|Year : 2017 | Volume
| Issue : 2 | Page : 56-62
Management of peri-implantitis: Remedy for the malady
Preetham Pulluri, Jayasheela Mallappa, Sowmya Nagur Karibasappa, Dhoom Singh Mehta
Department of Periodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||8-Jan-2018|
Room 5, Department of Periodontics, Bapuji Dental College and Hospital, Davangere - 577 004, Karnataka
Source of Support: None, Conflict of Interest: None
Peri-implant mucositis and peri-implantitis are diseases that affect the tissues surrounding a functional implant. Poor oral hygiene, smoking and previous history of periodontitis are known risk factors for the disease. The probing depth, the presence of bleeding on probing, suppuration and radiographs should be assessed regularly for the diagnosis else it can lead to implant loss and impaired function. In addition, the extent of the disease and pattern of bone loss are poorly described. There is limited information regarding the management of peri-implantitis. Various treatment modalities have been tried and tested, but there is yet to be a predictable outcome for peri-implantitis.
Keywords: Implant, implant failure, peri-implantitis
|How to cite this article:|
Pulluri P, Mallappa J, Karibasappa SN, Mehta DS. Management of peri-implantitis: Remedy for the malady. Int J Oral Health Sci 2017;7:56-62
| Introduction|| |
Dental implants are often the treatment of choice for the replacement of a tooth or teeth. Although implants are considered to be a predictable treatment option, peri-implant diseases do occur, posing significant challenges for both – the clinician and patient.
Peri-implantitis is an implant-related condition which is increasingly being noticed in the clinical setting, contributing to a significant proportion of implant failures. Implant failure due to peri-implantitis is a multifactorial disease process most likely attributed to the interaction of certain host factors with that of the biofilm. In addition, diagnosis and management of a peri-implant disease poses a major challenge to the clinician and relies on a rational and evidence based clinical approach. As dental implant treatment is becoming a routine part of daily dental practice, it is essential that the clinicians are able to assess the health of dental implants; develop preventive strategies for maintaining the fixtures and implement treatment strategies for ailing or failing implants.
According to Esposito, implant failures can be broadly divided into two categories:
(a). Early failures, which occur due to premature loading, surgical trauma or an impaired host healing response and (b). Late failures, which occur due to overloading and bacterial infection.
The soft and hard tissues surrounding an osseointegrated implant show some similarities with the periodontium in the natural dentition but the big difference lies in collagen fibers being nonattached and parallel to the implant surface instead of being perpendicular and in a functional arrangement from bone to cementum. A periodontitis-like process which occurs on the implants is peri-implantitis, and it can affect the implants. As untreated periodontitis may ultimately lead to the loss of natural teeth, peri-implantitis can similarly result in the loss of dental implants.
The inflammatory lesions that develop in the tissues around implants are collectively recognized as peri-implant diseases. In accordance with the classification of periodontal diseases in teeth, peri-implant disease includes two entities:
- Peri-implant mucositis - corresponds to gingivitis and
- Peri-implantitis - corresponds to periodontitis.
The term “peri-implantitis” was introduced in 1987 by Mombelli. Later Albrektsson and Isidor in the proceedings of the 1st European Workshop on Periodontology in 1994 gave the definitions as -peri-implant mucositis as an inflammatory response limited to the soft tissues surrounding a functioning oral implant and peri-implantitis as an inflammatory response that involves the loss of supporting bone in tissues surrounding an implant. However, the above failed to set a rigid clinical parameter, so in 3rd International Team for Implantology Consensus Conference-it was modified as “destructive inflammatory process affecting the soft and hard tissues around osseointegrated implants, leading to the formation of a peri-implant pocket and loss of supporting bone.” Clinical parameters were set as the presence of plaque, suppuration, bleeding on probing (BOP), and probing depth (PD) >5 mm.
There are several reports on the prevalence of mucositis and peri-implantitis that differ between 5% and 63.4%. Zitzmann et al. quantified the incidence of the development of peri-implantitis in patients with a history of periodontitis almost 6 times higher than in patients with no history of periodontal inflammation. According to a meta-analysis by Atieh 10%– 50% of all the dental implants showed signs of peri-implantitis.
| Retrograde Peri-Implantitis|| |
In 1992, McAllister et al. reported another entity separate from peri-implantitis known as retrograde peri-implantitis. It is defined as clinically symptomatic peri-apical lesion that develops within the first few months after implant insertion while the coronal portion of the implant sustains a normal bone to implant interface. It can be an active or an inactive lesion.
| Etiology of Peri-Implantitis|| |
The presence of bacterial biofilms has been noted in numerous experimental and clinical examinations as the primary etiological factor for the development and progression of peri-implant infections.
