowledgments
The author received no financial support and declares no potential
conflicts of interest with respect to the authorship and/or publica-
tion of this article.
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