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Health‐economic aspects of implant‐supported restorative therapy
Abstract
Background
It is poorly understood how much additional dental care patients consume subsequent to implant therapy. The aim of the present study was to evaluate costs associated with implant-supported restorative therapy during long-term follow-up.
Material and Methods
Costs associated with preventive measures and complication-related procedures over a mean follow-up period of 8.2 years were assessed in patient files of 514 Swedish subjects provided with implant-supported restorative therapy. The restorative therapy and each of the subsequent interventions were assigned a specific cost. Accumulated costs were calculated in three categories: (i) total cost including initial restorative therapy and complication-related interventions, (ii) cost of preventive measures alone and (iii) cost of complication-related procedures alone. Potential differences by background variables were analyzed using growth curve models.
Results
In the whole sample, costs during follow-up ranged from 878 € (95%CI 743; 1,014) for patients with single-tooth restoration(s) to 1,210 € (95%CI 1,091; 1,329) for subjects with full-jaw restoration(s). The majority of costs during follow-up originated from preventive measures (741 € 95%CI 716; 766). Among individuals receiving ≥1 intervention dealing with a complication (n=253), complication-related costs amounted to 557 € (95%CI 480; 634). For patients with full jaw restorations, the corresponding amount was 769 € (95%CI 622; 916). Procedures related to peri-implantitis and technical complications resulted in costs similar to each other. Implant loss generated greater costs than any other type of complication.
Conclusions
Costs related to implant-supported restorative therapy during follow-up were associated with the extent of initial therapy. The higher costs during follow-up noted in patients provided with full-jaw restorations were explained by complication-associated procedures. Implant loss was the most costly type of complication.
... Although complication rates are well documented in the literature with a plethora of systematic reviews [1,5,14,15], a limited number of studies addressed the maintenance costs of implant therapy. The existing studies are limited by their focus on highly selected patient cohorts and reliance on estimated costs, which may not accurately reflect the actual costs encountered in daily clinical practice [16,17]. ...
... The current study found that patients experienced a 13% increase in the number of appointments due to various complications in addition to their regular maintenance care appointments. While this resulted in additional costs and time for the patients, it is difficult to compare with existing literature since most studies only consider the absolute cost of maintenance or restrict their comparisons to tooth-and implant-supported restorations [17,[26][27][28][29]. ...
... The absolute yearly costs for regular maintenance care and resolving different complications amounted to 404 CHF, which is substantially higher than the total costs reported in a recent publication [17]. In their study, the authors assessed the total costs of complications that occurred over an observation period of 8.5 years and reported costs ranging from 878 to 1210 €, which is substantially lower than the costs observed in the current study. ...
Objectives
To assess the costs and efforts of maintenance therapy following implant treatment with fixed restoration over an observation period of 10 years.
Material and Methods
This randomized controlled clinical trial included 64 patients who were randomly assigned to receive one of two implant systems (AST or STM) and fixed restoration. Patients were included in a regular maintenance program and were examined at loading, 1, 3, 5, 8, and 10 years. Outcome measures included technical and biological complications, time, efforts, and costs to resolve them.
Results
A total of 97 implants were placed in 64 patients (AST: 54, STM: 43). Patient recall rates at 5 and 10 years were 89% and 67%. In general, technical complications were resolved within one to two appointments (mean = 1.5), and biological complications required a mean of 1.3 appointments. The overall regular maintenance time for the period of 10 years amounted to 77 min per year. Technical complications occurred in 39.5% of the patients, with screw‐loosening being the most common one (43.4% of all complications). The most time‐consuming technical complication was abutment fracture (94 min ± 68), followed by screw fracture (84 min ± 38). The prevalence of peri‐implant mucositis on the patient level was 30.2%, and it was 9.3% for peri‐implantitis. The average annual maintenance costs amounted to 9% of the initial cost of the implant treatment over the period of 10 years.
Conclusions
Additional regular maintenance costs and costs due to the treatment of potential complications have to be taken into consideration when placing dental implants. The majority of technical complications could be resolved within one appointment, whereas the time needed to treat biological complications varied between one and three appointments for peri‐implantitis.
... 115 The prevalence of dental implants has seen a significant upswing, rising from 0.7% during 1999-2000 to 5.7% in 2015-2016. 116 The most pronounced absolute surge in prevalence, 12.9%, was observed in individuals aged 65-74 years, whereas the most remarkable relative increase, approximately 1000%, was noted among those in the 55-to 64-year-old bracket. The projected prevalence for 2026 varies from a conservative 5.7% to an upper limit of 23%. ...
... The projected prevalence for 2026 varies from a conservative 5.7% to an upper limit of 23%. 116 A Swedish study 117 teeth and 119 implants, the mean number of "disease-free years" was 8.66 for implants, 9.08 for neighboring teeth, and 9.93 for contralateral teeth, with no statistically significant differences. Even though the number of disease-free years was the same, the extra cost of maintaining implants was five times higher than for teeth due to the high prevalence of peri-implantitis. ...
Periodontal and peri‐implant diseases result from a chronic inflammatory response to dysbiotic microbial communities and are characterized by inflammation in the soft tissue and the ensuing progressive destruction of supporting bone, resulting in tooth or implant loss. These diseases' high prevalence, multifactorial etiology, extensive treatment costs, and significant detriment to patients' quality‐of‐life underscore their status as a critical public health burden. This review delineates the economic and sociocultural ramifications of periodontal and peri‐implant diseases on patient welfare and healthcare economics. We delve into the implications of diagnosis, treatment, supportive care, and managing destructive tissue consequences, contrasting these aspects with healthy patients.
... For example, patients may be able to cover the initial cost of dental implants and their associated restorations at the time of implant placement, when they are employed and earning a living, but the long-term cost of supportive care may not be explained clearly to patients and may impact when they are no longer economically active (Alani et al., 2014). A Swedish study of 514 subjects recently calculated such costs (Karlsson et al., 2022), including the costs of preventive measures and of procedures to treat implant complications, over a period of 8.2 years. The mean cost ranged from €878 (single-tooth restoration) to €1210 (full-arch restoration), the larger proportion of the cost being for prevention (€741), while implant loss was the most expensive complication (€1508), followed by peri-implantitis (€1244). ...
... • Prosthesis cleaning/removal/modification, including controlling biofilm retentive factors and evaluation of the components of the prosthesis, whenever needed and feasible. If renewal is necessary, additional evaluation of the overall treatment planning should be made, considering the added costs and the cost-effectiveness ratio (Karlsson et al., 2022). ...
Background:
The recently published Clinical Practice Guidelines (CPGs) for the treatment of stages I-IV periodontitis provided evidence-based recommendations for treating periodontitis patients, defined according to the 2018 classification. Peri-implant diseases were also re-defined in the 2018 classification. It is well established that both peri-implant mucositis and peri-implantitis are highly prevalent. In addition, peri-implantitis is particularly challenging to manage and is accompanied by significant morbidity.
Aim:
To develop an S3 level CPG for the prevention and treatment of peri-implant diseases, focusing on the implementation of interdisciplinary approaches required to prevent the development of peri-implant diseases or their recurrence, and to treat/rehabilitate patients with dental implants following the development of peri-implant diseases.
Materials and methods:
This S3 level CPG was developed by the European Federation of Periodontology, following methodological guidance from the Association of Scientific Medical Societies in Germany and the Grading of Recommendations Assessment, Development and Evaluation process. A rigorous and transparent process included synthesis of relevant research in 13 specifically commissioned systematic reviews, evaluation of the quality and strength of evidence, formulation of specific recommendations, and a structured consensus process involving leading experts and a broad base of stakeholders.
Results:
The S3 level CPG for the prevention and treatment of peri-implant diseases culminated in the recommendation for implementation of various different interventions before, during and after implant placement/loading. Prevention of peri-implant diseases should commence when dental implants are planned, surgically placed and prosthetically loaded. Once the implants are loaded and in function, a supportive peri-implant care programme should be structured, including periodical assessment of peri-implant tissue health. If peri-implant mucositis or peri-implantitis are detected, appropriate treatments for their management must be rendered.
Conclusion:
The present S3 level CPG informs clinical practice, health systems, policymakers and, indirectly, the public on the available and most effective modalities to maintain healthy peri-implant tissues, and to manage peri-implant diseases, according to the available evidence at the time of publication.
... The use of prefabricated attachment systems such as locators (Zest Dental Solutions, Carlsbad, CA, USA), instead of utilizing individually fabricated attachments such as telescopic crowns or bars, drastically reduces the initial treatment costs in the edentulous mandible [13,14]. Several studies have shown that maintenance frequency [15] and associated costs [16] in such restorations are quite high, equaling or even exceeding initial treatment fees [14,17]. In particular, loss of retention and fractures of the prostheses in the area of the attachment constitute the two main technical complications [18,19]. ...
