| Abstract|| |
Context: India suffers from a heavy burden of oral diseases. Dental implants (DIs) are prescribed widely by the dental practitioners to replace lost natural teeth. There is no estimate, however, to determine the number of DIs or the number of people with peri-implantitis or the failure of implants after placement. In this modeling study, we attempted to estimate the prevalence of adult Indians who would choose DI in the near future and to calculate the peri-implantitis and failure of DI. Materials and Methods: Using the Global Burden of Disease database (2016), the number of dental caries in permanent dentition, periodontal diseases, and edentulism was obtained. Empirical assumptions of patients with anodontia in urban and rural areas who opted for DI, percentage of implants placed, the affordability factors, and mathematical models for DI were formed and executed. Peri-implantitis and survival data from literary evidence were collated. Results: Based on assumptions, 909,643 Indians, (830,231–858,703) would choose DI. Estimated number of peri-implantitis would be 145,543–254,700 and estimated number of failures should be 50,940–79,412 in the near future. Conclusions: In spite of the high economic challenge and the risks or complications of peri-implantitis, DIs are gaining prominence. It is the dentists' burden to face the renewed challenges due to emerge and provide remedial measures.
Keywords: Dental implants, edentulism, implant failure, implant survival, peri-implantitis
|How to cite this article:|
Thavarajah R, Sudharsan R, Joseph I, Elizabeth J, Umadevi KR, Ranganathan K. “Burden of the Triumph:” Burden of peri-implantitis in Indian population – A mathematical model. Indian J Dent Res 2018;29:497-506
|How to cite this URL:|
Thavarajah R, Sudharsan R, Joseph I, Elizabeth J, Umadevi KR, Ranganathan K. “Burden of the Triumph:” Burden of peri-implantitis in Indian population – A mathematical model. Indian J Dent Res [serial online] 2018 [cited 2019 Jul 16];29:497-506. Available from: http://www.ijdr.in/text.asp?2018/29/4/497/239406
| Introduction|| |
Loss of tooth or teeth causes a substantial toll in the form and function of masticatory apparatus. For example, loss of a single permanent postcanine tooth is reported to reduce the masticatory efficiency significantly. In addition, speech and self-esteem are other factors that are commonly compromised with loss of a tooth. Dental implants (DIs) are being marketed as a panacea for loss of tooth to restore the form and function. They come in varied shape, size, and models with different concepts catering to a diverse applications as well as clinical scenarios. Cost-wise, certain models of indigenous DI cost from INR 3500 (US$ 53) upward. DI gained prominence in the Indian market since 2000 and has been widely marketed. The market leaders created continuing dental education programs, skill enhancement programs, and training modules along with support bases for promoting their products. As the skill for diagnosis and placement of DI percolated among general dental practitioners (GDPs) and specialty dental practitioners, the placement of DI increased among Indians.
With increasing awareness of importance of oral hygiene, perception of esthetics, and convenience and advantages of having DI, more and more Indians sought DI. The increasing Indian per capita income, especially among the urban young adults coupled with increasing availability of DI placement facilities activated the DI seeking behavior among Indians. In surveys, as much as 85% of the respondents knew about DI and expressed willingness to place DI. The emerging concept of dental tourism coupled with low-price, high-volume model led India to be a sought out destination for DI placement.,,,
Till date, there is no available Indian record of the number of DI placed. All available evidence emanates only from the industry reports and their press releases or based on market forecasts., In all possibility, a majority of indigenous, cost-effective DIs are kept out of this system.
