Root of the matter

Implant failure is more often than you think, reports Tracey Hordern.

In June this year, the ABC Radio National Health Report program hosted by Dr Norman Swan featured a story about dental implants, which cited recent Australian research that raises serious questions about an industry that’s growing at over seven per cent a year globally and is estimated will be worth more than $12 billion by 2021.

Dr Swan’s interview was with Australian researcher and Batemans Bay dental surgeon, Dr Stephen E. Nelson, who discussed his recently completed PhD on the topic, titled “Improving Osseointegration Outcomes by Surgical Debridement of Microbial Biofilm in the Dental Implant Bone Bed”.

“The science that allowed implants was first conceived by the Swedish Professor [Per-Ingvar] Brånemark in the 1950s and then developed in the 1960s,” Dr Nelson explained to Bite. “His ambitious goal was based on his belief that no-one should go to bed with their teeth in a glass of water.”

Dr Nelson says the combination of two concerning factors that emerged from his research potentially makes for the perfect storm. “Number one is the surgical technique for inserting the implants and the second concern is the design of the implants themselves.”

According to Dr Nelson, with the proliferation of recent developments such as implants that can be completed in as little as two days, “We are increasingly seeing marketing campaigns that can promote immediate placement of dental implants—even into potentially infected extraction sockets.

“This approach is fundamentally reliant on a scientific platform which promotes bone sterility being preserved by our immune system. But immediate placement has resulted in increasing numbers of dental implants that suffer ongoing, unacceptable bone loss and ultimate failure,” he explains.

“If implants are not inserted correctly or the appropriate type of implant is not used, they may continually fall out and even compromise the gum and bone in the mouth.”— Henry Carus & Associates, injury lawyers

“We have shown that bone is not always sterile and that a human jaw microbiome is confirmed by DNA sequencing. Spontaneous cure of infection does not always occur. Bacterial biofilm infection delivered to alveolar bone from a tooth-borne infection may persist post extraction in a dormant bone infection which then may be refractory to non-surgical treatment.”

Further to this, Dr Nelson points out that in the early 1990s, the smooth surface implants were replaced across the industry with new, rough surface implants. “It was discovered that roughened surfaces stimulated greater stem cell activity against a roughened surface and this could facilitate the implant procedure to be more immediate.

“This development has been heralded as a bonus for the implant industry, the practice and the patient. However, our research indicates that the newer implant surface characteristics show that textured implants develop a significantly higher load of bacterial biofilm in comparison with smooth implants.”

Dr Nelson’s concludes: “There is no science to support the placement of oral implants into infected sockets or ‘apparently healed’ bone with osteolytic/osteosclerotic bone beds that have not been ecologically recovered by surgical debridement beyond sclerosis.”

Dr Nelson isn’t the only dentist sounding the alarm. This issue was raised by a former Australian dentist, Trixie Gardner (Baroness Gardner of Parkes) in the British House of Lords in 2014 as a public health issue on notice. Closer to home, Rosemary Kennedy, the Dental Advisor for more than 15 years to New Zealand’s national Accident Compensation Commission (ACC), initiated contact with Dr Nelson looking for evidence-based guidance regarding failed implants.

Unlike any other country, New Zealand’s ACC scheme provides no-fault coverage for medical and dental injuries. Kennedy stated in her communications that the ACC had paid out for approximately 15,000 failed dental implants over the past 15 years. Also, that some providers expected to just position replacement implants at the same site, yet in many cases the level of bone lost and replacement grafting had no predicable means of success.

“All implant devices have a failure rate—nothing is 100 per cent. It varies and unfortunately there’s some implants that will not integrate with bone.”—Dr Gerard Clausen, prosthodontist

Dental implants were considered—and are still advertised—to be successful in 95 per cent of cases. Yet according to the conclusion of a 2015 research paper on the popular ‘All-on-4’ concept, “The implant and prosthetic survival was 100 per cent, and patients benefited from the use of the All-on-4 treatment concept. However, unacceptable ongoing bone loss may be a warning sign of future problems and needs clinical attention. Overloading and surgery-related aspects need to be further investigated as possible explanations.”

So where does this leave Australian dental practitioners? According to injury lawyers, Henry Carus & Associates, the most common type of dental claims relate to the use of dental implants. Published on their website is the following cautionary note: “If implants are not inserted correctly or the appropriate type of implant is not used, they may continually fall out and even compromise the gum and bone in the mouth. Once the gum and bone becomes compromised, the patient may not be able to have any other implants inserted and may be left with the option of either a denture or no teeth at all.”

Dr Gerard Clausen, a registered specialist prosthodontist is more pragmatic in his approach. As a committee member for the Australian Dental Association (ADA) and a member of the association’s Dental Instruments Material Equipment Board, Dr Clausen recommends practical caution and ongoing education.

“All implant devices have a failure rate—nothing is 100 per cent,” says Dr Clausen. “It varies and unfortunately there’s some implants that will not integrate with bone. It’s also very important to explain clearly to patients all the potential pitfalls, for informed patient consent.

“I recommend explaining that there is always some risk and what that may or may not mean for them. Whether it’s a hip replacement, or a dental implant, the same things need to be explained and it should be a similar consent process.”

Dr Clausen points to the following summary from an internal ADA members-only Practical Guide publication: “Basically, we recommend that dentists undertaking continuing education programs keep up with the latest knowledge; choose the implant type and surface, and surgical techniques appropriate to both the implant type and the patient’s case carefully; and discuss all the risks and options with the patient, including the known risk of implant failure as it may apply to their particular case, to make sure that their consent to treatment is fully informed.”

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