... The form of the NiTi element The use of prefabricated attachment systems such as locators (Zest Dental Solutions, Carlsbad, CA, USA), instead of utilizing individually fabricated attachments such as telescopic crowns or bars, drastically reduces the initial treatment costs in the edentulous mandible [13,14]. Several studies have shown that maintenance frequency [15] and associated costs [16] in such restorations are quite high, equaling or even exceeding initial treatment fees [14,17]. In particular, loss of retention and fractures of the prostheses in the area of the attachment constitute the two main technical complications [18,19]. ...
While nickel-titanium (NiTi) is the primary shape memory alloy (SMA) used in endodontic instruments, restorative dental components so far have not been fabricated from SMAs. The flexibility of these materials may solve problems in implant prosthodontics resulting from non-parallel implant positions and transfer inaccuracies. Based on a prototype of a novel attachment system for implant overdentures, a finite element model was created and used for studying different loading situations and design parameters followed by numerical analysis aided design optimization. The results revealed that the basic design of the attachment is capable of compensating misalignments of supporting implants as well as transfer inaccuracies of a clinically relevant magnitude by accommodating the large deformations induced under masticatory loading upon martensitic phase transformation at almost constant stress. The application of NiTi resulted in the reduction of the reaction forces recorded in the surrounding of the supporting implant, as well, the reaction forces between male and female parts of the attachment system could be reduced which will minimize wear phenomena and subsequent maintenance costs. These effects were seen to be enhanced in the optimized design.
... Several studies investigating the biofilm-related etiology of peri-implant inflammation have identified plaque removal as an essential step in resolving PIM [7]. Therefore, plaque removal from the peri-implant sites is considered critical in the long-term management of dental implants [8]. Physical oral hygiene practices that remove dental plaque, such as toothbrushing [9] or oral detergent [10], should be prioritized for plaque removal. ...
Background
The purpose of this study was to confirm the improvement of peri-implant mucositis (PIM) in patients using the toothpick method (TPM) containing a natural ingredient: Cibotium barometz J. Smith (CB).
Methods
As a randomized, blind, controlled trial study, there were 21 participants in the CB TPM group (CBG), 20 participants in the chlorhexidine group (CG), and 19 participants in the saline group (SG). All three groups were examined both before and after TPM. We performed a paired t-test to determine the differences between the mean values of the three groups. We used ANOVA to evaluate the mean differences in clinical indicators, saliva tests, and periodontal bacteria.
Results
There were no significant differences in sociodemographic characteristics and oral health status between the three groups, thus ensuring homogeneity among the participants. Occult blood in the saliva test increased for SG and CG and decreased for CBG. Compared to the before-TPM condition, leukocyte and protein levels decreased for CG and CBG after TPM (p < 0.05). As a result of checking the effect size (Cohen’s d) before and after TPM according to the three groups, three species of bacteria were identified that showed a significant effect only on CBG, and two species were identified that showed a significant effect on CBG and CG (Cohen’s d ≥ 0.8).
Conclusion
This study confirmed the efficacy of CB-applied TPM on PIM patients and demonstrated its potential as a non-surgical treatment option. Therefore, practitioners could extensively use CB-applied TPM as a mechanical tool and safe chemical and biological removal agent for post-implant management in clinical settings.
Trial registration
The trial was registered in the International Clinical Trial Registry Platform (ICTRP) under the registration number KCT0008626 on 17/07/2023 and was retrospectively registered.
... Untreated peri-implantitis may lead to loss of implants, resulting in loss of function, impaired esthetics, and morbidity. Furthermore, treatment of peri-implantitis is, besides the inconvenience and discomfort for the patient, also demanding in terms of resources 10 . ...
Background
Dental implants are one of the most frequently used medical devices for therapeutic purposes in dentistry. Peri-implantitis is a severe, microbial biofilm-associated condition, characterized by inflammation in peri-implant soft tissues and destruction of supporting bone. It has been suggested that metal particles originating from the implant may influence the local host response to microbial biofilms.
Methods
Soft tissue biopsies were collected from implant sites with and without peri-implantitis in 21 patients. Micro Proton-induced X-ray Emission (µ-PIXE) analysis was used to localize, quantify and characterize titanium micro-particles within tissues. RNA sequencing was performed to evaluate potential associations between titanium micro-particles and gene expression profiles in peri-implantitis lesions.
Results
Titanium micro-particles are consistent findings in soft tissues surrounding dental implants. Their occurrence varies across patients but not between sites with and without peri-implantitis within the same individual. Most particles reside in a 2-mm wide tissue portion close to the implant/tissue interface. The time in function of the implants does not influence the volumetric density of titanium micro-particles, while implant systems do. Fourteen differentially expressed genes are identified when comparing peri-implantitis samples with high and low densities of titanium micro-particles. The gene-set enrichment analysis reveals functions related to the regulation of the immune response and epithelial development.
Conclusions
The present results indicate that titanium micro-particles are commonly found in tissues surrounding dental implants and are not associated with the occurrence of peri-implantitis.
... While maintenance costs can be high, for example, apical surgery for a root-filled tooth costs 5,320 SEK according to the reference price list of special dental practitioners [15], it also prolongs the survival of the tooth, meaning that turning to FDP for a tooth replacement is not needed. In this study, costs of any maintenance treatments were not included since there is a large variation of possible complications with RCT + PC and ISSC [33,13], and these complications can be treated in different ways [33,34]. However, this study can be used as a basis for such cost-effectiveness analyses. ...
Objective: The aim was to compare the cost-effectiveness of root canal treatment and an indirect restoration (RCT + PC) versus an implant-supported single crown (ISSC) in the case of a decayed first mandibular molar with a necrotic pulp. The study was based on Swedish population and the reference prices for dental treatments in Sweden. Materials and methods: The cost-effectiveness for RCT + PC and ISSC were calculated with the help of two decision trees. The initial costs were from the Swedish dental reference prices in 2024, and the probability values were from published articles based on Swedish data. Results: In Decision tree I, the expected costs for RCT + PC and for ISSC were 17,400 and 18,800 SEK, respectively. In the Decision tree II, the respected expected costs were 19,500 SEK and 18,800 SEK. The threshold probability values were 83 and 93% for RCT survival. Conclusions: Given the assumptions and limitations of this decision analysis, the probability of survival for RCT + PC needs to be in the range of 83–93% in order for it to be more cost-effective than ISSC, when deciding about treatment on a compromised first mandibular molar.
... The development of dental implants is driven by technological advancements [1][2][3], patient demand [4,5], aging population [4,[6][7][8], cost considerations [9][10][11][12], very high success rates between 90% and 98% [13][14][15], market growth-which is expected to expand at a compound annual growth rate (CAGR) of 9.8% from 2024 to 2030, reaching USD 9.62 billion by 2030 [16]-and patient expectations [17][18][19][20]. These factors collectively underscore the importance of ongoing innovation in the field of dental implants. ...
The development of dental implants has significantly advanced due to technological innovations aimed at improving their performance and patient outcomes. This work presents key factors influencing the success of dental implants, including osseointegration, which is the direct connection between living bone and the implant surface, and the various surface modifications that enhance this process. This review highlights the importance of surface roughness, chemical composition, and the use of bioactive coatings to promote better integration with surrounding bone tissue. Innovations such as nanotechnology, 3D printing, and smart surfaces are paving the way for more effective and personalized dental implant solutions. This review underscores the importance of ongoing research and development to improve success rates, enhance patient comfort, and reduce healing times. It focuses on creating cost-effective, reliable methods that integrate multiple functions, such as combining antibacterial and osteoconductive properties to improve overall implant performance.
... Removable implant-supported prostheses have transformed modern dentistry by providing patients with comfortable and functional alternatives for tooth replacement, especially in edentulous mandibles [12,13]. However, the persistent issue of component wear at the male-female interface of attachment systems [12,14] used for retaining implant-supported removable prostheses remains a significant concern in clinical practice, causing considerable maintenance costs [15,16]. With individually fabricated options such as telescopic crowns [17,18] and bars [19,20] often being considered cost-prohibitive, prefabricated single-standing components such as ball anchors (Figures 1 and 2) and locators have been adopted more widely. ...
