Significance of Implants in General Dentistry Practice!

A general dentist is mostly concerned with the study, diagnosis, prevention and treatment of the most common oral diseases which are dental caries and periodontal disease. Various treatment modalities involve the restoration of teeth, extraction or surgical removal of teeth, scaling and root planing,root canal treatment and replacement of missing tooth/teeth. However, a few challenging cases are reported leading to dilemma in diagnosis, treatment choice and the ultimate outcome.

The epidemic of caries and untreated periodontal diseases led to a concomitant increase in the extraction of teeth by dentists.A general dentist comes across cases of replacement of missing teeth on a regular basis.It can be challenging to decide the treatment plan in such a scenario due to the several options available (Figure 1). Replacement of the teeth in edentulous arches is recommended because when tooth loss occurs, masticatory function is diminished; when the underlying bone of the jaws is not under normal function it can slowly lose its mass and density, which can lead to fractures of mandible and reduction of the vertical dimension of the face. The physical appearance of the person is also noticeably affected.

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Using conventional method, the missing teeth can be replaced by using tooth or tissue supported prostheses. These include complete dentures for replacement of fully edentulous arches and conventional bridges or removable or fixed partial dentures for replacement of partially edentulous arches. An alternative method of replacement is the bone supported prostheses – dental implants (Figure 2).

Dental implant or fixture is defined by the Oxford Dental Dictionary as “a device specifically designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing retention for a prosthetic replacement of one or more teeth”. Over the last several years, many different types of implants have been invented, improving the quality and lives of many people suffering from dentition loss.

An implant can be used to support a single crown or a bridge or even to retain complete dentures.An endodontic implant can be used to provide increased retention and decrease tooth mobility.Many of the patients that a dentist encounters have insufficient dental support suitable for orthodontic anchorage or are not compliant with wearing extra-oral devices. Orthodontic implants have become broadly accepted as alternatives to extra-oral devices in such patients. Mini implants (orthodontic implants) are used in orthodontics as temporary anchorage devices.The many advantages of using mini-implants include ease of insertion, increased patient comfort, immediate loading and low price.

Implants are becoming the treatment of choice for a number of reasons. Most significant among these is the expected longevity, strength and stability offered by current implant treatment, as well as the predictability of implant treatment with current technologies. Today’s dental implants are strong, durable, and virtually indistinguishable from natural teeth and are typically placed in a single sitting. They offer long-term solution to tooth loss. In the presence of healthy tissues, a well-integrated implant with appropriate biochemical loads can have long term success rates of 93% to 98% for the fixture and 10 to 15 years life span for the prosthetic tooth. Implants are less dependent than tooth or tissue supported prostheses on the configuration of remaining natural teeth in the arch. They can be used to support prostheses for a completely edentulous arch, for an arch devoid of posterior tooth support and for almost any configuration of partial edentulism with tooth support on both sides of the edentulous space (Figure 3). The patient’s function when wearing a denture may be reduced to one sixth of that level formerly experienced with natural dentition; however an implant prostheses may return the function to near-normal limits. As implants are more successful and result in fewer complications, they develop a competitive advantage among the technical alternatives. In traditional dentistry the restoration reflects the existing condition of the patient. The dentist evaluates existing natural abutments first and fabricates a removable or fixed restoration accordingly. Treatment using implants is unique because additional foundation units may be created for a desired prosthodontic result.

General dentists around the world certainly have proven that it is well within the capability of every general practitioner to be able to surgically place dental implants. However, a large group of general dentists hesitate in doing this surgical procedure for various reasons. These include:-

1. The surgical procedure is technique sensitive
2. Need to undergo special training for performing the procedure
3. Expensive equipments
4. Confusion due to the various different types of implant systems available
5. Experience plays a vital role in the success of implant treatment
6. There may be a need to do bone grafting at the time of implant placement or before implant placement which is again technique sensitive
7. Risks associated with dental implants are higher compared to the alternative treatment options
8. It is harder to manage the complications associated with dental implants.

However, because of the awareness of implant treatment and patient needs, a majority of dental professionals have equipped themselves with the requirements of implant procedures and have gained knowledge about failures and associated complications.

Factors that affect the need and demand for dental implants can be described under macro-factors and individual factors.

