Latest / Straumann® ProTalk / Clinical Edition: The truth about peri-implantitis with Dr. Alberto Monje (video version)

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Clinical Edition: The truth about peri-implantitis with Dr. Alberto Monje (video version) · Straumann® ProTalk

• 0:00
  The less number of implants, the less number of peri-implantitis
• 0:04
  that is in the future.
• 0:05
  And that's a fact.
• 0:06
  To which extent, three dimensional position is responsible for
• 0:10
  everything we're seeing now?
• 0:11
  We all agree that implant malposition is a major factor actually.
• 0:16
  Those malposition implants, especially those ones that are
• 0:20
  outside of the Bone housing, are gonna be eight times more likely.
• 0:25
  Having peri-implantitis in the future.
• 0:27
  So these are some of the local factors that have to be controlled during
• 0:33
  the surgical and prosthetic phase in order to make peri-implantitis
• 0:39
  preventable and to make contemporary implant dentistry great again.
• 0:47
  Whether you're treating patients with soft tissue inflammation or advanced
• 0:51
  peri-implantitis and feel unsure how to tackle it, this conversation is for you.
• 0:56
  I had the privilege of discussing this topics with, in my opinion,
• 0:59
  one of the most knowledgeable experts in peri-implantitis disease
• 1:02
  and implant dentistry in general.
• 1:04
  Dr. Alberto Monje.
• 1:07
  Don't miss this conversation.
• 1:08
  I'm Dr. Christian Jarry, and this is Straumann ProTalk Clinical.
• 1:12
  Dr. Alberto Monje, what a privilege and an honor to have you with us
• 1:17
  in Straumann ProTalk Clinical.
• 1:18
  Thanks for coming.
• 1:19
  It's my pleasure.
• 1:21
  I would like to start with the foundation.
• 1:22
  First things first.
• 1:23
  We start with the.
• 1:25
  We see a lot of techniques, a lot of equipment, a lot of surfaces.
• 1:29
  Yet peri-implantitis seems to be still relevant and not only
• 1:33
  relevant present, but growing.
• 1:36
  Why?
• 1:38
  This is can be addressed by means of epidemiology or statistics, right?
• 1:43
  The more implants are being placed, the higher is gonna be the likelihood
• 1:46
  to keep on that prevalence of about 20 to 30% at the patient level.
• 1:51
  As contemporary implant industry keeps growing, peri-implantitis
• 1:55
  will keep being a tsunami, especially in emerging countries.
• 1:58
  Christian, on the top of that, there is something highly
• 2:01
  interesting to be highlighted.
• 2:03
  In what regards to peri-implantitis the epidemiological reports feature that
• 2:08
  peri-implantitis follows an implant or a site specific phenomena, which means
• 2:14
  is that, basically the prevalence at the patient level tends to be always
• 2:18
  significantly higher when compared to the prevalence at implant level.
• 2:22
  When we translate this message to the clinical basis, it means that there
• 2:26
  are some individuals that are deceased because they have one or multiple
• 2:30
  implants with peri-implantitis, but that doesn't mean that all the
• 2:33
  implants have peri-implantitis.
• 2:35
  So there might be some local factors that of course, if they are not addressed
• 2:40
  during the treatment planning phase.
• 2:44
  They will endlessly occur.
• 2:46
  Ah what's the bottom line of this?
• 2:48
  In a way this is a manmade disease where there are some predisposing
• 2:54
  factors or triggering factors that are actually promoted during the surgical
• 3:00
  phase, prosthetic phase, or even in identifying whether a given patient is
• 3:05
  a good candidate to get ridden implants.
• 3:07
  Got it.
• 3:08
  So if I understood right, we have many factors.
• 3:11
  There's individual response, there's professionally triggered
• 3:14
  response as we discussed.
• 3:15
  But it doesn't mean that a person with several implants, you
• 3:19
  have an individual that is more prominent to peri-implantitis.
• 3:22
  It could be one implant only.
• 3:23
  Not, did I get that right?
• 3:25
  So
• 3:25
  the host indeed plays a big role.
• 3:27
  And we know that because the host has to develop the inflammatory response.