Wear at the male–female interface of retentive elements in implant-supported removable prostheses is the most frequent complication in such applications. The lack of an ideal/optimal insertion path, as well as the fabrication inaccuracies, are the primary contributors to this issue. A male attachment with a common ball anchor enhanced by lateral flexibility was investigated as a solution, compared to the widely used rigid ball anchor design. A parametric finite element analysis was performed to compare the wear-inducing maximum strain at the female polymer counterpart by various attachment designs made from titanium and Nitinol. The evolution of mechanical strains causing wear in the female part, as well as the contribution of stresses and martensitic transformation in the implant’s flexible shaft, were evaluated under several insertion misfit scenarios. Results indicate that introducing a long flexible shaft in the titanium implant reduced maximum strains in the female attachment part by up to 61% as compared to the solid ball anchor. Further improvement was observed by using the shape memory alloy Nitinol as shaft material, leading to a minor reduction in stress and strain at the contact surface but allowing for a shorter abutment. Finally, the optimized Nitinol implant design with a short, necked flexible shaft promoting martensitic transformation at low plateau stress resulted in an approximate 90% reduction in maximum strains at the inner surface of the female part during manual insertion, which indicates a significantly reduced wear phenomenon at the contact.
... Hence, the successful, longterm maintenance and/or restoration of periimplant tissue health depends on the provision of appropriate preventive measures and interventions, which include: i) assessment and monitoring of the peri-implant tissue condition; ii) oral/peri-implant health promotion, behavioural change, and controlling of other risks and management of systemic diseases (ie diabetes); iii) periodical professionally delivered plaque removal as part of an SPIC, including elimination of plaque-retentive factors; and iv) treatment of peri-implant disease. 11,12 Implementing a consistent SPIC not only contributes to the maintenance of peri-implant tissue health 13 but also has the potential to prevent or delay the onset of peri-implant diseases, particularly among high-risk groups. 14 General dental practitioners (GDPs) play a fundamental role in providing SPIC. ...
The long-term maintenance or restoration of peri-implant tissues‘ health depends on the strategic implementation of preventive measures and interventions. These measures should be initiated before implant placement and continued throughout a patient's lifetime, as part of a tailored and comprehensive supportive peri-implant care (SPIC) programme. Central to the clinical efforts of maintaining and rehabilitating peri-implant tissues are several key factors, including the ongoing assessment and frequent monitoring of tissue health and stability, proactive oral health promotion, the control of risk factors and indicators and the provision of professional plaque biofilm removal. It is of paramount importance to underline that SPIC should not limit its scope exclusively to patients already in a state of peri-implant health; in fact, it is imperative that it should extend its protective effect to individuals who have been previously diagnosed and treated for peri-implant diseases, focusing on preventing its recurrence and progression, thereby avoiding further complications, such as implant loss.
This narrative review presents an overview of the current literature on the maintenance of peri-implant tissues‘ health and the steps of SPIC providing insights into the critical factors to be considered when managing dental implant patients in the general dental practice.
... 32 The EFP S3 treatment guidelines outline that surgical pocket elimination, bone recontouring, implantoplasty and regenerative techniques are recommended. 33,34,35,36 Evidence suggests the effectiveness of the regenerative treatment approaches is influenced by the configuration of the defect, implant surface characteristics, as well as surface decontamination. 33 software solutions like Dental Monitoring 2 (https://dentalmonitoring.com/) and Diagnocat 3 (www.diagnocat.com) ...
... Although implant loss is related to considerably greater costs compared to the peri-implantitis treatment, the need for repeated interventions after surgical periimplantitis treatment and the risk of reinfection leading to implant loss need to be discussed with the patient. 107 On the other hand, in the decision to "treat or remove," the gradually decreasing implant survival rates following the second or third attempt of reimplantation at the sites of previously failed implants sites should be considered. 108 ...
Peri-implant diseases define bacterial-plaque-induced inflammatory conditions affecting implant-surrounding tissues, classified as peri-implant mucositis and peri-implantitis. Peri-implant mucositis characterizes an inflammatory lesion that resides in the soft-tissue compartment, whereas at peri-implantitis sites, the lesions also feature progressive loss of implant-supporting bone. Inflammation resolution of and disease progression arrestment are the main therapeutic endpoints of peri-implant diseases treatment. The present position paper presents the current evidence and clinical recommendations of the European Association for Osseointegration for the treatment of peri-implant diseases. Mechanical biofilm removal along with the reinforcement of patient-administered oral hygiene is considered the standard treatment for managing peri-implant mucositis. It is recommended to assess the outcomes of peri-implant mucositis treatment 2 to 3 months after therapy, and in the absence of treatment success, a repeated intervention should be considered. Peri-implantitis treatment should follow a stepwise treatment approach, starting with a non-surgical treatment, and if not sufficient, followed by the surgical intervention. Surgical peri-implantitis therapies encompass non-reconstructive, reconstructive, and combined treatment modalities. Implantoplasty may be advocated for the treatment of supracrestal peri-implant defects, whereas reconstructive therapy is indicated at peri-implantitis sites featuring intra-osseous defects with a depth of ≥ 3 mm. Adjunctive reconstructive measures may be beneficial in enhancing radiographic defect fill and maintaining postoperative soft-tissue levels, which may have a great impact in aesthetic cases. The adjunctive use of systemic antibiotics during surgical therapy does not seem to improve the clinical outcomes. Regular supportive peri-implant therapy with biofilm removal should be an integral part of the treatment protocol of peri-implant diseases. In the presence of advanced bone loss at implants that do not play a strategic role in masticatory function, implant removal may be immediately considered.
... The long-term reliability of implant-supported fixed dental prostheses (FDPs) is nowadays not a matter of debate thanks to the wide body of evidence supporting such rehabilitative solutions (Duong et al., 2022;French et al., 2019;Jung et al., 2012;Roccuzzo et al., 2022). Nevertheless, in the last decade, scientific interest focused on treatment options aimed to reduce surgical invasiveness (Romandini et al., 2022), patient morbidity (Hof et al., 2014) and consequent financial costs (Karlsson et al., 2022). More specifically, among all available treatment options, the use of implant-supported FDPs with cantilever extension has been proposed (Halg et al., 2008) and its reliability in terms of implant-survival and success rates have been widely documented, as demonstrated by the many systematic reviews published on this topic (Freitas da Silva et al., 2018;Romeo & Storelli, 2012;Storelli et al., 2018;Zurdo et al., 2009). ...
Objectives:
To test the reliability of full zirconia implant-supported fixed dental prostheses with cantilever extension (FDPCs) after at least 1 year of function.
Materials and methods:
Thirty-five patients in need of implant-supported single unit crowns (SUC) and FDPCs in posterior areas were enrolled. After implant placement, patients were rehabilitated with screw-retained full-zirconia FDPCs. Implant survival rate, pocket probing depth (PPD), presence/absence of bleeding on probing (BoP), and presence/absence of mechanical/technical complications were recorded. Mesial and distal radiographic marginal bone levels (mBLs) from baseline (i.e., recall appointment 3-6 months after implant loading [T0]) to the follow-up examination (i.e., latest recall appointment after at least 12 months after T0 [T1]), were calculated.
Results:
Thirty patients with 34 FDPCs (31 SUCs and 3 FDPs) supported by 37 implants were available for analysis after a mean loading time of 2.6 ± 1.5 years (range: 13-87 months). No implants were lost. MBLs and mean PPD values did not change statistically significantly from T0 to T1 from 0.92 mm ± 0.42 to 0.96 mm ± 0.38 (95% CI: -0.07/0.17; p = .418) and from 2.99 mm ± 0.70 to 3.27 mm ± 0.71 (95% CI: -0.11/0.68; p = .25) respectively. Peri-implant mucositis was diagnosed in 22 cases. Screw-loosening and zirconia chipping occurred 1× in 4 patients.
Conclusion:
Within the limitations of the present proof-of-principle study, the use of full-zirconia FDPCs in posterior areas seems a valid and safe short-term treatment option.
... Peri-implant diseases are clinical realities in everyday practices, with approximately 1/3 of patients (and 1/5 of all implants) experiencing peri-implantitis [3]. Importantly, the microbial shifts for the progression from peri-implant mucositis to peri-implantitis are poorly understood [4,5]; whilst different solutions have been advocated for the treatment of peri-implantitis, at present there is no gold standard therapy that can predictably resolve this condition [6]. ...
Peri-implantitis is a disease influenced by dysbiotic microbial communities that play a role in the short- and long-term outcomes of its clinical treatment. The ecological triggers that establish the progression from peri-implant mucositis to peri-implantitis remain unknown. This investigation describes the development of a novel in vitro microcosm biofilm model. Biofilms were grown over 30 days over machined titanium discs in a constant depth film fermentor (CDFF), which was inoculated (I) with pooled human saliva. Following longitudinal biofilm sampling across peri-implant health (PH), peri-implant mucositis (PM), and peri-implantitis (PI) conditions, the characterisation of the biofilms was performed. The biofilm analyses included imaging by confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM), selective and non-selective culture media of viable biofilms, and 16S rRNA gene amplification and sequencing. Bacterial qualitative shifts were observed by CLSM and SEM across conditions, which were defined by characteristic phenotypes. A total of 9 phyla, 83 genera, and 156 species were identified throughout the experiment. The phyla Proteobacteria, Bacteroidetes, Firmicutes, Fusobacteria, and Actinobacteria showed the highest prevalence in PI conditions. This novel in vitro microcosm model provides a high-throughput alternative for growing microcosm biofilms resembling an in vitro progression from PH–PM–PI conditions.
