Dental Implants - Success or Failure

Media and consumer interest have heightened demand and expectations for implants as a solution to tooth loss. As a result there are an increasing number of implants being placed but, with less than satisfactory treatment planning and case assessment there are also increasing complaints about failures. When an implant fails it usually means that the super structure also fails, making any substantiated claims costly to the PI insurer and therefore to everyone via increased premiums. By not adequately assessing and planning cases dentists are not acting to protect their own interests or those of the profession.

Emerging issues in implant complaints

There are two emerging issues (leaving aside the issue of implants placed overseas for another article): firstly, patient driven treatment, where the patient refuses a removable option yet is biologically unsuitable for fixtures, can lead to placement of implants without adequate risk analysis and therefore a higher risk of failure. Secondly, a number of practitioners and most patients believe the treatment to be permanent and at low risk of failure. This is not the case according to dental literature.

Failure risks can be considered as restorative and surgical/periodontal. The prosthetic part of the treatment must be governed by first principles of occlusion and load, and because of the ease of machined components it is more predictable and if the occlusion is right, there is less risk of mechanical failure that conventional crowns and bridges. When implants fail, they are less amenable to treatment than natural teeth. There is reference in the literature to “failing” and “ailing” implants and it is recognised that there will always be implants which fail in the short term, but with time it is expected [and demonstrated in the literature] there will be more biological and technical issues resulting in increasing loss of implants.

Risk of failure

It appears that an increasing number of implants are being placed with no heed to the biological risks of failure. There is already (as well as emerging) published literature on this point but many dentists continue to place implants in cases which, given evidence based research, are at high risk of failure. As dentists we are used considering a risk hierarchy of factors for periodontal disease and caries. There are also risk factors to be considered when planning implants. There is well regarded literature which shows increasing loss or failure over time, and some cases of “spontaneous” failure with no known risk factors.

Emphasis in many planning cases is on the type of fixture and restoration and not on basic triage of suitability. In overlooking this foundation of treatment planning the result is increasing failures, complaints and therefore costs to the profession and the insurer.

High risk factors for peri-implantitis are:

  • Present active periodontal disease
  • History of past periodontal disease
  • Poor oral hygiene
  • Smoking (evidence showing it is less ranking than with periodontitis but still significant)
  • A small amount of literature identifies osteoporosis and Diabetes as risk factors but there is not enough evidence to rank them.

In summary

Every dentist should know the limitations and complications which arise from implant placement and advise the patients of these. The dentist should conduct a risk assessment on the likelihood of failure and add this to the general discussion of implant treatment. Expectations of patients should be aligned with this risk profile prior to embarking on treatment.

Although this is a now ageing article, I recommend the excellent review article by Drs Gary Greenstein and John Cavallaro: JADA 145(8) August 2014. In this article they cite the following recommendations to help reduce failures.

    1. Treat any periodontal or peri-implant pathosis before implant placement
    2. Fully assess medical history
    3. Make sure there is adequate bone height and width: if not augment
    4. Follow strict surgical protocol
    5. Construct a proper super structure
    6. Instruct patients in good oral hygiene and the absolute necessity for maintenance
    7. Over engineer cases where parafunction is obvious

Performing  and recording a risk analysis and then informing  patients of any heightened risk of failure is good risk management for you, not to do so is potentially negligent and can give rise to a basis for an expensive claim, usually involving a costly remedial treatment plan. Disregard for considering evidence based research would also result in a potential unprofessional conduct finding if the matter was taken to AHPRA, as would practicing beyond the scope of an individual’s formal training.

Dr Eryn Agnew

Community Relations Manager/ Professional Consultant

References

Failed dental implants: Diagnosis, removal and survival of reimplantations: Drs Gary Greenstein and John Cavallaro: JADA 145(8) August 2014; 835-841

Dental implant complications: etiology, prevention, and treatment: SJ Froum – 2015

Download pdf here.

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    Property maintenance - could your property cause an injury?

    Guild Insurance sees many insurance claims which have come about due to poor maintenance of a property.  In too many of these cases, the poor state of the building or its grounds is obvious and it’s quite surprising, as well as disappointing, that repairs haven’t been carried out before an incident has occurred.