In spite of its widespread popularity, the DI placement is technique sensitive, required adequate planning of DI, and preparation of site for DI. Placement of implants by GDP and an implant specialist made the difference. The survival of DI placed by inexperienced practitioners was 73.0% as against 95.5% by implant specialists., The use of surgical guidance stents for DI placement in India is limited and more than 90% of DIs are placed without stents. In Indians, besides the high prevalence of poor oral hygiene, factors such as high prevalence of diabetes mellitus, hypertension, and use of tobacco products have emerged as limiting steps for success of DI placed.,,, As reported in Global Burden of Disease (GBD) (2016) survey, there is an increasing burden of oral diseases, especially as dental caries, periodontal issues, and edentulous jaws among Indians. This leads to a lot of anodontia (partial or complete) and a significant percentage of them lose their teeth. A 15-year-old survey indicates that a significant percentage of Indian men and women between 15 and 80 years' age suffer from edentulism or partial anodontia. Till date, no effort has been put in to measure the estimate of the DI placed in India.,
The survival and success of DI are two different concepts. Success of DI is measured by the success in osseointegration even when the DI fails to survive. Survival is the period of retention of DI in the oral cavity. The gray zone of survival and success has been extensively debated. As this debate persists, an inflammatory disorder at the implant–tissue interface, called peri-implantitis, began to be increasingly reported. The cause of the peri-implantitis is varied and is analogous to the gingival/periodontal infections. There is no single large-scale studies of the peri-implantitis among DI placed among Indians and the long-term survival of such DI. In this manuscript, an attempt is made to identify the potential burden (in volume) by estimating the number of patients with DI, peri-implantitis, and with successful DI using the principle of mathematical modeling.
| Materials And Methods|| |
The preliminary data for this study were collected from the GBD 2016 survey. Previously described definitions and methodology were employed to identify the data for dental caries for permanent teeth, periodontal problems, and edentulism (≤9 teeth in the oral cavity). Data inputs and data points were collected from literature published from 1980 to 2016, fulfilling established criteria. All relevant publications from the past till 2016 have been used to collect the data, data extracted, optimized, and enriched using established mathematical models described in details elsewhere.
All collected data were combined using the Bayesian meta-regression tool DisMod-MR 2.1.16, (Disease Modeling Meta-Regression Tool-2, Free tool, Jan Barendregt, Department of Public Health of Erasmus University, Netherlands, Available from www.epigear.com). This system encompasses a series of described approach, as detailed earlier. The present study was performed for Indian data at the national level for 2016. Detailed results from GBD 2016 by type of caries of permanent teeth, periodontal problems, and edentulism were collected. The basic combined burden parameters in dynamic data are presented in visualizations at https://vizhub.healthdata.org/gbd-compare/. All published pertinent data were drawn http://ghdx.healthdata.org/about-ghdx/data-type-definitions. Data points from past years were identified and the collected data were used in this study from several source studies. The combined data can be visualized at https://vizhub.healthdata.org/gbd-compare/. All computations in GBD were repeated 1000 times, every time drawing from the distribution of the sampling error of data inputs, the uncertainty of data corrections for measurement errors, the uncertainty in coefficients from model fit, and uncertainty bounds for a quantity of interest defined by the 25th and 975th value of the ordered 1000 estimate values, which is expressed as the 95% uncertainty interval (UI). For the purpose of this study, only the numbers without the UI were used. The details of the model assumptions, apriori, beta, and the model flowchart can be accessed elsewhere.
For comparison within India, the GBD-India-specific database (https://vizhub.healthdata.org/gbd-compare/india) was used to gather the data and the methods of such data estimation were as per discussed in detail elsewhere.
Data and assumption
Under the standard mathematical modeling of GBD 2016, described in detail elsewhere, the data of incidence of dental caries, periodontal diseases, and edentulous people (≤9 teeth in oral cavity) for males and females, between ages of 15 and 79 years, were collected. As 66.86% of Indian population are reported to live in rural areas and rest in urban/semi-urban areas, the appropriate calculations were incorporated to estimate the age-wise burden of dental caries, periodontal diseases, and edentulous people in rural and other areas.
It was assumed that of the people suffering from dental diseases, across all age groups, 1 in 5 of rural population with dental caries and periodontal diseases undergo extraction of teeth. In the urban population, it was assumed that 10% of population in the age group of 15–49 years undergo extraction for dental caries and 15% of 50–79 years undergo extraction due to dental caries. Similarly, for periodontal diseases, 10% of the population undergo extraction in the age group of 15-39 years, 12.5% in 40-49 years and 15% in 50-79 years lose their teeth. These data were based on 2001–2002 reports of Pan India survey conducted by the Dental Council of India. These data together with edentulous people (<9 teeth) were used to estimate the burden of anodontia in urban and rural areas in the age group of 15–79 years.