... 10 Interestingly, these criteria have been maintained in many other studies from the same group even after the definition of the 2017 Consensus. 7,10,11,[14][15][16][17] Taking into consideration the related findings reported in all their manuscripts using this same series, this distinguished group of researchers in peri-implantitis used a combination of intraoral radiographs (78.1% of implants) and panoramic radiographs (21.9% of implants) for evaluating bone loss. 10 It is even more interesting that to define the onset and pattern of progression of peri-implantitis in their population, the assessment was solely based on radiographic and not clinical signs of progressive MBL. ...
Purpose:
The aim of this study was to establish an objective criterion in terms of marginal bone level (MBL) to know the prognosis of an implant.
Materials and methods:
A group of 176 patients in whom 590 implants were placed were included in this retrospective study. Patients older than 18 years, presenting either Kennedy class I or II edentulous section, or totally edentulous at least in one of the dental arches were included in this study. Those with any type of disturbance able to alter bone metabolism or with nontreated periodontal disease were excluded. Data on radiographic MBL at loading, 6 and 18 months later, age, gender, smoking habits, history of periodontitis, bone substratum, implant, and prosthetic features were recorded. Nonparametric receiver operating curves (ROC) were constructed for the MBL at 18 months in order to establish a distinction among high bone loser (HBL) and low bone loser (LBL) implants. Differences as a function of main variables were also determined, particularly abutment height and periodontal disease.
Results:
HBL implants lost at least 0.48 mm of MBL 6 months after loading; they reached at least 2 mm of MBL 18 months after loading. MBL rate followed a nonlinear trend, except in implants restored over long prosthetic abutments and in patients with history of severe periodontitis; in whom the rate of MBL over the time was nearly zero.
Conclusion:
Implants that lose more than 0.5 mm of marginal bone 6 months after loading are at great risk of not being radiographically successful anymore. Therefore, 0.5 mm of MBL is proposed as a distinctive and objective criterion of success in Implant Dentistry within a 6-month follow-up period. A prosthetic abutment height ≥2 mm resulted the most protective factor in the peri-implant bone maintenance.
Aim
To evaluate the impact of macrophage depletion on bone loss and inflammatory responses in a mouse model of peri‐implantitis, assessing macrophage depletion potential as a therapeutic strategy.
Materials and Methods
Using 6‐week‐old male C57BL/6 mice, peri‐implantitis was induced by placing a silk ligature around osteointegrated dental implants. Mice were divided into three groups: Healthy control (Healthy group); peri‐implantitis with liposomal phosphate‐buffered saline (PBS group); and peri‐implantitis with liposomal clodronate for macrophage depletion (CLOD group). Two weeks after ligature placement, micro‐CT, histological and real‐time PCR analyses were performed to assess bone density, leukocyte infiltration and cytokine levels.
Results
The CLOD group showed a significantly higher bone‐to‐implant contact (74%) and bone volume relative to total volume (79%) compared to the PBS group (53% and 54%, respectively) and Healthy group (64% and 66%, respectively). Histological analysis revealed significantly reduced leukocyte and macrophage counts in the CLOD group. Additionally, TNF‐α and IL‐10 levels were significantly decreased in the CLOD group compared with the PBS group.
Conclusion
Macrophage depletion effectively reduces bone loss and inflammation in peri‐implantitis. This study highlights targeting macrophages as a promising approach for managing peri‐implantitis, although further research is needed to optimize therapeutic strategies.
Objective
To analyse the effects of titanium implants coated with various antimicrobial peptide (AMP) layers on bacterial growth and early biofilm formation around the implants.
Methods
A novel AMP mixture was constructed using Type I collagen, sulfonated succinimide 4- (N-Maleimidylphenyl) butyrate, and AMPs. Titanium discs treated with chitosan and hyaluronic acid solutions were reacted with the AMP mixture to obtain AMP-coated titanium discs. The drug release properties and inhibitory effects on the growth and early biofilm formation of Porphyromonasgingivalis (P. gingivalis) ATCC BAA-308 or Staphylococcus aureus (S. aureus) ATCC 25923 were analysed.
Results
The antimicrobial activity of the 9-layer AMP-coated titanium discs against P. gingivalis ATCC BAA-308 and S.aureus ATCC 25923 was greatly higher relative to the 3-layer and 6-layer AMP-coated titanium discs (P < .05). The overall optical density and average optical density of titanium discs coated with 6 and 9 layers of AMPs were markedly inferior to those of uncoated titanium discs and discs coated with 3 layers of AMPs (P < .05). The drug release amounts from titanium discs coated with different layers of AMPs increased over time.
Conclusions
The prepared AMP-coated titanium discs effectively inhibit the growth of P. gingivalis and S. aureus, as well as early biofilm formation. The drug-laced discs demonstrate good durability and predictability in drug release, which may be beneficial for long-term therapeutic adoption.
Peri-implantitis, a complex condition that can lead to dental implant failure, is characterized by inflammatory destruction resulting from immune dysregulation. Oral microbial dysbiosis and foreign body stimulation are the main factors contributing to such dysregulation, impairing immune cell function and triggering an inflammatory response. Immune dysregulation plays a critical role in the pathophysiology of peri-implantitis, impacting the balance of T cell subsets, the production of inflammatory factors, and immune-related molecular signaling pathways. Understanding the relationship between immune dysregulation and peri-implantitis is crucial for developing targeted strategies for clinical diagnosis and individualized treatment planning. This review explores the similarities and differences in the immune microenvironment of oral bacterial infections and foreign body rejection, analyzes the relevant molecular signaling pathways, and identifies new key targets for developing innovative immunotherapeutic drugs and effective and personalized treatment modalities for peri-implantitis. Additionally, it addresses the challenges and potential directions for translating immunotherapy into clinical practice for peri-implantitis, offering insights that bridge the gaps in current literature and pave the way for future research.
Aim
To study the clinical, radiographic and microbiological outcomes after surgical treatment of peri‐implantitis, with or without adjunctive systemic antibiotics.
Materials and Methods
Eighty‐four patients (113 implants) with peri‐implantitis were randomized into three groups (A, amoxicillin and metronidazole; B, phenoxymethylpenicillin and metronidazole; or C, placebo). Treatment included resective surgery and implant surface decontamination with adjunctive antibiotics or placebo. Primary outcomes were probing pocket depth (PPD) reduction and marginal bone level (MBL) stability. Secondary outcomes were treatment success (defined as PPD ≤ 5 mm, bleeding on probing [BOP] ≤ 1site, absence of suppuration on probing [SOP] and absence of progressive bone loss of >0.5 mm), changes in BOP/SOP, mucosal recession (REC), clinical attachment level (CAL), bacterial levels and adverse events. Outcomes were evaluated for up to 12 months. The impact of potential prognostic indicators on treatment success was evaluated using multilevel logistic regression analysis.
Results
A total of 76 patients (104 implants) completed the study. All groups showed clinical and radiological improvements over time. Statistically significant differences were observed between groups for MBL stability (A = 97%, B = 89%, C = 76%), treatment success (A = 68%, B = 66%, C = 28%) and bacterial levels of Aggregatibacter actinomycetemcomitans and Tannerella forsythia , favouring antibiotics compared to placebo. Multiple regression identified antibiotic use as potential prognostic indicator for treatment success. Gastrointestinal disorders were the most reported adverse events in the antibiotic groups.
Conclusions
Adjunctive systemic antibiotics resulted in additional improvements in MBL stability. However, the potential clinical benefits of antibiotics need to be carefully balanced against the risk of adverse events and possible antibiotic resistance.
Objectives:
To determine the occurrence and clustering of complications in subjects restored with fixed implant-supported prostheses.
Methods:
241 subjects treated at one clinical center and provided with 729 implants were included in the present retrospective case series. A clinical and radiographic examination was performed after a mean follow-up period of 4.8 ±2.0 years. Additional information on occurrence of technical (chipping, loss of retention, fracture of components) and biological complications (marginal bone loss, implant loss) during follow-up was extracted from patient records. For each type of complication and complications overall, regression analyses were performed to identify potential risk factors. Cox-regression analyses were used to evaluate time-to-event for implant loss and technical complications.
