Peri-implant diseases and its management

Definition Peri-implant disease- Peri-implant disease is a collective

term for inflammatory processes in the tissues surrounding

an implant - Albrektsson & Isidor 1993, 1st EWP, Switzerland.

Definition of Mombelli A, Lang N.P 1998- pathological

inflammatory changes that take place in the tissue

surrounding a load bearing implant

Normal v/s peri-implant tissuesPeriodontal Peri-implant

Difference in probing and clinical condition

Peri-implant mucositis Albrektsson & Isidor (1994) reversible inflammatory reactions in

the soft tissues surrounding a functioning implant.

According to Kostovillis (2008) Inflammatory changes which are

confined to the soft tissue surrounding an implant with no signs of

loss of supporting bone.

Roos-Jansaker AM et al. prevalence is 48% of implants followed

from 9 to 14 years

Clinical features

• Probing depth > 4mm• BOP or suppuration

Histopathology Response to early plaque formation

Pontoriero et al. (1994)- Inflammation and probing depth change over a period of 3 weeks

Zitzmann et al. (2001) also concluded that at the end of 3 weeks of plaque built-up, increase in size of peri-implant mucosa from 0.03 mm2 at baseline to 0.2 mm2

Proportions of neutrophills increased in CT

Response to long standing plaque formation Ericsson et al.- Inflammatory response same In gingival tissues amount of tissue breakdown that

occurs during the 3 month interval is more or less fully compensated by the tissue built up during the subsequent phases of repair.

In the lesion within the peri-implant mucosa, the tissue breakdown is not fully recovered by reparative events. (reduced tissue built up)

Histopathology

Concluding remark

Shares similarity with gingivitis in terms of host

response and development of clinical signs.

it represents an obvious precursor to peri-implantitis.

Early detection is essential.

Peri-implantitis The term “Peri-implantitis” was introduced in the late

1980s (Mombelli et al. 1987) and was subsequently defined as “an inflammatory process affecting the soft and hard tissues around a functioning osseointegrated implant, resulting in loss of supporting bone” (Albrektsson & Isidor 1994).

In the consensus report from the 6th European

Workshop on Periodontology- peri-implant

mucositis was an inflammatory lesion that resides in

the mucosa, while peri-implantitis also affects the

supporting bone”. (Lindhe & Meyle 2008,

Zitzmann & Berglundh 2008).

Peri-implantitis- progressive loss of supporting

bone beyond biological bone remodeling.

Consensus report of Working Group JCP 2012

Retrograde peri-implantitis• First described by McAllister and colleagues.

Etiopathogenesis

Biofilm formation

Staph. Aureus for initiation and host response is

overwhelmed by gram –ve bacteria.

The connective exhibit B-lymphocytes and plasma

cell infiltration

Etiopath… The rate of disease progression and the severity of

inflammatory signs different than periodontitis

The increased susceptibility for bone loss around

implants may be related to the absence of inserting

collagen fibers into the implant

spontaneous continuous progression of the disease

with additional bone loss

Risk factors Previous periodontal disease Residual cement Smoking Genetic factors Diabetes mellitus Occlusal overload

Emerging Risk factors Rheumatoid arthritis Premature loading Alcohol consumption

Clinical features

Classification Newman and Flemming (1992) have proposed a

classification of non successful implants, based on the severity of peri-implantitis:

1. “Compromised successful implant” characterized by inflammation, hyperplasia, fistula formation occurring near an otherwise fully osseointegrated implant.

2. “Failing implant” characterized by progressive bone resorption, but the implant remains functional.

3. “Failed implant” in which infection persists around an implant whose function is compromised.

Classifications Based on the % of bone loss

Froum SJ, Rosen PS, 2012

Based on radiographic presentation of peri-implant bone loss as 5 main types: Zhang L, Geraets W, Zhou Y, et al, 2014

Diagnosis of peri-implantitis The examination of peri-implant tissues should

include:-1. Evaluation of oral hygiene standard.

Modified plaque index- Mombelli et al.2. Evaluation of peri-implant marginal tissues.

Probing, bleeding and suppuration3. Evaluation of bone-implant interface

Radiographs and mobility

Probing around implants Initial probing immediately before installing final

restoration using 0.25N probing force Gentle probing resulting in bleeding suggests the

presence of soft tissue inflammation presence of suppuration/exudate indicates

pathological changes Increasing probing depth and bleeding are

indicators for additional radiographic examination

Radiographs IOPA following placement and then following the

prosthesis installation should function as the baseline

Bone loss can have a number of nonbacterial causes including surgical technique, implant design, implant position, crestal thickness of bone, loose prosthesis/abutment, and excessive occlusal force

Treatment approaches

Treatment Objectives in the therapy of peri-implantitis:

1. The removal of bacterial plaque within the peri-implant pocket.

2. The decontamination and conditioning of the implant surface.

3. Elimination of the sites that cannot be maintained plaque-free by oral-hygiene procedures.

4. The establishment of an effective maintenance program.

CIST Cummulative interceptive and supportive therapy Cumulative therapy depending on the clinical and

radiographic diagnosis

Nonsurgical approach1. Mechanical debridement

Hand Instruments coated with titanium, carbon fiber,

polytetrafluoroethylene, plastic, polyetheretherketone,

or silicon.