Additional risk factors include:
- Interleukin-1 (IL-1) genotype polymorphism
- History of periodontitis
- Lack of compliance
- Systemic diseases - diabetes mellitus, immunosuppression, cardiovascular diseases
- Iatrogenic causes
- Lack of keratinized gingiva
- Previous history of failed implants.
| Etiology of Retrograde Peri-Implantitis|| |
- Overpreparation or overheating of osteotomy sites
- Presence of a foreign body
- Persistent or incompletely debrided periapical lesion.,
| Diagnosis of Peri-Implantits|| |
Diagnostic procedures used with implants need to be sensitive so that early signs and symptoms of infection can be detected and intervention initiated before substantial bone loss occurs. According to Mombelli and Lang, the parameters to be assessed include:
- Peri-implant probing-A rigid plastic probe is ideal for probing. The soft tissue cuff around an implant in a model has been shown to be about 3–3.5 mm and the connective tissue attachment of 1–1.5 mm.
- BOP: it has been shown that it is not a reliable predictor for progression of periodontal disease, instead its absence is a much better predictor for stability.
- Mobility: implant mobility is an indication of lack of osseointegration, but it is of no use in diagnosing early implant disease, rather it shows the final stages of de-integration. Periotest or RFA can be used to assess the stability of an implant.
- Radiography: bone loss is a definite indicator for peri-implantitis. The distance from implant shoulder to the alveolar bone crest is a reliable parameter providing the radiographs are properly standardized.
| Treatment of Peri-Implant Mucositis|| |
Nonsurgical therapy will suffice for detoxification and different methods used are:
- Cleaning with plastic curettes
- Local medication
- Photodynamic therapy.
According to the literature review by Renvert et al. in 2008, mechanical nonsurgical therapy could be effective in the treatment of peri-implant mucositis lesions. Adjunctive use of antimicrobial mouth rinses enhanced the outcome of mechanical therapy of such mucositis lesions.
| Decision Tree for the Treatment of Peri-Implantitis|| |
Aljateeli M, Fu JH, Wang HL in 2012 proposed a decision tree for treating peri-implantitis [Figure 1].
| Treatment of Peri-Implantitis|| |
Lang et al in 2004 gave consensus statements and recommendations for clinical procedures regarding implant survival and complications [Table 1].
|Table 1: Consensus statements and recommendations for clinical procedures regarding implant survival and complications|
Click here to view
| Nonsurgical Therapy for Peri-Implantitis|| |
Mechanical therapy approaches
Numerous tools are available for supra and sub gingival biofilm removal.
- Polishing brushes
- Rubber polisher
- Plastic, carbon, or titanium curettes
- Specially modified tips for ultrasonic systems
- Air powder flows.
Surface debridement constitutes the basic element for treatment of periimplant mucositis and peri-implantitis. However, the design of the implant may hinder the mechanical treatment of the infected surface. Reduction of the bacterial load to a level allowing healing is difficult to accomplish with mechanical means alone. Therefore, adjunctive therapies such as antibiotics and laser treatments have been proposed to improve the condition.
A study by Schwarz et al. mechanical debridement +0.2% chlorhexidine
- Improved BOP
- Peri-implant probing pocket depth
- Clinical attachment level at 6 months compared with baseline.
Renvert et al. showed that addition of antiseptic therapy to mechanical debridement does not provide adjunctive benefits in shallow peri-implant lesions with mean pocket PD <4 mm but seems to provide additional clinical improvements in deep peri-implant lesions with mean pocket PD >5 mm.,
Photodynamic therapy generates bactericidal effects against aerobic and anaerobic bacteria such as Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Streptococcus mutans and Enterococcus faecalis. The only prospective randomized clinical trial by Bassetti et al. covered 12 months of follow-up. After manual debridement by titanium curettes and glycine air powder treatment half of the patients received adjunctive photodynamic therapy and the other half received minocycline microspheres into implant pockets. After 12 months, the number of periopathogenic bacteria and level of IL-1ß decreased significantly in both groups without significant differences between them.
Local drug delivery
The use of minocycline with mechanical debridement by Renvert in 2008 demonstrated improvements in PDs that were significantly different from controls and were sustained for 6 months. Antimicrobial therapy using a local drug delivery system (Arestin) in the treatment of peri-implantitis was done by Persson in 2006 and microbial evaluation was done and lower levels of bacteria like A. actinomycetemcomitans, Tannerella forsythia, P. gingivalis, and Treponema denticola for up to 180 days.
