Editorial Type: CLINICAL
 | 
Online Publication Date: 10 Oct 2024

Prevalence of Decay and Tooth Condition Changes Adjacent to Restored Dental Implants: A Retrospective Radiographic Study

DDS, MS, PhD,
DMD,
DMD,
DMD,
DDS, MS, MSc,
PhD, and
DMD, MS
Article Category: Research Article
Page Range: 474 – 480
DOI: 10.1563/aaid-joi-D-24-00044
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This study examined the association between a dental implant and changes in adjacent teeth over time. Electronic health records of 1818 patients who received a dental implant were retrospectively evaluated over 14 years (2005–2019) in a university setting. The status of the adjacent tooth and vertical and horizontal distance from the implant platform to adjacent teeth were determined using digital intraoral radiographs taken at baseline and the last follow-up visit (1–14 years, median 4 years). In total, 1085 dental implants were evaluated. There were 234 instances of a change in the adjacent tooth. Decay was observed in 83 (7.6%) of adjacent teeth; the mean time to development was 4 years (range 1–14 years). Approximately 9% of adjacent teeth received direct restorations, 4.8% received indirect restorations, 1% received endodontic root canal treatment, and 5.6% were extracted. The mean horizontal distance between the implant platform and the adjacent teeth was 3.56 mm; the mean vertical distance from the contact point to the alveolar crest on the tooth side was 6.2 mm at the first time of the reported decay on X ray. These distances did not significantly influence the occurrence of caries. The prevalence of interproximal contact loss was higher on the mesial of the implant crown at 63% compared with 20% on the distal side. This large retrospective analysis identified that teeth adjacent to a dental implant were at risk of decay and changes in their condition. In addition, the implant-to-tooth distance and inadequate emergence profile may contribute as caries risk factors in addition to hygiene and a high sugar level diet. These findings appear essential for clinicians when making treatment decisions and discussing outcomes with patients.

Keywords: decay; dental caries; restoration; dental implant; crown

Introduction

Dental implants exhibit a high success rate in a university setting (98%) and have become a standard contemporary treatment option for persons missing 1 or more teeth.1 Millions of dental implants have been placed and restored with high patient satisfaction.2 Successful treatment with dental implants requires careful planning and case selection involving bone height, width, and health; precise surgical placement techniques; prosthetically driven restorations; and long-term maintenance protocols.3,4 Implant complications are reported extensively in the literature and often relate to failure regarding the factors above.5,6 However, little is known about the complications that extend to the adjacent teeth. Some complications that may affect the adjacent teeth include the potential for dental decay, the requirement for restorations, interproximal loss of contacts, or the development of periodontal disease.7–9

Several reports in the literature indicate that open contacts and subsequent decay occur between restored implants and adjacent teeth in molar regions.10–20 In a systematic review and meta-analysis of proximal contact loss in implant-supported restorations, the overall prevalence of interproximal contact loss (ICL) occurred in 20% of 11 699 restorations at the implant restoration level and 26.6% at the contact point level.20 The frequency of ICL was higher on the mesial, at both the implant restoration level (13.8%) and the contact point level (21.9%) than on the distal, where the prevalence was 3.3% and 11.0%, respectively. The event rate in the maxilla and the mandible at the contact level is reported to be similar (21.4% and 21.9%, respectively).20

Recent reports indicate that one of the complications on teeth adjacent to restored implants is an open contact that may occur during implant crown delivery or as a result of craniofacial growth changes and modifications that occur during adulthood after implant crown delivery.12–17 In support of the latter, it is reported that the proximal contact tightness between implant restoration and adjacent teeth decreased significantly at mesial and distal sites over time, particularly in the mesial in the first 3-month period after crown delivery. No matter the cause, interproximal contact loss creates opportunities for food impaction and subsequent periodontal defects, recurrent tooth decay, and peri-implant complications.10,11