• 3:31
  But there are few implants that are conditioned or are more
• 3:34
  prone to have peri-implantitis.
• 3:36
  And that can be explained by means of side specific prosthetic related implants.
• 3:42
  Related surgical related factors that are.
• 3:46
  Promoting this disease, a given implant, and on the other side of the
• 3:49
  coin, or promoting health in implants.
• 3:52
  Got it.
• 3:53
  And so we set the foundation, we say peri-implantitis seems to be a buzz.
• 3:57
  Buzzword, right?
• 3:57
  Oh, peri-implantitis.
• 3:58
  If it's bleeding is peri-implantitis.
• 4:00
  So we set the foundation, what is the current definition, what
• 4:04
  a clinician should watch out for.
• 4:06
  To really define what peri-implantitis really means,
• 4:10
  I adopt the definition proposed at the World Workshop in peri-implantitis
• 4:17
  diseases and conditions that define peri-implantitis being dysbiosis
• 4:21
  mediated inflammatory condition that occurs in clinical signs of
• 4:26
  inflammation with progressive bone loss.
• 4:29
  Nevertheless and very regrettably to us, we seldom can monitor a few for
• 4:34
  patients in order to check whether the bone loss that occur at the time of
• 4:38
  diagnosis was actually right from the beginning, right after final processis
• 4:44
  delivery, or it has been occurring because of a pathological phenomenon.
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  So I, in order to be practical, I do suggest to adopt three
• 4:55
  millimeters of bone loss and beyond.
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  All together with clinical signs of inflammation, so increased poke depth,
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  profuse bleeding, not one single spot of bleeding, profuse bleeding, the level
• 5:05
  of profuse ness is really what defines the presence of inflammatory phenomenon.
• 5:12
  I like that very much.
• 5:13
  And when we set the foundation, we you just define what
• 5:16
  pet Implantitis is, right?
• 5:18
  By definition.
• 5:19
  But how is the Alberto Monitor protocol with the patient?
• 5:22
  So you can check.
• 5:23
  Okay, now we're going south with that treatment.
• 5:26
  Is that a probing mark that you should watch out?
• 5:29
  You said three millimeter of pocket.
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  That's one element, but is it one side?
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  How do you establish that diagnosis and what is Alberto
• 5:37
  Monje decision making process and.
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  And actions.
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  First you diagnose and then how you go from there.
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  So in with regards to bone loss, whenever, I certainly ed that this is a diagnostic
• 5:50
  that this is the peri-implantitis case marked by three millimeters of bone loss,
• 5:54
  more than six millimeters of pockets.
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  And then of course, this clinical size of inflammation where suppuration might
• 6:01
  be pressing in a range from 10 to 40%, especially in the more advanced cases.
• 6:06
  Yeah.
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  Then, I like to take a cone-beam computed tomography.
• 6:09
  I like to know the number and the morphology of the residual walls, and
• 6:15
  very important also is to point out the role that has implant position on the
• 6:20
  decision making on whether to save it.
• 6:23
  And treat per implantitis or whether to extract it and start over.
• 6:28
  If you cannot modify these local confounders, again, the
• 6:31
  disease will endlessly recur.
• 6:33
  We cannot do anything.
• 6:34
  It's not a matter of the skills from the clinician.
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  It's not something related to the biomechanics or anything related, of
• 6:41
  course to the treatment modality applied for the treatment of peri-implantitis
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  that is this something that all the clinicians have to check then?
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  Once we conceive this case as a suitable scenario to manage
• 6:54
  peri-implantitis, I will still suggest to move towards a hygienic phase where
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  non-surgical therapy can be delivered.
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  And of course that's highly something very important if you have a patient that
• 7:07
  shows a higher risk profile is a smoker.
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  Has a poor control with glycemic control or let's say does have a
• 7:16
  plaque index greater than 20, 30%.
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  That means that plaque control is not really good.
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  Then you have to modify that during the hygienic phase before moving or before
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  doing reevaluation in order to figure out whether it's a suitable candidate
• 7:32
  to move towards surgical therapy.
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  When it comes to the surgical intervention, which in my cases I have.
