In 1977, Brånemark et al published an article entitled ‘Osseointegrated implants in the treatment of the edentulous jaw; experience from a 10-year period’. This study revolutionised clinical dentistry by demonstrating that it was possible to successfully use titanium implants to replace missing teeth. Implant-retained prostheses have since become a popular treatment modality, aiming to fulfil functional and aesthetic needs. As dental practitioners, we are constantly bombarded with updates about the latest dental implants, new techniques and expanded indications. However, the complications that may arise with implant rehabilitation are less commonly advertised and understood. Peri-implant disease is unarguably one of the most significant risks associated with implants. It is a multifactorial disease that, if not diagnosed at early stage, can ultimately lead to failure of the implant. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds, the numbers of patients presenting with the disease appears to be on the rise. What is peri-implant disease? Peri-implant disease is a condition that affects the tissues surrounding a functional implant; it includes both peri-implant mucositis and peri-implantitis. Peri-implant mucositis can be defined as ‘reversible inflammatory reactions in the soft tissues surrounding a functioning implant’ (Albrektsson, Isidor, 1994). Peri-implantitis is characterised by ‘inflammatory reactions with loss of supporting bone in the tissues Aims and objectives To discuss the management of peri-implant diseases in clinical practice. Expected outcomes Correctly answering the questions on page 58 will demonstrate that you understand the aetiology, diagnosis and treatment of peri-implant disease. Verifiable CPD hours: 1 surrounding a functioning implant’ (Lindhe, Meyle, 2008). Peri-implantitis yields many features in common with chronic periodontitis (Mombelli et al, 1987). Both involve alveolar bone loss, for instance. However, there is a zone of connective tissues that is attached to the root surface in periodontitis. In contrast, connective tissue does not attach directly onto implants, and there is no periodontal ligament. Therefore, the inflammatory lesion in peri-implantitis extends closer to the bone surface, which can be associated with a faster rate of progression and more aggressive consequences (Figures 1a and 1b). The prevalence of peri-implant disease is significant, with peri-implant mucositis affecting up to 80% of implant patients and peri-implantitis affecting 25% of patients (Zitzmann, Berglundh, 2008). Aetiology and risk factors Bacterial infections play the most important role in the failure of dental implants. Bacterial flora associated with periodontitis and peri-implantitis are found to be similar (Hydenrjik, Majjer, 2002). Studies have Peri-implant disease: a growing problem Reena Wadia and Neesha Patel discuss peri-implant disease, a multifactorial disease that appears to be on the rise 52 Private Dentistry June 2013 Reena Wadia BDS Hons(Lon) MJDF RCS(Eng) is an associate at Pure Periodontics, London and specialist registrar in periodontology at Guy’s Hospital, London. Neesha Patel BSc Hon(Can) BDS (Glasg) MFGDP(UK) MClinDent Periodontics(Lon) MRD RCS(Ed) is practice principal at Pure Periodontics, a specialist in periodontics as well as a consultant periodontist at King’s College Hospital, London. Figure 1a: Periodontitis Figure 1b: Peri-implantitis
Transcript
In 1977, Brånemark et al published an article entitled ‘Osseointegrated implants in the treatment of the edentulous jaw; experience from a 10-year period’. This study revolutionised clinical dentistry by demonstrating that it was possible to successfully use titanium implants to replace missing teeth. Implant-retained prostheses have since become a popular treatment modality, aiming to fulfil functional and aesthetic needs.
As dental practitioners, we are constantly bombarded with updates about the latest dental implants, new techniques and expanded indications. However, the complications that may arise with implant rehabilitation are less commonly advertised and understood.
Peri-implant disease is unarguably one of the most significant risks associated with implants. It is a multifactorial disease that, if not diagnosed at early stage, can ultimately lead to failure of the implant. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds, the numbers of patients presenting with the disease appears to be on the rise.