The importance and magnitude of ICL can also be assessed by examining treatment procedures performed on adjacent teeth after implant restoration. In 1 study of 78 single-tooth implants in 64 patients, the status of teeth adjacent to single-tooth implants showed a high proportion of intact or nontreated adjacent teeth in both the anterior (70%) and posterior regions (64%). None of the adjacent teeth required extraction or endodontic treatment, and only 4 needed restoration at the follow-up of 3 years.18

The horizontal distance between the implant platform and the adjacent teeth can contribute to the health of the adjacent tooth. In the Krennmair et al study population, this factor significantly influenced the interproximal bone loss of the anterior region but not the posterior region.18 In a case series study of 1162 consecutive patients with a single missing posterior tooth treated with 1377 external hex implants supporting 1365 restorations surrounded by natural teeth over 1–10 years, the survival and the long-term conditions of the adjacent teeth showed that no teeth were lost during the 10 years of the follow-up. Interproximal decay developed in 5% of the cases, and only 0.4% of the adjacent teeth required root canal therapy (RCT) due to decay or restoration.19

As limited data exist on the status of teeth adjacent to a dental implant over time, we aimed to retrospectively evaluate the conditions of teeth adjacent to a restored dental implant with respect to the prevalence of decay, root canal treatment, direct restorations, indirect restorations, and extractions after single implant-supported restorations were placed. We hypothesized that a dental implant and the distance between the implant and adjacent teeth influence dental decay on the adjacent teeth.

Material and Methods

This single-site, retrospective radiographic study evaluated single dental implants and adjacent natural teeth over 14 years (2005–2019). Institutional review board approval was obtained and complied with national and international human protection guidelines, including those of the current World Medical Association Declaration of Helsinki–Ethical Principles for Medical Research Involving Human Subjects. All subjects who received treatment for single dental implant restoration at the University of Kentucky College of Dentistry clinics and those who met the study criteria were identified by medical record review using the axiUm electronic health record system (Exan software, Las Vegas, NV).

Data collection

The digital radiographs of patients who received single implant-supported restorations at the University of Kentucky, College of Dentistry, were analyzed. At the last clinical examination, changes in the adjacent teeth were noted relative to caries, direct restoration, indirect restoration, RCT, extraction, and implant replacement. Current dental codes (ie, D6010, D6058, D6059, D6065, D6066, and D6066) were used to run a report to identify subjects who received single implant-supported restoration treatment at the College of Dentistry. Demographic information was extracted from the record, and digital intraoral radiographs (periapical for anterior implants and bitewing for posterior implants) were reviewed to identify the implant site, implant type, tooth conditions adjacent to implants, direct restorations, indirect restorations, RCT, missing/extraction, replaced with another implant, and date of the change of the conditions. In addition, the vertical and horizontal distance from the implant platform to the adjacent tooth was measured using the digital ruler in the MiPACS Dental Enterprise Viewer software (Medicor Imaging, Charlotte, NC).

Inclusion criteria

The study included records of patients 22 years or older who had a single implant-supported restoration placed at the College of Dentistry and retained the implant for at least 1 year.

Exclusion criteria

Excluded were records of patients with multiple implants supported fixed prostheses, lack of follow-up radiographs, and younger than 22 years of age.

Data analysis

Descriptive statistics were calculated for the demographic variables, tooth conditions, and implant features. Univariate differences in these outcomes were assessed between genders, implant types, implant tooth region, and adjacent tooth conditions using appropriate χ2 or Fisher exact tests. Due to right skewness, the primary outcomes of horizontal and vertical distance between the implant and adjacent tooth were log-transformed. To assess the relationship between these log-transformed distances and gender, implant type, implant tooth region, adjacent tooth condition, and interproximal contact status, a series of 2-sample t tests and separate multiple linear regression models were used. Model assumptions, including normality and homoscedasticity, were evaluated using plots and appropriate hypothesis testing. Across all analyses, a p-value of less than .05 was considered significant. All analyses were completed in R 4.2.1 (R Foundation for Statistical Computing; Vienna, Austria).