• 7:39
  To move towards this phase in about 80 to 85% of the cases.
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  I'm not very successful that much in non-surgical therapy.
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  I am not unfortunately.
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  Then it's a matter of checking defect configuration, soft tissue
• 7:53
  characteristics, and implant position.
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  That should be the checklist in order to figure out what path
• 7:59
  to choose in selecting the most readable treatment modality.
• 8:04
  So I will say that the endpoint in the treatment of peri-implantitis is to reduce
• 8:09
  the pocket to five millimeters or less.
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  We want to shift from an anaerobic environment towards an aerobic environment
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  in order to warranty long-term successful.
• 8:19
  Outcomes for that.
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  From a technical perspective, we have learned and we have learned so much
• 8:24
  from the field of periodontology, the goal is to flatten bone architecture.
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  So there are two ways to make it digestible to everyone.
• 8:34
  To close the pocket, the goal will be to bring the alveolar bone
• 8:37
  closer to the mucosal margin, right?
• 8:39
  Am I correct?
• 8:40
  Yeah.
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  Or to bring the mucosal margin closer to the bone by a means of
• 8:43
  either non resective interventions or resective interventions.
• 8:49
  Those indications to move towards either reconstructive therapy or open flap
• 8:54
  debridement are those intra bony defect.
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  So those defect, that exhibit, some level of containment where the blood
• 9:02
  can be stabilized, it can turn over into Coagula, and the coagulum can
• 9:06
  recruit osteo generator cells to, at the end of the day have newly
• 9:10
  formed bone and not the bone fillus.
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  So not all the cases are adequate indications to move towards
• 9:16
  surgical therapy, especially in what regards to reconstructive measures.
• 9:21
  We have to encourage the clinicians not to fool themselves, believing that in the
• 9:26
  treatment of peri-implantitis, the goal is to have vertical bone gain that's gonna
• 9:30
  be attributable to defect configuration,
• 9:32
  right?
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  You wanna stop the disease.
• 9:33
  Yeah.
• 9:34
  Yeah.
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  And then if you have such a scenario, there are other features
• 9:38
  that may condition the outcome.
• 9:40
  Our group recently showed that defect angle, it's pivotal,
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  to be well understood before.
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  Anticipating or expecting reconstructive outcomes as such, those defects that
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  are narrower than four degrees, the expectations can bypass significantly.
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  The average reported in the literature, which is about 2.5 millimeters.
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  So that's an important point to keep in mind.
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  And then if it's a non-con contained defect, we can name
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  it as a one world defect.
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  Few, two wall defects or intra bony defects shallower than three millimeters,
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  or those ones of course that exhibited horizontal pattern of bone loss or
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  the hiss type defects that there is no level of containment whatsoever should
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  be more suitable to undergo resective interventions in resective interventions.
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  I do believe in my treatment philosophy that implantoplasty plays a pivotal role.
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  And this is something very easy to understand.
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  Now, we do know, and that's one of the take home messages that was recently
• 10:44
  provided by the American Academy of Periodontology Joint Academy of
• 10:49
  Osseointegration consensus meeting is that the distance from the restorative margin
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  to the alveolar boundary in baseline is really what may dictate in the long run.
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  The higher prevalence of peri-implantitis that will favor either the concept
• 11:04
  of tissue level implant or bone level implant with a long transmucosal
• 11:09
  abutment, longer than two millimeters.
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  So in a way, we are shifting from an old fashioned implant, a bone level implant,
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  let's say, with an external connector or a non, or a connection that cannot warranty
• 11:22
  the lack of micro leakage into a tissue level implant or a bone level implant
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  with a longer transmucosal abutment.
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  Yeah.
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  And then of course when dealing with intra-prosthetic components, one
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  major key, and I do believe that's actually where relies more of the
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  cases nowadays, that exhibit failure in the treatment of peri-implantitis
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  titis is surface the contamination.
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  And many emerging technologies has be, have been released to the market recently.
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  I do have a high experience over the last five years with GalvoSurge, and
• 11:53
  we have noticed in a multicenter, randomized clinical trial that indeed
• 11:58
  it's a very promising tool outperforming the use of all the traditional methods.