What is peri-implant disease?Peri-implant disease is a condition that affects the tissues surrounding a functional implant; it includes both peri-implant mucositis and peri-implantitis.
Peri-implant mucositis can be defined as ‘reversible inflammatory reactions in the soft tissues surrounding a functioning implant’ (Albrektsson, Isidor, 1994). Peri-implantitis is characterised by ‘inflammatory reactions with loss of supporting bone in the tissues
Aims and objectives To discuss the management of peri-implant diseases in clinical practice.
Expected outcomes Correctly answering the questions on page 58 will demonstrate that you understand the aetiology, diagnosis and treatment of peri-implant disease.
Verifiable CPD hours: 1
surrounding a functioning implant’ (Lindhe, Meyle, 2008).
Peri-implantitis yields many features in common with chronic periodontitis (Mombelli et al, 1987). Both involve alveolar bone loss, for instance. However, there is a zone of connective tissues that is attached to the root surface in periodontitis. In contrast, connective tissue does not attach directly onto implants, and there is
no periodontal ligament. Therefore, the inflammatory lesion in peri-implantitis extends closer to the bone surface, which can be associated with a faster rate of progression and more aggressive consequences (Figures 1a and 1b).
The prevalence of peri-implant disease is significant, with peri-implant mucositis affecting up to 80% of implant patients and peri-implantitis affecting 25% of patients (Zitzmann, Berglundh, 2008).
Aetiology and risk factors Bacterial infections play the most important role in the failure of dental implants. Bacterial flora associated with periodontitis and peri-implantitis are found to be similar (Hydenrjik, Majjer, 2002). Studies have
Peri-implant disease: a growing problem Reena Wadia and Neesha Patel discuss peri-implant disease, a multifactorial disease that appears to be on the rise
52 Private Dentistry June 2013
Reena Wadia BDS Hons(Lon) MJDF RCS(Eng) is an associate at Pure Periodontics, London and specialist registrar in periodontology at Guy’s Hospital, London.Neesha Patel BSc Hon(Can) BDS (Glasg) MFGDP(UK) MClinDent Periodontics(Lon) MRD RCS(Ed) is practice principal at Pure Periodontics, a specialist in periodontics as well as a consultant periodontist at King’s College Hospital, London.
shown that the bacteria at the failing implant site consists of gram-negative anaerobic bacteria, such as Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus actinomycetemcomitans (Mombelli, Long NP, 1998).
The correlation between the presence of periodontitis and the development of peri-implantitis has been supported by a recent systematic review (Kotsovilis et al, 2008; Renvert, Persson, 2009).
Implants in partially dentate patients appear to be at a greater risk of peri-implantitis than implants in fully edentulous patients. There is a marked quantitative decrease in the number of periodontal pathogens around the implants in completely edentulous patients. It is possible that the natural teeth serve as reservoirs for periodontal pathogens from which colonisation of the implant sites occur (Aspe et al, 1989).
• Underlying systemic conditions such as diabetes.
Biomechanical factors, such as an occlusal overload, may play an important role in implant failure by resulting in progressive bone loss around the implant. The implants that suffer from traumatic failure have subgingival microflora representing a state of periodontal health (Mombelli, Mericske-stern, 1990).
Iatrogenic factors – such as lack of primary stability, poorly-positioned implants, premature loading during the healing period and poorly-fitting abutments or restorations – also appear to increase the likelihood of peri-implant disease (Quirynen et al, 1993; Lang, Bosshardt, Lulic, 2011).
Diagnosis Early diagnosis and treatment is often the key to complete resolution of the problem. However, although advanced cases of the disease will be clearly identifiable, it is often a great challenge to diagnose early and successfully.
Diagnosis of peri-implant disease relies
on crude parameters commonly used for the diagnosis of periodontal disease. Swelling and redness of the peri-implant marginal tissues and plaque/calculus accumulation are important signs of peri-implant disease (Figure 2).
