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Implant Tribune United Kingdom Edition

Implant Tribune United Kingdom Edition | 3/201518 searchthatcanprovideapredictable cureforwhatnowisnowanewbreed of disease. Peri-implantitis is re- lentless once established within fine threadsoftheimplant,andthebone resorption and soft-tissue problems that follow can result in spectacular problems.Partofthekeyissueprob- ably lies in the surface exposed to the susceptible patient’s oral envi- ronment, as most microbiologists will allege. The bacterial content and make-up of the biofilm is a reflec- tion of the surface on which it re- sides.Implantsurfaceshavebecome progressively rougher in order to hasten the early osseointegration processes and to try to provide pa- tients with their restoration quicker in an ever more competitive finan- cialenvironment. However, speed is not always help- ful. Experience shows that some thingsarebetterachievedgradually. Onceexposedtotheenvironment of a susceptible patient, the macro- topography of the threads provides anidealecologicalnicheforbacterial proliferation. Further nano-level features make the implant surface a veritable inflammation super highway for the pathogenic organ- isms.Predictablyenough,themicro- organisms found on the rough surface are usually the common pathogenic ones, but also some species are found that have previ- ously never been discovered in the oralcavity. Patientselectionissues We need to consider the types of patients whom we are now accept- ing for implant provision. At King’s CollegeHospital,thecriteriaforstate- sponsored implant provision largely involve patients with hypodontia andthosewhohavesufferedtrauma. Usually both cohorts are likely to present with well-maintained, mini- mallyrestoreddentitionorwithscope for oral health improvement prior to consideration for any restoration, let alone an implant. Unfortunately, we are unable to provide this treat- mentforsmokers. Thisisinstarkcontrasttothepatients who may be provided with implants in general and specialist practice, such as patients who are likely to have lost teeth as a result of plaque-associated diseases.Indeed,itcouldbeconsidered a paradox by many interested obser- versthatsomecliniciansareproviding patientswithimplant-retainedrestora- tions when they have shown that they are highly prone to plaque-associated disease via tooth loss and have not demonstrated any real capacity for changing that. Patients who smoke, those with a history of periodontitis and those with poor oral hygiene are wellknowntobeataverysignificantly higherriskofperi-implantitis. Biologicalversus mechanicalproblems Ifwearebeingfrank,thepathogenic bacteria-induced diseases are not the only long-term problem that we are nowseeing.Thereportedfrequencyof mechanical complications has risen over the years, but the reported prob- lems are probably only the tip of the iceberg, as many complications have not and will not be reported for a varietyofunderstandablereasons. Over time, the components of im- plants have shown notable weak- nesses. Screw loosening, fractured screws,looseabutmentsandthecrack- ingofceramiccanbelaboriousandex- pensive to manage. One aspect, which maybelostonsome,isthatsincethey lackaperiodontalligamentdentalim- plantscannotandwillneverbeableto acclimatise to changing occlusal and non-axialforces.Theseareverylikelyto create stresses within the masticatory system,therebyresultinginbreakages. These forces are compounded greatly if patients exhibit parafunction on a daily basis and that is sometimes an unknown risk factor until it is too late. Themoreimplantsthatareplaced,usu- allythefewerteetharepresent,resulting inanetreductioninphysiologicalfeed- backandtherebycreatinganincreased chanceoffailureofsometype. Ethical,moral andlegalissues These problems become much more worrying when viewed from ethical, valid consent and medico- legalperspectives.Thisisparticularly so when patients are convinced to undergo elective extractions of teeth that often seem reasonably intact or treatable with conventional proven treatmentstrategies. It appears that there is a worrying drift towards aggressive treatment with extractions in order to provide asupposedfull-mouthrehabilitation with multiple implants. The increas- ingly dubious practice of sacrificing teethforthesakeofimplantsappears to many concerned clinicians to be quite irrational. As ethical oral health practitioners, deliberately removing saveable teeth for prosthetic replace- ment using implants as support ap- pears to be consciously flying in the face of increasingly apparent evi- dence of various complications with implants and many would consider that approach to be foolish. How many“implantologists”doingthatto others would genuinely have it done to themselves or done to some close familymember? Plannedobsolescence A state-of-the-art implant today is likely to be obsolete tomorrow. Elec- tively removing teeth is irreversible and replacing teeth with implant- retained devices means that patients are trapped in the era of the implan- tologyinwhichthesewereplacedand restored, that means issues of ma- chining, surface blasting, roughness, platform switching, design and at- tempts at bone augmentation by cow, coral or Californian substances. The list goes on and on and will prob- ably continue to expand with what manymightconsiderhumanexperi- mentationwithoutlicence. Now comes the time for implant manufacturers to take stock of their many “market-driven” mistakes, in- cluding fast initial integration with theroughestpossiblesurfaces.Instead they need now to produce proven (i.e. not speculative) designs to better prevent these well-known problems ofinfectionandbreakage. A wiser, pragmatic approach ap- pears to be to concentrate everyone’s effortsonsavingteethandtherebyeke out their usefulness for the patient’s lifetime. Recently, the legendary Prof. Jan Lindhe, interviewed in the British Dental Journal, summarised the state ofplayasfollows:“Thereisanoveruse ofimplantsintheworldandanunder- useofteethastargetsfortreatment.” IMPLANT NEWS Aws Alani is a Consultant in Restorative Den- tistry at Kings College Hospital in London, UK, and a lead cli- nician for the management of congenital ab- normalities. 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