• 12:04
  Such as hydrogen peroxide or other local lead deliver antibiotics.
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  So this is something that of course, the industry and the clinicians
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  and the researcher, we must all align in order to figure out which
• 12:17
  are the most suitable methods to decontaminate the implant surface.
• 12:23
  I like this very much.
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  What a master class, Alberto.
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  I have to say, I'm blown away because you contextualize what the disease is, how
• 12:30
  we get there, three millimeter bone loss, six millimeter pocket measures, and then
• 12:36
  you shift it towards, okay, we diagnosed the disease, now we need to understand
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  where does that disease come from.
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  And then from there, how we move forward.
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  And I like how you contextualize how you approach and also the
• 12:48
  equipment and implant selection.
• 12:51
  What it's missing for me is where do you draw a line?
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  How much do you save it?
• 12:57
  Where do you take that out?
• 12:58
  Okay.
• 12:58
  That's a good question.
• 12:59
  I will say that there are four major factors actually that drive my decision
• 13:04
  making on whether to extract, I'm thinking whether it's worth to start over, right?
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  It's not a matter of just retrieving dental implants and placing implants
• 13:13
  either immediately or four months.
• 13:15
  We really have to think whether the patient really deserves.
• 13:19
  To have these new implants replaced because a given patient has already
• 13:23
  demonstrated being susceptible to have perio disease, peri-implantitis.
• 13:29
  So I want to favor long-term outcomes.
• 13:32
  I want to warranty somehow that my outcomes deliver are
• 13:37
  gonna be stable over time.
• 13:38
  I want to build up my legacy.
• 13:40
  And that's a good, an important take home message for all the youngsters.
• 13:44
  As long as patient related.
• 13:45
  Yeah, patient
• 13:46
  As you mentioned, three dimensional, for example.
• 13:49
  Of course, yeah.
• 13:49
  Then it's an no go, right?
• 13:50
  Yeah.
• 13:50
  Then there's no discussion.
• 13:52
  Might be some scenarios, right?
• 13:53
  Where you can try to save it just in those scenarios where.
• 13:59
  Those implants are not expendable from a biomechanical point of view.
• 14:05
  I'm gonna give you an example.
• 14:07
  There is one publication from our group that was recently released in
• 14:12
  the official journal of the European Academy of Osteointegration, the COIR,
• 14:16
  that we noticed that the three multiple.
• 14:20
  In three implant supportive multiple units.
• 14:24
  The middle implant, the implant right in the middle, as long as it's
• 14:27
  supported by three dental implants.
• 14:29
  The one in the middle is the one that will have a likelihood to develop our
• 14:33
  implant that is about three times higher.
• 14:35
  That's what we see.
• 14:36
  Those are our observations, right?
• 14:38
  First question that I ask myself, can I remove this dental implant
• 14:43
  without jeopardizing the stability of the prosthetic component?
• 14:47
  If the answer is yes, I will take it off.
• 14:50
  I will not face the risk.
• 14:52
  I will not make the patient to undergo to any non-surgical and or surgical therapy,
• 14:57
  assuming that the local factor is still gonna be there, and that the likelihood
• 15:01
  for disease recurring is very high.
• 15:03
  Got it.
• 15:04
  But as you pointed out, the clinicians should check always
• 15:08
  for some local confounders related to the prosthetic component.
• 15:12
  I'm gonna give you another example.
• 15:14
  Let's say that the prosthetic structure is not cleansible whatsoever.
• 15:20
  It doesn't have interproximal room for plaque control.
• 15:23
  And you tell the patient, okay, I have to deal with that first.
• 15:26
  I may need to change the prosthesis, or I may need.
• 15:29
  To modify it if the patient is not excited with that.
• 15:32
  If the patient is not willing to me, it drops from an unpredictable prognosis to
• 15:38
  a hopeless prognosis because I know that it doesn't really matter how I can manage
• 15:44
  the inflammatory processes at given time.
• 15:46
  Yeah, it'll recur because it's gonna be promoted by the same local factor
• 15:51
  that actually triggered the onset of peri-implantitis in the past.
• 15:54
  Yeah.
