Dental Implants: Peri-Implant Mucositis & Peri-Implantitis

• A dental implant is a nonbiologic device surgically inserted into the jawbone, replacing a tooth or providing support for multiunit prosthesis.
• A dental hygienist plays an important role in patient education and dental implant maintenance.
• Dental implants replace individual or multiple teeth, supporting fixed bridges or removable dentures.

Anatomy of an Endosteal Dental Implant

• The implant body is the "root" of the implant surgically placed in the living alveolar bone.
• The abutment is a titanium post attaching to the implant body.
• The abutment protrudes partially or fully through the gingival tissue and supports the crown or denture, biocompatible with the body.
• The components of the implant system are the implant body/fixture, abutment, and prosthetic crown/prosthesis.
• The implant body is surgically placed into living alveolar bone and acts as the "root" of the implant.
• Implant body are usually made of titanium or titanium alloy, lightweight, biocompatible, noncorrosive, and poor conductors.
• Titanium implant body might be softer than other dental restorative metals, easily scratched, and can cause inflammatory reactions.
• Ceramics like zirconia serve as alternative materials, with better outcomes for patients with thin gingival phenotype.
• The implant abutment is a metal post that connects the prosthesis to the implant body, secured in place, and protrudes into the oral cavity.
• Implant abutments can be made of titanium or zirconia (ceramic).

Peri-Implant Tissues

• Hard and soft tissues that surround the implant.
• Junctional epithelium attaches to the implant or abutment surface which serves as a biologic seal.
• Connective tissue runs parallel to the implant or abutment, or encircles the structure.
• No periodontal ligament or cementum exists.
• Alveolar bone is in direct osseointegration contact with the implant.
• Epithelium adapts to the abutment post or implant, creating a cuff-like perimucosal biological seal, functioning as a barrier between the implant and oral cavity.
• The sulcus is lined by sulcular epithelium, and the junctional epithelium surrounds the implant abutment or collar.
• The implant surface lacks cementum.
• On natural teeth, supragingival fibers brace the gingival margin and periodontal ligament suspends the tooth in its socket, and fibers are a barrier to infection.
• Supragingival fiber bundles support healthy gingiva against the abutment.
• There are no periodontal ligament fibers.
• Periodontal probe passes easily through the inflamed peri-implant soft tissues to apical connective tissue or close to peri-implant alveolar bone.
• Osseointegration is the direct contact of living bone with the implant body surface.
• Criteria includes absence of clinical mobility, no discomfort/pain, no increased bone loss, and <0.2mm of bone loss annually after the first year to determine success.

Peri-Implant Health

• Characterized by the absence of erythema, bleeding on probing, swelling, and suppuration.
• There are no visual differences between healthy peri-implant tissues and healthy periodontal tissues.
• Probing depths may be deeper at a healthy implant site.

Peri-Implant Mucositis

• Plaque biofilm-induced inflammation of soft tissues with no loss of supporting bone, localized around the dental implant.
• It occurs in 80% of patients and 50% of sites, reversing when etiologic factors are removed.
• Diagnosis requires visual soft tissue inflammation signs, bleeding and/or suppuration upon probing, increased probing depths, and absence of bone loss.
• Features knifed-edge tissue, rounded and thickened tissue, and no signs of significant pathology.

Peri-Implantitis

• It is periodontitis affecting soft and hard tissues surrounding functioning osseointegrated dental implant.
• Characterized by plaque biofilm-induced inflammation and progressive alveolar bone loss.
• Onset may occur early during follow-up, progressing in a nonlinear, accelerating pattern.
• A diagnosis comes through detecting radiographic bone loss around implant that range from 6.61% to 47%. Residual cement could also suggest peri-implantitis.
• Other diagnostic criteria include visual signs of inflammation, bleeding and/or suppuration, progressive bone loss comparing baseline to 12 months, or lack of baseline information showing radiographic evidence ≥ 3mm / probing depths ≥ 6mm.
• Bone resorption occurs after tooth loss, which leads to hard-tissue deficiencies.
• Contributing factors include loss of periodontal support, endodontic infections, thin buccal bone plates, extraction with additional trauma, traumatic injury systemic diseases impairing normal bone remodeling, pneumatization of maxillary sinus.
• Peri-implant mucositis results primarily from biofilm-induced infection and is considered a precursor to peri-implantitis.
• Peri-implantitis is a result of overwhelming bacterial infection, progresses similar to periodontitis, but no single microorganism implicated as the causative agent.