Macro-factors include:-

1. Overall population growth
2. Growth in disposable per capita income
3. Improvement  in education levels
4. Extent and severity of oral disease that can result in loss of teeth
5. Tooth loss itself

Individual factors include:-

• General health of the patient and any contraindications for the surgical implant procedure
• Configuration of the remaining teeth in the arch as well as the opposing arch
• Number of tooth spaces that need replacement by prostheses
• The preference of the patient and his or her willingness to undergo a more invasive surgical procedure required by the dental implant option
• Relative cost of the implant option compared to the alternative

Although they demonstrate a very high success rate, oral implants may fail for a number of reasons, often related to a failure in the osseointegration process. If the implant is placed in a poor position, osseointegration may not take place. Like natural teeth, dental implants may break or become infected and crowns may become loose. Dental implants are not susceptible to caries attack, but poor oral hygiene can lead to development of Peri-implantitis around the dental implant. Peri-implantitisis one of the common complications and leads to bone loss and implant failure (Figure 4).

A general practitioner should be able to manage a case of implant failure. Implants undergoing early or late failure show progressive bone loss and can be readily diagnosed on radiographs. Clinically, signs of infection such as the presence of fistula in the soft tissue covering the implants, purulent discharge on exploration, bleeding, discoloration of marginal gingival tissue, and discomfort to probing at the implant site may also be present. If left untreated, bone loss typically continues and, with time, complete loss of osseointegration will occur. The approach to treatment of ailing implants is often empirical and is an extension of modalities of treatment of periodontitis that occurs around the natural dentition. The goal is therefore to stop further bone loss and establish a healthy peri-implant soft tissue interface.Peri-implantitis can sometimes be treated, but in most cases the implant must be removed.In the case of a loose dental implant, the only treatment is to immediately remove all components of the implant to avoid the progressive destruction of the surrounding tissues.After a careful investigation of the clinical situation, the general practitioner must decide whether to carry out the implant removal or refer the patient to a specialist.All is not lost if a dental implant fails. It is sometimes possible to save an implant by building up the bone &gingival tissue surrounding it. However, in most cases the implant must often be removed and the area left to heal. Re-implantation procedure can be attempted once the area has recovered, which can take up to a year or until the dentist determines that the site is suitable. Depending on how well the area heals, a bone graft might be required to provide a better foundation for the implant and improve the chance of success.Scaling of dental implants is done using special instruments like plastic hand scalers, graphite and titanium hand scalers, ultrasonic scalers with titanium coated tips.

A general dentist considering the use of implants should be well versed with its contraindications as well. These include,

1. Systemic contraindications:-
2. Severe blood diseases
3. Within six months of an attack of myocardial infarction
4. Cerebral infarction and cerebral apoplexy
5. Severe immunodeficiency
6. Chemotherapy patients
7. Neuropsychiatric patients
8. Youth under the age of 15
9. Severe osteoporosis

• Local contraindications:-
• Insufficient bone quantity, but where bone augmentation procedures with bone graft is not possible.
• Severe periodontal diseases
• Intractable periodontitis
• High exposure to radiation
• Chronic osteomyelitis
• Bruxism
• Mouth closing disorders
• Heavy smokers
• Sjögren’s syndrome
• Poor oral hygiene

It can be an easy or difficult decision to remove a tooth and place an implant. Patients should also be involved in making that decision. Thorough informed consent should be provided, and a detailed discussion of the potential for success or failure should be made. The joint patient-dentist decision should be based on the amount of tooth structure remaining, occlusion, financial considerations, patient desire to keep the natural tooth, and patient acceptance of other needed procedures to retain the tooth. Clinical procedure can be successful if all factors are considered and treatment is accomplished properly (Figure 5).

During the past several years, great strides have been made in dental practices. With the advent of newer materials, newer techniques and a better understanding of the dental anatomy, dentistry has achieved newer levels. Dentistry has evolved over the years to bring to its patient’s better treatment options and restorative and prosthetic solutions which have higher success ratio and survival rates.

As new implant surface technologies develop and prosthetic options increase, the field of dental implantology continues to change. Implants are the nearest equivalent replacement to the natural tooth, and are therefore a useful addition in the management of patients who have missing teeth because of caries, periodontal diseases, trauma or developmental anomalies. General dentists considering the use of this treatment modality should be aware of the importance of treatment planning, assessment and teamwork in achieving successful outcomes and should gain the skills, education, and technology to add implants to their practice.

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