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D610

1
D E N IE

IMPLANT
COMPLICATIONS:
MULTIPLE TREATMENT MODALITIES;

D610

3
APPR

D608

OVED

0
APPR

OVED

FEW FINANCIAL OPTIONS

BY SCOTT FROUM, DDS, AND KYLE L. SUMMERFORD

lthough the high predictability and long-term success rate of dental implants is well documented in
the literature, complications and failures do occur.
Success and predictability of dental implants have
been well documented throughout the years with
purported success rates of more than 90%.1 These
success rates, however, have been established according to an
older criteria. An implant without pain, mobility, radiolucency,
or 1 mm of bone loss during the first year and .2 mm thereafter
was considered a success.2 A recent review that considered excessive bone loss as an additional criteria of implant failure suggested that implant survival and success rates in general dental
practices may be lower than those reported in studies conducted in academic or specialty settings and quoted an 80% success
rate.3 In addition, proportional with the increase in the volume
of dental implants being placed is the amount of adverse events
that will occur. Two recent systematic reviews and meta-analyses reported that the prevalence of peri-implantitis was present
in approximately 10% of implants and 20% of patients eight to
10 years after implant placement.4 Considering the number of
implants placed or projected to be placed from 2013 to 2017 in
the United States alone, this number would mean more than 1.2
million implants will require therapy for this disease.5
Some complications may be relatively minor and easy to correct, while others will be major and result in the loss of the implant or prosthesis. Implant complications can typically be categorized by temporal sequence and defined as either an early
or late complication. An early complication can be defined as
a problem that arises prior to osseointegration of the dental
implant, whereas a late complication occurs after the implant
osseointegrates and the final prosthesis is placed. In addition,
implant problems can further be subcategorized into biologic
or mechanical complications. Biologic complications involve
pathosis of the peri-implant hard and soft tissue. Mechanical
complications occur when the fatigue strengths of the dental
implant or restorative components are reached and breakdown
occurs resulting in material failure.
34

Early implant complications arise prior to dental implant integration and often are the result of intraoperative or short-term
postoperative problems. Typical early complications include intrasurgical problems such as hemorrhage, damage to adjacent teeth,
neurosensory disturbances, jaw fracture, and maxillary sinus
violations. Other early complications during implant placement
include overpreparation of the implant osteotomy or underpreparation of the implant osteotomy. Underpreparing an implant site
can result in surgically overheating the bone and bone necrosis if
the critical threshold of greater than 47C is reached by the surgical drills or dental implant.6 Contamination of the surgical site
and/or the dental implant surface from bacteria is also possible
during fixture placement, which can result in the failure of the
implant to integrate. Lack of primary stability, stability of the implant when it is first placed into the alveolus, can result in implant
micro-motion above 100 microns and loss of the implant due to
fibrous tissue bonding to the implant surface instead of bone.7
Late implant complications occur after the implant has integrated and the final prosthesis has been placed. Recognition
of these complications via radiographic and clinical analysis
is extremely important since many of these problems can be
corrected if detected early. On the other hand, if allowed to
progress, a minor complication can often result in loss of the
implant and/or prosthesis. Late complications of the dental
implant fall into the category of biologic or mechanical complications. Late biologic complications are those in which the
peri-implant soft and hard tissues are affected. Peri-implant
mucositis describes a reversible inflammatory reaction in
the mucosa adjacent to an implant,8 a term that has become
known as implant gingivitis. Studies show that the prevalence
of peri-implant mucositis can be as high as 50% to 80% of implants in function9 with the etiology of peri-implant mucositis
being bacterial plaque. Typical clinical presentation includes
erythema, edema, swelling, and redness (Figs. 1 and 1a). Although bleeding upon probing and increased probing depths
are not always indicative of peri-implant mucositis,10 the absence of these two factors usually means implant health.11

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IMPLANT COMPLICATIONS

FIG. 1

recalled within three weeks. If no resolution of the inflammation has occurred,

surgical intervention should occur.15
Peri-implantitis has been defined as an
inflammatory process that affects the tissues around an osseointegrated implant
in function and, like periodontitis, results
in loss of supporting bone6 (Figs. 3 and
3a). The prevalence of peri-implantitis
has been shown in some studies to range

FIG. 1a

FIG. 3

FIG. 3a

Treatment of peri-implant mucositis can

often be accomplished via nonsurgical
mechanical therapy. Although systemic
antibiotics have been shown to reduce
inflammation associated with peri-implant gingival tissue, as a monotherapy,
they have been shown to be ineffective
due to the bacterial recolonization of
the implant surface without mechanical
debridement.12 Studies show that proper
scaling and root planing with attention
to bacterial plaque removal can be effective in reducing peri-implant mucositis
lesions.13 Localized drug delivery has
also shown to have a positive effect in
reducing mucositis lesions in conjunction with mechanical debridement (Fig.
2), especially in the areas of the mouth
that are hard to reach.14 After nonsurgical intervention, the patient should be
FIG. 2