• 15:55
  And there another sensitive area is the static, of course, the static zone.
• 15:59
  It's more sensitive not only to address the disease, but also to enhance or
• 16:05
  to maintain patient reported outcomes.
• 16:07
  So I will say that those are the four elements that I will check into before
• 16:12
  deciding whether to go into the.
• 16:16
  Any type of intervention to rescue an infected dental implant
• 16:19
  or whether it's preferred Yes.
• 16:21
  To start or whether it's preferred?
• 16:22
  Yes.
• 16:22
  To start over.
• 16:24
  There is an another element of course, which can be somehow more objectively
• 16:28
  figured out, which is the extension.
• 16:31
  Of the disease, how much bone loss do you have Right around a given dental implant.
• 16:36
  Now we do have evidence that supports the fact that those implants
• 16:40
  with more than 50% of bone loss.
• 16:43
  So an average six to seven millimeters are gonna be, less responsive to any type of
• 16:49
  non-surgical and or surgical intervention.
• 16:52
  So that's my elements that I have in my checklist in order to
• 16:58
  figure out what's the prognosis.
• 16:59
  I love this.
• 17:00
  I love this very much in how you draw the line.
• 17:02
  This is very clear.
• 17:04
  You brought up quite a few scientifically based examples in some
• 17:09
  papers, and we have this section.
• 17:11
  It's not what we think, it's what we know.
• 17:14
  Right and evidence-based factors, and I asked you ahead of time to share
• 17:19
  with us one article that was impactful to you, either yours or somebody
• 17:23
  else's, but it was meaningful it helped you shaping the way you treat your
• 17:28
  patients, or how it changed the way.
• 17:31
  You treat your patients and you mentioned this article that is very nicely the
• 17:36
  role of local factors on the occurrence of Periimplantitis, a cross-sectional
• 17:41
  analysis with colleagues from the us, Spain, and Switzerland, a multicentric
• 17:45
  approach including Professor Buser.
• 17:47
  Why was this so meaningful to you?
• 17:50
  Because it actually pinpoints the role of local confounders much has been
• 17:54
  explored regarding the systemic factors.
• 17:57
  All the systemic drivers we can say behavioral elements that actually.
• 18:04
  Increase the likelihood to have peri-implantitis,
• 18:07
  but we already know them.
• 18:08
  We know that smokers, we do know that patients with diabetes jitu
• 18:12
  patients that do not enroll in supportive periotherapy are gonna
• 18:15
  be more exposed to peri-implantitis.
• 18:18
  The fact is that peri-implantitis, we commonly see.
• 18:21
  Also in healthy individuals and following a site, a specific prevalence.
• 18:28
  So that's something highly interesting and in fact, some local factors have not
• 18:33
  been very well explored in the literature.
• 18:35
  So since I have to face, because of the practice that I handle,
• 18:40
  peri-implantitis very frequently.
• 18:43
  I developed few observations.
• 18:45
  The first one was that most of the implants that develop peri-implantitis
• 18:49
  are those ones that actually have not been positioned in the
• 18:53
  ideal three dimensional position.
• 18:56
  And that was Christian, an interesting observation that I had.
• 18:59
  During my residency.
• 19:00
  Huh.
• 19:01
  And this was the reason actually why in the year 2015, I do believe
• 19:05
  that it was published in 2016.
• 19:08
  We published this paper in the IJOMI, where I collected all the
• 19:12
  images that reported at the time being on the prevalence treatment
• 19:17
  of peri-implantitis diagnosis.
• 19:19
  And I collect.
• 19:21
  Send this to three examiners with more than 20 years of clinical and
• 19:25
  academic experience, while researchers from three different continents, and
• 19:30
  they all agreed that in fact, those implants that were being reported in
• 19:33
  the literature as peri-implantitis implants, there were some local factors
• 19:38
  amongst them, implant malpositioning.
• 19:41
  So this comes from far back.
• 19:43
  I wanted to.
• 19:44
  Certainly test, these hypothesis in a more objective and with higher level of ity.
• 19:51
  And so this is the reason why we collected peri-implantitis
• 19:55
  patients, meaning patients that were diagnosed with pre implantitis
• 19:59
  and therefore they are from an.
