Dental Implant vs. Natural Tooth: Periodontal Perspective PDF

DENTAL IMPLANT VS NATURAL TOOTH: PERIODONTAL PERSPECTIVE LAUREN SPEVACK BSC, DMD, CERT. PERIO., FRCD(C), DIP. ABP MCGILL UNIVERSITY – SEPTEMBER 29, 2023 DR. LAUREN SPEVACK Ÿ PERIODONTIST BSc. DMD. Cert. Perio. FRCD(C). Dip. ABP Email: [email protected] La Clinique Paro Westmount 4458 Sherbro...

DENTAL IMPLANT VS NATURAL TOOTH: PERIODONTAL PERSPECTIVE LAUREN SPEVACK BSC, DMD, CERT. PERIO., FRCD(C), DIP. ABP MCGILL UNIVERSITY – SEPTEMBER 29, 2023 DR. LAUREN SPEVACK Ÿ PERIODONTIST BSc. DMD. Cert. Perio. FRCD(C). Dip. ABP Email: [email protected] La Clinique Paro Westmount 4458 Sherbrooke West, Westmount www.ParoWestmount.com 514-932-0932 OUTLINE Dental Implant vs. Natural Tooth: Anatomy Disease Maintenance ANATOMY DENTAL IMPLANT VS. NATURAL TOOTH Rose & Mealey Fig 26-1,2 Caton J, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and periimplant diseases and conditions – Introduction and key changes from the 1999 classification. J Periodontol 2018; 89(Suppl 1): S1–S8. HISTOLOGICAL CHARACTERISTICS OF A HEALTHY PERI-IMPLANT SITE? Healthy peri-implant mucosa averages 3-4 mm in height and is covered by either a keratinized (masticatory mucosa)or non-keratinized epithelium (lining mucosa) The portion of the peri-implant mucosa that is facing the implant/abutment contains a “coronal” portion that is lined by a sulcular epithelium and a thin junctional epithelium, and a more “apical” segment in which the connective tissue is in direct contact with the implant surface. The connective tissue lateral to the sulcular epithelium harbors a small infiltrate of inflammatory cells. Most of the intrabony part of the implant is in contact with mineralized bone, while the remaining portion faces bone marrow, vascular structures, or fibrous tissue. Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. MAIN HISTOLOGICAL DIFFERENCES BETWEEN HEALTHY PERI-IMPLANT & PERIODONTAL TISSUES? Compared to the periodontium, the peri-implant tissues do NOT have cementum and periodontal ligament. The periimplant epithelium is often longer and in the connective tissue zone there are no inserting fibers into the implant surface. The peri-implant tissues are less vascularized in the zone between the bone crest and the junctional epithelium when compared to the connective tissue zone of the periodontium. Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. Rose & Mealey Fig 26-1,2 Osseointegated implants lack a Periodontal Ligament Bone grows in close proximity to implant surface Soft tissues form tight Connective Tissue barrier with larger proportion of collagen & lower proportion of fibroblasts than natural teeth Rose & Mealey Fig 26-1,2 Because of lack of Cementum for collagen fiber insertion; fibers around implants are oriented parallel to implant surface Rose & Mealey Fig 26-1,2 Similar to natural teeth; epithelial cells attach to implant surface by hemidesmosomes & a basal lamina A sulcus forms lined by sulcular epithelium continuing apically with junctional epithelium Tooth: CT fibers insert into root apical to JE Implant: No insertion of CT fibers (No PDL) into Implant surface Vascular differences between periodontal & periimplant tissues: fewer blood vessels in periimplant mucosa Lack of CT fiber insertion & decreased vascular supply may lead to a greater susceptibility to plaque-induced inflammation, leading to bone loss (Peri-Implantitis) DISEASE DENTAL IMPLANT VS. NATURAL TOOTH WHAT ARE THE CLINICAL CHARACTERISTICS OF A HEALTHY PERI-IMPLANT SITE? In health, the peri-implant site is characterized by absence of: Erythema Bleeding on probing Swelling Suppuration Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. WHAT ARE THE MAIN CLINICAL DIFFERENCES BETWEEN HEALTHY PERI-IMPLANT & PERIODONTAL TISSUES? In health, there are no visual differences between peri-implant and periodontal tissues However, the probing depths are usually greater at implant versus tooth sites The papillae at the interproximal sites of an implant may be shorter than the papillae at interproximal tooth sites Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. MICROBIOLOGY Microflora of a healthy implant site & periodontally healthy tooth are comparable Both microfloras consist of predominantly grampositive, aerobic, non-motile bacteria with high percentage of cocci and few spirochetes Microflora of peri-implantitis site is similar to that of a periodontally diseased site. Shift to gram-negative, anaerobic, and motile bacteria with detection of pathogens such as Prevotella intermedia and Porphyromonas gingivalis. MICROBIOLOGY Similarly, increased plaque accumulation leads to subsequent inflammation resulting in increased periimplant probing depths, similar to periodontitis around teeth. MICROBIOLOGY Reinfection around implants: bacteria from the subgingival environment around teeth to the periimplant sulcus or pocket. Reinfection has been demonstrated as early as 14-28 days after second-stage surgery; when the abutment is connected to the implant Therefore the periodontal status of a patient can profoundly influence the periimplant health Implants too deep? Too close? 