Results:
In all, 30% of the 241 patients presented with at least one complication of technical and/or biological character during the follow-up period. Technical complications affected 19.5% of subjects, while 14.1% presented with marginal bone loss >2 mm. Implant loss occurred in 4.6% of subjects. While technical complications were noted already early during the maintenance period (<1,200 days), implant loss typically occurred during a later phase. A small subgroup of subjects (7.9%) experienced more than one type of complication.
Conclusions:
Complications occurred frequently and the most common type of complication was of technical character. Technical and biological complications occurred independently of each other.
Background
Periodontal regeneration can change tooth prognosis and represents an alternative to extraction in teeth compromised by severe intrabony defects. The aim of this study was to compare periodontal regeneration (PR) with tooth extraction and replacement (TER) in a population with attachment loss to or beyond the apex of the root in terms of professional, patient reported and economic outcomes.
Methods
This was a 10‐year randomized controlled clinical trial. 50 stage III or IV periodontitis subjects with a severely compromised tooth with attachment loss to or beyond the apex were randomized to PR or TER with either an implant or a tooth supported fixed partial denture. Subjects were kept on a strict periodontal supportive care regimen every 3 months and examined yearly. Survival and recurrence analysis were performed.
Results
88% and 100% survival rates were observed in the PR and TER groups. Complication free survival was not significantly different: 6.7‐9.1 years for PR and 7.3‐9.1 years for TER (P=0,788). In PR, the observed 10‐year attachment gain was 7.3±2.3 mm and the residual probing depths were 3.4±0.8 mm. Recurrence analysis showed that the 95% confidence interval of the costs was significantly lower for PR compared to TER throughout the whole 10‐year period. Patient reported outcomes and oral health related quality of life measurements improved in both groups.
Conclusions
Periodontal regeneration can change the prognosis of hopeless teeth and is a less costly alternative to tooth extraction and replacement. The complexity of the treatment limits widespread application to the most complex cases but provides powerful proof of principle for the benefits of PR in deep intrabony defect.
Objective:
To collate the body of evidence in economic studies of different dental interventions.
Methods:
Eligible English studies after 1980 were sourced from MEDLINE using MeSH terms and reviewed independently by 4 teams. Studies were grouped according to the type of dental intervention and their quality appraised using Drummond's Checklist.
Results:
The number of dental economic studies increased from 1980 to 2016. A total of 91 studies were identified following the search strategy. Most studies were conducted in the United States (n=23), followed by Germany (n=14), Australia (n=10) and the United Kingdom (n=9). Preventative dental interventions comprised 37% of included studies (n=34), followed by restorative (n=14), prosthodontic (n=13) and periodontal interventions (n=12). Cost effectiveness analyses (n=68) comprise 75% of full economic evaluation (EE) studies, followed by cost-utility (n=17) and cost-benefit (n=6). Quality assessment checklists identified 60 studies as good, 23 as moderate and 8 as poor. Common methodological limitations were identified in EE studies. Comparison of studies identified trends and common findings within each dental intervention.
Conclusion:
High quality economic studies are important in directing resources and funding by policy makers. Standardisation of reporting outcome measures will improve the potential for interpretation and comparison between studies. Research adhering to recommended quality assessment checklists will improve the overall quality of evidence to better identify cost-effective treatments for different dental interventions.
Objectives
The aim of the present review was to compare the outcomes, that is, survival and complication rates of zirconia‐ceramic and/or monolithic zirconia implant‐supported fixed dental prostheses (FDPs) with metal‐ceramic FDPs.
Materials and Methods
An electronic MEDLINE search complemented by manual searching was conducted to identify randomized controlled clinical trials, prospective cohort studies and retrospective case series on implant‐supported FDPs with a mean follow‐up of at least 3 years. Patients had to have been examined clinically at the follow‐up visit. Assessment of the identified studies and data extraction was performed independently by two reviewers. Failure and complication rates were analyzed using robust Poisson regression models to obtain summary estimates of 5‐year proportions.
Results
The search provided 5,263 titles and 455 abstracts. Full‐text analysis was performed for 240 articles resulting in 19 studies on implant FDPs that met the inclusion criteria. The studies reported on 932 metal‐ceramic and 175 zirconia‐ceramic FDPs. Meta‐analysis revealed an estimated 5‐year survival rate of 98.7% (95% CI: 96.8%–99.5%) for metal‐ceramic implant‐supported FDPs, and of 93.0% (95% CI: 90.6%–94.8%) for zirconia‐ceramic implant‐supported FDPs (p < 0.001). Thirteen studies including 781 metal‐ceramic implant‐supported FDPs estimated a 5‐year rate of ceramic fractures and chippings to be 11.6% compared with a significantly higher (p < 0.001) complication rate for zirconia implant‐supported FDPs of 50%, reported in a small study with 13 zirconia implant‐supported FDPs. Significantly (p = 0.001) more, that is, 4.1%, of the zirconia‐ceramic implant‐supported FDPs were lost due to ceramic fractures compared to only 0.2% of the metal‐ceramic implant‐supported FDPs. Detailed analysis of factors like number of units of the FDPs or location in the jaws was not possible due to heterogeneity of reporting. No studies on monolithic zirconia implant‐supported FDPs fulfilled the inclusion criteria of the present review. Furthermore, no conclusive results were found for the aesthetic outcomes of both FDP‐types.
Conclusion
For implant‐supported FDPs, conventionally veneered zirconia should not be considered as material selection of first priority, as pronounced risk for framework fractures and chipping of the zirconia veneering ceramic was observed. Monolithic zirconia may be an interesting alternative, but its clinical medium‐ to long‐term outcomes have not been evaluated yet. Hence, metal ceramics seems to stay the golden standard for implant‐supported multiple‐unit FDPs.
Treatment outcomes in implant dentistry have been mainly assessed as implant survival rates in small, selected patient groups of specialist or university clinical settings. This study reports on loss of dental implants assessed in a large and randomly selected patient sample. The results were aimed at representing evaluation of effectiveness of implant dentistry. Using the national data register of the Swedish Social Insurance Agency, 4,716 patients were randomly selected. All had been provided with implant-supported restorative therapy in 2003. Patient files of 2,765 patients (11,311 implants) were collected from more than 800 clinicians. Information on patients, treatment procedures, and outcomes related to the implant-supported restorative therapy was extracted from the files. In total, 596 of the 2,765 subjects, provided with 2,367 implants, attended a clinical examination 9 y after therapy. Implant loss that occurred prior to connection of the supraconstruction was scored as an early implant loss, while later occurring loss was considered late implant loss. Early implant loss occurred in 4.4% of patients (1.4% of implants), while 4.2% of the patients who were examined 9 y after therapy presented with late implant loss (2.0% of implants). Overall, 7.6% of the patients had lost at least 1 implant. Multilevel analysis revealed higher odds ratios for early implant loss among smokers and patients with an initial diagnosis of periodontitis. Implants shorter than 10 mm and representing certain brands also showed higher odds ratios for early implant loss. Implant brand also influenced late implant loss. Implant loss is not an uncommon event, and patient and implant characteristics influence outcomes (ClinicalTrials.gov NCT01825772).
© International & American Associations for Dental Research 2014.
Purpose:
This study assessed the cost-effectiveness from a societal perspective of a dental implant compared with a three-unit tooth-supported fixed partial denture (FPD) for the replacement of a single tooth in 2010.
Materials and methods:
A decision tree was developed to estimate cost-effectiveness over a 10-year period. The survival rates of single-tooth implants and FPDs were extracted from a meta-analysis of single-arm studies. Medical costs included initial treatment costs, maintenance costs, and costs to treat complications. Patient surveys were used to obtain the costs of the initial single-tooth implant or FPD. Maintenance costs and costs to treat complications were based on surveys of seven clinical experts at dental clinics or hospitals. Transportation costs were calculated based on the number of visits for implant or FPD treatment. Patient time costs were estimated using the number of visits and time required, hourly wage, and employment rate. Future costs were discounted by 5% to convert to present values.
Results:
The results of a 10-year period model showed that a single dental implant cost US 342 (hospital) more than an FPD and had an average survival rate that was 10.4% higher. The incremental cost-effectiveness ratio was 3,290 in a hospital for a prosthesis in situ for 10 years. The sensitivity analysis showed that initial treatment costs and survival rate influenced the cost-effectiveness. If the cost of an implant were reduced to 80% of the current cost, the implant would become the dominant intervention.
Conclusion:
Although the level of evidence for effectiveness is low, and some aspects of single-tooth implants or FPDs, such as satisfaction, were not considered, this study will help patients requiring single-tooth replacement to choose the best treatment option.