• 20:01
  Epidemiological point of view, they are deceased patients.
• 20:05
  And in these deceased patients, we wanted to figure out which were the
• 20:09
  local factors that either predisposed or protected from peri-implantitis.
• 20:13
  So it's a very fair comparison.
• 20:15
  Huh?
• 20:17
  It goes back to how we started, huh?
• 20:19
  Yes.
• 20:19
  With the Y. Yeah.
• 20:20
  How to detect the disease.
• 20:22
  And it was.
• 20:23
  Three dimensionally related to which extent, three-dimensional
• 20:27
  position is responsible for everything we're seeing now.
• 20:30
  That's a very interesting question and Christian, the thing is
• 20:34
  that we all agree that implant malposition is a major factor up to.
• 20:41
  It was being seldom being reported.
• 20:44
  And also we could not really make a, like an amount, on how responsible
• 20:50
  it's for the peri-implantitis cases for what we see nowadays.
• 20:54
  We cannot
• 20:54
  attribute a specific responsibility.
• 20:57
  We know it's present, guilty as charged, but we cannot put a piece of the pie
• 21:01
  That's the point until we publish this paper that suggested that actually.
• 21:06
  Those malposition implants, especially those ones that are outside of
• 21:10
  the Bone housing, are gonna be eight times more likely having
• 21:15
  peri-implantitis in the future.
• 21:17
  So these are some of the local factors that have to be
• 21:22
  controlled during the surgical and prosthetic phase in order to make.
• 21:27
  Peri-implantitis is preventable and to make a contemporary implant dentistry
• 21:33
  great again, Bert, let me ask you
• 21:35
  something.
• 21:37
  The role of digital technologies because today we ha we have the privilege to
• 21:42
  live in this digital world, that we can have three dimensional planning
• 21:46
  options, that we have more assertive plannings also more assertive and
• 21:50
  more precise implant placement.
• 21:53
  Do you think what we have seen in terms of evidences and consequences
• 21:57
  over this last 20 years of.
• 22:00
  Mostly not.
• 22:01
  So digital technologies, do you think this will have an impact in per
• 22:05
  implantitis in the future as well?
• 22:07
  Positively.
• 22:07
  You're gonna see a shift.
• 22:09
  Oh, in everywhere.
• 22:09
  Yeah.
• 22:10
  There are two clear niches.
• 22:12
  One niche that is indeed into all these technologies.
• 22:16
  Into enhancing the accuracy in the surgical and the prosthetic phase, but
• 22:21
  regrettably, to us, that represents less than 10% of the community that
• 22:25
  plays the dental implants, right?
• 22:26
  You have to remember that implant industry is highly profitable,
• 22:30
  especially in few countries.
• 22:32
  What does it mean that there is 90%.
• 22:34
  Of the undertrained or undereducated individuals, that they will not invest
• 22:40
  on those technologies in order to enhance the reliability of their treatments.
• 22:45
  So in a way, we're all narrowing down, the scientific community is narrowing
• 22:50
  down into preventive aspects that will allow us to report in our cohorts of.
• 22:56
  Patients a significantly reduction of peri-implantitis.
• 23:00
  But we have to keep in mind that many patients that we diagnose on the
• 23:03
  daily basis are coming from the other niche, from complications from ma
• 23:07
  manmade complications that made the implant higher susceptible to have
• 23:12
  peri-implantitis, and when they become contaminated, of course we have to
• 23:16
  talk about an inflammatory phenomenon.
• 23:18
  And don't take me wrong, I'm not trying to be provocative.
• 23:21
  peri-implantitis is an infectious disease.
• 23:25
  And there is an inflammatory response that actually leads to progressive breakdown,
• 23:31
  but that can be controlled during the surgical phase and the restorative phase.
• 23:35
  We do have all the clinical trends in order to prevent replant that even
• 23:40
  though they have not been reported in the literature very recently, the
• 23:44
  Spanish Society of Periodontology.
• 23:46
  Created a study used in the Delphi method app.
• 23:49
  So the Delphi methodology somehow helps you to give you some hints
• 23:53
  to foresee what might be the response over the next few years.
