Periimplantitis, periodontitis, endodontics: A dental market analysis and future trends

Abstract

Background: The ageing of the population and the importance of aesthetics has put pressure on the delivery of dental care. Bacterial infection in intra-oral cavities can develop into a pathogenic biofilm, which then induces inflammatory processes. One of the necessary dental treatment steps is the disinfection of the infected area, whether it is in the root canal, or in the periodontal, periapical, or peri-implant regions. The objective of this review was to assess the actual situation and trends in the treatments for three of the most important areas of dental health: peri-implantitis, periodontitis, and endodontics. Methods: Results from clinical studies, reports from dental associations, national health insurance records, and market reports were used to quantify the number of treatment needs. For peri-implantitis, the number of inserted implants and the prevalence of peri-implantitis build the basis for the computation. For periodontitis and root canal treatments (RCTs), health insurance figures, and reports on dental instrument orders are the data sources for the estimations. Results: The data show that the number of performed periodontitis and RCTs increase linearly over the year, mainly driven by demographic changes, i.e., increase in size and age of populations. The computed values show that the treatment need for peri-implantitis follows an exponential growth and may surpass that of periodontitis by 2023 in Europe and in the USA. Conclusion: Where dental implantology is growing, the rapid development of peri-implant diseases will burden the health systems. This should be addressed at different levels. At the practitioners’ level, this includes continuous training of staff and (re)investment in adequate material and infrastructures. At the governmental level, it includes policy development and reimbursement strategies as well as information dissemination in health insurance and dental associations. Last, but not least, R&D efforts in the public and private sectors should be implemented/boosted.

Full text

Abstract
Background: The ageing of the population and the importance of aesthetics put pressure on the delivery of dental care. Bacterial
infection in intra-oral cavities can develop into a pathogenic biofilm, which then induces inflammatory processes. One of the
necessary dental treatment steps is the disinfection of the infected area, whether it is in the root canal, or in the periodontal,
periapical, or peri-implant regions. The objective of this review is to assess the actual situation and trends in the treatments for
three of the most important areas of dental health: peri-implantitis, periodontitis, and endodontics.
Methods: Results from clinical studies, reports from dental associations, national health insurance records, and market reports
are used to quantify the number of treatment needs. For peri-implantitis, the number of inserted implants and the prevalence of
peri-implantitis build the basis for the computation. For periodontitis and root canal treatments (RCTs), health insurance figures,
and reports on dental instrument orders are the data sources for the estimations.
Results: The data show that the number of performed periodontitis and RCTs increase linearly over the year, mainly driven by
demographic changes, i.e., increase in size and age of populations. The computed values show that the treatment need for peri-
implantitis follows an exponential growth and may surpass that of periodontitis by 2023 in Europe and in the USA.
Conclusion: Where dental implantology is growing, the rapid development of peri-implant diseases will burden the health
systems. This should be addressed at different levels. At the practitioners’ level, this includes continuous training of staff
and (re)investment in adequate material and infrastructures. At the governmental level, it includes policy development and
reimbursement strategies as well as information dissemination in health insurance and dental associations. Last, but not least,
R&D efforts in the public and private sectors should be implemented/boosted.
Keywords: Peri-implantitis, Periodontitis, Endodontics, Dental care, Dental implantation
Introduction
Dental implants are the crown of today’s dentistry.
The need for dental implants can be expressed in one
exemplary statement: “In the world’s largest market, the
United States, more than 36 million Americans do not
have any teeth, and 120 million people in the United
States are missing at least one tooth.”1 Although dental
implants are becoming a standard solution to dental loss,
they come with the risk of bacterial-related complications.
Peri-implantitis is an inflammatory, usually irreversible
process induced by a pathogenic biofilm in the tissue
surrounding the functional osseointegrated implant,
leading to the loss of the supporting bone and, often, of
the implant. At a preliminary stage, mucositis in the peri-
implant soft tissue is a reversible inflammatory change
without bone loss. Peri-implantitis is to a dental implant
what periodontitis is to a natural tooth.
