Just Because You Can Place an Implant Doesn't Mean You Should

Author: Gum Specialist Dr Reena

There is a question that arrives, with remarkable regularity, in consultations involving periodontally compromised teeth. The tooth is mobile, the prognosis is guarded, the patient is understandably weary of the uncertainty. “Can we just take it out and put an implant in?” It lands as a solution. A clean slate. A titanium root that sidesteps the whole messy business of gum disease. The trouble is that the disease doesn’t read the treatment plan. And the implant has no idea it was supposed to be a fresh start.

Implants do not get periodontitis. But they absolutely get peri-implantitis - and in a patient carrying a history of periodontal disease, that risk is not theoretical. It is substantial, evidence-based, and frequently underestimated at the point of planning. This is not opinion. It’s evidence. Patients with a history of periodontitis show greater probing depths, greater bone loss and significantly higher rates of peri-implantitis than periodontally healthy patients. Failure rates on a patient level run at 25% in periodontitis patients against 3.8% in healthy controls. And crucially, much of this divergence doesn’t declare itself until beyond the five-year mark - the timepoint that most short-term success data flatters to deceive. 

The biology explains the vulnerability. A natural tooth sits within an exquisitely evolved periodontal complex - PDL fibres inserting into cementum, a vascularised ligament space, a supracrestal fibre arrangement that physically separates inflammation from bone. The peri-implant equivalent is scar tissue. Collagen fibres run parallel to the implant surface rather than into it. Vascularisation is reduced. The junctional epithelium is poorly adherent. There is no self-limiting mechanism. When peri-implantitis takes hold, it doesn’t creep - it accelerates. Non-linear, progressive, and structurally far less forgiving than its periodontal counterpart. An implant placed in an unstable periodontitis patient isn’t starting from zero. It’s starting at a disadvantage.

Before any implant is considered, the periodontal environment must be controlled - not partially managed, controlled. Active periodontitis must be treated. Residual pockets above 5mm are a known risk factor for peri-implant bone loss even after treatment has been completed. Healthy gums first. Always. Because implants don’t fix inflammation. They inherit it.

When implants are appropriate, the details of planning are everything - and millimetres genuinely matter. Poor implant positioning creates restorations with overhangs patients cannot clean. Over-deep placement creates pockets and biofilm traps that are essentially impossible to instrument. Insufficient interimplant spacing - less than 3mm - compromises embrasure form and plaque control. Many peri-implant problems that present clinically as hygiene failures are, at root, design failures. The patient is blamed for not cleaning something that was never designed to be cleaned. And cement, used as a retention method without meticulous attention to margin position, can act as a silent biological killer: a foreign body lodged subgingivally, not always visible radiographically, triggering an inflammatory cascade that looks indistinguishable from plaque-driven disease. Screw-retained, whenever possible. Margins at the mucosal level, never deep. Success isn’t about the implant brand. It’s about biology, design, and long-term care.

Equally, the choice between fixed and removable prostheses deserves more honest discussion than it typically receives. The patient who has struggled to maintain natural teeth is unlikely to manage a full-arch fixed implant bridge without significant professional support - and the tissue loss that often necessitates complex rehabilitation may also make fixed options aesthetically and practically suboptimal. Overdentures, in the right patient, offer superior hygiene access, better accommodation of ridge deficiency and outcomes that patients report as genuinely transformative. Fixed is not inherently superior. It is simply what patients most often ask for - because nobody has explained the alternative well enough.

Supportive care is not a bolt-on. Costa et al’s five-year data is stark: among patients diagnosed with peri-implant mucositis at baseline, 18% who attended regular maintenance developed peri-implantitis. Among those who didn’t attend - 44%. Mucositis is reversible (usually). Peri-implantitis is not. Once bone loss begins its accelerating, non-linear progression, the treatment options narrow and their outcomes become variable. Even surgically treated peri-implantitis carries a permanent diagnostic label – “stable peri-implantitis.” It does not revert to healthy. The implant that gets to that point needed better planning, better prosthetics, and better maintenance – usually all three.

There’s a pattern in how we respond to things that are broken and difficult: replace rather than repair, upgrade rather than maintain, choose the clean slate over the complicated work of salvage. Think of a beloved old teddy bear – patched, re-sewn, one eye slightly wonky - still held onto fiercely precisely because of the repair, not despite it. The conditions that caused the original failure travel with us into new jobs, new relationships, new starts of all kinds. The perio patient who couldn’t maintain their teeth will not automatically maintain their implants. The inflammation doesn’t care about the substrate. What actually changes outcomes is the environment: treating what’s unstable before adding something new, designing systems that can be maintained, and showing up for the long-term care that nobody glamorises but everyone needs. Keep what you can. Fix what needs fixing first. And be honest - with patients, and with yourself - about whether the clean slate you’re offering is really that clean!