Dental implants paper


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Dental implants paper

  1. 1. Dental Implants SUMMARYIntroductionA low priority treatment policy for adult dental treatment policy was formulated in the mid 1990sby the former Barnet Health Authority and this has not been recently updated. There has beenan increase in the demand for dental implant treatment in Barnet and Enfield Primary CareTrusts. This paper summarises the clinical effectiveness of dental implants and assessescurrent service provision for Barnet and Enfield residents.Traditional procedures for replacing missing teeth include partial dentures, complete removabledentures, or fixed bridges that attach to existing teeth or rest on the gums. However, forindividuals where this is not successful, such as those who have a weakened jawbone and areunable to manage removable dentures or chew food properly, implants may be a preferredoption.iA dental implant is a small screw shaped metal which is surgically inserted within the jaw boneto replace the root of missing tooth or teeth. An artificial tooth, partial denture or denture can beattached to the implant.The 1997 National Clinical Guidelines for dental implants consider three main subject groupswho may benefit from this treatment. These include:ii • People who are edentulous (toothless) in one or both jaws • Partially dentate individuals • Those requiring replacement of hard and soft tissues of the maxillofacial and cranial regionThere is evidence that dental implant treatment is effective in the treatment of missing root oftooth or teeth. It has been shown to improve self confidence, eliminate the need to ground downhealthy teeth and improve appearance. However, they are very expensive to manufacture, andrequire both specialised surgical instrumentation and expertise for their insertion.Severe complications from this treatment rarely occur. Complications such as infection,rejection, inflammation, damage to nerves may occur in only 5% of dental implant treatment.iiiRecommendation:All referrals for dental implants should be passed through exceptional circumstances panelexcept when indicated for patients with Oral cancer, developmental tooth defects and multipletraumatic tooth loss. 1
  2. 2. 1. Background1.1 Dental Implant TreatmentDental implant is a surgically implanted device which replaces the lost root portion of missingnatural tooth or teeth and provides support for the attachment of an artificial tooth. Theprocedure involves the surgical placement of the implant or implants in the upper or lower jaw, ahealing period (bone integrates with implant) and implant restoration to replace the missingtooth or teeth. Multiple implants are also used to provide support for dentures and bridges.Although the majority of dental implants successfully integrate with bone (osseo-integration), anumber of risk factors are associated with the failure of this process. These include poor bonequality, bone grafts, irradiation, immunosuppressive medications, and some disease states.Other conditions which may compromise treatment results are as follows: bruxism (grinding,gnashing or clenching teeth), alcoholism, tobacco smoking, and osteoporosis (porous bones).ivMechanical failures of implants are uncommon.The maintenance of high standards of oral hygiene is essential to the long-term success of anydental implant. The success of a final prosthesis however is dependent upon thorough pre-operative assessment and planning of the positioning of the implant(s), the skill of the surgeonin placing the implant, the skill of the clinician in designing the dental prosthesis and the skill ofthe technician in constructing the prosthesis.1.2 Types of Dental ImplantsThere are three main types of implants available and most are made from titanium. They includeroot form, plate form and subperiosteal implants. • Root form: This is the most widely used design and generally placed where there is plentiful width and depth of jawbone. It is similar in shape to the root of a tooth and the surface area is designed to promote good attachment to the bone. • Plate form: This special type of implant is placed into the bone and is used when the jaw bone is too narrow. • Subperiosteal Implant: Rests on top of the bone but under the gums and is used in cases of advanced bone loss.1.3 Benefits of dental implantsAccording to the Association of Dental Implantology, United Kingdom, some of the benefits ofdental implants include: • Implant secured or stabilised replacement teeth are more comfortable than conventional dentures because there is no slipping or movement. This eliminates the worries of dentures and improves self confidence. • Dental implants eliminate the need to grind down (modify) healthy teeth. With traditional practices, two teeth adjacent to a missing tooth must be ground down to anchor a bridge. 2
