Optimal periodontal conditions for successful implantation

No Yin without Yang

How can peri-implant infections be avoided and treated as needed? In addition to the newly presented classifications, this issue was a key topic at EuroPerio held in Amsterdam in June. In a symposium organized by the Austrian dental company W&H, Dr Karl-Ludwig Ackermann (Filderstadt, Germany) presented his clinical concept based on the NIWOP workflow (“No Implantology without Periodontology”).

Dr Karl-Ludwig Ackermann, a specialist in implantology and periodontology, has inserted many thousands of implants over almost 40 years. “Over time, you gather a wealth of experience and never stop honing your skills. Nowadays, I invest a lot more time and fight for each and every tooth. But if implants still prove necessary, I prepare my patients very carefully.”

Ackermann started off by mentioning the current prevalence of periodontitis, which already affects more than half of the 35- to 44-year-olds and almost two thirds among the 65- to 74-year-olds in Germany. Untreated periodontitis patients have a significantly higher risk of peri-implant infections. ^[1] According to Ackermann’s experience and based on the current literature, the risk is also higher if patients treated initially are not integrated in the requisite recall programme (supportive periodontal therapy, SPT).^[2] Patients with a history of periodontitis should be informed that without suitable aftercare, their implant prognosis is relatively unfavourable. In such cases, Ackermann speaks of ten years, whereas implants in patients who participate in a corresponding recall programme at his practice generally enjoy at least 20 years of implant success.

“Patients think that oral hygiene is no longer important when they have implants.” With this in mind, Ackermann’s team explains the causes of gum disease to patients, instructs them extensively in proper oral hygiene and the care of implant-supported prostheses and performs professional teeth cleaning and polishing at regular intervals. Implants are not inserted in affected patients without prior periodontal treatment. The recall interval for the SPT is between two and six months, although there are no clinically supported recommendations available at present. One important criterion is the efficiency of oral hygiene by the patient. “Manual dexterity usually decreases with advancing age, which means that a personal, closely monitored aftercare including treatment tailored to the patient’s age often becomes necessary.” Ackermann drew on a number of patient examples to illustrate his staged treatment concept which allows him to achieve long-time stable implant-prosthetic results – assuming good compliance on part of the patient. If peri-implantitis develops despite all efforts, Ackermann prefers to remove the affected implants at an early stage depending on the defect morphology: “Implant restorations may look like natural teeth, but they behave differently.” In his experience, it is in general not possible to decontaminate the relatively rough implant surfaces successfully and achieve long-term tissue stability – an issue particularly important in the aesthetic field.

During the ensuing discussion, led by EFP President Professor Anton Sculean (Bern, Switzerland), the question arose of when teeth should be extracted and replaced with implants – a question not easy to answer according to Ackermann. There is no algorithm available for it. Instead, pronounced mobility (grade 3) is decisive; he does not consider probing depths to be a reliable criterion. Sculean added that a 20-year-old patient with little plaque and ten or more deep pockets would have to be treated differently from a 40-year-old patient with extensive plaque and calculus but only a few deep pockets.

Ackermann’s belief is that patients with a history of periodontitis or current infection experience peri-implant problems in most of the cases. “The same is true of edentulous patients. We still do not know exactly which genetic mechanisms lead to periodontally-induced tooth losses”– another hotly discussed topic at EuroPerio.

1. Veitz-Keenan, A., et al.; Evid Based Dent 2017. 18 (1): 5.
2. Roccuzzo, M., et al.; Clin Oral Implants Res 2012. 23 (4): 389-395.