Prof. Froum, what first got you interested in peri-implantitis?
Prof. Froum: In the 80’s dental implants were a new phenomenon, attempted by few and watched critically by many. In the 1990’s and on into the early 2000’s, thanks to intelligent research, success rates were high, and popularity grew by double digits. That’s when the problem referrals started coming into our office.
Because peri-implant disease looked like periodontal disease, even if the etiology was not identical, as a periodontist and educator, I was interested, but I could see that, just as in the early implant days, it would take time and lots of work to find predictable solutions.
However, with peri-implantitis, because it was a problem no one wanted to see, the problem would have to be acknowledged before solutions could be adopted.
You encouraged the US periodontal society (AAP) to adopt guidelines and publish a position paper.
Prof. Froum: Yes, and that was a first step. The EFP and EAO have taken similar steps, seeking consensus around disease definition, etiology and treatment. Getting the societies and, in turn, the clinicians and industry to acknowledge and clarify the problem was no easy task.
We know that peri-implantitis occurs, within the general population of patients, but perhaps not with the same prevalence at all centers - and that’s an important distinction. However, systematic reviews of prevalence report that 5–10 years after implant placement, peri-implantitis affects about 10 % of implants and 20 % of patients.1 But let’s face it, implants have been the goose that laid the golden egg, and no one wanted to upset that egg basket!
That’s why we and others started with publications describing the problem, looking at the incidence and prevalence and testing potential treatment solutions. But we had to start by defining the problem. Without that, no one could agree on how often the problem occurs or, in turn, how we should treat it. Currently peri-implant mucositis and peri-implantitis have been defined, and even more useful, a proposal for a tiered disease classification has been published.2
Your first dental implant complications conference was in NYC in 2012. You went on to run three more. What was the response to those conferences? Do you think they were helpful?
Prof. Froum: We filled registration for our first conference in under six weeks. That’s when I knew we were providing something clinicians needed. The second and third conferences drew over 400–500 dentists. I appreciated that Straumann, the sponsor of our original conferences, acknowledged that need.
Since then, through further meetings, society presentations and a state-of-the-art conference sponsored by Geistlich on multidisciplinary treatment of peri-implantitis in Chicago in June 2017, we are reaching the tipping point, where we are teaching and moving toward consensus – on definition, diagnosis, proper treatment and maintenance.
Your Manhattan practice has become known for its treatment of peri-implantitis. What impact has that had on your practice and your relationship with your referring clinicians?
Prof. Froum: We’re proud of what we can do to treat peri-implantitis, but even if we end up with happy patients, peri-implantitis is not a “happy” event – for patients or their referring clinicians. For patients who had the unrealistic expectation that their implants were permanent solutions for problem teeth, there is not only disappointment and the prospect of more treatment but also the question of how things are going to be made right and who is responsible.
Certainly saving implants, even with advanced peri-implantitis, costs significantly less than removing the implants, reconstructing the hard and soft tissue lost due to the disease and replacing the implant and restoration. Even if explantation, augmentation and placement of a new implant and restoration are successful, the cost of a lost implant is approximately three to four times the cost of saving an implant. This cost combined with pain and time delay to restoration can be the difference between keeping and losing a patient.
How do you work with your referring clinicians?
Prof. Froum: When I was a kid in Brooklyn, a new barbershop opened right across the street from an old barbershop and undercut prices by advertising haircuts for 25 cents. Haircuts at that time were 75 cents and up. Soon the old barbershop hung a sign: “We fix 25 cent haircuts for two dollars.” And the old barbershop was a lot more successful than the new one. The lesson? You get what you pay for, and if there are problems down the road, you get what you pay for again!
We are honest with our clinical referrers and our patients, telling them the best and worst that could happen, and then we treat our patients as individuals.
A dentist friend of mine sent me charts and radiographs of one of his peri-implantitis patients, who happened to be his wife. He said, “Stu, will you treat her?” “No,” I said, “but I’ll teach you how to treat her.” Every year, on their anniversary, I get a radiograph of the healthy implant along with a nice thank you note.
The answer is education. We should all be able to diagnose and treat peri-implantitis. Hands-on courses (like the ones Paul Rosen and I give) teach clinicians the techniques that have been so effective in our hands.
In my consent form for implants I include the risk of peri-implantitis as a potential complication. I also tell patients that implants, like teeth, require homecare and professional maintenance and monitoring. If disease occurs and it’s diagnosed and effectively treated in an early state, the chances of treatment being successful and the patient retaining the implant are excellent. When a dentist or a patient wait until the disease has progressed to a point where the patient has pain or an abscess or advanced bone loss due to peri-implantitis, chances of successful treatment are greatly decreased.
How did you develop your peri-implantitis treatment protocols?
Prof. Froum: No one comes up with clinical solutions on his or her own. Collaborative research teams arrive at answers through the teachings of their mentors and by working together. I’m grateful to those who helped me understand periodontal disease and the scientific approach to problem solving, like Dr. Sigmund Stahl, who inspired my clinical research. Along with my research colleagues at the NYU Department of Periodontics and Implant Dentistry, I worked with Dr. Paul Rosen and my son Scott. Together, through trial and error and over two decades of implant therapy learning, we arrived at the solutions you can read about in our most recent publication.3
Your cleaning and regeneration protocol was originally published in 2012, and you followed up with your 2015 publication on 170 implants in 100 patients. What has all this work taught you about treating peri-implantitis?
Prof. Froum: That’s a question that could fill a book, and it has!4 But if I had to sum up, there are eight essential factors for success: (1) proper case selection, (2) flap access that ensures adequate blood supply, (3) extensive implant surface decontamination, including placement of a growth factor, (4) defect debridement, (5) defect fill with proper bone grafts and biologics, (6) coverage with an absorbable membrane, or if there is a deficiency of keratinized tissue, a connective tissue graft, (7) coronal flaps to ensure complete coverage of the membrane/ graft, and (8) professional maintenance with excellent homecare. The key is matching the individual diagnosis with the proper therapy. In our 2015 publication, working in this way resulted in 168 successes out of 170 consecutively treated peri-implantitis cases, with no mucosal margin recession (0.5 mm average gain), bone gains (1.77 mm average) and maintenance with follow-up two to ten years. That tells me that with the proper case selection, results can be predictable and maintained.
Has your knowledge about peri-implantitis changed your implant practice? Do you look at patients, site development and follow-up maintenance/ hygiene differently?
Prof. Froum: Yes. Patient risk factors, implant placement and angulation, proper prostheses for maintenance, and much more… We work top down, looking at how our end outcomes will match our patients’ needs and be maintainable. We have patients who are on two to three month recalls, and we are all in this together – patient, surgeon and restorative dentist.