Health: Dental Implants

Baroness Gardner of Parkes Excerpts

Wednesday 23rd July 2014 Grand Committee

Asked by

[Baroness Gardner of Parkes]

To ask Her Majesty’s Government what action they are taking to make the public aware of the medical need for periodontal checks following the fitting of dental implants.

[Baroness Gardner of Parkes (Con)]

My Lords, peri-implantitis may seem to be a somewhat obscure matter to debate today, but that is the very reason why I am raising the subject. As a long-retired dentist, I was quite unaware of the condition. I found it most interesting when I heard Professor Nick Donos, head and chair of periodontology and director of research at the UCL Eastman Dental Institute, address an international dental conference on this subject in London last month. I thank him and others who have provided me with valuable material for the discussion tonight.

This is an important and growing health problem and there needs to be an awareness and a degree of understanding of the present position and the growing risks associated with this increasingly popular form of dental treatment. The condition is peri-implantitis. When I attended my first international dental conference in 1955 in Copenhagen, dental implants were a new idea and early cases reported by those dentists present had often failed spectacularly. In some cases, large portions of a jaw were lost in the process, mainly due to the rejection of the foreign body—the dental implant —by the patient’s immune system.

Time moved on and it was found that the metal titanium was accepted by the body. Since then, titanium-rooted dental implants have become widely used in the replacement of missing teeth. Half a million adults have at least one dental implant, according to the latest Adult Dental Health Survey. Studies suggest that one third of these patients will have a milder disease—peri-implant mucositis—which is common and treatable. If undetected or untreated, these red swollen gums can develop into peri-implantitis, which is associated with both inflamed gums and jawbone loss around the implants. As with so many health conditions, smokers have a significantly higher risk of peri-implantitis.

The European Association for Osseointegration emphasises the importance of appropriate patient selection. Most of us would accept that view and, as patients, we would expect to receive sound advice from the appropriately trained dentists performing implant procedures. It is important to indicate for the patient, particularly in complex cases, that implant dentistry should be seen as a multidisciplinary treatment. Within the objectives of the General Dental Council curriculae for dental specialists, it is indicated that periodontology, the treatment of gum conditions, is the specialty in charge for the planning and execution of the surgical component, and prosthodontics is the branch of dentistry that deals with replacement of missing parts with artificial structures and executes the relevant implant superstructures.

Complications of implant therapy, particularly peri-implantitis, are within the objectives of periodontology. Some experts studying the condition of peri-implantitis, a growing problem, believe that there should be formal national registration of implants, national health and private, in the UK. This would probably be the first in Europe, and would enable regulation of the type and quality of the implant-related procedures.

An implant is a titanium screw that is inserted into the jaw under a controlled protocol and, when fused with the bone, forms an artificial tooth root. Their use is growing rapidly in the UK, and although they are costly they are often considered the treatment of choice for replacing missing teeth. They can also be used as a support for a more extensive prosthesis.

When I googled “dental implant”, as a patient often would if they had heard about this treatment, I was disturbed to read the advertisement:

“Get smiling again with our same-day dental implants”.

That is surely what can cause adverse conditions post-treatment and is contrary to all the recommendations from the official dental bodies, which believe the patient must be fully assessed prior to treatment and informed and treated if there is an existing periodontal condition before the implant procedure. It must also be made clear to them that an implant is not a treatment you just have and forget. Regular follow-up visits are required to ensure that a periodontal condition does not develop, first into mucositis, and then progress on to the more serious disease, peri-implantitis, which causes loss of bone supporting the implant and often loss of the implant itself.

Remembering the time when so many women were at serious risk from cheap silicone breast implants and the heavy cost of dealing with unsatisfactory, even dangerous, treatments, including removal or replacement of these, it is particularly important that we are aware that many people seeking dental implants are tempted by cheap offers from abroad. These usually have the great disadvantage that the patient does not have continuing care and may be totally unaware that periodontal follow-up is essential to ensure continuing oral health. These patients certainly need to be clear that care and control of the gums before and following implants are most important.

My noble friend Lord Colwyn sends his regrets that he is unable to be here tonight. He also sends the message, as someone who has done implants himself, that implants should be put only into healthy mouths.

When I tabled this Question for Short Debate, I had seen nothing in the press on the subject. I was pleasantly surprised to see that on 14 July the Daily Telegraph had a very informative article on peri-implantitis titled “The ‘Time Bomb’ in Dental Implants” about a patient, age 52, who had four teeth implanted at a cost of £13,000 in 2002. Three months ago this patient felt a lump on her lower jaw, near one implant. She went to have this checked, and it responded to antibiotics, but the X-ray showed that the bone supporting the implant was receding, and the diagnosis was peri-implantitis.

Ten years ago this disease was almost unknown, but it is now a serious possible consequence of implantation, particularly when the implant patient has not continued to have regular periodontal checks, with treatment if necessary, following an implant. Some studies suggest that one-third of implant patients will be infected, and because jawbone loss is silent and invisible, people do not realise that they are at risk. Early warning signs are red, swollen gums and bleeding, which is often apparent when tooth-brushing; smoking seems to aggravate the situation, and significantly more smokers develop peri-implantitis.

The Faculty of Dental Surgery at the Royal College of Surgeons points out that long-term assessment and maintenance need to be assured if this threat to stability of the implant is to be prevented. It believes that the General Dental Council should introduce minimum standards of education and training for complex dental treatment, such as implants, to ensure patients are treated by a qualified professional. It supports the view that the General Dental Council should include peri-implant assessment and maintenance in the undergraduate curriculum. Too often the practitioner who inserts the implant does not provide long-term support for the patient, discharging them back to their general dental practitioner.

Periodontal disease has been associated with diabetes, cardiovascular disease and pneumonia. Some people speculate that an increase of bacteria in the body may aggravate these conditions but it is not considered to cause them. Professor Donos says:

“The main challenge is for the patients suffering from periodontal disease who represent a significant proportion of the population. As you know, due to the silent nature of the disease, it does not always provide ‘pain’ as a symptom for the patient”.

He continues:

“I think it is important for the public to be informed that even though implants are successful and offer great functional and aesthetic solutions in terms of replacing missing teeth, appropriate patient selection is required”—

as my noble friend Lord Colwyn said—

“control of periodontal disease before and after implant placement is essential and all risk factors need to be controlled through regular follow up according to the susceptibility profile of the patient”.

In my experience, pain is the thing that brings many patients into the dental surgery. I cannot end this dental discussion without mentioning the report this week that 26,000 children in England aged between five and nine have been hospitalised to have multiple tooth extractions in 2013-14, which is nearly 500 children a week, at a huge cost to the NHS and a great disturbance and upset for the children and their families. However, that is a debate for another time: I flag it up here for the Minister.

Tonight, I hope that patients who want and should have dental implants will benefit from understanding the importance of dealing with periodontal conditions before and after treatment. I look forward to a positive response from the Minister and to his assurance that his department will create public awareness of this condition.