Results

One thousand eight hundred eighteen patient records met the inclusion criteria, resulting in 1085 implants in the study. The mean age of patients who received an implant was 63 years (range: 23–93 years); 59.4% were male (Table 1). Overall, 234 (21.6%) adjacent teeth became affected over time. Decay was detected on the adjacent tooth more often in the first 4 years with interquartile range (IQR) = 2–7 years, 1–14 years, and a mean of 4 years (Figure 1).

Figure 1.Figure 1.Figure 1.
Figure 1. Frequency of decay per time.

Citation: Journal of Oral Implantology 50, 5; 10.1563/aaid-joi-D-24-00044

Table 1 Characteristics of the study population and dental implants
Table 1

Of 1085 implants analyzed, 2 types were identified: 55% were Tissue-level Straumann® dental implants (Straumann USA LLC, Andover, MA) and 45% were Bone-level Straumann® dental implants (Table 1). Most implants were placed in posterior regions (91.2%), whereas 8.8% were in anterior areas. Four hundred forty-five (41%) implants were placed adjacent to virgin teeth, and 640 (59%) were adjacent to restored teeth.

The median horizontal distance between the implant platform and the adjacent teeth was 3.4 mm (IQR: 2.4–4.5 mm) with the type of implant being significantly associated with the distance. The mean horizontal distance between the implant platform and adjacent teeth for bone-level implants was significantly smaller than that of tissue-level implants (p = .012). The horizontal distance was also significantly smaller for anterior teeth than posterior teeth (p < .0001). A slight but nonsignificant decrease in the mean horizontal distance was observed in females compared with males (p = .181) and for adjacent virgin teeth compared with those previously restored (p = .128; see Table 2).

Table 2 Univariate horizontal distance summaries for all analyzed dental implants with respect to gender, implant type, location, and adjacent tooth condition
Table 2

Table 3 summarizes the results of fitting a logistic regression model containing each of the 4 variables considered in the univariate analysis above. After adjusting for the effects of the other variables, posterior teeth still had an estimated 20% larger mean horizontal distance than anterior teeth (p < .0001). The implant type differences were no longer significant after adjustment, with tissue-level implants associated with an estimated 3% adjusted increase in mean horizontal distance compared with bone-level implants (p = .137). Marginally significant differences between males and females were observed with almost a 4% adjusted increase in mean horizontal distance observed in males (p = .084). A nonsignificant 3% adjusted decrease in the horizontal distance was observed for adjacent virgin teeth compared with those that had been previously restored (p = .110).

Table 3 Factors associated with decay determined by multiple regression log-transformed distance model; a posterior tooth was significantly more likely to be associated with decay and change in tooth condition than an anterior tooth in males
Table 3

The median vertical distance from the contact area to the crest of the bone was 6.1 mm (IQR: 5.4–6.8 mm) on the mesial side of the implant and 5.9 mm (IQR: 5.3–7.0 mm) on the distal side of the implant (Tables 4 and 5). There was a marginally significant difference between males and females on the vertical distance on the distal side of the implants (p-value = .058). Tables 6 and 7 show the mean vertical distance on the mesial and distal sites and minimal differences when examined for gender, posterior vs anterior site, and ICL.

Table 4 Univariate vertical distance summaries on the mesial site of a subset of 77 patients
Table 4
Table 5 Univariate vertical distance summaries on D sites of a subset of 77 patients
Table 5
Table 6 Multiple regression log-transformed vertical distance model on M sites of a subset of 77 patients
Table 6
Table 7 Multiple regression log-transformed vertical distance model on D sites of a subset of 77 patients
Table 7

In summary, the prevalence of decay and condition changes on the adjacent teeth was 21.6% (Figures 2 through 5). The mean time to observe the development of the decay and changes in the condition of the adjacent teeth was 4.6 years with a decay prevalence rate of 7.6%. After dental implant placement, 8.9% of adjacent teeth were treated with direct restorations (ie, composite or amalgam restorations), and 4.8% received indirect restorations (ie, full-coverage crowns). Of note, 5.6% of the adjacent teeth were extracted due to root decay, 2% were replaced with another implant, and 0.9% received root canal therapy.

