systemic and local factors contributing to peri-implantitis (research proposal)

2012-2013

Student ID Number: 1248527 Mohammad K. Alhomsi. MSc Implantology.

[SYSTEMIC AND LOCAL FACTORS CONTRIBUTING TO PERI-IMPLANTITIS] A Research Proposal for Module 1 (MET 182) about peri-implantitis in relation to the systemic risk factors and local risk factors. A retrospective cohort study modified and combined with a case control and cross sectional qualitative study. To give a broader view and a better understanding of the peri-implantitis and the most effective systemic risk factors or local risk factors inducing it, leading to thoughts and suggestions of preventive methods, possible treatment and management, prognosis and both operator and patient awareness.

Student ID Number: 1248527 | Research Proposal for Module 1 (MET182) Assessment Cardiff University 2012-2013

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Contents

Table of Figures ...................................................................................................................................... 3

Background ............................................................................................................................................. 4

Endogenous factors (systemic and local): .......................................................................................... 5

Systemic factors: ............................................................................................................................ 5

Local factors .................................................................................................................................... 6

Purpose and Aims ................................................................................................................................... 7

Methods and Materials .......................................................................................................................... 8

Data Handling and Statistical Analyses .................................................................................................. 9

Justification of the Study and Expected Results ................................................................................9, 10

References .......................................................................................................................................11, 12

Words count: 2671


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Table of Figures

Figure 1: Peri-implantitis high lighted on an implant (art work) ........................................................... 4

Figure 2: (art work) image showing infected dental implant ................................................................. 5

Figure 3: Cohort Study Design ................................................................................................................ 7


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Systemic And Local Factors Contributing to Peri-implantitis

(Research Proposal by: Mohammad K. Alhomsi)

Background:

The success and predictability of osseointgrated dental implants have forever

changed the philosophy and practice of dentistry. Patients have experienced much

success with endosseous dental implants (Adell R et al 1990, Buser D et al 1997,

Lekholm U et al 1999). Despite the long term predictability of implants, however,

biologic, technical, and esthetic complications do occur in a percentage of cases, both

early and late (Adell R et al 1981, Alberktsson T et al 1986, Buser D et al 1991). The early

ones take place at the time up to abutment connection and are easier to diagnose

because of the of osseointegration, which defined as establishment and maintenance of

bone to implant contact, while the late implant failures result from the inability to

maintain osseointegration, the most prominent and insidious complication around

dental implants, emerging at a later stage is peri-implantitis (Charalampakis G et al

2011). Some complications are relatively minor and easy to correct, but others result in

loss of implants and failure of prostheses.

Fig. 1

Peri-implantitis is very similar to periodontitis but instead being around a tooth it will be

around an implant. It is defined as an inflammatory process affecting the tissues around

an osseointegrated implant in function, resulting in loss of supporting bone (Mombelli A

et al 1998).

Clinicians had, for many years, always focused on overloading, prosthetic aspect,

technical aspect and implant related factors as causes for implant failure and

complications, neglecting the fact that systemic and local factors plus various systemic


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diseases could affect the outcome of an implant and it’s failure relevantly by inducing a

peri-implantitis or increasing the implant surroundings vulnerability to bacterial

infections and biological complications.

Fig. 2

It is imperative for clinicians to recognize risk factors and contraindications to implant

therapy so that problems can be minimized and patients can be accurately informed

about risks. As such, the clinician must be knowledgeable in this area and inform

patients about risk factors and contraindications before placing an implant or initiating

treatment. Some conditions are probably best described as “risk factors” rather than

“contra-indications” to treatment because implants can be successful in almost all

patients; implants may be less predictable in some situations, and this distinction should

be recognized. It is always coming back to the clinician whether implant treatment is

indicated or not. And this is a list of factors that are thought to increase the risk for

implant failure: Medical and Systemic Health-Related Issues: Diabetes, Bone metabolic

disease (e.g., osteoporosis), Radiation therapy (head and neck), Immunosuppressive

medication, Immunocompromising disease (e.g., HIV, SLE) (Beikler T et al 2003); Habits

and Behavioral Considerations: Smoking and tobacco use (Bain CA et al 1993),

Parafunctional habits, Substance abuse (e.g., alcohol, drugs); Intraoral Examination

Findings: Atrophic maxilla, Current infection (e.g., endodontic), Periodontal disease.

