- Dr. David Alfaro
Are dental implants "permanent" and "painless"?
"We specialize in making dental implants a painless & stress-free experience....."
"Our doctors use the latest techniques and technologies to give you your new permanent teeth....."
"Teeth in one day is the perfect solution...."
I could go on and on and on and on......
These are just a few examples of statements that I see everyday in dental advertisements and websites for local dental clinics right here in Vancouver. I know that as a dentist myself, the big brother tools that social media applications utilize to target ads obviously direct more implant related traffic to my newsfeed, so I am probably exposed to more of it that the general population.
But.....people come in to my office asking, "do you do the teeth in a day that I heard of on the radio?" Or asking if I can guarantee that their dental implant will be permanent and painless. Oh yea....and can you match the price of this dental office (whips out a coupon for an implant and crown for $2000)?
So this type of dental advertising is obviously working. But we all watched Mad Men.....do you really want to be "sold" a dental implant?
Let us talk about dental implants.....
What is a dental implant?
Humans have been trying to replace missing teeth for thousands of years, so dental implants are not really a new thing. After a bunch of failed concepts, the modern dental implant is a titanium alloy screw which is placed into the jawbone in a minor dental surgery. Crowns, Bridges and connections for dentures can then be attached to the implant.
Have you ever hung a mirror with a drywall screw? It is basically the same process. You drill a hole in the drywall (jawbone), you put in that plastic thingy that embeds into the drywall (the implant), and then you screw a little screw into the plastic thing (whatever you want to connect to the implant, be it a crown, bridge or parts for a denture). It is a simple concept, but it is a VERY ADVANCED dental treatment.
Modern root form dental implants were developed in Europe in the 60's and 70's, but it wasn't until the 1980's that the technique became widely accepted accross North America. They have not been around too long, and there has been a lot of evolution.
There are currently thousands of dental implant manufacturers across the world. It is a big industry that is spending big bucks trying to get dentists to use their products.
Do dental implants work?
This is a highly controversial topic in implant dentistry, and it comes down to how implant research is performed, and interpereted. I have to nerd out to explain.....sorry.
During the infancy of dental implant research, the studies were just trying to prove that the implant fused to the bone; a process now termed OSSEOINTEGRATION. It was a new technique that was not widely accepted, so they just had to show, "Look! The implant is fused to the jaw!"
A "successful" implant in those earlier studies was basically one that was fused to the bone. It could have been placed poorly, have gum disease (as long as it didn't hurt), and even have experienced what I consider to be a significant amount of loss of the supporting bone (up to 1.5 mm), yet if it stuck in place, it was successful. Furthermore, the failure of up to 15% of dental implants in a 5-year study of an implant system or technique, was still considered to be "successful". (Albrektsson Criteria)
This is not success in my books.
After it became clear that, yes, we seem to have a product that fuses to the bone, researchers started implementing stricter criteria for success. Unfortunately, there is no standardized criteria that is used across dental implant research to universally describe the "success" of a dental implant.
Most studies now have some variation of a definition of "success", where they consider a successful implant to be one that is fused to the bone, has not experienced bone loss, is devoid of gum disease and is able to support a restoration.
What about dental implants that did not work out perfectly, but still fused to the bone?
In research studies, some of the dental implants fuse to the bone, but end up with long term gum problems, or may just not be in the right place to support the intended restoration. Since these implants have fused to the bone, according to the older success criteria they could be considered "successful", but realistically, they aren't. They have problems.
Researchers have called this "survival", and this is what dental implant companies advertise when they are talking about how well an implant works. But this is not success! A patient with a "surviving" dental implant can have chronic inflammation around the dental implant, requiring constant attention and even surgical management. This is a very frustrating, time consuming, and financially taxing outcome. And it happens frequently.
What are realistic success and survival statistics for dental implants?
It depends on how nerdy you want to get. I am a bigtime nerd, so I look at the research and really try to compare things to the reality of my everyday practice.
One of the first things that I look at when I evaluate any kind of article, is the "external validity" of the research. Most dental research is performed in highly controlled environments, where patients are carefully selected and monitored. Smokers, people with gum disease, people who have broken teeth due to bruxism (grinding), those who have had accidents, or people with certain medical conditions, are usually not selected for dental implant research. Furthermore, participants are kept to unrealistic standards of oral hygiene.