  3. 3. • Improved appearance: Bone ossifies around the implant resulting in preservation of bone structure. This therefore maintains the shape of the jaw bone which would have otherwise shrunk as a result of the missing teeth.2. Evidence of clinical and cost effectiveness of dental implants2.1 Clinical EffectivenessDental implants have been shown to be an effective treatment for replacing missing teeth. Theiruse as a clinical intervention for replacing missing teeth has now been accepted as part ofmainstream treatment supported by over 10 years of longitudinal research demonstratingclinical effectiveness. Evidence from randomised controlled trials show increased ability to chewtough food, and increased patient satisfaction with implants in comparison to normal dentures.The success rate generally is about 90% in the mandible and 80% in the maxilla, at 10 years.v viAn NHS needs assessment conducted in Scotland showed that:vii•At 10 years, < 15% of fixed partial dentures supported by dental implants were removed or inneed of replacement•At 15 years nearly one third were removed or in need of replacementTable 1 shows the results of a 5 year prospective multicenter trials with Branemarkosseointegrated implantsviii are shown in table 3. It is important to note that the success criteriaused here were not necessarily identical or always identified.Table 1: Cumulative success rates (%) of implants according to the type of treatment Maxilla Mandibles eSingle-tooth restorations 99.6 100Partially edentulous fixed bridgework 92.0 94.2Complete edentulous fixed 86.8 100bridgeworkOverdentures 73.4 96.5The use of dental implants in the reconstruction of oral cancer patients is well documented andhas significantly improved their rehabilitation.ix Large defects of the hard or soft tissues in themaxillofacial region, whether congenital or acquired, are treated more frequently with the aid ofdental implants.x2.2 Cost effectivenessAlthough dental implants are very expensive to manufacture and require specialised surgicalinstrumentation and surgical expertise for their insertion, there have been limited economicevaluations conducted. However for clinical conditions where no alternative form of treatment isappropriate, the impact of this treatment on the quality of life takes precedence. A typicalscenario would be an 85 year old that is unable to tolerable dentures, has not been eatingproperly and has become malnourished as a result. 3
  4. 4. According to a review by the Cochrane Collaboration to determine if there were differences inpatient satisfaction and cost effectiveness, weak evidence was found that patients are generallyless satisfied with conventional denture made after oral surgery to improve the retention of thedenture than with denture retained by implants.xiA measure of dental patients values and preferences was used to assess attitudes ofedentulous patients receiving implant and other dental reconstructive therapies. The implantgroup were found to be younger and better educated and rated implant reconstruction moredesirable than the non implant denture group.xiiIn a randomized clinical trial in patients with resorbed mandibles and persistent problems withtheir conventional dentures, the costs of different treatment strategies were compared. TheADIOS –study on the total societal cost showed that the resources used to treat a patient withan overdenture on a transmandibular implant can be used to treat almost seven patients with acomplete new set of dentures.xiii The cost of treatment with implants is higher than the othertreatment options even if it lasts 20 years.2.3 Quality and SafetyComplications of dental implant surgery include swelling, pain, bleeding, possible infection, andpartial numbness at implant site. Nerve disturbances that may be permanent and bone fracturecan occur, as can rejection of the implant. However, severe complications are rare.3. Current service provision3.1 Dental implant treatment in EnglandIn view of the increased demand for implant treatment in a diverse patient population across awide spectrum of clinical disorders, the Royal College of