36

FIG. 4

decontamination, the flap can be apically

or coronally positioned. In addition, various regenerative technologies, including
bone and soft-tissue grafts, growth factors, and barrier membranes have been
used to rebuild lost tissue support around
the dental implant (Figs. 5 and 5a). Different methods of guided bone regeneration around implants affected with periimplantitis were demonstrated, and the
results have been shown to be stable for
a follow-up period of up to seven years.18
That being said, no gold standard of periimplant disease has been documented
and available evidence does not allow
specific recommendations for the therapy of peri-implantitis.19
FIG. 5

from 11% to as high as 47% of implant

sites analyzed.16 Most literature reviews
agree that once bone loss has occurred
around an implant, nonsurgical therapy
is not as effective as surgical treatment.17
Surgical intervention by the dentist or
specialist includes raising a full thickness
flap around the affected dental implant
in order to completely expose the dental implant surface (Fig. 4). Mechanical
debridement with hand and high-speed
instrumentation as well as irrigation with
various medicaments is advocated in order to detoxify the implant surface and
alleviate bacterial contamination. After

FIG. 5a

With a better understanding of the

many treatment modalities available to
treat peri-implant disease, we now have
to consider the limited financial options

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IMPLANT COMPLICATIONS

a patient has when paying for this treatment. Of course, fee-for-service with
no insurance involvement is the preferable method of payment. This, however,
may be cost prohibitive when the surgical methods of treatment often accompany bone grafts and/or membranes,
biologics, soft-tissue grafts, and other
augmentation materials. Insurance reimbursements and involvement are often solutions to help patients have access to peri-implant disease treatment.
Insurance submissions and obtaining
approvals are often confusing when it
comes to peri-implant treatment. The
first step in understanding the tangled
web of insurance is to understand that
insurance companies have created their
own definition and standard of treatment for peri-implant disease. Insurance companies do not recognize periimplant mucositis, only peri-implantitis.
In addition, most insurance companies
will only accept treatment in the form
of surgical access, debridement, and flap
replacement without the use of regenerative treatment. For example, this was
taken directly off of Aetna Dentals website: Despite large numbers of publications available regarding peri-implantitis
treatments, there are no long-term studies
which indicate that the uses of osseous
contouring, placement of barriers or bone
grafts are superior to flap reflection with
debridement. Therefore, Aetna considers
flap reflection with debridement as the accepted clinical protocol for peri-implantitis treatment.
The key to having treatment covered
by insurance companies and giving the
patient a chance at reimbursement is to
use the correct ADA 2013 and 2014 CDT
codes, which have been updated and
include quite a few dental codes billed
directly to insurance companies for the
treatment of peri-implant disease. The
following codes are the correct codes
used for implant services:
D6100 implant removal, by report
(include supporting narrative)
D6101 debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap
entry and closure
38

D6102 debridement and osseous

contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure
D6103 bone graft for repair of periimplant defect not including flap
entry and closure or, when indicated,
placement of a barrier membrane or
biologic material to aid in osseous regeneration
D6080 implant maintenance procedures when prostheses are removed and
reinserted, including cleansing of prostheses and abutments
Despite many of the dental insurance
companies exclusions and limitations
on covering the costs associated with
treatment of peri-implantitis, if the correct codes are used, payment may be

rendered. Of course, the terms of carriers

and groups of different contracts vary.
Unless the patients insurance group
contract specifies implants are an actual
covered benefit, the fees for implant services will be denied entirely. It becomes
imperative that staff members check the
insurance plan of the patient prior to any
treatment recommendation or case presentation to determine whether implant
services are a covered or noncovered
benefit.
Below are examples of two recent patients who were diagnosed with periimplantitis in which preauthorizations
were filed with three major dental insurance carriers. Each patients dental plan
indicated that each group policy contained implants and related services as
an actual covered benefit.

EXAMPLE NO. 1.

Patient A:
Diagnosed with severe peri-implantitis.
The patient was in a financial crisis at the time and asked that we submit
to his primary insurance and secondary insurance.