Probing the peri-implant sulcus with a blunt, straight, plastic or metal periodontal probe allows the assessment of: • Peri-implant probing depth• Bleeding on probing • Suppuration from the peri-implant space. Studies have shown that successful implants generally allow a probe penetration of approximately 3-4mm in the peri-implant sulcus. Bleeding on probing and suppuration are clear
Private Dentistry June 2013 53
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Figure 2: Inflammation of peri-implant tissues
52 PD June Patel.indd 2 31/05/2013 14:35
indications of disease (Figure 3) (Gupta et al, 2011).
Adequate baseline radiographs determine the peri-implant bone status as well as the marginal bone level. These can then be compared to future radiographs to determine if additional bone loss, beyond ‘normal’ has occurred.
Progressive bone loss is a defi nite indicator of peri-implantitis (Figure 3), but it should not be confused with physiological bone remodelling around the implant during the fi rst year of function (Albrektsson et al, 1986; Meffert, 1992).
Implant mobility is an insensitive measure in detecting early implant failure. More advanced peri-implantitis is characterised by mobility of the fi xture, indicating failure of osseointegration.
Management Comprehensive treatment of peri-implant disease remains an enigma to most dentists but is largely dependent on the underlying aetiology at play.
When the main aetiological factor is bacterial infection, the fi rst phase of treatment involves the control of acute infection and the reduction of infl ammation. This involves the removal of plaque deposits and improved patient compliance with oral hygiene until a healthy peri-implant site is established. This may be suffi cient to re-establish gingival health.
The implants that are affected with peri-implantitis are contaminated with soft tissue cells, microorganisms and microbial by-products. The defect must be debrided.
Prophy jet and the use of a high pressure air powder abrasive has been advocated, as this removes the microbial deposits, does not alter the surface topography and has no adverse effect on cell adhesion.
Various chemotherapeutic agents, such as contact with a supersaturated solution of citric acid have been used for the preparation of the implant surfaces.
Soft tissue laser irradiation has also been used (Deppi et al, 2001).
Additionally, the systemic administration of antibiotics that specifi cally target gram-negative anaerobic organisms has shown an alteration in the microbial composition and a sustained clinical improvement (Roos-Jansaker et al, 2003).
A local delivery device with fi bres containing polymeric tetracycline has been tried and this resulted in signifi cantly lower total anaerobic counts (Mombelli et al, 2001).
The type of osseous defects should be identifi ed before deciding on the surgical treatment modality. If vertical one- to two-wall defects (less than 3mm) are found, then the resective surgery may be used to reduce the pockets, to smoothen the rough implant surfaces, to correct the osseous
architecture and to increase the area of the keratinised gingiva (Jovanovic, 1993).
To arrest the progression of the disease and achieve a maintainable site for the patient, surfaces with threads may be indicated for alteration with high-speed diamond burs and polishers to produce a smooth continuous surface (Jovanovic, Spickermann, Richter, 1992).
Various bone grafting techniques and materials and guided bone regeneration (Figures 4a and 4b) have been successfully used for the regeneration in three-wall or circumferential defects. Porous titanium granules have also recently been advocated to try and treat advanced peri-implant osseous defects.
When biochemical forces are considered as the main aetiological factors, occlusal equilibration (ie, improvement of the implant number and position and changes in the prosthetic design) can arrest progression.
Long-term success of any peri-implant treatment strategy requires a strict maintenance programme carried out at regular intervals.
Conclusion Given the large number of implant placements each day around the world, a high prevalence of peri-implantitis can be anticipated, which underlines the necessity for a predictable therapy. Assiduous research is still required for the treatment of peri-implantitis, because there is still no standard protocol for its management.
ReferencesFor the list of references that accompany this article please email [email protected].
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Figure 5a: Peri-implant bone defect (image courtesy of Dr Patty Chou)
Figure 5b: Use of regeneration (image courtesy of Dr Patty Chou)
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Figure 3: Bleeding on gentle probing Figure 4: Evidence of ‘saucer shaped’ bone loss around implant
