Immediate Extractions: To Implant or Not to Implant?

That is the question!

Wouldn't it be nice to whip in an implant every time a tooth is removed? Not bother waiting for sockets to heal? Not worrying about ridge augmentations or which membrane to use? If it were only that simple!

Where do periodontists stand on immediate placement of implants into extraction sockets?

There's a lengthy literature telling us that we should let the extraction sites heal before placing a fixture. On top of that, there's been a push to encourage us to practice bone replacement therapy after every extraction (see Newsletter 1). The restorative folks want optimum site preparation. They expect periodontists to place implants in the proper location for their restorations, regardless of whether there's enough bone or not. Who cares if 3-6 extra months (sometimes more) are tagged onto the course of treatment, so long as the fixture's in the right spot? The question is, why can't implants be placed at the time of tooth removal? It would certainly save the patient a lot of time...and the prosthetics could be done months earlier.

Drs. Devorah Schwartz-Arad and Gabriel Chaushu* wanted to know which protocol to follow. Should they wait and let the extraction sockets heal before placing implants? Or insert them at the time teeth were removed? To get a handle on the diametrically opposite approaches, they reviewed the dental literature of the last fifteen years, study by study. They reviewed 77 papers in all, analyzing a host of factors including: how many millimeters beyond the apices the implants were placed, what materials were used to fill the voids between the implants and the extraction socket walls, were membranes used, flap design, antibiotic usage, and more.

They drew the following conclusions:

1. Implants placed into fresh extraction sockets have a high survival rate, between 93.9 % to 100%.
2. Implants must be placed 3 to 5 mm. beyond the apex to gain a maximal degree of implant stability.
3. Implants should be placed as close as possible to the alveolar crest level (0 to 3 mm).
4. There is no consensus regarding the need for gap filling and the best grafting material.
5. The use of membranes does not imply better results; on the contrary, membrane exposure may lead to adverse complications.
6. The absolute need for primary closure remains to be established.

What have our experiences been at PAPA? The success rate is the same whether dental implants are placed immediately into extraction sites, or after waiting for an appropriate healing time. However, in areas of greater esthetic demands, we find more predictable results when we allow the sockets to heal first.

* Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Perio1997;68:915-923.

Avoid Periodontal Surgery...Use Tetracycline Fibers!

Two decades ago, an alarm bell was sounded: there was no need for periodontal surgery as long as you followed the Keyes prescription of baking soda and hydrogen peroxide. Then there were the Drs. Snow preaching a conservative scaling approach, and Dr. Trieger prescribing scaling and clindamycin for what ailed the gums. Patients were taking control of their periodontal treatments, and periodontists were viewed as left wing, knife happy dicers and slicers. The nails were being hammered into the coffin of conventional periodontal surgery, and cheers were being heard from those who rail against anything that smacks of the "establishment." Along comes Actisite, (Proctor & Gamble, Cincinnati, OH), and the death knell of periodontists is, once again, being sounded across the land.

So what is Actisite? Actisite is an elastic fiber consisting of ethylene vinyl acetate polymer, impregnated with tetracycline HCL. The idea is that the fiber is placed into a periodontal pocket for a period of days, during which the tetracycline is slowly released.

Studies compared the effects of these fibers to conventional root planing. While some found that placing the fibers had a positive benefit after six months, their effects began to be nullified after one year. Now comes a 5 year study by Wilson, et al +.

Wilson and his colleagues culled a group of 26 patients from an original group of 113 patients who were used in a 6-month multi-center evaluation of adjunctive tetracycline fiber therapy with scaling and root planing. These 26 individuals were interested in continuing the study for five years. Each patient had one site treated with scaling and root planing alone, and another treated with scaling and root planing plus tetracycline fiber. Five years after the original study, the patients were reevaluated.

The results? There was no statistical difference between the two forms of therapy when probing pockets and attachment levels. There was a short-term benefit from the combined therapy, but it tailed off to the point of becoming insignificant with time. The authors concluded by questioning the usefulness of tetracycline fiber therapy in long-term treatment of periodontal diseases.

+ Wilson Jr. TG, McGuire MK, Greenstein G, and Nunn M. Tetracycline fibers plus scaling and root planing versus scaling and root planing alone: similar results after 5 years. J Perio 1997;68:1029-1032.

What About Non-Insulin Dependent Diabetics?

We all know the link between insulin-dependent diabetics and periodontal disease. But should we worry about non-insulin dependent diabetics as much? Few studies have explored whether NIDDMs (non-insulin dependent diabetes mellitus) are at greater risk for more severe alveolar bone loss progression than those that do not have NIDDM. Taylor et al** performed just this study over a two year period.

The authors studied a group of Pima Indians, 362 subjects in all. The examination included a medical history, physical examination, and review of inpatient and outpatient medical care records. Their data were compared to examinations taken on 24 subjects having NIDDM. All subjects had more than 20 teeth, and none were lost during the study. None had more than 25% bone loss as seen on radiographs. None of the 24 subjects having NIDDM experienced any change in their medical status during the 2-year course of the study.

The study concluded that those subjects suffering from NIDDM experienced an increased incidence of bone loss when compared to the control group. NIDDM also increased the risk for more severe progression of alveolar bone loss, though the loss may not be constant at all ages (younger subjects with NIDDM had a greater progression of alveolar bone loss than the older subjects).

It was recommended that dentists be aware that patients with NIDDM are at increased risk for more severe progression of periodontitis, and to treat these patients accordingly.

** Taylor G.W. et al. Non-Insulin dependent diabetes mellitus and alveolar bone loss progression over 2 years. 1998;J Perio 69:76-83.

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