Surgeons of England publishedguidelines in 1997, through the Clinical Audit Committee. The stated aim was to assist clinicalproviders and health authorities to make an informed assessment of patients who may beconsidered suitable for dental implant treatment within the National Health Service (NHS). Thisdocument makes several recommendations on where dental implants may be appropriate ornot, and is used by some PCTs to make funding decisions either directly or via an exceptionalcircumstances panel.It provides guidance on the selection of patients for dental implant treatment within the NHS. Ineach category a list of treatment options and a checklist to be considered before proceeding todental implant treatment is provided. It recommends the audit of treatment outcomes.Inclusion criteria for treatmentThere are three groups of patients considered for treatment and they are: 1. Edentulous in one or both jaws: a. Severe denture intolerance (such as gagging, pain); b. Prevention of severe alveolar bone loss. 2. Partially dentate: a. Preservation of remaining healthy teeth; b. Complete unilateral loss of teeth in one jaw. 4
  5. 5. 3. Maxillofacial and cranial defects: a. Intraoral prostheses, e.g. considerable amounts of missing hard and soft tissue; b. Extraoral/cranial prostheses, e.g. partial or total loss of ears, eyes or nose.3. 2 Service Provision of Dental Implant treatment in BarnetDental implants have normally been excluded from all Barnet PCT contracts and serviceagreements. General medical and oral/dental factors which may contraindicate or modifytreatment are included in the guidelines. The draft of criteria for the provision of dental implanttreatment by the Barnet Primary Care Trust adheres to these guidelines and has a policy torestrict approval of dental implant treatment to patients in the three designated groups.However, funding can be agreed on an individual named patient basis following clinicalrepresentations from hospital consultants working in multidisciplinary teams of restorative andsurgical training.Table 2 shows the General Medical and Oral/ Dental factors considered when making decisionsregarding implant treatment.Table 2: Factors considered prior to dental implant treatmentGeneral Medical Factors Oral/Dental FactorsAge and Life expectancy: There is no upper age Health of the mucouslimit providing the patient has a good life membranes: It is inadvisable toexpectancy. Treatment is delayed in young treat patients with seriousindividuals until growth is complete. erosive and ulcerative lesionsAdequately controlled general health: General Quality of remaining tooth:health should be good enough to undergo Periodontal tissues (gum, bonessurgical and prosthodontic treatment. Subjects and supporting tissues of teeth)with diabetes should be adequately controlled. have to be healthy and dentition sound.Special precaution is taken with those that Periodontal health oral hygiene:undergone irradiation to the jaws Treatment is contraindicated in patients with poor oral hygiene and untreated periodontal disease, and dental cariesTobacco smoking compromises treatment. Parafunctional activitiesFailure rates are approximately twice as high in including grinding or clenching ofsmokers.xiv teeth: Caution should be exercised in accepting these patientsPsychoses/neuroses: treatment is contraindicated Degree of available bone:in subjects with severe psychosis/neuroses Treatment requires adequate bone quality and volume in 5
  6. 6. relation to anatomical structures and planned prosthesis.Treatment is contraindicated in bleedingdisorders, bone disorders, drug or substancemisuse, and may be in patients who are at highrisk of endocarditis.3.3 Policies of other PCTsMany PCTs have instituted some form of access management to dental implants. A summary ofthese is included in Appendix 1.3.4 Treatment activity in the NHSThere is marked variation in the number of patients treated with endosseous dental implantswith the NHS hospitals. Many consultants manage less than 10 such patients a year.xv Thedemand for implant treatment of both partially dentate and edentulous patients has grownconsiderably. In addition there are a number of people who have more extensive loss of oraland facial tissue for whom osseointegrated implants can offer a significant improvement overprevious treatment modalities.The figure below is a diagrammatic representation of need for dental implants and the priorityfor the provision of treatment presented as a continuum or range with multi-dimensions from theNHS Scotland needs assessment.3.5 Treatment Activity in BarnetIn Barnet, dental implant treatment is rarely funded and only in exceptional circumstances.Table 3 shows that in 2005-2006 there were 11 requests for funding: 2 were approved, 6 werenot and 3 awaiting decision.Table 3. Dental Implant Funding Requests in Barnet 2005-06Year Hospital No. of Approved Not approved Pending requests2005/06 6