Risk Factors

• History of previous periodontal disease
• Poor plaque biofilm control and lack of regular maintenance therapy
• Smoking
• Residual cement
• Biomechanical forces and overload
• Spatial placement of implants
• Implants can fail because of ill fitting prosthesis that result in occlusal interference with protrusive movements.
• Positioning of implants to close together or to far facially.
• Soft tissue indicators of a failing implant include peri-implant pocket, bleeding after probing, and suppuration.
• Implant mobility is the best indicator for implant failure.
• Radiographic signs include vertical destruction of crestal bone, wedge-shaped defects, and bone loss.
• Available treatment methods include nonsurgical periodontal instrumentation, antiseptics/ chlorhexidine, local and/or systemic antibiotics, and access flap surgery & bone grafting.
• There is no standard protocol.
• Using nonsurgical periodontal instrumentation with local minocycline or chlorhexidine can he helpful.
• Subgingival glycine air powder polishing to remove biofilm may reduce inflammation.

Probing

• Initial to asess peri-implant tissues after the final restoration is installed; some surgeons avoid any until healing is complete after abutment connection.
• It is recommened to use light force since the peri mucosal seal is weakly adherent to the titanium surface.
• Plastic probes are often preferred, but metal probes are okay if pressure is kept light.

Bleeding and Suppuration

• Indicators of peri-implant tissue inflammation and improve biofilm removal.
• The presence of bleeding or increased probing depth warrants radiographic assessment.
• All locations must be recorded.
• Radiographs should be taken prior to cementation and when implant crown is on.
• It is also recommended to take post-prosthetic insertion x-ray when cement is present and to include follow-up approximately once a year.
• Baseline radiographs include placing initial implant, placing final prosthesis, and during implant maintenance.

Goals of Maintenance Therapy

• Maintenance of alveolar bone support
• Control of inflammation
• Healthy implant
• Fully functional neighboring teeth

Dental Appointment Maintenance

• Modern implants can be difficult to recognize so the exact locations must be documented in the chart clearly.
• Update radiographs annually prior to instrumentation
• Supragingival scaling with traditional instruments
• Subgingival scaling with titanium metals/instruments.
• Individualized treatment plans depends on previous examinations, evaluation of peri-implant tissue health/stability, any occlusal issues, self care assessments, and a radiographic examination.
• A 3-month maintenance interval for the first year and then every 3 to 6 months unless there is less bone support.
• Patients with fixed or removable, supported restorations - should see someone every 6 months.
• Meticulous care is vital for long-term implant care so instruction in self-care techniqes for natural/ supported teeth should alwasy me demonstrated.
• The material compatible with dental implants.
• Air is an important component of the oral aids used.
• Do not use routine implants, abutments, but improve titanium that would only be surface.
• Use dental abrasives for rough implants (glycine is always great!)
• Preventing care is important because neglect/poor plaque controls the source of the infection.
• Fixed prosthetic crowns sit over implants.
• Patients challenge with adaptation in the crowns when they mimic natural tooth function.
• Patients need to use floss along margins.
• Restore to resemble to be used to fix with dentures and complex prostheses.
• Standard soft toothbrush.
• Power toothbrush with titanium
• Interdental brushes for biofilm removal.
• Floss and irrigators subgingivally. Antimicrobial to care for everything at the end.
• Traditional dentures.
• O-rings and magnets, with clips.
• Removable.
• Tools: Titanium!
• Fewer devices!
• Selective easy to use!
• Tufted floss to use to clean or gauze
• Tufted is helpful!

Test your knowledge of peri-implant mucositis and peri-implantitis, including characteristics and diagnostic criteria. Learn about the causes and diagnostic processes associated with these conditions, as well as implant body materials.