There are no reliable data on the number of Indian patients who had opted for DI in the year 2016. Among those with anodontia, including those who are edentulous in urban areas, it was assumed that 1% of 15–19 years, 1.5% of 20–29 years, 2% in 30–44 years, 2.5% in 45–59 years, and 3% in 60–79 years had opted for DI. In rural areas, it was assumed that 1 in 1000 of anodontia patients opted for DI. The number of patients preferring DI was thus calculated.
The survival of DI is estimated to be at 94.4% over a period of 60 months in certain Asian study while a recent meta-analysis reveals it to be at 91.27% over 60-month period.,, For modeling for this study, both these values are used.
Incidence of peri-implantitis is reported to range from 16% to 28% with severity increasing with number of implants placed, host systemic conditions including diabetes mellitus and hypertension, and also conditions such as tobacco use and poor oral hygiene. For the purpose of this study, the values of 16% were taken as lower and 28% as highest estimate of incidence of peri-implantitis. The risk posed by diabetes mellitus, hypertension, and tobacco use was not considered as it has been well documented that they are highly prevalent among Indians and are influencing factors in implant survival and peri-implantitis., We chose to ignore these estimates as no comprehensive Indian studies or meta-analysis for data were found in our literature search. In reality, these factors could increase the peri-implantitis or decrease the implant survival. However, as the endeavor of the present study is to bring out a robust estimate, only lowest estimates were used for this study.
| Results|| |
The GBD 2016, mathematical modeling estimated that, of all the Indians in the age group of 15–79 years, 368,126,580 suffered from dental caries, 191,471,254 from periodontal issues, and 38,898,946 from severe tooth loss (>9 teeth) or edentulism. The age group, gender, and locality (rural/urban) distribution are depicted in [Table 1].
|Table 1: The prevalence of dental caries, periodontal diseases, and edentulism by age, gender, and location of residence as estimated by the Global Burden of Diseases, 2016, in India|
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The global prevalence of edentulism is given in [Figure 1], the model fit is given in [Figure 2], while that of the prevalence rates of edentulism in India (Gender) is given in [Figure 3]. The Indian state-wise distribution of permanent teeth dental caries, periodontal diseases, and edentulism for both genders and all ages is given in [Figure 4]a,[Figure 4]b,[Figure 4]c.
|Figure 3: Prevalence of edentulism in India; 2016 (a) males; (b) females; (c) both genders|
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|Figure 4: Distribution of gender of all ages among Indian states. (a) Permanent teeth dental caries. (b) Periodontal diseases. (c) Edentulism|
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Using the assumption as described in the materials and method, it was identified that approximately 62,869,770 had at least one tooth extracted due to dental caries and 33,717,248 had lost their tooth due to periodontal issues. The distribution of age group and locality is depicted in [Table 2]. Assuming the DI being placed as described earlier, it was estimated that 325,240 individuals who lost tooth/teeth due to dental caries, 219,435 who lost tooth to periodontal problems, and 364,968 who suffered severe loss of teeth got treated with DI. Overall, 909,643 Indians in the age group of 15–79 years were estimated to have DI placed. The estimated number opting for DI in India is depicted in [Table 3]. Based on assumptions, of these 909,643 Indians, 830,231–858,703 would have DI in a 60-month period (survival) while 145,543–254,700 would suffer from peri-implantitis. About 50,940–79,412 DIs would have failed in the 60-month period.
|Table 2: Estimated number of rural/urban population with partial anodontia in India, 2016|
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|Table 3: Estimated number of Indians opting for dental implants in India, 2016|
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| Discussion|| |
The burden of oral and dental diseases is huge for India. Being one of the most populous countries with high prevalence of dental caries [Figure 4]a and periodontal issues [Figure 4]b as well as severe tooth loss, India undergoes significant economic hardship, loss of working hours, huge disability-adjusted life years, and years living with disability due to these diseases., In addition to these, the unequal distribution of dentists in urban and rural divide, illiteracy, education, awareness, and economic concerns retards the treatment-seeking behavior. In a recent analysis, it has been estimated that in India, dental treatment expenses is one of the foremost factors that causes catastrophic health expenses that push a significant percentage of Indians to poverty.
