Chapter 14 Peri-implantitis: a condition of our time
In scientific and clinical circles, it is somewhat reassuring to be able to say which came first in a particular circumstance, unlike with the chicken and the egg. Periimplantitis would not be possible without implants but does that evidence help us with prevention or treatment? While it may be possible to feel smug in the knowledge that peri-implantitis only occurs in the presence of implants, the comfortable feeling wears off very quickly when one asks the questions, why does it happen and how do we treat it when it does? It is defined as an infectious disease that causes an inflammatory process in the soft and hard tissues surrounding an osseointegrated implant, leading to the loss of supporting bone. The growth in recent decades of the number of dental implants being placed has been astounding and so it is probably not surprising that there has also been an increase in peri-implantitis. With the advent of the use of titanium as a material of choice and its demonstrably effective characteristic of promoting osseointegration the ground was prepared for a true revolution in clinicians’ ability to treat tooth loss and re-establish function and aesthetics. Despite the plethora of types of implants, estimates put this in excess of 1,300, and the variety of study and research methods, the overall success rates remain high, often well above 90%, which is enviable for any procedure. Those with a pessimistic outlook continue to err on the side of caution, warning that we still do not have enough long-term evidence to be sure, whereas those patients who have enjoyed the undoubted benefits of the appliances for many years seem more quietly convinced. Risk factors There are a variety of risk factors that have to be considered before the placement of implants and which can influence the subsequent development of peri-implantitis. These include:
• Poor oral hygiene
• Tobacco use
• A history of periodontitis and noncompliance to treatment
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• Systemic conditions that are not adequately treated or controlled such as
diabetes mellitus and osteoporosis
• Post-irradiated jaws
• Parafunctional habits such as bruxism
• Iatrogenic factors; e.g. insufficient primary stability and premature loading
during the healing period.
In addition to these specific factors overall important considerations that determine success are careful patient selection and implant placement (position, number and surgical competence). Signs and symptoms As with other oral conditions, patients may not notice signs or complain of symptoms until a disease process is well established, periodontitis being an obvious example. So regular checks are required for implant patients, the frequency being dictated by the individual and some of the risk factors above. Signs that may become apparent include:
• Increase in probing depth over progressive review appointments
• Bleeding on probing and poor oral hygiene
• Presence of inflamed tissue evidenced as swelling, bleeding, colour change,
plaque/calculus accumulation
• Suppuration and exudation from peri-implant space
• Continued loss of supporting bone on follow-up radiographs
• Loss of 0.2 mm annually of supporting bone once the anticipated physiological
alveolar remodeling has taken place.
While some of these signs will be non-symptomatic, the patient may complain of some or any of the following:
• Dull aches or tenderness when brushing or on palpation
• Occasional pain from the area
• A bad taste/bad breath: possibly when exudates are present
• Increasing mobility (in cases of a failed implant)
• Swelling in the facial/oral area, e.g. due to lymphadenopathy.
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Parallels with periodontitis It is not surprising that peri-implantitis and periodontitis are mediated by similar organisms and processes, given that the anatomy and physiology of the implant surfaces and tissue environment are so similar and that the microcosm thus created is so comparable. So, does a history of periodontal disease predispose a patient to a greater risk of peri-implantitis? Research suggests that this is not the case, the more important factor being on-going good oral hygiene and effective plaque control rather than a history of periodontal pocketing, as a recent study has reinforced1. This observation finds support too from a different angle in Cochrane Collaboration studies2,3. These have indicated that despite the huge range of available implants alluded to above, and despite their variety of smooth and roughened surface properties (much played upon in the rivalry of competing manufacturers) there is no evidence to date that one pattern has an overall superiority to any other. This contrasts with Cochrane conclusions in other areas where the superiority of powertoothbrushes in plaque removal might well be of particular value in the prevention of peri-implantitis4. Investigations Given that implant treatment is time consuming, technically challenging and expensive patients are naturally concerned when it is suspected that all is not well. Investigations therefore need to be fully explained to the patient as well as possible outcomes. This needs to be done with care and sensitivity. Although covered in the original examination and assessment, verify whether iatrogenic factors have changed such as faulty restorations or impacted foreign material. Assess too whether biomechanical forces are in balance by evaluating the occlusion for the presence of parafunction or occlusal overload. There may be mobility and if so removal of the restoration such as a crown may be necessary to establish if it fractured or if the implant itself is fractured. Checking for active periodontitis in other sites is routine but has this occurred or reoccurred since the previous review? Are there other pathologies of the bone? In some cases it may be necessary to perform exploratory surgery. The only differential diagnosis is for peri-implant mucositis.