Figure 2.Figure 2.Figure 2.
Figure 2. Direct restoration after dental implant restoration.

Citation: Journal of Oral Implantology 50, 5; 10.1563/aaid-joi-D-24-00044

Figure 3.Figure 3.Figure 3.
Figure 3. Recurrent decay resulted in indirect restoration replacement after dental implant restoration.

Citation: Journal of Oral Implantology 50, 5; 10.1563/aaid-joi-D-24-00044

Figure 4.Figure 4.Figure 4.
Figure 4. RCT to the adjacent tooth after dental implant restoration.

Citation: Journal of Oral Implantology 50, 5; 10.1563/aaid-joi-D-24-00044

Figure 5.Figure 5.Figure 5.
Figure 5. Tooth adjacent to the restored implant was extracted and replaced with an implant after dental implant restoration.

Citation: Journal of Oral Implantology 50, 5; 10.1563/aaid-joi-D-24-00044

Factors associated with decay or change in crown status are shown in Tables 8 through 10. The most notable finding was that posterior teeth adjacent to a dental implant were more often restored with a crown in females than males (7% vs 3%, p = .002).

Table 8 Prevalence of decay and changes to the conditions of the adjacent teeth after implant restoration per gender
Table 8
Table 9 Prevalence of decay and changes to the condition of the adjacent teeth after implant restoration per location
Table 9
Table 10 Prevalence of decay and changes to the condition of the adjacent teeth after implant restoration per implant type
Table 10

Discussion

This study sought to longitudinally analyze many dental implant sites to understand better the prevalence of decay and other conditions in teeth adjacent to restored implants. To the authors’ best knowledge, although there is previously reported data from private dental clinics, this is the first retrospective analysis on the prevalence of decay on teeth adjacent to restored implants in a university setting.10,11,18,19 Our analysis of 1085 dental implants found that 21.6% of adjacent teeth were susceptible to disease-related changes during a median follow-up period of 4 years. Dental decay and restorations of the adjacent teeth occurred in 234 teeth (21.6%). The next most frequent occurrence was extraction (N = 61). The adjacent tooth was replaced with an implant in 22 cases (2%), and RCT was performed on 10 (1%) adjacent teeth. The mean horizontal distance was more than 3 mm, and the mean vertical distance was more than 6 mm, which may have influenced the appearance of the conditions reported herein.

Plaque-induced dental caries and a high-sugar diet are the main factors in the decay formation process.21 In dental implant restoration, the distance between the implant and adjacent teeth can create (i) a nonhygienic space and (ii) an inadequate subgingival contour of the implant “emergence profile,” both of which can be considered caries risk factors to the teeth adjacent to a restored implant.4 Evidence suggests that qualitative and quantitative changes in bacteria and biofilms, including Streptococcus mutants, occur when appliances are introduced to the dental environment for a prolonged time.25 These changes in characteristics and aggressiveness are reported by Kozak et al.25

Therefore, factors that cause decay on teeth adjacent to restored implants are also influenced by the biological width around dental implants, which dictates the horizontal distance from the platform of the implants to the adjacent teeth.10–13,25–28 On the other hand, the loss of the interproximal contacts and more than 5 mm vertical distance from the contact point to the alveolar bone crest next to the tooth dictates the interproximal papilla’s presence.10–13,25–28 The horizontal and vertical distances between the implant and the adjacent teeth may affect the soft tissue coverage on the adjacent teeth, which may cause loss of attachments and root exposure of the adjacent teeth.10–13,25–28 Gingival recessions and loss of attachments are ordinary following tooth extraction or full-thickness flap elevation to place an implant. The consequence of an exposed root surface that is more susceptible to decay, along with plaque accumulation or food impactions due to the ICL, helps explain the prevalence of decay next to a restored implant.