Treatment approved by primary insurance (Delta Dental):

D6101 debridement of aperi-implant defect and surface cleaning of exposed
implant surfaces, including flap entry and closure
Treatment denied by primary insurance (Delta Dental):
D6103 bone graft for repair ofperi-implant defect not including flap entry and
closure or, when indicated, placement of a barrier membrane or biologic material to
aid in osseous regeneration
Treatment approved by secondary insurance (Aetna Dental):
D6080 implant-maintenance procedures, including removal of prosthesis, cleansing of prosthesis, and abutments and reinsertion of prosthesis
Treatment denied by secondary insurance (Aetna Dental):
D6101 debridement of aperi-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure
D6103 bone graft for repair ofperi-implant defect not including flap entry and
closure or, when indicated, placement of a barrier membrane or biologic material to
aid in osseous regeneration

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IMPLANT COMPLICATIONS

EXAMPLE NO. 2:

Patient B:
Diagnosed with moderate peri-implantitis.
The patient is capable of paying for treatment but asked to submit services to
insurance for reimbursement.
Treatment denied by sole insurance company (MetLife Dental):
D6103 bone graft for repair ofperi-implant defect not including flap entry and
closure or, when indicated, placement of a barrier membrane or biologic material to
aid in osseous regeneration
D6101 debridement of aperi-implant defect and surface cleaning of exposed
implant surfaces, including flap entry and closure
Treatment approved by sole insurance company (MetLife Dental):
D6080 implant-maintenance procedures, including removal of prosthesis, cleansing of prosthesis, and abutments and reinsertion of prosthesis

As we see, there seems to be a misunderstanding in the gold standard approach when it comes to a uniformed
policy for dental insurance coverage in relation to the treatment of peri-implantitis.
The presented ADA codes are still very
new, and the following table is an average
of multiple well-known insurance companies usual customary rate (UCR) for
different implant disease services based
on zip codes for the following major cities
located throughout the United States.
New York City: 10022
Los Angeles: 90067
Chicago: 60604

It should be emphasized that regardless of the treatment modality, a prerequisite for successful therapy is the establishment and maintenance of proper
home-care practices and supportive care
at regular intervals. This has been documented in the literature with respect to
both periodontal and peri-implant maintenance and treatment outcomes. Many
studies suggest that patients who are
placed on three-month recare schedules
typically perform better than those seen
on longer intervals and tend to keep their
teeth for longer periods of time.20 Optimal
home care, short maintenance intervals,
and proper treatment are keys to success

TABLE 1
PERI-IMPLANTITIS PROCEDURE

NEW YORK
CITY

LOS
ANGELES

CHICAGO

Implant removal (by report)

$500.00

$475.00

$500.00

Debridement peri-implant defect

$350.00

$200.00

$350.00

Debridement/osseous peri-implant defect

$475.00

$375.00

$450.00

Bone graft repair/peri-implant defect

$675.00

$550.00

$675.00

Implant maintenance procedures

$300.00

$150.00

$275.00

when dealing with peri-implant disease.

In addition, treatment, whether nonsurgical or surgical intervention, must be
performed in a timely manner. Sacrifices
in treatment or delay of services should
not occur, because the progression of this
disease can be quick in nature. Accurate
peri-implant coding and submissions
when dealing with insurance companies
are a must to facilitate services and expedite reimbursements.
REFERENCES
1. Adell R, Lekhom U, Rockler B. A 15-year study of
osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981;10:387.
2. Albrektsson T, Zarb G, Worthington P. The longterm efficacy of currently used dental implants.
A review and prognosis criteria for success. Int J
Oral Maxillofac Implants 1986;1:11.
3. Da Silva JD et al. Outcomes of implants and
restorations placed in general dental practices: A
retrospective study by the Practitioners Engaged
in Applied Research and Learning (PEARL)
Network. JADA. July 1, 2014;145:704-713.
4. Mombelli A, et al. The epidemiology of
peri-implantitis. Clin Oral Implants Res.
2012;23(Suppl. 6):67-76.
5. 2013-2017 US Dental Implant Market iData
Research Inc. 2013.
6. Esposito M, Hirsch J, Lekholm U, et al. Biological
factors contributing to failures of osseointegrated
oral implants. I. Success criteria and epidemiology.
Eur J Oral Sci 1998;106:527.
7. Brunski JB. Biomechanical factors affecting the
bone-dental implant interface. Clin. Materials
1992;10:153-201.
8. Albrektsson T, Isidor F. Consensus report of
session IV. In: Lang NP, Karring T, ed. Proceedings
of the First European Workshop on Periodontology.
London: Quintessence, 1994:365-369.
9. Lindhe J, Myle J. Peri-implant diseases:
Consensus report of the Sixth European
Workshop on Periodontology. J Clin Periodontology
2008;35(suppl 8): 282-285.
10. Ericsson I, Lindhe J. Probing at implants and
teeth: An experimental study in the dog. J Clin
Periodontol 1993;20:623-627.
11. Salvi G, Lang N. Diagnostic parameters for
monitoring peri-implant conditions IJOMI
2004;19(SUPPL):116-127.
12. Mombelli A, van Oosten MA, Schurch E, Lang
NP. The microbiota associated with successful or
failing osseointegration titanium implants. Oral
Microbiology and Immunology. 1987;2:145-151.
13. Roos-Jansaker AM, Renvert S, Egelberg J.
Treatment of peri-implant infections: a literature
review. J Clin Periodontol 2003;30:467-485.
14. Renvert S. Nonsurgical treatment of peri-implant
mucositis and peri-implantitis: a literature review. J
Clin Perio Sept. 2008;35(8 Suppl):305-315.
15. Heitz-Mayfield LJA et al. The therapy of peri-

