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On inflammation-immunological balance theory—A critical apprehension of disease concepts around implants: Mucositis and marginal bone loss may represent normal conditions and not necessarily a state of disease

Journal article
Authors Tomas Albrektsson
Torsten Jemt
Johan Mölne
Pentti Tengvall
Ann Wennerberg
Published in Clinical Implant Dentistry and Related Research
Volume 21
Issue 1
Pages 183-189
ISSN 15230899
Publication year 2019
Published at Institute of Odontology
Institute of Biomedicine, Department of Pathology
Institute of Odontology, Section 2
Institute of Clinical Sciences, Department of Biomaterials
Pages 183-189
Language en
Keywords crestal bone loss, defense against disease, foreign body reaction, immunologic reaction, inflammation, osseointegration, peri-implantitis
Subject categories Biomaterials Science


© 2018 Wiley Periodicals, Inc. Background: Oral implants have displayed clinical survival results at the 95%-99% level for over 10 years of follow up. Nevertheless, some clinical researchers see implant disease as a most common phenomenon. Oral implants are regarded to display disease in the form of mucositis or peri-implantitis. One purpose of the present article is to investigate whether a state of disease is necessarily occurring when implants display soft tissue inflammation or partially lose their bony attachment. Another purpose of this article is to analyze the mode of defense for implants that are placed in a bacteria rich environment and to analyze when an obtained steady state between tissue and the foreign materials is disturbed. Materials and Methods: The present article is authored as a narrative review contribution. Results: Evidence is presented that further documents the fact that implants are but foreign bodies that elicit a foreign body response when placed in bone tissue. The foreign body response is characterized by a bony demarcation of implants in combination with a chronic inflammation in soft tissues. Oral implants survive in the bacteria-rich environments where they are placed due to a dual defense system in form of chronic inflammation coupled to immunological cellular actions. Clear evidence is presented that questions the automatic diagnostics of an oral implant disease based on the finding of so called mucositis that in many instances represents but a normal tissue response to foreign body implants instead of disease. Furthermore, neither is marginal bone loss around implants necessarily indicative of a disease; the challenge to the implant represented by bone resorption may be successfully counteracted by local defense mechanisms and a new tissue-implant steady state may evolve. Similar reactions including chronic inflammation occur in the interface of orthopedic implants that display similarly good long-term results as do oral implants, if mainly evaluated based on revision surgery in orthopedic cases. The most common mode of failure of orthopedic implants is aseptic loosening which has been found coupled to a reactivation of the inflammatory- immune system. Conclusions: Implants survive in the body due to balanced defense reactions in form of chronic inflammation and activation of the innate immune system. Ten year results of oral and hip /knee implants are hence in the 90+ percentage region. Clinical problems may occur with bone resorption that in most cases is successfully counterbalanced by the defense/healing systems. However, in certain instances implant failure will ensue characterized by bacterial attacks and/or by reactivation of the immune system that now will act to remove the foreign bodies from the tissues.

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