3mm? Enough keratinized tissue? Was patient able to perform OH adequately? Were they instructed how to? Restoration? What do we do Now? Can this be treated? Remove implants? Then what? DEFINITIONS Peri-Mucositis: presence of a plaque-related inflammatory soft tissue infiltrate without concurrent loss of peri-implant bone Peri-Implantitis: An infectious condition of the tissues around osseointegrated implants with loss of supporting bone and clinical signs of inflammation (bleeding and/or suppuration on probing) 5th ITI Consensus Heitz-Mayfield: Peri-implantitis 2013 Albrektsson & Isidor 1994 Zitzmann& Berglundh 2008 CLINICAL CHARACTERISTICS OF PERI-IMPLANT MUCOSITIS? The main clinical characteristic: Bleeding on gentle probing Erythema Swelling and/or Suppuration may also be present. An increase in probing depth is often observed in the presence of peri-implant mucositis due to swelling or decrease in probing resistance. The major etiological factor is plaque accumulation. Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. WHAT IS PERI-IMPLANTITIS? 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. Clinical characteristics of peri-implantitis: clinical signs of inflammation bleeding on probing and/or suppuration, Increased probing depths and/or recession of the mucosal margin Radiographic bone loss compared to previous examinations Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. PERI-IMPLANT HEALTH Connective tissue immediately adjacent to implant collar is rich in collagen and relatively acellular & avascular Collagen fibers typically orient in a parallel manner to the implant surface, making them much weaker and more prone to periodontal breakdown and subsequent bacterial invasion IMPLANT SURFACE DECONTAMINATION 1. Mechanical debridement 2. Powered air abrasive systems 3. Use of antiseptics, adjunctive administration of local and/or systemic antibiotics 4. Access flap surgery with or without the use of bone-regenerating procedures and implant surface modifications 5. Photodynamic therapy 6. Laser disinfection MAINTENANCE DENTAL IMPLANT VS. NATURAL TOOTH PROBING Probing measurements around implants can be deeper than around teeth PDs can be affected by implant placement / depth and type of implant restoration MONITORING PERI-IMPLANT HEALTH What clinical methods and instruments should be used to detect the presence or absence of inflammation at an implant site? The clinical methods to detect the presence of inflammation should include visual inspection, probing with a periodontal probe, and digital palpation Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. MONITORING PERI-IMPLANT HEALTH Why is it important to probe peri-implant tissues during a complete oral examination? It is necessary to probe peri-implant tissues to assess the presence of bleeding on probing, and to monitor probing depth changes and mucosal margin migration (Recession) This assessment may alert the clinician to the need for therapeutic intervention There is evidence that probing of the peri-implant tissue using a light probing force is a safe and important component of a complete oral examination Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. PROBING Changes in probing depths is a reliable indicator for attachment loss around implants Probing depths at Maintenance Recalls must be compared to the Baseline probing depths in Health MONITORING PERI-IMPLANT HEALTH What peri-implant probing depths are compatible with peri-implant health? It is not possible to define a range of probing depths compatible with health; of more importance are the clinical signs of inflammation. Can peri-implant health exist around implants with reduced bone support? Yes, peri-implant tissue health can exist around implants with reduced bone support. Berglundh et al. 2018. 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. PROBING Positive correlation between repeated periimplant bleeding on probing and histologic signs of inflammation Periimplant probing was recommended to monitor implant health in both the 1978 and 1988 National Institutes of Health (NIH) Implant Consensus Development statements PROBING Type and thickness of tissue surrounding can affect periimplant PDs Keratinized tissue margin usually associated with shallower depths; mucosa generally associated with deeper probing depths RADIOGRAPHY Radiographs are recommended at time of implant placement, abutment insertion and prosthesis insertion. Follow up radiographs are generally taken annually If no complications are detected radiographically or clinically, the interval could be lengthened to 2 years NORMAL? HEALTH? SUCCESS? CRITERIA FOR IMPLANT SUCCESS (1986) No Mobility No Radiographic peri-implant radiolucency Vertical bone loss < 0.2mm annually after implant’s 1st year No pain, infections, neuropathies, paresthesia, violation of mandibular canal In the context of the above: successful rate of 85% after 5 years; 80% after 10 years CRITERIA FOR IMPLANT SUCCESS (1993) No Mobility No Radiographic peri-implant radiolucency Vertical bone loss < 0.1mm annually after implant’s 1st year No pain, infections, neuropathies, paresthesia, violation of mandibular canal In the context of the above: successful rate of 90% after 5 years; 85% after 10 years IMPLANT HEALTH Ideal clinical conditions No pain or tenderness upon function No mobility No increase in pocket depth No bleeding on probing No exudate, purulence