Continued on p. 108
40

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IMPLANT COMPLICATIONS

Continued from p. 40

16.

17.

18.

19.

20.

implantitis: A systematic review. Int J Oral

Maxillifac Implants 2014;29(suppl):325-345.
Koldsland O et al. Prevalence of peri-implantitis related
to severity of the disease with different degrees of
bone loss. J Perio Feb. 2010; 81(2)231-238.
Kotsovilis S, Karoussis IK, Triant M, Fourmoseuses
I. Therapy of peri-implantitis: A systemic review. J
Clin Periodontology 2008;35:621-629.
Froum SJ, Froum SH, Rosen P. Successful
management of peri-implantitis with a regenerative
approach: A consecutive series of 51 treated
implants with 3- to 7.5-year follow-up. IJPRD Feb.
2012; 32(1).
Chan H et al. Surgical treatment of peri-implantitis:
A systematic review and meta-analysis. Accepted
for publication J. Perio 2015.
Wilson TG Jr. Maintaining periodontal treatment. J

PREPARATION IS KEY

Continued from p. 64
FIG. 5

FIG. 7

FIG. 6

FIG. 8

Am Dent Assoc. 1990;121(4):491-494.

SCOTT FROUM, DDS,

is a periodontist and
co-editor of SurgicalRestorative Resource
e-newsletter, as well
as a contributing
author for DentistryIQ
and Dental Economics. He is a clinical
associate professor at the New
York University Dental School in the
Department of Periodontology and
Implantology. Dr. Froum is in private
practice in New York City. You may contact
him by email at drscottfroum@yahoo.com.
KYLE L. SUMMERFORD

is an independent
dental consultant. His
professional career of
13 years in dentistry
has given him expert
knowledge in various
areas of practice management. He is a
professional speaker focusing on various
topics such as increasing profits, staff
etiquette training, and maximizing dental
insurance benefits. He has authored
many articles that have been featured
in Dental Economics, DentistryIQ.com,
and Surgical-Restorative Resource.
Visit his websites at www.ddsguru.
com and www.rescuemydentalpractice.
com, available to dentists and team
members for educational purposes. You
may contact Mr. Summerford by email
at dentalpracticeoptimization@gmail.com
with any inquiries regarding his practice
management consulting services.

108

FIG. 9

An e.max crown was created on tooth

No. 15 (Fig. 7). As evident in the postoperative photo and bitewing (Figs. 8 and
9), there has been a significant improvement in the esthetics, form, and fit as
compared to the original crown.
One other definite improvement will
be in the strength of the crown. The recommendations for occlusal reduction for
specific crowns are there for a reason.
Most fractures I have noticed involving all-ceramic restorations or porcelain
fractures involving PFMs have resulted
from an inadequate thickness of porcelain. Most of the time, this is the operators fault, as the tooth was prepared inadequately. As much as we would like to
blame bruxism or the laboratory, most of
the time it is the archer, not the arrow
that causes our restorations to fail.
With that in mind, it is imperative that
we not only prepare the tooth properly for
whatever type of restoration we choose to
place, but that we also choose the proper
restoration for the tooth being treated,
taking every factor into account. There is
nothing more frustrating than an aggravated patient who needs a recent crown
redone because it broke or because it

looks terrible. The costs of remakes due

to inadequate reduction, patient frustration with remakes, and the fact that these
remakes are done at no charge can put a
big damper on our production. Our offices do not run for free, so the more efficient
we become, the less time and money we
waste, and the happier our patients and
we will be.
ADAMO E.
NOTARANTONIO,
DDS, FICOI, AAACD,

is in private practice
in Huntington, N.Y.
Accredited by the
American Academy of
Cosmetic Dentistry and elected to the
American Board of Cosmetic Dentistry,
Dr. Notarantonio has completed the
Dawson Academy Core Curriculum series
and is currently training at the Kois
Center in Seattle.

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