  7. 7. Eastman’s 1 Did not meet criteria Dental Hospital2006/07 Eastman’s 2 1 did not meet criteria and Dental the other was not registered Hospital with a Barnet GP Guy’s 8 2 met 3 did not meet criteria 3 are awaiting Hospital criteria information3.6 Treatment activity in Enfield15 patients had dental implant treatment from 2003-06: 8 (53.3%) were 3-13 months old andhad treatment in (2003-05) and the other 7 had treatment in 2006 and were aged 16-76 years.Although the diagnosis for which dental implant treatment was done is not given, it is mostprobable that those aged 3-13 months had congenital malformations.4 Cost Implications of dental implant treatmentPeople for whom there is currently no effective treatment, other than dental implants, includethose with maxillofacial defects from congenital or developmental defects, major trauma, ortreatment of tumours. There are also exceptional circumstances where chewing of food may bedifficult resulting in impairment of health and alternative methods of treatment which includedentures and fixed bridges are inappropriate; dental implant treatment therefore is the onlyoption. Table 4 shows the cost of dental implant and alternative options.Table: 4 Costs of Denture, bridges and dental implantProcedure Cost (£)Complete set of dentures upper and lower jaws 250-300Bridges 400-500Dental Implant 2000 and overIn the years 2005-2007, 11 requests for funding were made in Barnet and the costs ranged from£2,000-£12,432. The following is a breakdown of the requests: • Total cost of 9 request-£41,405 (the cost of 2 requests are unknown) • Total cost of 2 that met criteria for funding and were approved- £16,630 • Total cost of 3 awaiting decision- £10,582. • 6 were not approved of which total cost of 4 -£14,193 7
  8. 8. 5. ConclusionDental implant treatment has been shown to be clinically effective in providing a functionaldentition in cases of severe and severe disfiguring oral and dental pathology such as patientswith oral cancer and developmental tooth defects. However it is an expensive procedure andmany patients can be treated adequately using alternative interventions at a lower cost. Itfollows that the opportunity cost of implant treatment is the oral benefits forgone of conventionaltreatments. The evidence in this report suggests they are large. Therefore, dental implanttreatment should only be advocated on an individual patient basis in exceptional circumstanceswhere alternative treatment is inappropriate.6. RecommendationAll referrals for dental implants should be passed through exceptional circumstances panelexcept when indicated for patients with: a. Oral cancer b. Developmental tooth defects c. Multiple traumatic tooth lossAda Okoli, Health Promotion SpecialistEdith Okolo, Assistant Director for Health ImprovementChikwe Ihekweazu, Specialist Registrar in Public HealthMayur Bhatt, Dental AdviserJuly 2007Appendix 1 8
  9. 9. 1. Camden PCT’s policyCriteria governing funding approved in Camden▪ Oral Cancer - Individuals who have undergone surgery for oral cancers and relatedproblems where conventional prosthetic treatment may be extremely difficult due to the residualanatomy.▪ Major Trauma e.g. road traffic accidents which have resulted in the loss of several teethand bone.▪ Development Abnormalities - Individuals who have development abnormalities of theorofacial structures, e.g. cleft palate or sever hypodontia with several teeth missing.▪ Denture Problems –- Individuals who suffer from severe alveolar bone resorption and who are completelyunable to wear conventional dentures successfully and where those dentures are wellconstructed.