Schar et al. in 2013 said that nonsurgical mechanical debridement with adjunctive use of PDT is equally effective in the reduction of mucosal inflammation as with the adjunctive use of minocycline microspheres up to 6 months but photodynamic therapy may represent an alternative treatment modality in the nonsurgical management of initial peri-implantitis. Complete resolution of inflammation was not routinely achieved in any of the cases.
Laser treatment can be done with or without flap access. Various typrs of lasers have been used: neodymium-doped: yttrium aluminium garnet, Erbium: yttrium aluminium garnet (Er: YAG), CO2 and Diode laser with variable results. A meta-analysis performed by Mailova et al. showed that in humans showed an overall weighted mean difference of 0.00 mm (95% confidence interval = −0.18–0.19 mm) PD reduction between the laser and conventional treatment groups (P = 0.98) for nonsurgical intervention. A literature review by Ashnagar in 2014 concluded that lasers showed an initial positive outcome after a 6-month follow-up but during follow-up, the results were somehow unstable and relapse was reported. According to the review, Er: YAG seems to have more documentation and application.,
A systematic review by Muthukuru in 2012 to evaluate the efficacy and safety of nonsurgical treatment of peri-implantitis suggested that submucosal debridement with adjunctive local delivery of antibiotics, submucosal glycine powder air polishing or Er: YAG laser treatment may reduce clinical signs of peri-implant mucosal inflammation to a greater extent relative to submucosal debridement using curettes with adjunctive irrigation with chlorhexidine.
| Consensus Statement: Nonsurgical Intervention Third Eao Consensus Conference 2012|| |
- Peri-implant mucositis can be treated successfully.
- Peri-implantitis has limited success with mechanical debridement
- Clinical recommendations
- Patients should be monitored regularly for:
- Plaque control
- Signs of peri-implant inflammation
- A regular maintenance program for the long-term management of peri-implantitis lesions.
| Surgical Treatment of Peri-Implantitis|| |
Any surgical protocol should begin with defect debridement and implant surface decontamination of the implant. The goal of defect debridement is to completely remove the granulomatous tissue and tissue tags around the implant surface after flap reflection. This will expose bone marrow cavities that allow the proliferation of cells that contribute to healing.
Various approaches of surgical treatment include:
The main objective of this therapy is to arrest the progression of the disease and to achieve a maintainable site by the patient. Implant topography should be altered with high-speed diamond burs and polishers to produce smooth continuous surfaces. Performed before any osseous resective therapy is initiated and with profuse irrigation.
Guided bone regeneration
In 2007, Roos-Jansåker et al. were able to show a good response to therapy (implants pocket reduction of 2.9–3.4mm and new bone fill of 1.4–1.5mm) for peri-implantitis sites treated with either bone grafts alone or bone grafts in conjunction with a resorbable collagen membrane.
Recently, Wiltfang et al. in 2012 have reported significant bone fill (3.5 mm) in 12 months clinical trial in which peri-implantitis sites were treated with surface decontamination and regenerative flap surgery with autogenous and xenogeneic bone graft. However, in a recent systematic review by Sahrmann et al. in 2011 have concluded that complete fill of the bony defect using guided bone regeneration (GBR) seems not to be a predictable outcome. The mucosal health status is not considered in most studies. Well-controlled trials are further advocated to determine predictable treatment protocols for the successful regenerative treatment of peri-implantitis using GBR technique.
Peri-implant resective therapy
Depending on the configuration of the defects, resective surgery can be carried out for the elimination of peri-implant lesions, whereas regenerative therapies may be applicable for defect filling. The basic principles include the elimination the periimplant osseous defect using ostectomy and osteoplasty. It is indicated in moderate to severe horizontal bone loss, moderate (<3 mm) vertical bone defects (1 and 2 wall bone defects), reduce the overall pocket depth and implant position in the unesthetic area. Resective surgery has been shown to be effective in reduction of BOP, PDs and clinical signs of inflammation. Implantoplasty can be considered a useful adjunct along with resective surgery to smooth and decontaminate portions of an implant left exposed by peri-implantitis lesions.
When nonsurgical and surgical therapies are ineffective, the simplest and most gentle form of treatment is explantation by unscrewing against the insertion direction. Indications include suppurative exudate, overt BOP, severely increased periimplant PD (≥8 mm), peri-implant radiolucency which may be extending along the outline of the implant (>half length) and mobility.
| Consensus Statement: Surgical Intervention Third Eao Consensus Conference 2012|| |
- Superior to nonsurgical therapy for peri-implantitis
- Should include:
- Removal of the granulation tissue
- Thorough cleaning of the contaminated surface.