According to the World Health Organization, oral
disorders are the most common causes of the global
burden of disease, and periodontal diseases are the second
most common oral disease worldwide after dental decay.2
According to the European Federation of Periodontology
(EFP), periodontitis is the “most common chronic
inflammatory disease,” with 6 out of 8 people showing
some degree of periodontal inflammation.3 However,
treatment need not necessarily lead to therapy.4 Therefore,
this data from the EFP is not an indication of how many
periodontal treatments are performed on a daily basis in
a dental practice.
Endodontics focuses on the treatment of root canals
and tooth pulp to keep the natural tooth in a healthy state.
In endodontics, as for periodontitis and peri-implantitis,
the control of the bacterial burden is essential, and a
complete disinfection of the site is the overarching aim of
Peri-implantitis, periodontitis, endodontics: Dental market
analysis and future trends
Loic Alain Ledernez1*
ID
, Michael Eckhardt Bergmann2
ID
, Markus Jörg Altenburger1
ID
1Department of Operative Dentistry and Periodontology, Center for Dental Medicine, Medical Center – University of
Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
2Department of Microsystems Engineering (IMTEK), Laboratory for Sensors, Albert-Ludwigs-University of Freiburg, Freiburg,
Germany
*Corresponding Author: Loic Alain Ledernez, Email: loic.ledernez@gmail.com
Received: July 22, 2021, Accepted: February 7, 2022, ePublished: March 29, 2023
https://johoe.kmu.ac.ir
10.34172/johoe.2023.01
Vol. 12, No. 1, 2023, 1-7
Review Article
Citation: Ledernez LA, Bergmann ME, Altenburger MJ. Peri-implantitis, periodontitis, endodontics: dental market analysis and future
trends. J Oral Health Oral Epidemiol. 2023;12(1):1–7. doi:10.34172/johoe.2023.01
Journal of
Oral Health and Oral Epidemiology

Ledernez et al
J Oral Health Oral Epidemiol. Volume 12, Number 1, 20232
the respective therapies.
The objective of this review is to assess the actual
situation and trends in the number of performed
treatments for three dental procedures that include a
disinfection step: peri-implantitis, periodontitis, and
endodontics. The regions in focus are Germany, Europe
as a whole, and the United States.
Methods
Peri-implantitis
Peri-implantitis therapies are usually paid out-of-pocket
and are not reported by health authorities. Therefore,
to estimate the peri-implantitis treatment statistics, we
followed a three-step reasoning: 1) How many implants
are already inserted? 2) How many inserted implants
lead to peri-implantitis? 3) How many treatments does a
dental implant need if peri-implantitis is diagnosed?
1. We assessed the number of inserted dental implants
from reports from the dental companies Straumann
and Nobel Biocare, the American College of
Prosthodontists, and the Millennium Research
Group. On the one hand, according to the new
classification of periodontitis and peri-implantitis
by the EFP and the American Academy of
Periodontology (AAP ), both diseases are considered
treatable but not curable.5,6 This means that patients
with peri-implantitis should regularly come to
their dentists for maintenance therapy. Hence, the
number of implants to be treated in a given year is
not the number of inserted implants in that year,
but statistically, the cumulative number of inserted
implants, which is much higher.
2. On the other hand, the insertion of a dental implant
does not necessarily lead to the occurrence of
peri-implantitis. Hence, we need to consider the
prevalence and incidence of peri-implantitis as
reported in the scientific literature. The number of
peri-implantitis cases can then be calculated from
the cumulative number of inserted implants over the
years and the prevalence of peri-implantitis.
3. The current guideline for the treatment of peri-implant
infections recommends regular check-up (ideally
initially every three months and then according
to individual risk) in order to identify the need for
follow-up treatment at an early stage.7 In case follow-
up treatment is necessary, a professional cleaning and
disinfection of the implant should take place at least
twice a year.8–10 Will the patients come to their dentist
that often? This frequency seems realistic according
to the survey of 435 699 people worldwide,11 which
showed that nearly 68% visit their dentist at least
once a year and about 50% get a professional dental
cleaning on a yearly basis. Therefore, treatment need
can reasonably be estimated to be twice the number
of peri-implantitis cases.