In spite of increasing the dental workforce still, a significant percentage of Indians do not have access to dental care. These result in large populations who suffer from dental caries of permanent teeth, periodontal problems, resulting in varying degrees of teeth loss [Figure 2] and [Figure 4]. Available estimates of burden of dental diseases are often locoregional in nature or at least a decade old. The most recent estimate uses the GBD approach in 2015. The present estimate is probably the first of its kind for a specific oral disease prevalence estimate in India.
The assumptions in the GBD approach have been debated and discussed in several publications. The other assumptions in the present study are arbitrary in nature and rely on a previous India-wide survey done more than a decade and ½ years ago. There is a dearth of population-level statistics for the prevalence of dental caries and periodontal infections. Several publications have pointed these aspects.,, The recent GBD-India approach has armed us to explore the same.
With changing perception and economic growth, a significant number of Indians explored DI as an option to extend the life of the dentition when teeth are missing or cannot be maintained with reasonable effort. Although the literature cites that a significant percentage of Indians, including in rural areas, are aware of DI, affordability is an area of concern.,,, Market reports of DI and dental materials account only for well-recognized brands while minor player's reports often are not in open domain and the extent of its use often goes unnoticed., In 2015, it was reported by market experts that only 220,000 implants were placed. However, the number of people or the type was not described along with the source of such estimate. The report further estimates that the number of DI placed is 2 per 10,000 population, while in the USA, it is 174, and in Brazil, it was reported to be 75. The true extent of DI placed is not described and the true volume or number of DI imported/manufactured is not in the open domain. Furthermore, a substantial market for DI exists beyond the scrutiny of such reports and bills.
A typical Indian dentist is believed to have more inclination toward delivering cosmetic results rather than playing the role of oral physician. Decade-old surveys indicate that the burden of noncarious, nongingival/periodontal, nontooth loss-related oral diseases is quite high while recent reports also are in support of the same notion. An attempt has been made to update the combined burden.
DI has emerged as a solution to extend the life of dentition but has its fair share of burden. The concept of DI relies on the phenomenon of osseointegration, wherein the artificial, bio-inert DI integrates with ever remodeling jawbones after placement. While in most of the cases, successful integration occurs, systemic conditions such as diabetes, hypertension, oral hygiene, and tobacco use determine the health of periodontium-DI junction. In ideal situation, the gum–DI interface, like the healthy sulcular epithelium, should be free of disease process. In reality, the ideal gum–DI interface is never healthy, and when the level of infection exceeds a minimum threshold, the disease, peri-implantitis, begins to appear. Peri-implantitis may be caused due to bacterial infections, poor oral hygiene, surgical trauma, genetic predisposition, DI surface characteristics, faulty or incorrect prosthetic design, occlusal overload, or improper surgical placement besides numerous other factors. Furthermore, literature has debate on the exact definition of peri-implantitis. The probing pocket depth, bleeding on probing and/or pus, and radiographic marginal bone levels are the main parameters that are employed to define peri-implantitis.
When DI is persistent and spread, the uncontrolled disease processes and subsequent chain of immunological events may result in resorption of the alveolar bone. This may also contribute to reduced survival of implants. Survival of DI is determined by the degree of osseointegration, aptness of technique of DI placement, extent of force dissipation, force vectors, and peri-implantitis besides numerous other host, operator, and DI factors. Literature clearly differentiates between the success and survival of DI.,
With a huge population, high prevalence rates of illiteracy, unequal divide of distribution of oral health services among rural/urban areas, increasing cost of dental services, poor political patronage for oral health policy promotion, etc., have markedly increased the burden of dental caries and periodontal pathologies., The national level marked difference in prevalence of dental caries of permanent teeth, periodontal issues as well as edentulism [Figure 4]a,[Figure 4]b,[Figure 4]c. This disparity of oral disease occurrence and availability of oral health services between the Indian states is also a cause of concern as reported earlier. It is to be noted that the states with high density of dentist population have more reported burden of oral diseases, probably highlighting the existence of referral bias.
