Peri-Implant Health and Mucositis PDF

PERI-IMPLANT HEALTH and PERI-IMPLANT MUCOSITIS Learning objectives Describe the etiology and the pathology of peri-implant health and peri-implant mucositis Record, interpret clinical and radiographic information and Diagnose peri-implant heath and peri-implant mucositis Fo...

PERI-IMPLANT HEALTH and PERI-IMPLANT MUCOSITIS Learning objectives Describe the etiology and the pathology of peri-implant health and peri-implant mucositis Record, interpret clinical and radiographic information and Diagnose peri-implant heath and peri-implant mucositis Formulate relevant research questions ADEE Learning outcomes 3.1.1, 3.2.5, 3.2.8, 3.2.9, 5.1.1 PERI-IMPLANT TISSUES ❖ The ridge mucosa at sites of implant installation adapts to the new functional demands and the soft tissue that surrounds dental implants becomes established and is termed a peri-implant mucosa. (Lindhe et al. 2015) ❖Features of the peri-implant mucosa are established during the process of wound healing that occurs: Subsequent to the closure of mucoperiosteal flaps following implant installation (one‐stage procedure) or Following abutment connection (two‐stage procedure) surgery (Lindhe et al. 2015). Outer peri-implant mucosa (keratinized oral epithelium) Barrier epithelium Connective tissue attachment Connective tissue Bone (Source Clerehugh et al. 2024)  Osseointegration: a direct functional and structural connection between living bone and the surface of a load carrying implant. (Albrektsson and Senneby 1991) Healing of the mucosa results in the establishment of a soft tissue attachment (transmucosal attachment) to the implant. This attachment serves as a seal that prevents products from the oral cavity reaching the bone tissue, and thus ensures osseointegration and the rigid fixation of the implant (Lindhe et al. 2015). In the healthy peri-implant unit, the peri-implant mucosa is 3-4mm high (Clerehugh et al 2024) Outer surface of the peri-implant mucosa is keratinized oral epithelium that in the marginal border is connected to a thin barrier epithelium (similar to the junctional epithelium) that faces the implant (Lindhe et al. 2015). The barrier epithelium is about 2 mm long with an underlying zone of connective tissue of about 1.5 mm. The epithelium is attached to the implant via hemidesmosomes. The fibres in the connective tissue run parallel to the implant surface with no attachment to its surface. The soft tissue attachment to implants is properly established several weeks following surgery (Lindhe et al. 2015).  Crestal bone‐level change Following implant installation and loading, modeling of the bone occurs, and during this process some crestal bone height is lost. Studies in animals have demonstrated the location of the implant–abutment interface (microgap) determines the amount of this initial marginal bone loss. (Araujo and Lindhe 2018) The crestal bone reduction that occurs in this healing phase apparently varies between brands and seems to be related to the design of the implant system used. After this initial period about 75% of implants experience no additional bone loss and osseointegration takes place. (Araujo and Lindhe 2018)  PROBING PERI‐IMPLANT TISSUES Lang et al. (1994) from animal studies reported that at sites with healthy mucosa or mucositis, the tip of the probe identified the apical border of the barrier epithelium with an error of approximately 0.2 mm, while at sites with peri‐implantitis, the measurement error was much greater at 1.5 mm. When a normal probing force is applied to healthy tissues, the probe seems to reach similar levels at implant and tooth sites. Probing inflamed tissues at implant sites will result in a more advanced probe penetration and the tip of the probe may come closer to the bone crest (Lindhe et al. 2015). It is recommended that clinicians obtain baseline radiographic and probing measurements following the completion of the implant- supported prosthesis. (Berglundh et al 2018) 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. HEALTHY PERI‐IMPLANT SITE (Source Berglundh 2019)  CLINICAL CHARACTERISTICS OF A HEALTHY PERI‐IMPLANT SITE Absence of erythema Absence of bleeding on probing Absence of swelling Absence of suppuration It is not possible to define a range of probing depths compatible with health (Berglundh et al 2018) Pocket probing on dental implants should be conducted with a light force, approximately 0.25 N. (Renvert et al 2018) MAIN CLINICAL DIFFERENCES BETWEEN HEALTHY PERI‐IMPLANT AND PERIODONTAL TISSUES In health, there are no visual differences between peri‐implant and periodontal tissues. 