Y. Jo Wong DDS, MS, BSc; Lewis Lampert DDS, MA, BS
Limited evidence indicates that patients with periodontitis were at higher risk for implant failure and greater marginal bone loss as compared with patients who were periodontally healthy
Six observational clinical studies of various designs showed statistically significantly better implant survival (OR 3.02, 95 percent CI 1.12-8.15) and statistically but not clinically significantly, less marginal bone loss(Standard Mean Difference 0.61mm, 95 percent CI 0.14-1.09) in healthy patients compared to patients with a history of periodontitis.
Are patients with a history of periodontitis at higher risk of implant failure and marginal bone loss compared to periodontally healthy patients?
Two investigators independently screened three electronic data bases for articles published in English between July 1, 2008 and January 1, 1990. The inclusion criteria comprised comparison of periodontal/peri-implant variables in partially-dentate people with periodontitis and people who were periodontally-healthy with at least a 3-year follow-up; and evaluation of changes in bone level. The authors included six prospective and retrospective studies, but only five studies were eligible for meta-analysis of implant survival, and four were eligible for meta-analysis of bone loss around implants.
The authors reviewed six prospective and retrospective studies which included a total of 609 subjects and 1801 implants. Meta-analysis of five studies on implant failure showed statistically significantly better survival rates in healthy patients than those with a history of periodontitis(OR 3.02, 95 percent CI 1.12-8.15). Meta-analysis of four studies showed statistically significantly greater bone loss for periodontal patients than for healthy controls (Standard Mean Difference 0.61 mm, 95 percent CI 0.14-1.09). It was not clear for two of the studies by the same author (Mengel) whether the patients of the 2007 study(1) were a subset of those reported in the 2005 study(2). The authors did not observe any heterogeneity among studies using the Mentel-Haenszel test.
Limited evidence indicates that patients with periodontitis experienced increased risk of implant failure and more marginal bone loss as compared with patients who were periodontally healthy.
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Importance and Context:
With the baby boomers aging and living longer, there is tremendous demand for replacing missing teeth. With advances and success in dental implants in recent years, restoration of the edentulous mouth to a highly functional and aesthetic state has become a reality. Although some systematic reviews have shown favorable dental implant outcomes in patients with a history of periodontitis, other systematic reviews have shown that these patients experience early and late dental implant failures.
Strengths and Weaknesses of the Systematic Review:
The authors clearly listed inclusion and exclusion criteria. Language was restricted to English, so all of the relevant literature might not have been identified. There was no gray literature search, and the reviewers did not seek clarification of missing and unclear information from original authors. Three independent reviewers performed a full text assessment of six clinical trials. Outcome measures included implant survival/failure, peri-implant parameters, changes in radiographic and marginal bone level, probing pocket depth, and gingival index. They used Kappa statistics to assess reviewer agreement, which was good.
Strengths and Weaknesses of the Evidence:
Most of the observational studies included only a small number of patients. Implant survival/failure data was implant-based rather than patient-based, which would not account for underlying biological and behavioral factors associated with susceptibility to implant complications and failures. Characteristics of the patients were heterogeneous, which limited interpretation of the meta-analysis results. Also, the period of follow-up varied between studies. Confounding factors that could have increased risk of implant failure (like smoking and prosthesis overloading) were not considered.
Implications for Dental Practice:
This review showed that patients with a history of periodontitis experienced higher odds of implant failure and experienced a higher level of marginal bone loss around implants in 3-10 years compared to their periodontally-healthy counterparts. The increase in marginal bone loss is small(Standard Mean Difference 0.61mm, 95 percent CI 0.14-1.09) and not clinically significant. Patients who lost teeth due to periodontitis should be informed of the higher risk but not be discouraged from getting implants.
(1). Mengel R, Behle M, Flores-de-Jacoby L. Osseointegrated implants in subjects treated for generalized aggressive periodontitis: 10-year results of a prospective, long-term cohort study. J Periodontol, 2007 Dec;78(12):2229-37
(2). Mengel R, Flores-de-Jacoby L. Implants in patients treated for generalized aggressive and chronic periodontitis: a 3-year prospective longitudinal study. J Periodontol, 2005 Apr;76(4):534-43
Mengel R, Flores-de-Jacoby L. Implants in regenerated bone in patients treated for generalized aggressive periodontitis: a prospective longitudinal study. Int J Periodontics Restorative Dent, 2005 Aug;25(4):331-41