• 23:58
  Even though there has not been scientific reports in order to support those
• 24:03
  statements, but we all agreed that in what regards to preventive aspects
• 24:08
  related to peri-implantitis 70 percent of the items that were selected and
• 24:14
  were highly controversial, believe me we all agreed that these were actually the
• 24:19
  tendencies to prevent peri-implantitis.
• 24:21
  So we all know by using high technology highly regarded devices.
• 24:28
  Adequate implant system that have been tested by using cleanable prosthesis, by
• 24:35
  using longer Transmucosal ab Abandonments.
• 24:38
  We figured that because we know that the transition zone is highly important,
• 24:42
  not only for aesthetic, but also.
• 24:44
  To minimize the micro leakage that can compromise this inflammatory response.
• 24:49
  That those are some tendencies in order to prevent peri-implantitis
• 24:52
  titis in the future.
• 24:53
  So those individuals that want to do the things in the right way,
• 24:57
  they will experience a significant reduction of peri-implantitis titis.
• 25:00
  The other ones may not, but it's not because they there
• 25:04
  is no education out there.
• 25:05
  It's because they don't want to embrace that education.
• 25:09
  I
• 25:09
  see.
• 25:10
  So bottom line clinicians should be more careful.
• 25:13
  Digital technologies will help, but in our perspective, it will take a little
• 25:17
  bit longer because we have many budget sensitive countries, for example.
• 25:21
  They have, they will take longer to adopt certain technologies,
• 25:27
  clinical choices.
• 25:29
  Education is the key.
• 25:30
  That's the bottom line.
• 25:32
  Indeed.
• 25:32
  Yeah.
• 25:33
  The prevention of peri-implantitis status is something feasible.
• 25:36
  We all know that it's a tsunami, but most of them, when critically assessing
• 25:40
  a peri-implantitis case, it's gonna be very likely that there are some local
• 25:45
  factors that if you critically assess, you will figure out were actually
• 25:50
  was the genesis of peri-implantitis and to what factor was attributable.
• 25:56
  Bert, this is going as an incredible masterclass.
• 25:59
  I see a wealth of knowledge right in front of me here.
• 26:04
  You got to that point, right?
• 26:06
  You know what you know now, and you know we have the technologies that
• 26:09
  we have now in our hands, but it hasn't always been that way, correct?
• 26:14
  So you had your learning curve to that point, and I have this
• 26:17
  section called Experience Taught Me.
• 26:21
  If you could go back in time with the knowledge base that you have.
• 26:25
  Is there a particular situation you would've approached differently
• 26:28
  that you're not so proud how you did it in the past that you say
• 26:32
  I wish I could go back there and.
• 26:34
  Take that patient in a different route.
• 26:35
  Okay.
• 26:36
  So in terms of managing peri-implantitis, what I'm trying to inspire to my trainees
• 26:43
  is that the learning curve is really long.
• 26:46
  What I'm trying is to make it shorter for them.
• 26:48
  I failed so much in managing peri-implantitis because I do believe that
• 26:53
  the implants, whenever they are treated.
• 26:55
  Because of peri-implantitis related bone defects, they tended to respond
• 26:59
  similar to teeth with periodontitis.
• 27:01
  And that's not the case.
• 27:03
  So think twice before thinking about rescue in a dental
• 27:07
  implant or moving forward.
• 27:09
  And besides of that, a take home message from a preventive perspective,
• 27:13
  especially for the youngsters, we are very enthusiastic about
• 27:16
  facing digital technologies, about placing multiple dental implants.
• 27:21
  Doing fancy treatment strategies, it's worth to think about minimally
• 27:28
  invasive approaches, the less number of implants, the less number of
• 27:34
  peri-implantitis that is in the future.
• 27:36
  And that's a fact.
• 27:37
  And we have to think about patient reported outcomes.
• 27:40
  We, I do believe that now with all these tremendous growing field of
• 27:46
  regeneration in the alveolar bone, and we are becoming more predictable
• 27:51
  because of the enhancements from material sciences and also.
• 27:54
  From the different approaches.