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Treatment options In the event that peri-implantitis is diagnosed, there are several treatment choices available, although again as Cochrane indicates3 there is no clear gold-standard in terms of positive outcome for any of these to date. As with the treatment of periodontal disease, the steps are first to try and reduce the adverse microbial load in plaque, followed by more radical surgical intervention. Culturing of the plaque and antibiotic therapy can prove effective but continuing good oral hygiene by the patient is also seen as crucial. Resective treatment to reduce pocket depth and enable improved patient access is the initial surgical response but finally, removal of the implant may be the only solution to the continuing bone loss; albeit the one that neither patient nor clinician desire. The long-term goals are to stop the progression of the disease and maintain the implant site. Depending on the aetiology of the problem, a specific treatment is selected. Appropriate management of peri-implantitis often requires referral to a periodontist. Any acute bacterial infection should be controlled to reduce tissue inflammation through mechanical debridement, localised and/or systemic antimicrobial therapy and most importantly improved patient compliance with oral hygiene until a healthy peri-implant site is established. At re-evaluation, if the patient does not have a satisfactory response to the nonsurgical therapy, surgery should be considered. Detoxifying the implant surface can be undertaken using mechanical devices (e.g., high pressure air powder abrasive, laser decontamination) and/or by applying chemotherapeutic agents (e.g., supersaturated citric acid or tetracycline applied with cotton pellets or a brush). In terms of periodontal surgical approaches, flap management can be performed with either (or both) resective and regenerative approaches, depending on the morphology and size of the bone destruction5. However, just as in any other clinical field of decision making, the treatment provided depends as much on professional culture and attitude as on the condition itself. A study recently published, for example, indicated differences of attitude between periodontists in the UK and Australia in terms of aetiology, prevalence, diagnosis and management of peri-implantitis6. Most specialists in both countries identified the prevalence of peri-implant pathology at between 0-25% but although there was agreement as to the role of plaque in the pathogenesis of the diseases, UK specialists were more likely to include adverse loading and smoking as aetiological factors.
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The summary is tediously familiar. In spite of our advances in technical ability and scientific knowledge one universal truth still holds good; prevention is better than cure and optimal plaque control reigns supreme. Chicken, egg or micro-organism? References
1. Cho-Yan Lee J et al. Residual periodontal pockets are a risk indicator for peri-
implantitis in patients treated for periodontitis. Clin Oral ImplantsRes 2012; 23:
325-333.
2. Esposito M et al. Interventions for replacing missing teeth: different types of
dental implants. Cochrane Database of Systematic Rev 2007, Issue 4. Art. No.:
CD003815.
3. Esposito M et al. Interventions for replacing missing teeth: treatment of peri-
implantitis. Cochrane Database Syst Rev 2010; (6): CD004970, 2012.
4. Robinson PG, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington
HV, Glenny AM, Shaw WC. Manual versus powered toothbrushing for oral
health. Cochrane Database Syst Rev 2005; Apr 18; (2): CD002281.
5. Hsu A and Kim. How to manage a patient with peri-implantitis. J Can Dent
Assoc 2014; 79: e24.
6. Mattheos N, Collier S, Walmsley AD. Specialists’ management decisions and
attitudes towards mucositis and peri-implantitis. Br Dent J 2012; 212: E1 (2012).
Published online: 13 January 2012 | doi:10.1038/sj.bdj.2012.1
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