Ultrasonic tips or polishing cups coated with carbon

fiber or plastic

Air abrasive systems that use low abrasive amino acid,

glycine powder

2. Occlusal therapy

An analysis of the fit of the prosthesis

Prosthesis design changes, improvement in

implant number and occlusal equilibration can

contribute to the arrest of peri-implant tissue

breakdown progression

3. Antimicrobial therapy

Systemic antibiotic

Amoxicillin-CV 625mg BID

Metronidazole 200mg TID

Local antimicrobial Minocycline microspheres (1mg Arestin)

doxycycline hyclate gel

Tetracycline fiber (Actisite)

Implant surface decontamination:

Saline, citric acid,

hydrogen peroxide, EDTA

Laser• The commonly used lasers for the decontamination of

the implant surface are: Nd:YAG (1064 nm), Erbium:yttrium-aluminium garnet(Er:YAG)(2940 nm), Diode (660 nm), and Carbon dioxide (10600 nm) lasers

• Er:YAG laser could remove the bacterial-contaminated titanium oxide layer, thus promoting reosseointegration

Nevins M, Nevins ML, Yamamoto A, et al. 2014

Photodynamic therapy• The activation of these dyes, such as toluidine

blue-O, using specific wavelength of light

(630– 700 nm) causes the release of oxygen

radicals that will decimate periodontal

pathogens. Konopka K, Goslinski T. 2007

Surgical interventions1. ACCESS FLAP The objective of the access flap is to gain

access to submucosal implant surface for debridement and decontamination

2. Implantoplasty

• Clinical trial reported that implants treated with implantoplasty had a higher implant survival rate compared with those that were treated with an apically positioned flap only

Romeo E, Ghisolfi M, Murgolo N, et al, 2005

• 2 gm amox 1 hr prior to surgery• FTF to expose the area• Debride the defect with titanium or plastic curettes• Air powder abrasive (Bicarbonate powder) for 60 Sec• 60 sec irrigation with sterile saline• 60 sec application of tetracycline • Defect filled with Bone Graft• Membranes are placed to cover all surfaces• Flap released and coronally advanced and sutured.

REGENERATIVE APPROACH

• The effectiveness of 4 surgical procedures (access flap and debridement alone, Surgical resection, regeneration with bone grafts, and guided bone regeneration) were studied in a systematic review and meta-analysis

• Each of the 4 procedures yielded roughly 2 to 3 mm PD reduction

• 2-mm increase in bone height was associated with the regenerative procedures in a systematic review

Chan HL, Lin GH, Suarez F, et al 2014

MAINTENANCENeeds to be individually determined

Needs to be enforced by doctor and HygienistPatient need to assume responsibility

Low Risk Patients-Highly motivated-Excellent oral hygiene-One or two implants-No associative risk factors

Moderate Risk Patients

-Loss of motivation-Fair oral hygiene-3-6 implants-Moderate smoker (half pack)-Controlled medical issues

High Risk Patients-Unmotivated-Poor oral hygiene-Previous periodontitis->6 implants-Smokers more than half pack-Poorly controlled systemic diseases

There is no single superior antiinfective method available.

Surgical interventions achieved greater probing depth reduction and clinical attachment gain compared with nonsurgical

Access flap surgery shows resolution in only 58% of the lesions.

The combination of resective and regenerative surgical techniques seemed to have favorable treatment outcomes in the management of periimplantitis.

Reosseointegration of a previously contaminated implant

surface is possible but highly variable and unpredictable.

Summery & Conclusion Similarity between periodontal and peri-implant

diseases Early diagnosis of peri-implantitis is imperative

Several risk factors exist for the development of peri-implantitis, which can guide patient selection and treatment planning.

Treatment of peri-implantitis should be tailored to the severity of the lesion (as outlined by the CIST protocol), which ranges from non surgical to surgical approach

Refrences 1. Rosen P, Clem D, Cochran D, et al. Peri-implant mucositis and peri-

implantitis: a current understanding of their diagnoses and clinical implications. J Periodontol 2013;84(4):436–43.

2. Froum SJ, Rosen PS. A proposed classification for peri-implantitis. Int J Periodontics Restorative Dent 2012;32(5):533–40.

3. Schwarz F, Herten M, Sager M, et al. Comparison of naturally occurring and ligature-induced peri-implantitis bone defects in humans and dogs. Clin Oral Implants Res 2007;18(2):161–70.

4. Zhang L, Geraets W, Zhou Y, et al. A new classification of peri-implant bone morphology: a radiographic study of patients with lower implant-supported mandibular overdentures. Clin Oral Implants Res 2014;25(8):905–9.

5. Padial-Molina M, Suarez F, Rios HF, et al. Guidelines for the diagnosis and treatment of peri-implant diseases. Int J Periodontics Restorative Dent 2014;34(6):e102–11.

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8. Jia-Hui Fu, Hom-Lay Wang. Can Periimplantitis Be Treated? Dent Clin N Am.2015:59;951–980.