    What can go wrong?

    There are a range of incidents which can occur due to poor maintenance of a property.  Staff can be injured leading to a worker’s compensation claim as well as staff being absent from work for an extended period.  Visitors to the premises, such as customers, clients or contractors, can also suffer injuries leading to public liability claims.  As well as the insurance claims which need to be managed, there’s the added stress of knowing that someone has been injured while at your premises.  Some of these injuries can be very serious and life changing.  Unfortunately, the hazards which lead to these injuries are often not viewed as seriously as they should be.  Yet with appropriate property maintenance many of these injuries could be avoided.

    Case 1

    A client entered a building and tripped over an edge of carpet which was ripped and curled up.  The client sustained a fractured wrist when they landed.

    Case 2

    An awning out the front of a building was old and worn out.  During heavy winds it broke off from the building and hit a person walking past at the time.

    Case 3

    While walking through the carpark of a premises, a staff member has tripped on a large crack in the asphalt which had caused the surface to be uneven.  They fractured their ankle as they fell.

    Case 4

    Poor maintenance doesn’t just lead to people suffering injuries, it can also lead to further damage to the property.  An old deteriorating roof collapsed when hit by heavy rain as it no longer had the strength to support the weight of this rainfall.  This led to excessive water damage within the building.

    Property maintenance tips

    • Have a documented maintenance program in place. This requires a schedule for regularly checking the property to identify hazards as well as details on what needs to be serviced, repaired or replaced and when.
    • Be aware of the out-of-sight, out-of-mind hazards. Many properties have roofs, guttering and downpipes in poor condition due to a lack of maintenance as no one has thought to get up on the roof and inspect it. Include the less obvious hazards in the maintenance program.
    • Have a maintenance budget. Some maintenance work can be planned, other work will come up unexpectedly when something breaks down. You need to be able to find money to fix hazards when identified.
    • Be sure to use qualified tradespeople to undertaken maintenance work. While it can be tempting to undertake some DIY and save money, the risk of things not being maintained or repaired correctly will not be worth the savings in the long term.
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    Orthodontic and third-party agreements: risks and concerns.

    In recent times, there has been a growing number of companies on the internet offering orthodontics like braces, aligners, and other products that people can use at home. While the convenience is very appealing for patients, the same can’t be said about the risks and concerns that come with partnering with foreign-based aligner companies. With the recent demise of two overseas aligner providers, some dentists have not been able to continue patient care in the middle of a course of orthodontic treatment. This has resulted in patient complaints against dentists, who had no part in the companies’ collapse but are left to manage the fallout and develop a re-treatment plan with another aligner provider.

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    The ADAVB recommends that any member undertaking orthodontic treatment with third-party aligner providers familiarise themselves with the risks and ensure that they are not exposing themselves to additional liability, which may place them in a precarious position when defending a claim.

    Major concerns 

    Treatment plans by aligner companies are often computer-generated offshore with some input from a technician. Blindly following these plans may result in a compromised outcome and potentially irreversible damage. Orthodontists often make changes before a satisfactory plan is reached and may even further modify plans during treatment, depending on the progress. As the clinician, you’re responsible for the treatment and any adverse outcomes, not the aligner company that generated the treatment plan.

    As a result, any claims by patients would most likely be against the dentist or the clinic. Contractual and duty of care considerations need to be taken into account. Even if the contract says the aligner company will cover your liability, that can’t be enforced. By Australian law, the dentist cannot delegate liability for treatment performed to another party. So, in the end, the problem comes back to bite the dentist.

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    A claim against the aligner provider would necessitate chasing shelf and overseas companies, making it almost

    impossible for the patient. The patient will turn to the only person they can reach and direct the blame to – their dentist. It should be noted that at present, there are two class action claims in courts overseas against aligner providers, but these may take years to play out, and it’s unknown if they will be successful.

    An insurer is not privy to the contracts dentists sign or warranties offered by aligner companies. This means warranties deflect back to the dentist and may not be covered under a professional indemnity policy. In Australia, health service providers cannot give warranties, so that part of the company’s “promise” is worthless unless it relates specifically to the aligners themselves (breakages, replacements, etc), not treatment outcomes. 

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