Peri-Implantitis: A Comprehensive Guide PDF

PERI-IMPLANTITIS Learning objectives Describe the etiology and the pathology of peri-implantitis Record and interpret clinical and radiographic information relating to peri-implantitis and diagnose peri-implantitis Formulate relevant research questions ADEE Learning outcomes 3.1.1, 3.2...

PERI-IMPLANTITIS Learning objectives Describe the etiology and the pathology of peri-implantitis Record and interpret clinical and radiographic information relating to peri-implantitis and diagnose peri-implantitis Formulate relevant research questions ADEE Learning outcomes 3.1.1, 3.2.5, 3.2.8, 3.2.9, 5.1.1 Peri-implantitis (Source Berglundh et al 2015) Diagnosis of peri‐implantitis indicated by the clinical finding of bleeding on probing and radiographic bone loss. (Source Berglundh T. et al 2022) Clinical appearance of a peri‐implant infection with suppuration and bleeding following probing of the deep (>6mm) peri‐implant pocket (Source Heitz-Mayfield et al 2015) Supramucosal peri‐implant biofilm accumulation and associated peri‐implant infections. (a) Biofilm present on the implant supported bar and implant abutments. (b) Biofilm present on the titanium abutment surfaces and exposed implant threads (Source Heitz-Mayfield et al 2015) Clinical symptoms of peri‐implantitis. Note the large amounts of plaque and calculus and visible signs of inflammation in the peri‐implant mucosa (Source Berglundh et al 2015) PERI‐IMPLANTITIS IS: A plaque‐associated pathological condition occurring in tissues around dental implants. Characterized by inflammation in the peri‐implant mucosa and subsequent progressive loss of supporting bone (Berglundh et al 2018) Prevalence varies from 14-30% (Derks and Tomasi 2015)  CLINICAL CHARACTERISTICS OF PERI‐IMPLANTITIS Peri‐implantitis sites exhibit clinical signs of inflammation, bleeding on probing and/or suppuration, increased probing depths and/or recession of the mucosal margin in addition to radiographic bone loss compared to previous examinations. At sites presenting with peri‐implantitis, probing depth is correlated with bone loss and is, hence, an indicator for the severity of disease. It is important to recognize that rate of progression of bone loss may vary between patients. (Berglundh et al 2018) ❖ Peri‐implant mucositis is assumed to precede peri‐implantitis. ❖ Data indicate that patients diagnosed with peri‐implant mucositis may develop peri‐implantitis, especially in the absence of regular maintenance care. ❖ Evidence from observational studies shows that patients exhibiting poor plaque control and not attending regular maintenance therapy are at higher risk of developing peri‐implantitis. ❖ The features or conditions characterizing the progression from peri‐implant mucositis to peri‐implantitis in susceptible patients have not been identified. (Berglundh et al 2018) ❖ The onset of peri‐implantitis may occur early during follow‐up as indicated by radiographic data. ❖ Peri‐implantitis, in the absence of treatment, seems to progress in a non‐linear and accelerating pattern. ❖ Data suggest that the progression of peri‐implantitis appears to be faster than that observed in periodontitis. (Berglundh et al 2018) DOES PROGRESSIVE CRESTAL BONE LOSS AROUND IMPLANTS OCCUR IN THE ABSENCE OF SOFT TISSUE INFLAMMATION? ❑ Observational studies have indicated that crestal bone level changes at implants are typically associated with clinical signs of inflammation. ❑ However, there are situations in which peri‐implant bone loss may occur due to iatrogenic factors, including malpositioning of the implant or surgical trauma. (Berglundh et al 2018) ARE THERE ANY SPECIFIC MICROBIOLOGICAL AND IMMUNOLOGICAL CHARACTERISTICS OF PERI‐IMPLANTITIS? No specific or unique bacteria or proinflammatory cytokines have been identified (Berglundh et al 2018) WHAT ARE THE MAJOR RISK INDICATORS FOR PERI-IMPLANTITIS? ▪ There is strong evidence that there is an increased risk of developing peri‐implantitis in patients who have a history of severe periodontitis, poor plaque control, and no regular maintenance care after implant therapy. ▪ Data identifying smoking and diabetes as potential risk indicators for peri‐implantitis are inconclusive. (Berglundh et al 2018) ▪ People with diabetes should be informed of an increased risk for peri-implantitis (Herrera et al 2023) ▪ There is some limited evidence linking peri‐implantitis to factors such as post‐restorative presence of submucosal cement and positioning of implants that does not facilitate oral hygiene and maintenance. ▪ The role of peri‐implant keratinized mucosa, occlusal overload, titanium particles, bone compression necrosis, overheating, micromotion and biocorrosion as risk indicators for peri‐implantitis remain to be determined. (Berglundh et al 2018) ▪ Implants that have been placed under less than ideal circumstances are often encountered in day‐to‐day practice. As a result, there may be an increased prevalence of peri‐implantitis associated with these situations. (Berglundh et al 2018)  DEFINITION OF A CASE OF PERI‐IMPLANTITIS IN DAY‐TO‐DAY CLINICAL PRACTICE Diagnosis of peri‐implantitis requires: Presence of bleeding and/or suppuration on gentle probing. Increased probing depth compared to previous examinations. Presence of bone loss beyond crestal bone level changes resulting from initial bone remodeling. (Berglundh et al 2018)  DEFINITION OF A CASE OF PERI‐IMPLANTITIS IN DAY‐TO‐DAY CLINICAL PRACTICE In the absence of previous examination data diagnosis of peri‐implantitis can be based on the combination of: Presence of bleeding and/or suppuration on gentle probing. Probing depths of ≥6 mm. Bone levels ≥3 mm apical of the most coronal portion of the intraosseous part of the implant. ❑ Visual signs of inflammation can