Peri-implantitis etiology, diagnosis and management

Full text

Peri-implantitis
Hotel Monroe Beirut - Lebanon
21 September 2010
ITI Middle East Section Meeting

Introduction
Definition and
clinical diagnosis
Management
Prevention

Oral implants have enjoyed high clinical success rates over the last decade,
with an explosion of numerous surfaces and designs of implants all claiming
to have superior quality over another.
Introduction
It should be recognized however, that clinical complications or failures do
occur and as such, a challenge is posed to the clinician in terms of initial
diagnosis of peri-implant diseases and subsequent management.

A peri-implant disease is a descriptive term used to describe a non specific
inflammatory reaction in the host tissues.
Introduction
“Peri-implantitis” should be distinguished from “peri-implant mucositis” in
that the former is defined as, “an inflammatory reaction with loss of
supporting bone in the tissues surrounding a functioning implant”,4 while
the latter involves a reversible inflammation localized to the soft tissues
only.
Peri-implantitis may display some or all of the following symptoms;
bleeding on probing, increased probing pocket depth, mobility, suppuration
and pain.

Introduction

The trends show that there is a “cluster phenomenon” whereby peri-
implantitis failures tend to occur in a subset of patients, similar to that seen in
chronic periodontitis.**
•A systematic review of the incidence of biological and technical complications in implant dentistry reported
in prospective longitudinal studies of the last 5 years. (Berglund T, Person L, Kline B. J Clin Periodontal 2002;
** A long term survey of tooth loss in 600 treated periodontal patients. (Hirschfield L, Wasserman B. J
Periodontal 1978
Introduction
The incidence of peri-implantitis is quite rare, ranging from 2-10%.*
Though this condition is somewhat rare at present, there is little doubt
that as the length of time of implants in vivo increases, the incidence of
this condition will also increase.

There is a statistically significant higher incidence of peri–implantitis for
implants placed in patients with a history of chronic periodontitis (28.6%)
compared with periodontally healthy individuals (5.8%).* The correlation
between the presence of periodontitis and the development of peri–
implantitis has been supported by a recent systematic review.**
*Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri–
implantitis: a systematic review. J Clin Periodontol 2008; 35: 621–629.
**Renvert S, Persson GR. Periodontitis as a potential risk factor for peri–
implantitis. J Clin Periodontol 2009; 36 (Suppl. 10): 9–14.
Introduction

Therefore it is not surprising that the treatments suggested for peri-implantitis
are based on the available evidence on the treatment of periodontitis.
Peri-implant diseases: Consensus Report of the Sixth European Workshop on
Periodontology. 2008 Jan Lindhe, Joerg Meyle.
Introduction

Management of perimplantitis generally works on the assumption that there
is a primary microbial etiology. Furthermore, it is assumed that micro-
organisms and/or their byproducts lead to infection of the surrounding tissues
and subsequent destruction of the alveolar bone surrounding an implant. *
* Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Periodontol
2000 2002; 28:177-189.
Introduction

Definition
Inflammatory reaction in the mucosa surrounding an implant with signs of loss
of supporting bone.
(Zitzmann & Berglundh 2008 Journal of Clinical Periodontology 6'Th European workshop
on Periodontology)
Peri-implantitis

Diagnosis of peri-implantitis relies on crude parameters commonly used for
the diagnosis of periodontal diseases.
Typical signs and symptoms of peri-implantitis include; *
Clinical Diagnosis
* Etiology, diagnosis, and treatment considerations in peri-implantitis. (Mombelli, A. Curr- O pin
Periodontal 1997; 4:127-136)
** The diagnosis and treatment of peri-implantitis.( Mombelli A, Lang NP..
Periodontal 2000 1998; 17:63-76)

Evidence of vertical destruction of the
crestal bone.
Formation of a peri-implant pocket (>
4mm),
Bleeding or suppuration after gently
probing,
Tissue redness and swelling
Mobility (insensitive in detecting early
implant failure).

Clinical Diagnosis
Clinical signs of peri-implantitis may not always be evident. Standardized
radiographs are suggested one year after fixture placement and every
alternate year thereafter.*
•Dental implants:
maintenance, care and
treatment of peri-implant
infection.
Chen S, Darby I. Aust
Dent J 2003; 48(4):212-
220.

Clinical Diagnosis

Microbiology
Numerous animal and human studies have clearly shown that bacterial
plaque which is allowed to build up on implants leads to inflammatory
changes of the adjacent soft tissues.
An early study, which compared the microbiota surrounding successful and
failing titanium implants found that failing sites had a significantly higher
proportion of micro-organisms traditionally associated with periodontal
diseases.
The relationship between these inflammatory changes in the soft tissues
and subsequent progression to involve bone loss that is observed in peri-
implantitis is not clarified.

