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I am often asked by undergraduates, what has been the biggest change in clinical dentistry since I qualified over 30 years ago. While there have been many, perhaps the increasing use of osseo-integrated implants during this time has been transformative for many patients and clinicians alike. While an essay on replacing missing teeth 30 years ago would have focused on dentures and destructive fixed bridges, the increasing use of osseo-integrated implants has transformed dentistry.
Having placed my first implant in 2003, I was struck by the utility of implants in replacing teeth. And in my first placement, under close mentorship, the procedure appeared simpler than many other areas of dentistry, or so I initially thought. One could easily be lulled into a false sense of security, much as on a weekend course where drilling into a plastic mandible, all seems rather straightforward. However, as my surgical and restorative implant experience grew, I became increasingly aware that implant placement and restoration was not without significant challenges, and the adage ‘horribly easy or easily horrible’ seemed rather apt. As with many other areas of dentistry, the day you think it will be an easy procedure, will be the day something surprises you and you swiftly transition to the easily horrible zone. Prior preparation and planning with due consideration of potential complications before they occur remains key.
Although I have followed up many completed implant cases where the soft tissue remains healthy, this is dependent on meticulous oral hygiene from the patient and regular supportive professional maintenance and monitoring. However, recent issues of Dental Update have highlighted the challenges of managing peri-implantitis. Indeed, an article published in Dental Update's special issue on periodontology has been awarded the first equal prize for graduates in the British Dental Industry Association/British and Irish Dental Editors and Writers (BDIA/BIDEWF) New Communicators Awards.1
While much is written and researched about peri-implantitis, when osseo-integration breaks down, patients and clinicians often face a very significant challenge. The challenge, as I see it, is that the implant surfaces, while beautifully designed to allow osseo-integration, are very difficult to decontaminate when osseo-integration fails, and the surface is biofilm contaminated. A variety of mechanical and chemical solutions has been suggested to decontaminate the implant surface, but consistency of outcomes remains a challenge.
As implant placement has become increasingly common, so have presenting cases of peri-implantitis, and I am left wondering where the majority of the burden of dealing with failing implants will fall. As anyone who has carried out much implant dentistry is aware, dealing with prosthetic issues second time around can be very challenging, particularly when identifying the implant system and aged components. A while ago I was involved in a publication around dental pain in care homes2 and it was very clear that this is a significant issue. As more of the ageing population have dental implants, dealing with them in practice, or care homes, may not only be a phenomenon, but phenomenally difficult to manage.
While implants have no doubt revolutionized many aspects of dentistry, consideration should be given to the future maintenance burden of implant treatment and where this burden might fall. Consideration of the full range of treatment modalities to replace teeth is as relevant now as it was 30 years ago, as is ensuring patients are facilitated, as best they can be, to perform oral hygiene measures at home. This will often need individually tailored adaptation of oral hygiene measures, and stressing to the patient that much as teeth can fail, so might implants in the future. As implants are often placed to resolve lack of adaptation to dentures, failure of implants may in some cases mean very significant challenges second time around.
As always, measured, informed discussions with patients will be key as we look to find the optimal long-term treatment, with a manageable maintenance burden, wherever this burden falls.