The aim of this study was to compare the long-term outcomes of implants placed in patients treated for periodontitis periodontally compromised patients (PCP) and in periodontally healthy patients (PHP) in relation to adhesion to supportive periodontal therapy (SPT).
One hundred and twelve partially edentulous patients were consecutively enrolled in private specialist practice and divided into three groups according to their initial periodontal condition: PHP, moderate PCP and severe PCP. Perio and implant treatment was carried out as needed. Solid screws (S), hollow screws (HS) and hollow cylinders (HC) were installed to support fixed prostheses, after successful completion of initial periodontal therapy (full-mouth plaque score <25% and full-mouth bleeding score <25%). At the end of treatment, patients were asked to follow an individualized SPT program. At 10 years, clinical measures and radiographic bone changes were recorded by two calibrated operators, blinded to the initial patient classification.
Eleven patients were lost to follow-up. During the period of observation, 18 implants were removed because of biological complications. The implant survival rate was 96.6%, 92.8% and 90% for all implants and 98%, 94.2% and 90% for S-implants only, respectively, for PHP, moderate PCP and severe PCP. The mean bone loss was 0.75 (+/- 0.88) mm in PHP, 1.14 (+/- 1.11) mm in moderate PCP and 0.98 (+/- 1.22) mm in severe PCP, without any statistically significant difference. The percentage of sites, with bone loss > or =3 mm, was, respectively, 4.7% for PHP, 11.2% for moderate PCP and 15.1% for severe PCP, with a statistically significant difference between PHP and severe PCP (P<0.05). Lack of adhesion to SPT was correlated with a higher incidence of bone loss and implant loss.
Patients with a history of periodontitis presented a lower survival rate and a statistically significantly higher number of sites with peri-implant bone loss. Furthermore, PCP, who did not completely adhere to the SPT, were found to present a higher implant failure rate. This underlines the value of the SPT in enhancing the long-term outcomes of implant therapy, particularly in subjects affected by periodontitis, in order to control reinfection and limit biological complications.
We assess the cost-effectiveness of dental implant first-line strategy vs. fixed partial denture strategy in patients suffering from one single missing tooth.
The model used a simulation decision framework over a 20-year period. Potential treatment switches can occur every 5 years. Transition probabilities come from literature, epidemiological reports or expert opinions. They have been programmed using specific distribution ranges to simulate the patients' and practice variability, and to take into account parameter uncertainty. Direct medical costs have been assessed according to a cost survey. Probabilistic sensitivity analyses were conducted using 5000 Monte-Carlo simulations, generating confidence intervals of model outcomes.
We found that mean cost-effectiveness of the bridge strategy is higher than the implant strategy.
Implant as the first-line strategy appears to be the 'dominant' strategy, considering the lower overall costs and the higher success rate.
Objectives
The aim was to evaluate the overall occurrence and potential clustering of biological and technical complications in implant dentistry.
Material & Methods
596 patients provided with implant‐supported reconstructions were evaluated for the occurrence of (i) technical complications, (ii) peri‐implantitis and (iii) implant loss during a period of 9 years. Time and type of event were scored, and potential risk factors were explored through parametric modelling of survival and hazards. Clustering of complications was assessed at the patient level and patient satisfaction was evaluated by questionnaire completed at the 9‐year examination.
Results
42% of patients were affected by technical and/or biological complications during the 9‐year observation period. Extent of therapy (Hazard Ratio 2.5: patients with partial jaw restorations; HR 3.9: patients with full jaw restorations) and a history of periodontitis (HR 1.6) were identified as risk factors. While technical complications occurred mostly as isolated events, 41% of subjects identified with peri‐implantitis and 52% of subjects with implant loss also presented with other complications. The hazard for technical complications and implant loss peaked at 0.7 years and 0.2 years, respectively, while the hazard for peri‐implantitis was consistent throughout the observation period. The overall proportion of satisfied patients at 9 years was high (95%) and only minor differences between individuals with and without complications were noted.
Conclusions
Complications following implant‐supported restorative therapy were common findings. Extent of therapy and periodontitis were identified as risk factors. While technical complications occurred in an isolated pattern, peri‐implantitis and implant loss demonstrated clustering with other types of complications.
Objective
The aim of the present study was to assess interventions and their consequences with regard to further bone loss at sites diagnosed with peri‐implantitis.
Material & Methods
In 2017, records of 70 patients diagnosed with moderate/severe peri‐implantitis at ≥1 implant sites 4 years earlier were obtained. Changes of marginal bone levels during the study period assessed on radiographs and predictors of disease progression were identified by cox regression and mixed linear modelling. Patient files were analyzed for professional interventions related to the treatment of peri‐implantitis.
Results
Mean bone loss (±sd) at implants diagnosed with moderate/severe peri‐implantitis was 1.1 ±2.0 mm over the observation period of 3.3 years. While non‐surgical measures including submucosal and/or supra‐mucosal cleaning of implants were provided to almost all patients, surgical treatment of peri‐implantitis was limited to a subgroup (17 subjects). Surgically treated implant sites demonstrated a mean bone loss of 1.4 ±2.4 mm prior to surgical intervention, while only minor changes (0.2 ±1.0 mm) occurred after therapy. Clinical parameters (bleeding/suppuration on probing and probing depth) assessed at diagnosis were statistically significant predictors of disease progression.
Conclusions
Non‐surgical procedures were insufficient to prevent further bone loss at implant sites affected by moderate/severe peri‐implantitis. Surgical treatment of peri‐implantitis markedly diminished the progression of bone loss. Clinical assessments of bleeding on probing and probing depth at diagnosis predicted further bone loss.
This article is protected by copyright. All rights reserved.
Objective
The aim of this study was to evaluate the occurrence and consequences of technical complications in implant‐supported restorative therapy.
Material & Methods
The occurrence and consequences of technical complications in implant‐supported restorative therapy over a mean follow‐up period of 5.3 years were assessed based on documentation in files from 2,666 patients. Risk indicators were identified by the use of survival models, considering repeated events. Results were expressed as hazard ratios (HR) including 95% confidence intervals.
Results
Technical complications occurred in 24.8% of the patients. Chipping and loss of retention were the most common, affecting 11.0% and 7.9% of supraconstructions, respectively, while implant‐related complications (e.g., implant fracture) were rare. More than 50% of the affected patients experienced technical complications more than once and almost all reported complications led to interventions by a dental professional. The extent of the supraconstruction was the strongest risk indicator for both chipping (HR < 0.2) and loss of retention (HR > 3).
Conclusion
Over a 5‐year period, technical complications in implant‐supported restorative therapy occurred frequently and their management required professional intervention.
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
Purpose:
To assess the estimated cumulative survival (ECS) and explore the technical and biologic complications of 256 TiUnite implants (Nobel Biocare) supporting one-piece cast abutment/metal-ceramic implant-supported single crowns (ISCs) in situ for up to 14 years.
Materials and methods:
A prospective sequentially recruited cohort of 207 patients received 256 metal-ceramic ISCs on TiUnite implants between 2001 and 2014. All but 24 patients with 27 crowns were clinically evaluated between January 2014 and April 2015 in conjunction with or in addition to their tailored maintenance program. Radiographs were obtained, and any previously recorded treatments associated with the crowns were tabulated. The ECS and standard errors were calculated with the life table actuarial method and Greenwood's formula, respectively. The log rank test was applied to assess differences between anterior and posterior crowns. Complication incidence, severity, and economic burden, measured in time/cost accounting units (TAUs), were tallied and compared descriptively. Independent groups were compared with the Mann-Whitney U test and related groups with the Wilcoxon Signed Rank Test.
Results:
The mean clinical service time of the crowns was 5.61 years (44 ≥ 10 years). The 14-year ECS was 95.95% ± 3.20% with no significant difference between anterior and posterior prostheses. Only seven implants lost marginal bone ≥ one thread from the time of crown insertion. There were 30 nonterminal complications (16 biologic, 14 mechanical). The associated economic burden was low (n = 35 TAUs).
Conclusion:
High gold-alloy one-piece cast abutment/metal-ceramic ISCs on TiUnite implants exhibited excellent longevity and few complications over 14 years.