Here is the endogenous (systemic and local) factors already mentioned above but in

more details:

Systemic factors:

1. Age:

Several studies report that there is not a statistically significant relationship between

patient age and implant failure (Kondell et al 1988, Meijer et al 2001).


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2. General health conditions:

Consensus was reached that a compromised medical status (uncontrolled) of the

patient has a negative influence on implant survival (Esposito et al 1998, Weyant et al

1994), these may include general diseases such as bone metabolic disorders, rheumatic

diseases, hormonal diseases, immunological disorders and malabsorption syndromes.

3. Diabetes mellitus:

Diabetes mellitus is associated with many systemic as well as oral complications. In the

oral cavity diabetes can cause xerostomia, caries and periodontitis because diabetes has

a negative influence on the inflammatory mechanism and apoptosis (Taylor et al 2004,

Graves at al 2006).

4. Smoking:

Smoking is a well documented risk factor for dental implant success because of its

negative local and systemic effects (Meffert et al 1997). During the consultation visit

with the patient it is important that the clinician explains that smoking can lead to

complications after implant insertion which may end by implant failure.

Local factors:

1. Bone:

Presence of sufficient healthy bone at the recipient site is one of the most important

factors for successful osseointegration (Buser D et al 2009).

Usually the mandible has a denser and thicker cortical layer than the maxilla and in both

jaws this cortical layer tends to be thinner and more porous posteriorly, moreover in the

mandible the trabecular bone component is denser than in the maxilla and in anterior

areas more than posterior areas (Friberg B et al 1991, Truhlar R. S et al 1997).

Many studies report that implants placed in a site with a missing buccal bone wall have

a great rate of soft tissue complication and/or compromised long term outcome (Buser

D et al 2009).

2. Patient undergoing irradiation therapy:

Following tumour surgery in the maxillofacial region, patients may suffer from large soft

tissue and skeletal defects. Irradiation therapy provokes early (acute) and late (chronic)

changes in oral tissues, bone cells and blood vessels. In fact, not only the tumour cells

are affected, but the entire cell population. The acute changes affecting mainly soft

tissue structure and may include mucositis, dermatitis and xerostomia.


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The chronic changes affecting bone and may include cell death, increased susceptibility

to infection, delayed and impaired bone healing. Irradiation therapy should not be

considered an absolute contraindication for implant therapy, especially in the mandible

and when the total irradiation doses to the implant site less than 55 Gy.

Hyperbaric oxygen (HBO) therapy prior to implant placement (to provide support to

areas with compromised blood flow) might be advisable in some instances because it

may reduce soft tissue complications, it also might reduce failure rate in maxillary

implants but it does not seem to reduce the failure rate of implant inserted in mandible

to any greater extent. During implant candidate selection, patient with soft tissue

ulceration, exposed necrotic bone, history of protracted healing after irradiation should

be treated with extreme caution (Eposito et al 1998).

It would be very useful to find out what factors are more involved in peri-implantitis,

then management of peri-implantitis could be through the underlying factors which will

increase the chance of preventing it.

Purpose and Aims:

This study is aiming to Follow up patients diagnosed with peri-implant disease from the

time of implant placement to the time of diagnosis. Identifying associated clinical and

microbiological features of peri-implant disease. correlate and characterize more

accurately the risk factors most associated with peri-implantitis. Then to allow a better

understanding of this contribution and introduces a further knowledge of the situation.

thereby a convenient prevention methods, considerations and treatments could be

achieved.


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Methods and Materials:

Data collection of around 1000 patients with implants placed already from the archives

of the NHS and Dental Schools in the UK (or other alternative databases).