The results of this retrospective radiographic analysis agree with previously published data regarding caries.10,11,18,19 In prior reports, it was noted that 17% of caries occurred on teeth adjacent to restored implants in the posterior region. This coincided with the distance between the implant and the tooth (4.1 mm).10,11 In this study, the prevalence of decay was 7.6%, lower than abutment tooth decay in a natural tooth-supported fixed prosthesis, which approximates 20%.22–25 This finding suggests that single dental implant restoration is more favorable in some cases than natural tooth-supported fixed prosthesis in high caries risk patients.

The incidence of open interproximal contacts and decay was reported in this study. An average of 6 mm vertical distance and 3 mm horizontal distance were reported as cofactors on those changes to the conditions of the teeth adjacent to the restored dental implants. Gingival recessions and attachment loss may have contributed to root surface exposure and caries susceptibility. Many teeth were restored with direct and indirect restorations, and others were treated for RCT or extracted and replaced with another dental implant, indicating that adjacent teeth were susceptible to dental disease and its progression over the 14-year retrospective study data. It is worth noting that long-term studies on adult facial growth have indicated differences in growth patterns between males and females.29 Females’ cumulative growth was mainly in the vertical dimension while males accumulated more horizontal growth increments.29 Hence, these gender differences may partially reflect how the static dental implants relate to the adjacent teeth in the long term.

In a report by Misch et al,19 0.4% of adjacent teeth required endodontics, and 5% developed interproximal decay within 10 years of follow-up. None of the teeth adjacent to single implants was lost from endodontic failure or caries. In our study, with 14 years of follow-up, we noted that 1% of teeth adjacent to restored implants received RCT, double Misch’s findings; 7.6% of adjacent teeth developed interproximal decay, a 34% increase from Mische’s findings.19 However, findings from these 2 studies suggest that the incidence of endodontic procedures is lower than that of a natural tooth-fixed prosthesis (∼15%) of the adjacent tooth.12–24

Limitations

There were several limitations to this study. First, it was difficult to account for different magnifications and angulations of the digital radiographs, which could contribute to measurement error. Second, we did not count the number of teeth in the mouth of the participants and realized that persons with fewer teeth might impose more significant stress on the implant and adjacent teeth, which may have influenced the results. Third, because of the nature of this retrospective radiographic study, we did not have sufficient information to evaluate the periodontal health of the implants and adjacent teeth. Therefore, the number and percentage of adjacent teeth with clinical attachment loss and concurrent root exposure and/or periodontitis that placed them at higher risk for caries were not ascertained. Retrospective studies only allow us to explore association rather than cause-and-effect relationships. The study population may or may not represent the general population as there was no element of random sampling. However, this data would provide an excellent basis for planning a future prospective study.

Conclusion

This large retrospective analysis identified that teeth adjacent to a dental implant were at risk of decay and changes in their condition. In addition, the implant-to-tooth distance and inadequate emergence profile may contribute to caries risk factors associated with dental implants. Nonimplant factors contributing to the risk of decay include poor hygiene and a high-sugar diet. These findings appear essential for clinicians when making treatment decisions and discussing outcomes with patients.

Abbreviations

RCT

root canal treatment

ICL

interproximal contact loss

IRB

institutional review board

M

mesial

D

distal

Note

All authors have contributed substantially to the study’s conception and design. AK and CM were responsible for the acquisition of the data. In addition, all authors were involved in data analysis, interpretation, drafting the manuscript, and revising it critically. They have given final approval for the version to be published and agree with its accuracy. This study was not supported. The authors report no conflicts of interest related to this study.

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Copyright: 2024
Figure 1.
Figure 1.

Frequency of decay per time.

Figure 2.
Figure 2.

Direct restoration after dental implant restoration.

Figure 3.
Figure 3.

Recurrent decay resulted in indirect restoration replacement after dental implant restoration.

Figure 4.
Figure 4.

RCT to the adjacent tooth after dental implant restoration.

Figure 5.
Figure 5.

Tooth adjacent to the restored implant was extracted and replaced with an implant after dental implant restoration.

Contributor Notes

* Corresponding author, e-mail: ahmad.kutkut@uky.edu
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