Does this relate to who "needs" dental implants in real life? NO! It is smokers, people with gum disease, people with bad oral hygiene and those who have had accidents, that are most often missing teeth. Can I therefore take the findings of a research study and apply it to this group of people? No way!
Then there is the heterogeneity of the dental implant procedure itself. There are thousands of implant companies, with thousands of designs. There are dozens of ways you can "restore" an implant. Surgical techniques and protocol are highly variable between practicioners, and ultimately patients are all different. You have to look up articles specific to your implant system, used the way that you want to, to understand the success/survival of the procedure. Are you going to read a review on the handling of a 4x4 SUV in snow, if you are looking to buy a hybrid city vehicle? Not likely. They both may have seatbelts, airbags, and headlights, but they aren't comparable.
Dental implant companies are always pumping out new implant designs and restoration concepts. Long-term success articles (10 years or more) are therefore very rare, and often describe implants and/or techniques that have gone by the wayside. Many implant companies are promoting dental implants that have very little long term clinical research to support them. The first things I ask when a rep comes along pushing a new product are, "can you show me 5-year clinical trial data? Is there any ten year data?" Is that information in their shiny brochure with fancy images? Not often. They have to get back to me via email.
Lastly, going back to success vs survival, there are various definitions on what a surviving dental implant is. Inflammation of the gums around a dental implant, is called "peri-implant mucositis", and loss of the supporting bone around a dental implant is called "peri-implantitis". There is no concensus as to how to define "peri-implantitis"; is bone loss without infection ok? how much bone loss is ok? will bone loss lead to infection? There is therefore a high variability in what researchers consider to be successful or surviving.
With all of these variables, how can we in the dental profession make a sweeping statement with a specific number for implant success or survival?
But that is what patients want to hear.
If we look at a cross section of the dental research, we know that dental implants fuse to the bone at very high rates, in most scenarios, and even in very compromised situations. Unlike the earlier studies, where the loss of 15% of dental implants over a five-year study would be considered successful, we are seeing "survival rates" in the high 90's for almost every published article you can find out there.
Yes. We know. Implants fuse to the bone.
Where it gets muddy is when we look at implant "success". To me, and to my patients as well, a "successful" dental implant, is one that goes in without complication, heals without complication, fuses to the bone, allows for the placement of the intended restoration without modification or compromise in the design, and functions comfortably without pain, without gum swelling and without breaking of the prosthetic components or implant itself.
I am going to drop a truth bomb here. Nothing works out perfectly in life, even dental implants.
The prosthetic complications such as the chipping of a crown, or a loosened screw, yea they are a nuisance and cost money to fix.....but if you plan ahead for failure and inform your patients that it WILL HAPPEN at some point, they are easily resolved.
Peri-implantitis, however, is a differrent beast, and it is out there. A lot! Depending on what definition the article uses, some researchers believe that around 1/3 of dental implants will develop some sort of gum inflammation around them during their lifespan. This is a shockingly high number that dental implant companies, and dentists, are not revealing when they use the term implant "survival".
A "success" rate in the 60-90% range will just not sell dental implants, so people report the "survival rate", which may include these ailing dental implants.
10 year implant survival and systematic review; note the high variability in success rate definition and therefore success rates, but high survival rates (table 4).
Peri-implantitis and Peri-implant mucositis; note the variability in definition of peri-implantitis
Frequency of Peri-implant diseases; note the difference in statistics between per patient and per implant
What does one believe?
With the correct planning, implementation and maintenance, dental implants can work very well, and are an excellent replacement for missing teeth. It takes years of training and experience to truly understand not just the successes of implant dentistry, but the challenges. A dentist working with dental implants must be comfortable not only explaining the potential complications that can arise, but should have a good understanding of how to manage them.
I am not a very good sales person. I am not out there telling my patients that implants are "perfect", "painless" or "permanent". That is just plain misleading. Yea, I may not be "selling" as many cases as the guy/gal down the street, and I may not be doing the riskier "fancy" procedures, but you know what? I sleep well at night knowing that I gave my patients an honest opinion with realistic viewpoints of the challenges of implant dentistry.
That is invaluable.
Thanks for reading!
p.s this article just scrapes the surface on implant dentistry, if there are specific topics that you want me to cover, please send me a line!
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