- Adjunctive measures (submucosal air polishing, Er: YAG laser treatment, locally delivered antimicrobials) may result in greater reduction in BOP and PD
- Resection of the bony wall, filling of the defect or surface modifications of the implant can be considered in adjunction to mechanical instrumentation.
| Treatment of Retrograde Peri-Implantitis|| |
Many treatment modalities are available like implant extraction, peri-apical surgery, debridement, regenerative procedure, local decontamination (antimicrobials/lasers), and use of antibiotics. No conclusive evidence to advocate any specific treatment approach.
| Cumulative Interceptive Supportive Therapy|| |
It is not a single procedure, rather a sequence of therapeutic procedures with increasing antibacterial potential and type of therapy based on the severity and extent of the lesion. It is a:
- Protocol of therapeutic measures
- Depends on the clinical and the radiographic diagnosis
- Cumulative in nature.
Four steps are there in this procedure – A, B, C, and D [Figure 2].
After probing, if the peri-implant sulcus allows more than 5 mm of penetration of a periodontal probe then a radiograph is taken. If there is clear evidence of bone loss, then a microbiological sample is taken. Should there be evidence of an anaerobic flora, the patient is given treatments: A and B, and in addition is placed on systemic antimicrobial therapy (C) with an agent specifically effective against strict anaerobes (Ornidazole-1gm for 10 consecutive days).
If the bone destruction has advanced considerably, surgical intervention to correct the tissue morphology or to apply GBR techniques may be necessary (D). Such treatment would, however, only be given in addition to the other measures (A, B, and C). The goal of this cumulative treatment approach is to intercept peri-implant tissue destruction as early as possible and to avoid explantation due to the loss of osseointegration.,
In 2004, it was modified and called AKUT-concept by Lang et al. [Table 2]. The basis of this concept is a regular recall of the implanted patient and repeated assessment of plaque, bleeding, suppuration, pockets, and radiological evidence of bone loss.
| Supportive Periodontal Therapy Recommendation|| |
No evidence available to suggest the frequency of recall intervals or to propose specific hygiene regimes but supportive therapy includes
- Training patient for self-performed plaque control with individually designed professional supportive care program
- Professional plaque-control measures (every 3–6 months)
- Clinical examinations every 3, 6, or 12 months depending on severity
- Radiographic documentation
(Implant placement, postprosthetic, and re-evaluation every 1 year)
Misch et al. gave consensus regarding Implant success, survival, and failure at the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference in 2008 [Table 3].
| Outcomes After Treatment|| |
Re-osseointegration after treatment of peri-implantitis at different implant surfaces in the dog was done in 2001 by Persson et al. Treatment regimen resulted in resolution of peri-implantitis and bone fill in adjacent bone defects. Further, while substantial “re-osseointegration” occurred to an implant with a rough surface, bone growth on a previously exposed smooth surface was minimal.
Subramani and Wismeijer reviewed the literature on decontamination of titanium implant surfaces following peri-implantitis and the effect of various cleaning methods on re-osseointegration and concluded that both mechanical and chemical decontamination techniques should be applied alongside regenerative surgical procedures to obtain optimum re-osseointegration and successfully treat peri-implantitis. In recent years, lasers and photodynamic therapy have shown minor beneficial results, which need to be confirmed by long-term clinical studies with comparable groups.
| Conclusion|| |
A review by Heitz-Mayfield and Andrea Mombelli in 2014 showed that successful treatment outcomes 12 months following therapy of peri-implantitis could be achieved in a majority of patients. While favorable short-term outcomes were reported in many studies, lack of disease resolution as well as progression or recurrence of disease and implant loss despite treatment were also reported.
Their recommendations include:
- Pretreatment phase should include oral hygiene assessment, smoking cessation, and prosthetic evaluation
- Surgical access when the resolution of peri-implantitis is not achieved with nonsurgical treatment
- Postoperative systemic antibiotics and mouth washes during the healing period must be advocated
- 3 to 6 months maintenance, including oral hygiene instruction and supramucosal biofilm removal.
Hence, treatment for peri-implantitis includes patient education regarding maintenance and proper oral hygiene practices along with an organized recall care system on a regular basis.
Financial support and sponsorship
Conflicts of interest
There are no conflflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]