- Individuals who suffer significant neuromuscular disorders, e.g. facial paralysis andParkinsons disease, which makes it impossible for them to wear a conventional upper denture.However the necessity to maintain implant abutments adequately needs to be considered.Examples of cases that the PCT would probably not fund include the following:▪ Implants for single teeth▪ Implants as a first choice method of prosthetic retention▪ Implants for bridge abutments to replace complete dentures▪ Implants for retention of partial dentures▪ Implants for hypodontia where ten or more teeth are present in each jaw▪ Where the oral hygiene is not maintained at a sufficiently high standard▪ Where there is a reduced prognosis for the remaining teeth because of periodontaldisease or dental caries.2. Carmarthenshire Local Health BoardIn view of the current financial situation, implants will not be commissioned.They will only be purchased in exceptional circumstances and when prior approval has beenobtained by hospital dental staff.This procedure is not available on cosmetic grounds.Implants may be considered for some patients with:▪ Cancer▪ Congenital maxillo-facial defects▪ Major bone loss through traumaIn a number of cases, surgical treatment is unfortunately not possible for clinical reasons.A very small number of patients with severe denture intolerance, who may have tried a well-made and well-adjusted denture for at least one year without success, may be considered for anosseo-integrated implant. This procedure may also be considered if a psychiatric orpsychological opinion suggests real need for an individual patient.3. North Lincolnshire Primary Care Trust 9
  10. 10. Dental Implants not commissioned in all circumstances except▪ post cancer reconstruction,▪ major trauma with bone▪ loss anodontia.Cochrane Review- The Cochrane Library, Issue 3,2003Faculty of Dental Surgery- National Clinical guidelines 19974. Bristol, Bristol South and West, North Somerset, South Gloucestershire PCTs▪ All cases referral to Exceptional Funding Panel (EFP) if there is an indication ofexceptional need for treatment.5. Guildford & Waverley Primary Care Trust▪ Not normally funded6. Somerset Primary Care Trust▪ All cases referral to Exceptional Funding Panel (EFP)7. Ashton Leigh And Wigan PctAll referrals for dental implants must meet the Greater Manchester criteria for this procedure.The PCT’s dentistry advisor will screen all funding requests for this procedure.8. Suffolk PCT▪ Dental implants are low priority for all patients unless there is no practical alternative.NHS treatment will only be provided for patients meeting the eligibility criteria. The categories ofpatient for whom implants should be considered are those where there is no practicalalternative. These are individuals who: -▪ have suffered major trauma▪ have congenitally missing teeth▪ have had surgery for a cleft palate▪ have had major resection to treat carcinomaOnly in the most exceptional circumstances will implants be available for patients with problemdentures or who require single tooth replacement.REFERENCES 10
  11. 11. i Amanda Crosse. Reviewed policy agreed by Cambridgeshire Clinical Priorities Forum on 13th July 2005ii The guidelines for selecting appropriate patients to receive treatment with dental implants: Priorities for theNHS. Faculty of Dental Surgery, National Clinical Guidelines 1997, Royal College of Surgeonsiii Frequently Asked Questions about Dental Implants.Dental Implants.comiv Clinical experiences with dental implants. Patrick J. Henry. Adv. Dent Res. 13: 147-152, June, 1999v Adell R, Eriksson B, Lekholm U. Et al. A long-term follow-up study of osseointegrated implants in the totallyedentulous jaws. Int J Oral Maxillofac Implants 1990; 5: 347-359vi Albrektsson T. A multi-centre report on osseointegrated oral implants. J Pros Dent 1988; 60:75-84vii Scottish Needs Assessment Report. Dental Implants.2004viii Clinical experiences with dental implants. Patrick J. Henry. Adv Dent Res 13:147-152, June, 1999ix Marx R E, Morales M J. The use implants in the reconstruction of oral cancer patients. Dent Clin N Am 1998;42: 177-202x Parel S M, Tjellstrom A. The United States and Swedish experience with osseointegration and facialprostheses. Int J Oral Maxillofac Implants 1991; 6: 75-79.xi Coulthard P et al. Interventions for replacing missing teeth: preprosthetic surgery versus dental implants.Cochrane reviewxii Cost-effectiveness of Dental Implants: A Utility Analyis. J Dent Educ.1990; 54: 668-69xiii Jacobson J, Maxson B, Mays K, Peebles J, Kowalski C. Cost effectiveness of implant retained mandibularoverdentures.xiv Bain CA, Moy PK(1993). The association between the failure of dental implants and cigarette smoking. Int. J.Oral Maxillofacial Implants 8:609-615xv The provision of dental implants in the National Health Service Hospital dental services- A nationalquestionnaire. British Dental Journal, 160 Jan 2001