Periodontitis
We first looked into the data provided by the statutory
and private German health insurances12 and considered
the relevant positions related to periodontitis treatments.
These positions are P200, P201, P202, and P203 of
the BEMA (Einheitliche Bewertungsmaßstab für
zahnärztliche Leistungen = uniform standard for the
assessment of dental services, i.e., statutory health
insurance), and 4070, 4075, 4090, and 4100 of the GOZ
(Gebührenordnung für Zahnärzte = fee schedule for
dentists, i.e., private health insurance).
Because few countries collect data on the treatments
being performed,13 we assume a five-fold ratio between
the number of periodontal treatments carried out in
Europe compared to Germany. This is based on the
following considerations:
• The prevalence of periodontal disease in European
countries14 though diagnosis of periodontal disease
varies from country to country and prevalence values
are only an approximation.15
• The spending on oral healthcare services in European
countries16 though the relatively higher cost of
healthcare in Germany alters the relation between
cost and number of treatments.
The periodontitis market in the United States has been
evaluated by Flemmig and Beikler over many years.17
They observed a low percentage of treatments in relation
to the prevalence of periodontitis, increasing from about
4% in 1990 to 5% in 2006. By extrapolating the percentage
of the population undergoing periodontitis treatment
(from the figures of 1990, 1999, and 2006) and taking into
account the demographics of the United States, one can
compute the number of periodontal treatments for the
year 2019 and the following years.
Endodontics
Similar to the periodontitis case, we used the data provided
by the statutory and private German health insurances12
to estimate the number of root canal treatments (RCTs)
performed in Germany. For the European market, the
number is estimated to be five times that of the German
market. This ratio is here further underpinned by the
22.5% market value share of Germany (in $) compared
to that of the European market in the “endodontics and
orthodontics” sector.18 To cross-check those results, an
alternative method was applied based on the number
of sold files used for RCT from a report on the dental
instrument purchases.18 In order to forecast the future
number of endodontic treatments, one should consider
the trend from the Future Market Insights report,18
though tared to the figure from the health insurance
for the year 2019. Assuming that the number of files
per treated tooth is the same in the USA as in Europe,
the number of treated teeth in the United States (ZUSA)
is calculated using the ratio ZUSA/ZEU = FUSA/FEU, with FUSA

J Oral Health Oral Epidemiol. Volume 12, Number 1, 2023 3
Trends in dental treatment needs
representing the number of sold files in the United States.
Results
Peri-implantitis
The penetration rates of dental implants given by
Straumann for 2011 and 2017 are shown in Table 1 for
Germany and the United States.19,20 The reports give
figures for many more countries. These numbers correlate
well with data from other sources:
• Nobel Biocare: 12 Mio. implants were inserted in
201221 (vs. 14.2 Mio. worldwide, calculated from data
from the Straumann Group19 in 2011)
• Millennium Research Group: “Last year [2012], an
estimated 1.26 Mio. dental implant procedures were
performed in the United States”22 (vs. 1.59 Mio. from
Straumann Group19 in 2011)
• American College of Prosthodontists (2017):
“Approx. 2.3 million implant-supported crowns are
made annually”1 (vs. 2.6 Mio. in the USA from the
Straumann Group20 in 2017)
Scientific reports show that peri-implantitis occurs
statistically years after implant insertion and that its
prevalence and incidence increase dramatically in the
lifetime of the inserted implants. This means that the
treatment need in a particular year is not related to the
number of inserted implants in that year.
• “Prevalence (patient level) for peri-implant
mucositis (inflammation of the mucous membrane)
and peri-implantitis vary from 19 to 65% and 1 to
47%, respectively. The weighted average prevalence
for peri-implant mucositis is 43% (1196 patients,
4209 implants) and 22% for peri-implantitis (2131
patients, 8893 implants).”7
• Another industry independent analysis of the
effectiveness of peri-implantitis therapy in a Swedish
population in 2016 showed that after 9 years, 60%
of patients suffered from moderate or severe peri-
implant changes.23
• The incidence and progression of peri-implantitis
was reported to be non-linear and to accelerate over
time.24
• Several studies also showed 100% implant-related
mucositis in patients.25–27
Hence, we concluded that the number of implants
presenting peri-implantitis in a given year is, statistically,
the sum of all implants inserted up to 9 years ago (because
it is not curable) × 60% (prevalence after 9 years). The
needed peri-implantitis treatment in that given year is
twice that value due to the realistic two treatments per
year. That value is the number of implants that require
a primary therapy and, subsequently, a maintenance
therapy, as shown in Figure 1 and Figure 2.
