PERI-IMPLANT DISEASE, A GROWING PROBLEM
Dr Reena Wadia
BDS Hons (Lon), MJDF RCS (Eng)
Associate at Pure Periodontics, London
Specialist Registrar in Periodontology, Guy’s Hospital, London
Dr Neesha Patel
BSc Hon (Can), BDS (Glasg), MFGDP (UK), MClinDent Periodontics (Lon), MRD RCS (Ed)
Practice Principle at Pure Periodontics
Specialist in Periodontics
Consultant Periodontist, Kings College Hospital, London
INTRODUCTION
In 1977, Brånemark et al published an article entitled ‘Osseointegrated implants in the
treatment of the edentulous jaw; experience from a 10-year period’1. 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, which 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’2. Periimplantitis is characterised by ‘inflammatory reactions with loss of supporting bone in the tissues
surrounding a functioning implant’3.
Peri-implantitis yields many features in common with chronic periodontitis4. Both involve alveolar
bone loss. However, there is a zone of connective tissues which 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 (Figure 1).
Figure 1- Periodontitis (left) versus peri-implantitis (right)5
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.6
AETIOLOGY AND RISK FACTORS
Bacterial infections play the most important role in the failure of dental implants. Bacterial flora
that are associated with periodontitis and peri-implantitis are found to be similar.7 Studies have
shown that the bacteria at the failing implant site consists of gram-negative anaerobic
bacteria, such as Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus
actinomycetemcomitans.8 The correlation between the presence of periodontitis and the
development of peri–implantitis has been supported by a recent systematic review 9,10. 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
occurs11.
Other patient-related risk factors include: inadequate oral hygiene, smoking, parafunctional
habits and underlying systemic conditions such diabetes. Biomechanical factors, such as an
occlusal overload, may play an important role 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 health12.
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.13,14
DIAGNOSIS
Early diagnosis and treatment is often the key to complete resolution of the problem. However,
although advanced cases of disease will be clearly identifiable, it is often a great challenge to
diagnose early disease 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).
Figure 2- Inflammation of peri-implant tissues15
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 and 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 indications of disease (Figure 3).15
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 definite indicator of periimplantitis (Figure 3), but it should not be confused with physiological bone remodelling around
the implant during the first year of function16. Implant mobility is an insensitive measure in
detecting early implant failure. More advanced peri-implantitis is characterised by mobility of
the fixture, indicating failure of osseo-integration.
Figure 2- Bleeding on gentle probing5
Figure 3- Evidence of ‘saucer shaped’ bone loss
around implant5
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 first phase of treatment involves the
control of acute infection and the reduction of inflammation. This involves the removal of
plaque deposits and improved patient compliance with oral hygiene until a healthy periimplant site is established. This may be sufficient 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 used17. Additionally, the systemic administration of antibiotics that specifically target
gram-negative anaerobic organisms has shown an alteration in the microbial composition and
a sustained clinical improvement18. A local delivery device with fibers containing polymeric
tetracycline has been tried and this resulted in significantly lower total anaerobic counts19.
The type of osseous defects should be identified before deciding on the surgical treatment
modality. If vertical 1 to 2-wall defects (< 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 keratinized gingiva20. 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 surface21. Various bone grafting techniques and materials and guided bone
regeneration (Figure 4), have been successfully used for the regeneration in 3-wall or
circumferential defects. Porous titanium granules have also recently been advocated to try
and treat advanced peri-implant osseous defects.
Figure 4- Peri-implant bone defect (left) and use of regeneration (right)23
When biochemical forces are considered as the main aetiological factors, occlusal
equilibration i.e. 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 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.
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