The following variables to be collected from clinical and radiographic both from paper

patient files and from the database in an individualized designed form to the possible

extent: age, gender, medical history (e.g., cardiovascular diseases, diabetes,

osteoporosis… etc, with associated medications and therapies), smoking habit (current

smoker, previous smoker, never smoked, snuff), smoking dose (heavy, moderate, light

smoker), periodontal condition (healthy, gingivitis, previous periodontitis, current

periodontitis, level of oral hygiene, incident of peri-implantitis.

Dose of smoking: Light smoking was considered 1–9 cigarettes/day, moderate 10–15

cigarettes/day and heavy smoking >15 cigarettes/day.

Level of oral hygiene performance: Suboptimal level of oral hygiene was set at O’Leary’s Plaque Index above 20%, implying more than 20% of all sites with visible plaque on consecutive recall visits. The study design is mainly a retrospective cohort study could be modified with a combination of case control study and cross sectional qualitative study. Identify a cohort that has been assembled in the past (in this study case it is the patients with implant(s) already placed), collect data on predictor variables (measured in the past), follow up the cohort, collect data on outcome variables (measured in past or present). Fig. 3

Then a modification could be applied by introducing a control group (patients with already placed implants but with no peri-implantitis), then a cross sectional qualitative study could be used while collecting data to describe the characteristics of the population.


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Data Handling and Statistical Analyses: Both descriptive statistics and statistical analyses to be performed with a statistical package such as SPSS or other alternatives statistical programs. Variables to be presented as absolute and relative frequencies (%). The statistical computational unit to be at the subject level. Clinical recordings and extracted data to be taken at site level and pooled to a mean value per patient. In all analyses, data could be normally distributed or nonparametric tests to be performed. Chi-squared tests to be applied to study associations between categorical variables. Kruskal Wallis tests to be used to study differences between the groups of a categorical variable with regard to a dependent continuous variable. Follow up Mann Whitney (MW) U tests to be performed between pairs of groups to find out which groups are statistically significant from one another. Results to be regarded statistically significant at P < 0.05. However, for the multiple Mann Whitney (MW) U, Bonferroni correction (a method used to counteract the problem of multiple comparisons. It is considered the simplest and most conservative method to control the family wise error rate) (Bonferroni C.E et al 1935) to be applied and thus used a stricter alpha level of 0.05/6 = 0.0083 for determining significance. Justification of the Study and Expected Results: This study strength lies within its study design as it guarantees that the measurement of predictor variables was not biased by knowledge of which subjects had the outcome of interest. an advantage over case control studies that all of the subjects who developed the outcome (cases) and all those who did not (control) come from the same population. Cohort designed studies can measure incidence and prevalence and this is considered a major interest in this study which resembles the anticipated outcome (e.g., incident of peri-implantitis in poorly controlled diabetes is 4.3 in every 10 around 43%, prevalence of peri-implantitis in patients over 69 years old is 58%). One of the main weaknesses is that there could be no control over the nature and the quality of the measurements that were made. Also, the existing data may not include information that is important to answer the research question. Thus, they may be incomplete, inaccurate, or measured in ways that are not ideal for answering the research question, a way to eliminate this problem was introducing a group control and/or a cross sectional qualitative study as a modification to this retrospective cohort study.

http://en.wikipedia.org/wiki/Multiple_comparisons

http://en.wikipedia.org/wiki/Familywise_error_rate


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The expected results are to have accurate measurements of incidence and prevalence to peri-implantitis and correlates it by percentages to the different systemic risk factors and local risk factors. Comparing these results with the control group by the previously mentioned analytical methods and tools. In conclusion, this study is meant to give a broader view and a better understanding of the peri-implantitis and the most effective systemic risk factors or local risk factors inducing it, leading to thoughts and suggestions of preventive methods, possible treatment and management, prognosis and both operator and patient awareness. Another beneficial outcome of this study is to have valuable collected data could be ready to use for further investigations and in future prospective trials.


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References:

- Adell R, Lekholm U, Rockler B, et al: A 15-year study of osseointegrated implants in the treatment of the edentulous jaw, Int J Oral Surg 10:387, 1981.

- Adell R, Eriksson B, Lekholm U, et al: Long-term follow up study of osseointegrated implants in the treatment of totally edentulous jaws, Int J Oral Maxillofac Implants 5:347, 1990.