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) CLINICAL METHODS AND INSTRUMENTS TO BE USED TO DETECT THE PRESENCE OR ABSENCE OF INFLAMMATION AT AN IMPLANT SITE Visual inspection Probing with a periodontal probe Digital palpation (Berglundh et al 2018)  WHY IS IT IMPORTANT TO PROBE PERI‐IMPLANT TISSUES? Probing of the peri‐implant tissue using a light probing force is a safe and important component of a complete oral examination. To assess the presence of bleeding on probing To monitor probing depth changes and mucosal margin migration. The assessment may alert the clinician to the need for therapeutic intervention. (Berglundh et al 2018)  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 (Berglundh et al 2018) Probing depths depend on the height of the soft tissue at the location of the implant (Berglundh et al 2018) Peri‐implant tissue health can exist around implants with reduced bone support following treatment of peri‐implantitis (Berglundh et al 2018, Renvert et al 2018)  HISTOLOGICAL CHARACTERISTICS OF A HEALTHY PERI‐IMPLANT SITE The healthy peri‐implant mucosa averages 3 to 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. (Berglundh et al 2018)  HISTOLOGICAL CHARACTERISTICS OF A HEALTHY PERI‐IMPLANT SITE 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) (Source Derks et al., 2022) (Source Berglundh et al 2015) MAIN HISTOLOGICAL DIFFERENCES BETWEEN HEALTHY PERI‐IMPLANT AND PERIODONTAL TISSUES Compared to the periodontium, the peri‐implant tissues do not have cementum and periodontal ligament. The peri‐implant epithelium is often longer and in the connective tissue zone there are no inserting fibers into the implant surface. 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) Summary: When compared with periodontal tissues, peri-implant tissues lack cementum and periodontal ligament; thus, there are only two peri- implant tissue layers, alveolar bone and peri-implant mucosa. Additional differences are found in the peri-implant mucosa: the peri- implant epithelial attachment is usually longer; the connective tissue exhibits no fibres inserting into the supra-crestal area; and vascularization is lower. Case definition of peri-implant health in day-to-day clinical practice: absence of clinical signs of inflammation; absence of bleeding/suppuration on gentle probing; no increase in probing depth compared to previous examinations; no bone loss, absence of bone loss beyond bone level changes resulting from initial bone remodeling. (Renvert et al 2018; Berglundh 2019) (Source Berglundh et al 2015) PERI-IMPLANT MUCOSITIS Diagnosis of peri‐implant mucositis indicated by the clinical finding of bleeding on probing and absence of radiographic bone loss (Source Berglundh T et al. 2022) Peri-implant diseases are infectious in nature and are caused by bacteria from dental biofilms (Lang and Berglundh 2011). Peri‐implant mucositis is an inflammatory lesion of the peri‐implant mucosa in the absence of continuing marginal bone loss. Peri‐implant mucositis is primarily caused by a disruption of the host– microbe homeostasis at the implant–mucosa interface and is a reversible condition at the host biomarker level (Heitz-Mayfield and Salvi 2018) Prevalence ranges from 32-45 % (Decks and Tomasi 2015)  There is strong evidence from animal and human experimental studies that plaque is the etiological factor for peri‐implant mucositis. (Berglundh et al 2018) Host response to bacterial challenge at implants includes the development of clinical signs of inflammation and the establishment of inflammatory lesions with blood vessels, plasma cells and lymphocytes in the mucosal/ gingival connective tissues. (Berglundh et al 2015, Clerehugh et al 2024) There is evidence from experimental human studies that peri-implant mucositis can resolve. Resolution of the clinical signs of inflammation may take more than 3 weeks following reinstitution of plaque/biofilm control. (Berglundh et al 2018)  It is assumed that peri-implant mucositis is the precursor to peri- implantitis, as is gingivitis for periodontitis, and that a continuum exists from healthy peri-implant mucosa to peri-implant mucositis and to peri-implantitis (Jepsen et al. 2015) There is limited evidence for non–plaque‐induced peri‐implant mucositis. (Berglundh et al 2018)  CLINICAL CHARACTERISTICS OF PERI‐IMPLANT MUCOSITIS Bleeding on gentle probing Erythema, swelling and/or suppuration may also be present. Clinical signs of inflammation are necessary for a diagnosis of peri‐implant mucositis. An increase in probing depth is often observed in the presence of peri‐implant mucositis due to swelling or decrease in probing resistance. (Berglundh et al 2018) HISTOLOGICAL CHARACTERISTICS OF PERI‐IMPLANT MUCOSITIS A well‐defined inflammatory lesion lateral to the junctional/pocket epithelium with an infiltrate rich in vascular structures, plasma cells, and lymphocytes. The inflammatory infiltrate does not extend “apical” of the junctional/pocket epithelium into the supracrestal connective tissue zone. (Berglundh et al 2018) ENVIRONMENTAL AND PATIENT‐SPECIFIC RISK INDICATORS FOR PERI‐IMPLANT MUCOSITIS ❖ Etiological factor is plaque accumulation. ❖ Host response to the bacterial challenge may vary between patients. ❖ Smoking, diabetes mellitus, and radiation therapy may modify the condition. (Berglundh et al 2018) Clinical symptoms of peri‐implant mucositis, including varying signs of redness and swelling. Probing resulted in bleeding from the margin of the peri-implant mucosa (arrows). (Source Berglundh et al 2015)  (a) (b) (a) Clinical photograph of a site with healthy gingiva and peri‐implant mucosa. (b) Same site following 3 weeks of plaque formation. (Source Berglundh et al 2015) DEFINITION OF A CASE OF PERI‐IMPLANT MUCOSITIS IN DAY-TO-DAY CLINICAL PRACTICE Diagnosis of peri‐implant mucositis requires: Presence of bleeding and/or suppuration on gentle probing with or without increased probing depth compared to previous examinations. Absence of bone loss beyond crestal bone level changes resulting from initial bone remodeling. Visual signs of inflammation can vary. Peri‐implant mucositis can exist around implants with variable levels of bone support. (Berglundh et al 2018) Source Carra et al. (2022)