Irrespective of the factors, these diseases pose heavy burden on Indian population. In spite of the heavy burden of dental caries, periodontal pathologies, and subsequent tooth loss, fewer Indian seek DI. The cause for this phenomenon has been previously described earlier.,
The clinical presentation of peri-implantitis includes redness, swelling, exudate, periodontal pocket formation, and alveolar bone loss. The peri-implantitis is reported to be a multifactorial, multiresponsive condition that has no recommended or accepted protocols for treatment. In most of the instances, peri-implantitis tissue is not submitted for histopathological scrutiny. Hence, in most of the instances, the clinical diagnosis is only relied on. A review of a small cohort of peri-implantitis reveals that besides inflammation of peri-implant tissues, evidence of hyperplasia and ulceration of pocket epithelium along with a presence of a mixed population of inflammatory cells were noted. Another similar study of 117 biopsies from peri-implantitis showed that in about 50% cases, more aggressive lesions such as pyogenic granuloma, giant-cell granuloma, or Actinomyces-related inflammation were diagnosed. Clinically, these entities failed to respond to conventional treatment. Recently, it is reported that 1.5% of all oral malignancies reported from a single center are such peri-implantitis-associated cases. The study also proceeds to conclude that there is no current epidemiologic evidence to support any specific risk for cancer associated with DI. The proposed materiovigilance program for dental materials and equipment, once implemented, would help to study the impact in more meaningful manner.
As there are no data on number of DI placed in India, this modeling study was employed. The market level reports are highly contradicting the figures. The market reports indicate 220,000 DI being placed in India in 2015 while the present study estimates that about 900,000 Indians could have DI placed., There is no literature to support or refute the results of this study model. There could be element of bias and assumption bias incorporated as in any other modeling study. But usually, the market reports tend to overestimate or underestimate the figures since there are no central surveillance bodies to monitor to provide exact figures. Furthermore, the study fails to consider the age, gender, urban-rural divide, influence of systemic factors, and most importantly oral hygiene status and operator errors. In addition, all the biases in the GBD studies are bound to be added in this modeling study. The results of the present study shall be interpreted with caution, considering its modeling limits and assumptions, as it provides only a robust estimate until a complete, evidence-based survey is published. Till such a publication emerges, the data presented could be utilized to make decisions by all the stakeholders – industry, academia, practitioners, and patients for informed decision process. Furthermore, most importantly, the study fails to account for the loss of DI and peri-implantitis due to improper treatment planning as also proper maintenance.
The increasing dental tourism and increasing number of “branded” DI placement in overseas patient could cloud the actual estimate. Furthermore, there is no uniform technique and standardization of DI placement procedure. In a study, it is estimated that the survival of DI increases with specialists placing than GDP placing. The influence on the experience/skills of the operator, use of surgical guide, and treatment planning are crucial factors that determine the success and survival of the DI. In addition, continuous monitoring/maintenance of DI and health of the peri-implant tissues are important.,, Patients often neglect the health of DI after placements. Severity of common prevalent conditions such as tobacco use, diabetes mellitus type 2, hypertension, and cardiovascular diseases often associated inversely with incidence of peri-implantitis and survival of DI. Given the fact that India suffers from these conditions more commonly than any other countries in the world, the incidence of peri-implantitis and poor survival of DI is expected to be more common in India than the other countries. The present estimates of 145,543–254,700 suffering from peri-implantitis and about 50,940–79,412 DI failing in the next 60-month period are worrisome. Although about nearly 0.9 million DIs are estimated to be placed, a significant number would complain of peri-implantitis or poor survival, which increases the continuing financial burden.
| Conclusions|| |
DI is increasingly alleviating the aftermaths of partial or complete anodontia in many Indians. This is important as life expectancy of average Indians is increasing albeit with poor oral health. DI, to an extent, at least provides relief to the affordable citizens. This triumph over the partial or complete anodontia is not without additional burden. Besides the huge economic implication of a poor success or survival of implants, high volume of peri-implantitis poses additional challenges requiring newer resources such as skill for management. Although unsupported by studies/reports, a significant percentage of severe peri-implantitis cases extend beyond the spectrum of inflammatory reaction to gross pathologies, including but not limiting to oral malignancies. In view of all the risks, the triumph of DI comes with huge costs that are duly to be addressed. With DI gaining prominence among Indians, renewed challenges are due to emerge. As oral physicians, it is dentist's duty to be prepared for this emerging challenge and burden.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Rooban Thavarajah
Marundeeshwara Oral Pathology Services and Analytics, B.1, Mistral Apts., Wipro Street, OMR - IT Express Highway, Sholinganallur, Chennai - 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]