- Alberktsson T, Zarb G, Worthington P, et al: The long-term efficacy of currently used dental implants: a review and prognosis criteria for success, Int J Oral Maxillofac Implants 1:11, 1986.

- Kondell, P.A., et al., The tissue-integrated prosthesis in the treatment of edentulous patients. A follow-up study. Swedish dental journal, 1988. 12(1-2): p. 11-6.

- Meijer, H.J., R.H. Batenburg, and G.M. Raghoebar, Influence of patient age on the success rate of dental implants supporting an overdenture in an edentulous mandible: a 3-year prospective study, Int J Oral Maxillofac Implants, 2001. 16(4): p. 522-6.

- Esposito, M., et al., Biological factors contributing to failures of osseointegrated oral implants. (II). Etiopathogenesis. Euro J Oral Science, 1998. 106(3): p. 721-64.

- Weyant, R.J., Characteristics associated with the loss and peri-implant tissue health of endosseous dental implants. Int J Oral Maxillofac implants, 1994. 9(1): p. 95-102.

- Taylor, G.W., M.C. Manz, and W.S. Borgnakke, Diabetes, periodontal diseases, dental caries, and tooth loss: a review of the literature. Compendium of continuing education in dentistry, 2004. 25(3): p. 179-84, 186-8, 190; quiz 192.

- Graves, D.T., et al., Diabetes-enhanced inflammation and apoptosis--impact on periodontal pathology. Journal of Dental Research, 2006. 85(1): p. 15-21.

- Consensus Report Implant Therapy II. Annals of Periodontology, 1996. 1(1): p. 816-820.

- Meffert, R.M. and D.G. Singleton, Reactors' Summary Clinical Trials on Endosseous Implants, Part I. Annals of Periodontology, 1997. 2(1): p. 314-314.

- Friberg B, Jemt T, and Lekholm U, Early failures in 4,641 consecutively placed Branemark dental implants: a study from stage 1 surgery to the connection of completed prostheses. Int J of Oral Maxillofac Implants, 1991. 6(2): p. 142-6.

- Truhlar R. S et al, Distribution of bone quality in patients receiving endosseous dental implants. J Oral Maxillofac surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 1997. 55(12 Suppl 5): p. 38-45.

- Buser D, Weber HP, Bragger U, et al: Tissue integration of one stage ITI implants: 3-year results of a longitudinal study with hollow-screw implants, Int J Oral Maxillofac Implants 6:405, 1991.

- Buser D, 20 Years of GUIDED BONE REGENERATION 2009: Quintessence.


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- Buser D, Mericske-Stern R, Bernard JP, et al: Long-term evaluation of non-submerged ITI implants. Part 1. 8-year life table analysis of a prospective multi-center study with 2359 implants, Clin Oral Implant Res 8:161, 1997.

- Lekholm U, Gunne J, Henry P, et al: Survival of the Branemark implant in partially edentulous jaws: a 10-year prospective multicenter study, Int J Oral Maxillofac Implants 14:639, 1999.

- Mombelli A, Lang NP: The diagnosis and treatment of peri-implantitis, Periodontol 2000 17:63, 1998.

- Bain CA, Moy PK: The association between the failure of dental implants and cigarette smoking, Int J Oral Maxillofac Implants 8:609, 1993.

- Beikler T, Flemming, TF: Implants in the medically compromised patient, Crit Rev Oral Biol Med 14:305, 2003.

- DeBruyn H, Collaert B: The effect of smoking on early implant failure, Clin Oral Implant Res 5:260, 1994.

- Charalampakis G, LeonhardtA°, Rabe P, Dahle´n G. Clinical and microbiological characteristics of peri-implantitis cases: a retrospective multicentre study, Clin Oral Implant Res 23, 2012, 1045–1054

- Bonferroni, C. E. "Il calcolo delle assicurazioni su gruppi di teste." In Studi in Onore del Professore Salvatore Ortu Carboni. Rome: Italy, pp. 13-60, 1935.

systemic and local factors contributing to peri-implantitis (research proposal)

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