Peri-implantitis is an inflammatory disease affecting soft and hard tissues surrounding dental implants. As the global number of individuals that undergo restorative therapy through dental implants increases, peri-implantitis is considered as a major and growing problem in dentistry. A randomly selected sample of 588 patients who all had received implant-supported therapy 9 y earlier was clinically and radiographically examined. Prevalence of peri-implantitis was assessed and risk indicators were identified by multilevel regression analysis. Forty-five percent of all patients presented with peri-implantitis (bleeding on probing/suppuration and bone loss >0.5 mm). Moderate/severe peri-implantitis (bleeding on probing/suppuration and bone loss >2 mm) was diagnosed in 14.5%. Patients with periodontitis and with ≥4 implants, as well as implants of certain brands and prosthetic therapy delivered by general practitioners, exhibited higher odds ratios for moderate/severe peri-implantitis. Similarly, higher odds ratios were identified for implants installed in the mandible and with crown restoration margins positioned ≤1.5 mm from the crestal bone at baseline. It is suggested that peri-implantitis is a common condition and that several patient- and implant-related factors influence the risk for moderate/severe peri-implantitis (ClinicalTrials.gov NCT01825772).
To assess and compare the outcomes and economic complication burden of three-unit tooth-supported fixed dental prostheses (TFDPs) and implant-supported single crowns (ISCs) provided to a sequential cohort in a specialist prosthodontic practice over a 15-year period.
Sequential patients requiring replacement of a single missing tooth between 1996 and 2010 with a metal-ceramic three-unit TFDP (n = 145 patients, n = 174 prostheses) or ISC (n = 174 patients, n = 220 prostheses) were included. Prostheses subjectively judged at insertion to have an unfavorable 10-year prognosis (17 TFDPs, 0 ISCs) were removed from statistical analyses. The estimated cumulative survival (ECS) was calculated with the life table actuarial method and standard errors calculated with the Greenwood formula. Differences in outcomes between all prostheses and those replacing only anterior or only posterior teeth were assessed with the log rank test. Complication incidence, severity, and economic burden, measured in time/cost accounting units (TAUs), were tallied and compared descriptively.
The 15-year ECS did not differ for 112 TFDPs (92.75% ± 3.28%) and 81 ISCs (95.95% ± 2.92%) replacing posterior teeth. However, the 15-year ECS was significantly greater for 139 ISCs (93.33% ± 6.44%) than for 45 TFDPs (82.82% ± 6.50%) replacing anterior teeth. The economic burden of nonterminal complications for both prostheses was low (mean = 0.3 and 0.2 TAUs per prosthesis for TFDPs and ISCs, respectively). This equated to 3 TAUs/100 years in clinical service and 4 TAUs/100 years in clinical service for the TFDPs and ISCs, respectively.
The survival of three-unit TFDPs and ISCs over 15 years was not statistically different when replacing posterior teeth, but ISCs survived significantly better when replacing anterior teeth. The complication rates of the TFDPs and ISCs were similar, but the economic burden for the TFDPs was greater.
Aims:
Over the past decades, the placement of dental implants has become a routine procedure in the oral rehabilitation of fully and partially edentulous patients. However, the number of patients/implants affected by peri-implant diseases is increasing. As there are--in contrast to periodontitis--at present no established and predictable concepts for the treatment of peri-implantitis, primary prevention is of key importance. The management of peri-implant mucositis is considered as a preventive measure for the onset of peri-implantitis. Therefore, the remit of this working group was to assess the prevalence of peri-implant diseases, as well as risks for peri-implant mucositis and to evaluate measures for the management of peri-implant mucositis.
Methods:
Discussions were informed by four systematic reviews on the current epidemiology of peri-implant diseases, on potential risks contributing to the development of peri-implant mucositis, and on the effect of patient and of professionally administered measures to manage peri-implant mucositis. This consensus report is based on the outcomes of these systematic reviews and on the expert opinion of the participants.
Results:
Key findings included: (i) meta-analysis estimated a weighted mean prevalence for peri-implant mucositis of 43% (CI: 32-54%) and for peri-implantitis of 22% (CI: 14-30%); (ii) bleeding on probing is considered as key clinical measure to distinguish between peri-implant health and disease; (iii) lack of regular supportive therapy in patients with peri-implant mucositis was associated with increased risk for onset of peri-implantitis; (iv) whereas plaque accumulation has been established as aetiological factor, smoking was identified as modifiable patient-related and excess cement as local risk indicator for the development of peri-implant mucositis; (v) patient-administered mechanical plaque control (with manual or powered toothbrushes) has been shown to be an effective preventive measure; (vi) professional intervention comprising oral hygiene instructions and mechanical debridement revealed a reduction in clinical signs of inflammation; (vii) adjunctive measures (antiseptics, local and systemic antibiotics, air-abrasive devices) were not found to improve the efficacy of professionally administered plaque removal in reducing clinical signs of inflammation.
Conclusions:
Consensus was reached on recommendations for patients with dental implants and oral health care professionals with regard to the efficacy of measures to manage peri-implant mucositis. It was particularly emphasized that implant placement and prosthetic reconstructions need to allow proper personal cleaning, diagnosis by probing and professional plaque removal.
AimThe comparative cost-effectiveness of retaining or replacing molars with furcation involvement (FI) remains unclear. We assessed the cost-effectiveness of retaining FI-molars via periodontal treatments versus replacing them via implant-supported crowns (ISCs).Methods
Using tooth-level Markov-models, we followed a molar with FI degree I or II/III in a 50-years-old patient over his life-time. Tooth-retaining periodontal treatments (scaling and root planning, flap debridement, root resection, guided-tissue-regeneration, tunnelling) were compared with tooth-replacement using ISCs. We analysed costs, time until first re-treatment, and total time of tooth or implant retention. The model adopted a private-payer-perspective within German healthcare. Transition probabilities were calculated based on current evidence. Monte-Carlo microsimulations were performed, and robustness of the model and effects of heterogeneity assessed using sensitivity analyses.ResultsDespite requiring re-treatment later than other strategies, ISCs were the most costly therapy. Compared with most periodontal treatments, ISCs were retained for shorter time than natural teeth regardless of the degree of FI, the patients’ age, or risk profile (smoker/non-smoker).Conclusions
Based on available data and within its limitations, our study indicates that retaining FI-molars via periodontal treatments might be more cost-effective than replacing them via ISCs. Changes in the underlying evidence or the setting might alter these results.This article is protected by copyright. All rights reserved.
Background
In addition to traditional clinical parameters, the need to include patient-reported assessments into dental implant research has been emphasized.AimThe aim of this study was to evaluate patient-reported outcomes following implant-supported restorative therapy in a randomly selected patient sample.Material and Methods
Four thousand seven hundred and sixteen patients were randomly selected from the data register of the Swedish Social Insurance Agency. A questionnaire containing 10 questions related to implant-supported restorative therapy was mailed to each of the individuals about 6 years after therapy. Associations between questionnaire data, and (i) patient-related, (ii) clinician-related and (iii) therapy-related variables were identified by multivariate analyses.ResultsThree thousand eight hundred and twenty-seven patients (81%) responded to the questionnaire. It was demonstrated that the overall satisfaction among patients was high. Older patients presented with an overall more positive perception of the results of the therapy than younger patients and males were more frequently satisfied in terms of esthetics than females. While clinical setting did not influence results, patients treated by specialist dentists as opposed to general practitioners reported a higher frequency of esthetic satisfaction and improved chewing ability. In addition, patients who had received extensive implant-supported reconstructions, in contrast to those with small reconstructive units, reported more frequently on improved chewing ability and self-confidence but also to a larger extent on implant-related complications.Conclusion
It is suggested that patient-perceived outcomes of implant-supported restorative therapy are related to (i) age and gender of the patient, (ii) the extent of restorative therapy and (iii) the clinician performing the treatment.
Background
Costs for single-implant treatment are mostly described for the initial treatment. Information on the additional cost related to aftercare is scarce.Objective
To make an estimation of complication costs of single implants in periodontally healthy patients after 16–22 years and to compare costs for various prosthetic designs.Materials and methodsPatients with a single implant were recalled for a clinical examination and file investigation. Prosthetic designs included single-tooth (ST) and CeraOne (CO) abutments supporting a porcelain-fused-to-metal (PFM), all-ceramic (CER), or gold-acrylic (ACR) crown. Costs related to failures or technical, biologic, and aesthetic complications were retrieved from patient's records. Total and yearly additional complication costs were calculated as a percentage relative to the initial cost. Chair time needed to solve the complication was recorded and prosthetic designs were compared by Kruskal–Wallis tests.ResultsFifty patients with 59 surviving implants were clinically investigated. Additional complication costs after a mean follow-up of 18.5 years amounted to 23% (range 0–110%) of the initial treatment cost. In total, 39% of implants presented with no costs, whereas 22% and 8% encountered additional costs over 50% and 75%, respectively. In 2%, the complication costs exceeded the initial cost. The mean yearly additional cost was 1.2% (range 0–6%) and mean complication time per implant was 67 min (range 0–345 min). Differences between prosthetic designs (CO, ST-PFM, ST-ACR) were statistically significant for total cost (P = 0.011), yearly cost (P = 0.023), and time (P = 0.023). Pairwise comparison revealed significant lower costs for CO compared with ST-ACR reconstructions.Conclusion
Patients should be informed about additional costs related to complications with single implants. The mean additional cost spent on complications was almost one-quarter of the initial treatment price. A majority of implants presented with lower additional costs, whereas the highest complication costs were related to a smaller group with 22% of the implants needing more than half of the initial cost for complication management. Expenses were significantly different for various prosthetic designs.