Periodontitis
Adding the figures shown in Table 2 and 3, we arrive at a
total of 30.23 Mio. teeth of statutory and private patients
treated for periodontitis in 2019 (note that a therapy
usually consists of several treatments or sessions). A
German oral health study28 showed that on average
2.7 teeth (for the 35- to 44-year-olds) to 3.1 teeth (in
younger seniors, i.e., 65- to 74-year-olds) present a severe
periodontal disease. If a patient is treated for periodontitis
(as accounted in Tables 2 and 3), the dentist will treat on
average three teeth per treatment. This means that 10.1
million periodontal treatments (sessions) were performed
Table 1. Number of inserted implants
2011 2017
Penetration
rate (per 10k
Inhab.)
Quantity
(Mio.)
Penetration
rate (per 10k
Inhab.)
Quantity
(Mio.)
Germany 120 0.97 160 1.32
Europe 80 4.07 110 5.63
USA 50 1.59 80 2.55
Figure 1. Computed number of inserted dental implants in the United States. The sum of implants inserted up the 9 years before (here 2012, hatched area) is
the relevant reference to estimate the number of needed treatments in the target year (here 2021)

Ledernez et al
J Oral Health Oral Epidemiol. Volume 12, Number 1, 20234
in Germany and 50.38 million periodontitis treatments
were carried out in the EU (Incl. Germany) in 2019. In
the USA, nearly 19.7 Mio. periodontal treatments were
performed in 2019 (Table 4).
To forecast the number of periodontitis treatments for
the coming years, we take the value from the annual report
of the National Association of Statutory Dental Health
Insurance29: “Expenditure on periodontological services
increased by 3.1 percent. The long-term upward trend
in the area of periodontal treatment is reflected in the
increase in the number of cases. In the field of periodontal
treatment, the number of cases has risen by a total of
around 49% over the past 15 years, or by an average of
2.7% per year.” For the European market, we apply a five-
fold ratio to the German market. The forecasted values
for the U.S. market can be computed for the coming years
based on the data gathered by Fleming et al. (see Table 4).
This leads to the forecast shown in Figure 3.
Endodontics
Adding up the relevant positions of the statutory and
private health insurances (see Table 5), a total of about
9.3 Mio. root canals were prepared in Germany in 2019.
Assuming an average of 1.73 root canals per tooth,30 the
number of treated teeth (RCT) was approximately 5.38
Mio. in Germany. For the European market, five times
the value for the German market leads to approximately
26.90 Mio. RCTs.
Future Market Insights18 reported that 32.47 million
files were sold in Europe. This is higher than the
determined number of treatments using the data from
health insurance. An explanation for this difference may
be the price difference of the sold files inside the European
market, which would lead to a deviance from the five-
fold ratio assumed above. The difference may further be
explained by possible evaluation deviations in the survey
of the practices provided by the Federal Chamber of
Figure 2. Computed peri-implantitis treatment need. The need follows an exponential growth because peri-implantitis cannot be cured as it is considered a
chronic oral disease
Table 2. Statutory health patients in 2019 in Germany
BEMA position BEMA description Quantity
P200
Systematic treatment of periodontal diseases
(supra- and sub-gingival debridement),
closed procedure per treated single-rooted
tooth
14 774 700
P201
Systematic treatment of periodontal diseases
(supra- and sub-gingival debridement),
closed procedure per treated multi-rooted
tooth
7 999 300
P202 Surgical therapy per single-root tooth 87 700
P203 Surgical therapy per multi-root tooth 106 800
TOTAL 22 968 500
Note. BEMA = Einheitliche Bewertungsmaßstab für zahnärztliche
Leistungen = uniform standard for the assessment of dental services.