Gram negative anaerobic rods, spirochaetes and fusiform bacteria were found
in higher proportions at peri-implantitis sites as compared with healthy sites,
which were predominantly composed of coccoid forms.*
Microbiology

The clinical implication is, if traditional periodontal pathogens are found, then
the disease process could be similar to periodontal disease and patients
with a history of chronic periodontitis may be at increased risk of peri-
implantitis. It is suggested, that the microbiology associated with implants
are related to the bacteria already resident in the oral cavity, that is, that the
remaining teeth can act as reservoirs for seeding of bacteria in the peri-
implant tissues.

* Mombelli A, Van Oosten MAC, Schurch E, Lang NP. The microbiota associated with
successful or failing osseointegrated titanium implants. Oral Microbial Immanuel 1987;
2:145-151.
Traditional periodontal pathogens such as Porphyromonas gingivalis (Pg),
Actinomyces actinomycetemcomitans (Aa) and Prevotella intermedia (Pi)
have been shown to colonize the peri-implant sulcus from 1 to 3 months
after exposure to the oral environment.*
Microbiology

Management
An explosion of human and animal studies in the last 20 years has addressed
the issue of treatment of peri-implant infections, with little scientific evidence to
support a specific treatment modality (for review see Roos-Jansåker et al.
2003).34 Management of periimplantitis generally works on the assumption
that there is a primary microbial etiology.
Furthermore, it is assumed that micro-organisms and/or their byproducts
lead to infection of the surrounding tissues and subsequent destruction of
the alveolar bone surrounding an implant. Mombelli (2002),8

(1) The disturbance and/or removal of the bacterial biofilm in the peri-
implant pocket
(2) “Decontamination” and conditioning of the surface of the implant
(3) Correction via reduction or elimination of sites that cannot be adequately
maintained by oral hygiene measures
(4) Establishment of an effective plaque control regime
(5) Re-osseointegration
suggests five considerations in the therapy of peri-implantitis:
Management

A hygienic phase should be started which will improve the patient's
hygiene level through a process of remotivation and reinstruction with
regard to plaque control.
The implant neck should be accessible to the patient so that hygiene
can be maintained even if this means modifying the superstructures.*
Management
* Non-surgical treatment of peri-implant mucositis and peri-implantitis: a literature review.
Renvert S, Roos-Jansaker A-M, Claffey N. 2002

Management

The “cumulative interceptive supportive therapy”(CIST),37 suggests a
protocol for the monitoring of healthy implants and the interception of peri-
implant diseases (Fig.3).
Management
This protocol relies on PPD, BOP and radiographic evidence of bone loss.
As each parameter becomes more severe, more complex treatment is
introduced, with each subsequent treatment incorporating that of the
previous.
For example, according to this protocol, if a PPD of 6mm is displayed,
positive for BOP and greater than 2mm bone loss, combination therapy of A
+ B + C + D is instituted.

•Protocol A (mechanical debridement) : In case of implants with
evident plaque and/or calculus deposits adjacent to only slightly
inflamed periimplant tissues (Bleeding On Probing is positive)
•Protocol B (antiseptic treatment): It is performed in
situation where in addition to plaque and BOP, probing
depth in increased up to 4-5 mm. Chlorhexidine
digluconate either in the form of daily rinse of 0.1%,
0.12% or 0.2 or as a gel applied to the site of desired
action.
Management
Cumulative interceptive supportive therapy (CIST) protocol is divided into
four stages of treatment: **

•Protocol C (antibiotic treatment): When probing depth value of the
periimplant sulcus or pocket increases to 6 mm or more. Beside
the protocol A and B, an antibiotic directed at the elimination of
gram negative anaerobic bacteria is administrated.
•Protocol D (regenerative or resective therapy): Only if
infection is controlled successfully by A, B and C as evidenced
by an absence of suppuration and reduced edema. It is aimed
to restore the bony support of the implant by means of
regenerative techniques. **
Management
E. Explantation using specially designed instruments

Management

Decision trees for the diagnosis and interception of peri-implantitis have
been suggested and the complexity of some of these regimes is reflective
of our current understanding(or lack of) about the etiology of peri-
implantitis.
Management

*PD denotes probing depth, and BOP bleeding on probing
Implant reconstructions in periodontally susceptible patients, Stanley Man-Lung Lai *, Kwan-Yat Zee), Esmonde F.
Corbet Hong Kong Dental Journal 2008;5:11-8
Decision tree for C.I.S.T

A systematic review for 25 animal studies for re-osseointegration on
previously contaminated surface gives the following results (Renvert et al.
2009 Clinical Oral Implants Research)
Recent Study
•Open flap debridement combined with implant surface decontamination is
scarcely documented.
•No single method of implant surface decontamination (e.g. hydrogen
peroxide, saline irrigation, Chlorhexidine irrigation, citric acid, air-powder
abrasive, and laser) can be considered superior.