• 27:56
  We do believe that all the cases are good to become regenerated, and
• 28:00
  it might be, but that might not be the preference for the patients.
• 28:05
  So my encouragement is that the youngsters actually are embraced by
• 28:10
  this minimally invasive interventions and think more about the patient as the
• 28:16
  core of the treatment more than on the.
• 28:19
  Clinical outcomes which might be meaningless for the patients.
• 28:23
  And to get to a point where it's always minimally invasive and
• 28:27
  minimally as minimal as possible, a maintenance program should be in place.
• 28:32
  That's, it cannot neglect effect.
• 28:34
  That's people tell.
• 28:34
  Yeah, that's people tell.
• 28:35
  And this is an issue that we have in the Mediterranean countries that most of our.
• 28:40
  Patients are actually either erratic or non-compliant, is not the same
• 28:44
  thing in the central European countries or in the Scandinavian countries.
• 28:48
  There are more compliers.
• 28:49
  So again, we have to think twice whether a patient really shall carry dental
• 28:55
  implants, whether it's a good candidate, and this is why, to me, still the hygienic
• 29:00
  phase in the treatment of periodontitis.
• 29:02
  The treatment of peri-implantitis titis.
• 29:04
  It's so key to certainly double check.
• 29:07
  Whether a patient is gonna comply, whether the patient is really
• 29:10
  motivated to face a treatment.
• 29:13
  'cause to me it's worthless just to place dental implants, that I know that in
• 29:17
  the future they will have complications.
• 29:20
  I like this very much because people except from accident, but
• 29:24
  people don't lose their teeth.
• 29:27
  By the grace of Yeah.
• 29:29
  Or destiny.
• 29:30
  There are reasons why they lost their teeth, very likely.
• 29:33
  Same reasons why they will lose their implants.
• 29:35
  We need to take care of them.
• 29:36
  Yeah.
• 29:36
  Evidence from our groups suggested that supportive periotherapy
• 29:40
  in implant carriers actually make a tremendous difference.
• 29:44
  As such, those erratic individuals, those ones that come once a year or
• 29:49
  spontaneously, because they wanted to check up another tooth or whatever
• 29:53
  they are five times more exposed to develop peri-implantitis, one compared
• 29:58
  to regular compliers, and this is something that has to be conveyed up.
• 30:03
  Front and in a very transparent manner to all the patients, to know that if they
• 30:07
  don't come to regular checkups, it's a matter of time to have complications.
• 30:12
  I don't want patients to be really disappointed with me in the future if
• 30:18
  as long as they really understand that they have to be consequence in facing
• 30:23
  a treatment that is life lasting.
• 30:25
  This is not a matter of just meeting one day.
• 30:27
  Yeah.
• 30:28
  Placing dental implants and say bye.
• 30:30
  Yeah.
• 30:31
  I love this.
• 30:32
  Yeah.
• 30:33
  Alberto.
• 30:33
  Sadly, this conversation is coming to an end.
• 30:37
  I wish we had a whole day.
• 30:38
  I could just pick your brain because this is an incredible masterclass.
• 30:41
  I learned tons and it was a pleasure having this talk with you to our audience.
• 30:47
  That would like to contact and learn on your program's, educational
• 30:51
  offerings, how they can reach out,
• 30:53
  they can reach using social media email address of course.
• 30:57
  And I can provide them all the information that they request.
• 31:01
  So let's do this.
• 31:03
  You share with me all the links to Alberto Monje.
• 31:06
  His educational offerings will be listed in a description of the video as well
• 31:10
  as the article you brought up today.
• 31:13
  Of course.
• 31:13
  Yeah.
• 31:14
  Alberto, it was a pleasure to have you with us.
• 31:15
  It was my honor.
• 31:16
  Thank you very much for inviting me to this fantastic and
• 31:19
  very inspirational ProTalk.
• 31:21
  Super.
• 31:21
  Thank you.
• 31:22
  And to all of you, if you found this content relevant, you have to
• 31:26
  drop a comment, tell us that you liked it or not, and give it a like.
• 31:31
  And tell all your friends.
• 31:32
  Sharing is caring.
• 31:34
  Until the next episode, ciao.