Table 3. Private patients in 2019 in Germany
GOZ position GOZ description Quantity
4070 Surgical therapy per tooth with single root
canals 4 070 000
4075 Surgical therapy per tooth with several root
canals 3 060 000
4090 Flap OP, open curettage anterior tooth per
periodontium 50 000
4100 Flap OP, open curettage posterior tooth per
periodontium 80 000
Total 7 260 000
Note. GOZ = Gebührenordnung für Zahnärzte = fee schedule for dentists.
Table 4. Number of periodontitis treatments in the United States
Year Population
Number of
treatments in
thousands
Percentage of treatments
in relation to the
population (%)
1990 252 120 309 10 000 3.97
1999 281 710 909 13 000 4.61
2006 294 993 511 15 000 5.08
2019 329 978 171 19 766 5.92 (determined from a
linear regression line)

J Oral Health Oral Epidemiol. Volume 12, Number 1, 2023 5
Trends in dental treatment needs
Dentists (BZÄK). It can also be that files are sold but not
used or not used for endodontic treatments.
According to Future Market Insights,18 32.66 million
endodontic files were sold in North America in 2019.
From a market share value of about 89.4% (in $) for the
United States (rest = Canada, where the file cost is similar),
it is possible to calculate that 29.2 Mio. endodontic files
were sold in the United States in 2019. Keeping the same
ratio of endodontic files to RCT, an estimated 25.58 Mio.
root canals were treated in 2019 in the United States. This
is displayed in Figure 4.
Discussion
Peri-implantitis
Table 1 shows a 33% growth rate between 2011 and 2017.
Various factors explain the growth of the market for
dental implants:
• Demography: As populations are ageing,31 the need
for dental prostheses increases;
• Affordability: The cost of dental implant systems is
decreasing with new generations. Moreover, medical
tourism is an expanding market lowering the cost
hurdle of dental implants32;
• Training: The number of dentists trained in implant
placement is increasing, albeit disparately.33,34 New
education tools and techniques facilitate continuous
education35;
• Aesthetics: People are increasingly opting for
cosmetic surgery and dental implants.36
The number of dental implant insertions is increasing
rapidly as shown above. The demand for peri-implantitis
treatments is growing even faster: the latter is indeed
calculated based on the cumulative sum of inserted
implants. Our calculation shows that the need for
treatment will almost double in about 6 years. This steep
development was also recognized by the Millennium
Research Group22: “The number of dental implant
procedures is expected to double in 7 years to 2 540 000.”
This figure predicted in 2013 for the year 2020 is lower
than our actual estimation of 2.89 Mio. computed for
2020 in the United States, confirming that the dental
implant market is developing even faster than predicted
in 2013.
Periodontitis
In Germany, there is a considerable discrepancy between
periodontitis diagnosis (Approx. 25% of the people with
statutory health insurance) and periodontitis therapy
(only Approx. 2%).4 Therefore, compared to the very high
prevalence, there is undoubtedly a therapy deficiency.
One reason might be that periodontal inflammation does
not cause pain,3 at least in its mild form. There might also
be a lack of confidence in the treatment outcome. In fact,
the IQWIG (German Institute for Quality and Efficiency
in Health Care) evaluated the efficacy of current treatment
methods. It reported that the closed mechanical therapy
brings only a slight benefit compared to no treatment;
All other therapy concepts (laser, photodynamic therapy,
Widman flap technique, and surgical pocket elimination
with osteoplasty), individualized oral hygiene education
program, enamel matrix derivatives, antiseptic pocket
irrigation, subgingival air-polishing, and chlorhexidine
rinse showed no benefit over the closed mechanical
therapy.37 This result was confirmed by a longitudinal
analysis of the accounting data of German statutory
health insurance BARMER GEK, allowing an empirical
consideration of the periodontal treatment results.