•A complete fill of the osseous defect by applying the principles of GBR is
unpredictable, only a partial resolution of the defect may be expected. *
•Regenerative procedures using bone grafts, bone substitutes or GBR do
not yield predictable outcomes.
•It is unknown whether the use of systemic antibiotics is required or not.
Recent Study
•Biologic complications, prevention and management, Giovanni E. Salvi.
(ITI World Symposium, 2010)

The main issue is prevention
Prevention
1 ) Suitable patient selection
2 ) Infection control
Implants should not be placed if the
infection cannot be controlled by the
dentist or by the patient.
Great care should be taken with implant placement so as to avoid damaging
the host bone. The implant must at no time be contaminated in order to
prevent retrograde peri-implantitis.

3 ) Hygienic restoration design
The prosthetic reconstruction must be placed in such way that it is accessible to
hygiene at the periimplant area.
Accessibility

Not hygienic restoration design (but with good aesthetics) -
Poor design led to high risk of failure

Not accessible crowns and consecuent bone destruction led
to high risk of failure
In cases where aesthetics and hygiene come into conflict, the patient should be
informed about the consequences that restoration with no access to hygiene can
lead to failure.

4 ) Periodic recall visits
Periodical clinical examination should
include:
Probing: Bleeding on probing is
indicative of mucosal inflammation and
is a warning sign us about supporting
tissue loss.
Check up for presence of suppuration.
Radiographs. They should be taken to
evaluate the supporting bone levels,
especially when all the clinical symptoms
suggest the presence of peri-implantitis.

5 ) Early detection of pathologies
Pathologies should be treated at an early stage. The sooner they are
detected, the simpler the treatment will be.
References:
Peri-implant diseases: diagnosis and risk indicators. Heitz-Mayfield LJA.
Peri-implantitis in partially edentulous patients: association with inadequate plaque control. Giovanni Serino,
Christer Ström

Conclusions
Peri-implantitis is arguably one of the most significant risk factors associated
with late implant failures.
The relevance, contribution and impact of other factors such as implant
surfaces, smoking, history of chronic periodontitis and occlusal loading remains
obscure and undoubtedly further long term studies are necessary for
clarification.
Despite a projected increase in the incidence of peri-implantitis, the clinician
is faced with a difficult decision-making process from beginning to end. It must
be recognized that peri-implantitis is a multifactorial disease process, which may
include factors such as, host immune response and susceptibility, microbiology,
host modifying factors and local environment.

So far, single case presentations have provided evidence that bone fill of
perimplantitis defects resulting from previous perimplantitis may be achieved
following anti infective therapy and using biological principle of guided tissue
regeneration GTR
(Lehmann et al 1991; Hammerle et al 1995; Persson et al 1996).
However, the re-osseointegration of a previously contaminated implant surface
into regenerated bone has not yet been demonstrated hisotologically
(Wetzel et al. 1999).
Nevertheless, the fact that new bone does fill osseous defects, as documented
by an increase in radiographic bone density, represents a healing process most
likely resulting in further implant stability over time*1.
Conclusions

Clinical Case

Peri-
Implantitis

Protocol
A,B,C,D

Loading

3 Years
Follow up

X-Rays
Review

Limited scientific evidence is available to endorse or recommend a specific
modality for treatment and it seems that like periodontal disease, one
regime may be successful in one patient and not another.
Take home message
Until further research is available, the clinician should make a clinical
judgment based on the individual case using a rational and evidence-
based approach.
C.I.S.T protocol therapy can facilitate remodeling adjacent to the bone-
implant interface; the dynamic nature of the bone and its ability to respond to
changes can bring long term success if treated adequately with patience. In
the previous shown case C.I.S.T protocol was rigidly followed which resulted
in salvaging an otherwise lost implant.
Illustrations and demo pictures adapted from internet open
sources.

Clinical case pictures is courtesy of Dr. Ninette Banday, Dr. Abdul Naser Tamim, Dr. Arif Ali Al Juniabi
Thank you
Dr. Abdul Naser Tamim &
Dr. Arif Al Junaibi
atfahmi@ahs.ae
aali@ahs.ae

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with dental implants: their prevention, diagnosis and treatment. Corbet 2000
Clinical Oral Implants Research Supplement No.1 Volume 11. 2000.
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29(3):197-212.
9. Mombelli A, Lang NP. Antimicrobial treatment of peri-implant infections . Clin
Oral Implants Res 1992; 3:162-168.
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