vary and that recession of the mucosal margin should be considered in the probing depth evaluation. (Berglundh et al 2018) ❖ Studies on treatment of peri‐implantitis reveal that anti‐infective treatment strategies are successful in decreasing soft tissue inflammation and in suppressing disease progression. (Berglundh et al 2018)  HISTOLOGICAL CHARACTERISTICS OF PERI‐IMPLANTITIS Peri‐implantitis lesions extend apical of the junctional/pocket epithelium and contain large numbers and densities of plasma cells, macrophages and neutrophils. In addition, peri‐implantitis lesions are larger than those at peri‐implant mucositis sites. (Berglundh et al 2018)  Peri‐implantitis initially affects the marginal part of the peri‐implant tissues and the implant may remain stable and in function for varying periods of time (Berglundh et al 2015) Implant mobility is not an essential symptom for peri‐implantitis, but may occur in the final stage of disease progression and indicates complete loss of integration. (Berglundh et al 2015) Progression of peri‐implantitis is more pronounced at implants with rough than at those with smooth surfaces. (Berglundh et al 2015) ▪ Peri‐implantitis lesions are poorly encapsulated, can lead to increased probing depth, extend to the marginal bone tissue, and may, if allowed to progress, lead to the loss of the implant (Berglundh et al 2015). ▪ The large numbers of neutrophils in the peri‐implantitis lesion and the absence of an epithelial lining between the lesion and the biofilm, indicate that the peri‐implantitis lesions have features that are different from those of periodontitis lesions (Berglundh et al 2015)  (a) (b) (a) Clinical photograph showing an implant supported prosthesis where there is inadequate access for plaque removal and an associated peri‐implant infection (suppuration and bleeding). (b) Clinical photograph after remodeling of the implant‐supported prosthesis to enable access for plaque removal (Source Heitz-Mayfield et al 2015)  (a) (b) Clinical photographs from an implant‐supported crown in the premolar position in the left side of the mandible. (a) No or minor signs of inflammation in the surrounding mucosa. (b) Probing resulted in bleeding and suppuration from the implant site in the lateral incisor position. (Source Berglundh et al 2015) ❖ Bone loss around implants appears to be symmetric, that is there is a similar amount of bone loss at mesial, distal, buccal, and lingual aspects of the implants (Berglundh et al 2015). The bone defects often appear crater-like (Clerehugh et al 2024) ❖ The morphology of the osseous defect, may vary depending on the buccal–lingual (palatal) dimension of the alveolar ridge: In sites where the width of the ridge exceeds that of the peri‐implantitis lesion, a buccal and lingual bone wall may remain and a crater form. In sites with a narrow ridge, the buccal and lingual bone will be resorbed and lost during progression of peri‐implantitis (Berglundh et al 2015)  Crater-formed bone destruction Swelling and suppuration RADIOGRAPHIC EXAMINATION OF DENTAL IMPLANTS ❑ It is recommended that the clinician obtain baseline radiographic and probing measurements following the completion of the implant supported prosthesis. ❑ An additional radiograph after a loading period should be taken to establish a bone level reference following physiological remodeling. (Berglundh et al 2018) Decks et al., (2022) mention an additional radiograph obtained after an initial (one‐year) function period may then serve as an ideal baseline as physiological remodeling will be completed. ❑ If the patient presents for the first time with an implant‐supported prosthesis the clinician should try to obtain clinical records and previous radiographs in order to assess changes in bone levels (Berglundh et al 2018)  HARD ‐ AND SOFT‐TISSUE DEFICIENCIES Main factors associated with hard‐ and soft‐tissue deficiencies at potential implant sites? The healing process following tooth loss leads to diminished dimensions of the alveolar process/ridge representing hard and soft‐tissue deficiencies.  HARD ‐ AND SOFT‐TISSUE DEFICIENCIES Larger deficiencies may occur at sites exposed to the following factors: loss of periodontal support, endodontic infections, longitudinal root fractures, thin buccal bone plates, buccal/lingual tooth position in relation to the arch, extraction with additional trauma to the tissues, injury, pneumatization of the maxillary sinus, medications, and systemic diseases reducing the amount of naturally formed bone, agenesis of teeth, pressure from soft‐tissue supported removable prosthesis, and combinations. What factors are associated with recession of the peri‐implant mucosa? The principal factors for recession of the peri‐implant mucosa are: malpositioning of implants, lack of buccal bone, thin soft tissue, lack of keratinized tissue, status of attachment of the adjacent teeth and surgical trauma. (Berglundh et al 2018) Does the presence/absence of keratinized mucosa play a role in the long‐term maintenance of peri‐implant health? The evidence is equivocal regarding the effect of keratinized mucosa on the long‐term health of the peri‐implant tissue. It appears, however, that keratinized mucosa may have advantages regarding patient comfort and ease of plaque removal. (Berglundh et al 2018)  What is the role of the peri‐implant bone in giving form to the peri‐implant soft tissues? The papilla height between implants and teeth is affected by the level of the periodontal tissues on the teeth adjacent to the implants. The height of the papilla between implants is determined by the bone crest between the implants. Results are equivocal whether the buccal bone plate is necessary for supporting the buccal soft tissue of the implant in the long‐term. (Berglundh et al 2018)