Based on the “extraction-free survival” outcome over a
four-year period, it showed that periodontally treated
patients have an approximately 64% chance of keeping
their treated tooth compared to a 73% risk of further
Figure 3. Number of treatments for periodontal inflammation in the United
States and Europe. The very high prevalence for periodontitis counterbalances
the fact that few people take care of their periodontal condition
Table 5. Number of root canal treatments for statutory and private patients
in 2019 in Germany
Position Description Number
P32 (BEMA) Root canal preparation (statutory patients) 8 206 900
2410 (GOZ) Root canal preparation (private patients) 1 100 000
Total 9 309 900
Note. BEMA = Einheitliche Bewertungsmaßstab für zahnärztliche
Leistungen = uniform standard for the assessment of dental services.
GOZ = Gebührenordnung für Zahnärzte = fee schedule for dentists.
Figure 4. Number of root canal treatments in the United States and Europe

Ledernez et al
J Oral Health Oral Epidemiol. Volume 12, Number 1, 20236
tooth extraction for the precisely matched untreated
reference population.13 In other words, the prevalence
of periodontitis is not a good indication of the number
of treatments being actually performed. Indeed, the
prevalence of periodontal disease is decreasing.38
However, the ageing of the population and the increase in
the prevalence of diabetes16 counterbalance those trends
and the absolute number of treatments remains high and
slightly increasing over time. Information campaigns
about the importance oral hygiene and regular visits to
the dentists are on-going and may increase the percentage
of treatment actually sought by patients needing it in the
coming years.39
Endodontics
In 2017, the main German statutory health insurance
(BARMER) reported a slight decrease in the age- and
gender-standardized rate of claimed RCTs over the years
2010 to 2015 from 6.4% to 5.8%.40 However, this decrease
is not reflected in the number of sold files reported in
the Future Market Insights report.18 The first reason may
be that the increase of the German population partly
compensates for the rate of claimed treatments. Secondly,
the ageing of the population may cause an increase in the
number of sold files. As shown in the BARMER report,40
the claim rate is not constant across the age group but is
significantly higher among the 35- to 80-year-olds. This,
in turn, means that an ageing society, as can be observed
in all industrialized countries, implicates an increasing
need for RCTs.
Conclusion
The ageing of the population increases the prevalence of
oral diseases and periodontitis will remain the second most
common oral disease for the coming years. However, in
the particular case of periodontitis, treatment need does
not necessarily lead to therapy; although the absolute
number of periodontal treatments will remain high
because of the high prevalence among the population
worldwide, it is only increasing slowly. The request for
endodontic treatment may remain much lower than for
periodontitis. However, driven by the acute pain, the
need for treatment generally leads to actual treatment;
Therefore, the absolute number of RCTs is relatively close
to the treatment need, and both increase mainly due to
demographic reasons.
Peri-implantitis is a totally different situation: It is the
result of the insertion of a foreign body. Affordability
and aesthetics, driving the increase of dental implant
insertions, is indirectly increasing the need for peri-
implantitis treatment. Because it is a chronic disease, the
treatment need is growing exponentially. It remains to
be seen whether the treatment need for peri-implantitis
will lead to actual treatment being sought by patients.
Whether there is a discrepancy between treatment need
and performed treatment (as for periodontitis) or not (as
for endodontics), the forecasts show that the number of
actual treatments for peri-implantitis may surpass that
of periodontitis therapy by 2023 in Europe and in the
United States.
Acknowledgments
This work was supported by the German Federal Ministry of
Education and Research (grant number 03VP06620).
Authors’ Contribution
Conceptualization: Loic Ledernez, Markus Altenburger.
Data curation: Loic Ledernez.
Formal analysis: Loic Ledernez.
Investigation: Loic Ledernez.
Methodology: Loic Ledernez, Markus Altenburger.
Project administration: Michael Bergmann.
Supervision: Michael Bergmann, Markus Altenburger.
Software: Loic Ledernez.
Resources: Michael Bergmann, Markus Altenburger.
Validation: Loic Ledernez, Markus Altenburger.
Visualization: Loic Ledernez.
Writing–original draft: Loic Ledernez.
Writing–review & editing: Loic Ledernez, Michael Bergmann,
Markus Altenburger.
Competing Interests
The authors declared no conflict of interest.
Funding
This work was supported by the German Federal Ministry of
Education and Research (grant number 03VP06620).
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