Dental Clinical Policy Bulletins (2024)

Number: 036
(Updated)

Subject: Treatment of Peri-implantitis

Date: September 23, 2013

Important Note

This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We reached these conclusions based on a review of currently available clinical information including:

Clinical outcome studies in the peer-reviewed published medical and dental literature
Regulatory status of the technology
Evidence-based guidelines of public health and health research agencies
Evidence-based guidelines and positions of leading national health professional organizations
Views of physicians and dentists practicing in relevant clinical areas
Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

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.

Background

Peri-implantitis is defined as an inflammatory process affecting the tissues around an osseointergrated implant in function resulting in loss of supporting bone. Clinical signs are deep probing depth (> 5 mm) bleeding and/or suppuration on probing. Loss of supporting bone usually forms a circumferential crater defect. Large scale studies detected peri-implantitis in 12% of implants in function for at least five years and 43% of implants in function for 9-14 years. Biofilms consist predominately of gram negative anaerobes and are similar to those found in chronic periodontit*, but bone loss is more rapid in peri-implantitis. Risk factors include poor oral hygiene, smoking, diabetes and a history of chronic periodontitis.

Codes¹

D4241 - gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant
D6101 - Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure
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 peri-implant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration
D6104 - Bone graft at time of implant placement

Revision Dates

Original policy: September 10, 2012
Update: September 23, 2013

The above policy is based on the following references:

¹American Dental Association. Current Dental Terminology, CDT-2011-2012: 26.**

²American Dental Association. Current Dental Terminology, CDT-2013: 30, 52.***

³Niklaus P. Lang; Tord Berglundh: Peri-implant diseases: Where are we now? Consensus or the Seventh European Workshop on Periodontology. Journal of Clinical Periodontology Volume 38, Issue Supplement s 11. Pages 178-181, March 2011.

⁴Esposito M; Grusovin MG, Tzanetea E, Piatelli A, Worthington HV (2010): Interventions for replacing missing teeth: Treatment of perioimplantitis. Cochane database Syst Rev: 2008: (2) CD004970.4

⁵Esposito M; Grusovin MG, Tzanetea E, Piatelli A. Worthington HV Interventions for replacing missing teeth: Treatment of perioimplantitis. Cochane database Syst Rev: 2012: 1 CD004970.

⁶Esposito M; Grusovin Worthington HV; Coulchard P; Jokstard A; Interventions for replacing missing teeth: Treatment of perioimplantitis. Cochane database Syst Rev: 2002 (3): CD003069.

⁷Renvert S Roos-Jansaker A-M, C Laffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: A literature review. J Clin Periodontal 2008; 35 Supl. 8.

⁸Roos- Janasaker AM; Renvert S; Egelberg J: Treatment of perio-implant infections; a literature review. Journal of clinical periodontology 2003 Jun; 30(0) 467-85.

⁹Lisa J.A. Heitz- Mayfield & Niklaus P. Lang; Comparative biology of chronic aggressive periodontitis vs. peri-implantitis. Periodontology 2000, Vol 53, 2010, 1-15.

¹⁰LJA Heitz – Mayfield: Diagnosis and management of peri-implant diseases. Aust Dent J. 2008 Jun; 53 Suppl 1:S43-8. doi: 10.1111/j.1834-7819.2008.00041.x

^11MManar Aljiateeli; Jia-Hui Fu; Hom – Lay Wang; Peri-implant Bone Loss: Current Understanding. Clin Implant Dent Relat Res. 2012 May; 14 Suppl 1:e109-18. doi: 10.1111/j.1708-8208.2011.00387.x. Epub 2011 Oct 10.

¹²Ata-Ali J; Candel-Marti ME; Flichy-Fernadez AJ; Penarrocha-Oltra; Balaguer-Martinez JF; Penarrocha Diag M. Peri-implantitis: associated microbiota and treatment. Medicina oral, patologia y circgia bucal/ 2001 Nov; 16(7): 937-43.

¹³Byrne, Gerard; Critical summaries socket preservation of implant sites: a critical summary of Ten Heggeler JMAG, Slot DE, Van der Weijden GA. effect of socket preservation therapies following tooth extraction in non-molar regions in humans: a systematic review (published online ahead of print Nov. 22, 2010). Clin Oral Implants Res 2011; 22(8):779-788. doi:10.1111/j.1600-0501.2010.02064.x. JADA October 2012 143(10): 1139-1140.

¹⁴Elangovan, Satheesh. Complete regeneration of peri-implantitis–induced bony defects using guided bone regeneration is unpredictable. The Journal of the American Dental Association July 1, 2013 vol. 144 no. 7 823-824. http://jada.ada.org/content/144/7/823

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.