The current reporting of complications associated with FDPs is inadequate and misleading. Complications,which incur significant monetary costs, will particularly impact the perceived value (worth or importance)that patients derive from their prostheses.Effective documentation of complications should include type (biologic and technical), incidence, and severity. The fiscal burden of treatment should be quantified. Comparisons of different restorative materials,techniques, and procedures should be meaningful.Data collated prospectively or retrospectively and pooled over time should allow for comparisons within and between different practice settings. The proposed classification, based on the fiscal consequences of complications, achieves these objectives.Effective documentation of complications in conjunction with actual or projected survival data and personal clinical experience will enable clinicians to provide realistic information of the expected clinical service of dental prostheses.
For the restoration of an anterior missing tooth, implant-supported single crowns (ISCs) or fixed dental prostheses (FDPs) are indicated, but it is not clear which type of restoration is more cost-effective. A self-selected trial was performed with 15 patients with ISCs and 11 with FDPs. Patient preferences were recorded with visual analog scales before treatment, 1 month following restoration, and then annually. Quality-adjusted tooth years (QATYs) were estimated by considering the type of reconstruction for replacing the missing tooth and its effect on the adjacent teeth. A stochastic cost-effectiveness model was developed using Monte Carlo simulation. The expected costs and QATYs were summarized in cost-effectiveness acceptability curves. ISC was the dominant strategy, with a QATY increase of 0.01 over 3 years and 0.04 over 10 years with a higher probability of being cost-effective. While both treatment options provided satisfactory long-term results from the patient's perspective, the lower initial costs, particularly laboratory fees, were responsible for the dominance of ISCs over FDPs.
Little is known about the cost minimization and cost effectiveness involved in maintaining teeth and implants for patients treated for periodontal disease.
A retrospective study was carried out encompassing all patients who had initial periodontal treatment followed by implant placement and maintenance therapy in a specialist practice in Norway. The neighbouring tooth and the contra-lateral tooth were used as controls. The number of disease-free years and the extra cost over and above maintenance treatment for both teeth and implants were recorded.
The sample consisted of 43 patients with an average age of 67.4 years. The patients had 847 teeth at the initial examination and received 119 implants. Two implants were removed 13 and 22 years after insertion. The prevalence of peri-implantitis was 53.5% at the patient level and 31.1% at the implant level. The prevalence of periodontitis was 53.4% at the patient level and 7.6% at the tooth level. The mean number of disease-free years was: implants: 8.66; neighbouring tooth: 9.08; contra-lateral teeth: 9.93. These mean values were not statistically significantly different from each other. The extra cost of maintaining the implants was about five times higher for implants than for teeth.
The number of disease-free years was the same for neighbouring teeth, contra-lateral teeth and implants. However, due to the high prevalence of peri-implantitis, the cost of maintaining implants was much higher than the cost of maintaining teeth.
The objective of this systematic review was to assess the 5- and 10-year survival of implant-supported fixed dental prostheses (FDPs) and to describe the incidence of biological and technical complications.
An electronic Medline search complemented by manual searching was conducted to identify prospective and retrospective cohort studies and case series on FDPs with a mean follow-up time of at least 5 years. Patients had to have been examined clinically at the follow-up visit. Failure and complication rates were analyzed using standard and random-effects Poisson regression models to obtain summary estimates of 5-year and 10-year survival and complication rates.
The updated search provided 979 titles and 257 abstracts. Full-text analysis was performed for 90 articles resulting in a total 32 studies that met the inclusion criteria. Meta-analysis of these studies indicated an estimated survival of implants supporting FDPs of 95.6% after 5 years and 93.1% after 10 years. When machined surface implants were excluded from the analysis and only rough surface implants included, the survival rate increased to 97.2% after 5 years. The survival rate of implant-supported FDPs was 95.4% after 5 years and 80.1% after 10 years of function. When the analysis was done exclusively for metal-ceramic FDPs, hence the old gold-acrylic FDPs were excluded, the survival rate increased significantly. The survival rate of metal-ceramic implant-supported FDPs was 96.4% after 5 years and 93.9% after 10 years. Only 66.4% of the patients were free of any complications after 5 years. The most frequent complications over the 5-year observation period were fractures of the veneering material (13.5%), peri-implantitis and soft tissue complications (8.5%), loss of access hole restoration (5.4%), abutment or screw loosening (5.3%), and loss of retention of cemented FDPs (4.7%).
It may be concluded that implant-supported fixed dental prostheses (FDPs) are a safe and predictable treatment method with high survival rates. However, biological and technical complications were frequent (33.6%). To minimize the incidence of complications, dental professionals should make great effort in choosing reliable components and materials for implant-supported FDPs and the patients should be placed in well-structured maintenance system after treatment.
The aim of this cost-effectiveness analysis (CEA), performed from a societal perspective, was to compare costs and consequences of an individually tailored oral health educational programme (ITOHEP) based on cognitive behavioural strategies integrated in non-surgical periodontal treatment compared with a standard treatment programme (ST).
A randomized (n = 113), evaluator-blinded, controlled trial, with two different active treatments, was analysed with respect to their costs and consequences 12 months after non-surgical treatment. Costs referred to both treatment costs and costs contributed by the patient. Consequences (outcome) were expressed as the proportion of individuals classified as having reached the pre-set criteria for treatment success after non-surgical treatment ("successful-NSPT").
More individuals in the ITOHEP group reached the pre-set criteria for treatment success than individuals in the ST group did. The CEA revealed an incremental cost-effectiveness of SEK1724 [€191.09; SEK9.02 = €1 (January 2007)] per "successful-NSPT" case, of which treatment costs represented SEK1189 (€131.82), using the unit cost for a dental hygienist.
The incremental costs per "successful-NSPT" case can be considered as low and strengthens the suggestion that an ITOHEP integrated into non-surgical periodontal treatment is preferable to a standardized education programme.
To determine the incidence of peri-implantitis in individuals with mucositis in a 5-year follow-up study.
A sample of 212 partially edentulous individuals, rehabilitated with dental implants, underwent periodontal and peri-implant clinical examinations in 2005 (baseline). Five years later, 80 individuals who had been diagnosed with mucositis in the baseline examination were re-examined. These individuals were divided into two groups: one group with preventive maintenance during the study period (GTP; n = 39), and another group without preventive maintenance (GNTP; n = 41). The following parameters were clinically evaluated: plaque index, bleeding on periodontal and peri-implant probing, periodontal and peri-implant probing depth, suppuration and peri-implant bone loss. The influence of biological and behavioural risk variables associated with the occurrence of peri-implantitis was analysed using univariate and multivariate logistic regression analyses.
The incidence of peri-implantitis in the global sample was 31.2% (GNTP = 43.9% and GTP = 18.0%).
The absence of preventive maintenance in individuals with pre-existing peri-implant mucositis was associated with a high incidence of peri-implantitis. Clinical parameters, such as bleeding on peri-implant probing, periodontal probing depth and the presence of periodontitis were associated with a higher risk of developing peri-implantitis.
Assessment of effort (number of visits) and costs of tooth preservation 10 years after initiation of anti-infective therapy.
Data of 98 patients who had received active periodontal treatment 10 years ago by the same examiner were analysed to gather information on effort and costs of supportive periodontal therapy (SPT). Clinical examination, interleukin-1 (IL-1) polymorphism test, smoking, search of patients' files (i.e. initial diagnosis), as well as a questionnaire on medical history and socioeconomic data were performed. Statistical analysis was performed using multivariate linear regression analysis.
During 10 years of SPT patients had 14.8+/-7.4 visits. Number of visits was statistically significantly higher for individuals with a mean plaque control record >or=24 %. The number of subgingival scalings per tooth ranged from 0 to 14 (mean: 1.17). On tooth level several confounders could be identified: tooth type, initial bone loss, furcation involvement, abutment status, and previous regenerative surgery (p <or = 0.003). Costs for therapy per tooth during SPT ranged from 1.21 euro to 404.72 euro with mean costs between 60.52 euro and 91.99 euro. On tooth level the tooth type, initial bone loss, abutment status, furcation involvement, and previous regenerative surgery showed statistical significance (p <or= 0.002).
Costs for tooth retention via SPT are relatively low compared with alternatives (e.g. implants or bridgework) even in periodontally impaired teeth.