Number: 036
(Update)

Subject: Treatment of Peri-implantitis

Date: November 13, 2017
 

Important note

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical 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 practicing in relevant clinical areas, and other relevant factors).

 Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers 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. 

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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 5 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 periodontits, 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

D6081 - Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure.  This procedure is not performed in conjunction with D1110 or D4910.

Revision Dates

Original policy: September 10, 2012
Update: September 23, 2013; July 23 , 2014; August 25, 2015; October 20, 2016; November 13, 2017

The above policy is based on the following references:

¹American Dental Association. CDT 2017 Dental Procedure Codes.*

²Niklaus 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.

³Esposito M; Grusovin MG, Tzanetea E, Piatelli A, Worthington HV (2010): Interventions for replacing missing teeth: Treatment of perioimplantitis. Cochrane database Syst Rev: 2008: (2) CD004970.
4Esposito M; Grusovin MG, Tzanetea E, Piatelli A. Worthington HV Interventions for replacing missing teeth: Treatment of perioimplantitis. Cochrane database Syst Rev: 2012: 1 CD004970.
 ⁵Esposito M; Grusovin Worthington HV; Coulchard P; Jokstard A; Interventions for replacing missing teeth: Treatment of periimplantitis. Cochrane database Syst Rev: 2002 (3): CD003069.
 ⁶Renvert 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.
 ⁷Roos- Janasaker AM; Renvert S; Egelberg J: Treatment of periimplant infections; a literature review. Journal of clinical periodontology 2003 Jun; 30(0) 467-85.
 ⁸Lisa J.A. Heitz- Mayfield & Niklaus P. Lang; Comparative biology of chronic aggressive periodontitis vs. peri-implantitis. Periodontology 2000, Vol 53, 2010, 1-15.
 ⁹LJA 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
 ¹⁰M Manar 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.

¹¹Ata-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.

¹²Byrne, 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.

¹³Elangovan, Satheesh. Complete regeneration of peri-implantitis–induced bony defects using guided bone regeneration is unpredictable. J Am Dent Assoc. 2013 Jul;144(7):823-4.

*Copyright 2016 American Dental Association. All rights reserved.

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.