Dental Implants Information

Peri Implantitis

 What Is Peri-Implantitis?

Whenever conventional 2 stage implants are inserted into the bone of the upper or lower jaw, the clock starts ticking for the development of peri-implantitis. The longer the implants are in the mouth the higher the chances are for this type of bone loss, which will ultimately affect the entire implant and lead to its removal. At this point at the latest the treatment with conventional implants has failed.

Peri-implantitis occurs after the successful osseo-integration of the implant. This is especially unfortunate, since the disease starts to attack just as everything looks fine and the patient starts using the implant.

Peri-implantitis starts at the oral cortical and leads to its increasing erosion. Implantitis is distinguished from the endosseous rest-ostitis, which typically stems from a reactivation of older, dormant root infections. (Fig. 1)


Fig. 1: This X-ray shows four separately diagnosable bone resorbing diseases:

 

  • Visible bone loss at the cuspid distal-cresta due to (infectious) perio-dontitis.
  • Over pressed edodontic filling material at the tip of the root has led to an apical ostitis and the bone surrounding the apex has dissolved.
  • At the crestal aspect of the mesial implant we can see the crater like bone loss which is typical for a peri-implantits.
  • An ostisis is visible around the lower endosseous part of the distal implant, probably stemming from the rest of the radiopaque filling material.

Mild Cases

In mild cases bone loss around the implant is 1-3mm with some weak signs of inflammation of the mucosa, which may cause mild pain. These cases are treated symptomatically with local disinfectant and pain medication. It is known today that antibiotic therapy is not successful in stopping the progression of peri-implantitis (regardless of the severity).

Medium Cases

In cases of medium severity around 50% of the vertical bone along the implant is lost. The main problems are the recurrent emergence of pus and bleeding, the unsightly aesthetic appearance and foul smell.

Severe Cases

In serious cases of peri-implantitis nearly all bone matter gets resorbed, and deep soft tissue pockets result. Constant infection, discharge and heavy bleeding are the results. When pockets are surgically removed, the teeth’s appearance strongly deteriorates and enormous amounts of food get stuck between the implants and bridges (Fig. 1, Fig. 2).


Fig. 2: Example: The bone surrounding all three implants in the upper right jaw is lost up to the apex of the implant (here: conventional full screw implants). Although the patient suffers persistent severe intra-oral infection, she does not agree to an implant removal since she is aware she will lose all her chewing ability. The implants placed in the back of both sides of the lower jaw are lost due to peri-implantitis. One highly atrophic mandible remains. Another treatment approach with conventional 2 stage implants is not possible.


Fig 3: Nearly the entire bone along these conventional 2 stage implants is lost due to infective peri-implantitis. Most patients will not accept the peri-implantitis becoming so severe. They will request a removal of the implants at a much earlier stage.

What Are The Causes of Peri-Implantitis and the Reasons for Its High Prevalence?

The oral cavity holds millions of bacteria which are typically washed away by drink, food and saliva. These bacteria settle on all hard surfaces inside the mouth and will multiply in favorable conditions. We know this from our own teeth.

The problem with almost all conventional 2 stage implants is that they are manufactured with a rough endosseous surface. This is done to achieve a strong grip between the implant and the bone, a strong osseo-integration.

We know today that bone will retract 1-3 mm along all such implants within the first months of usage. Rough implant surfaces will become exposed and quite likely colonized by bacteria.

The typical dental implant patient has lost their teeth due mainly to a persistent lack of sufficient oral hygiene (i.e. negligence). In other words: the «non-cleaners» within the population receive their implants earlier than others. However, conventional dental implants with rough surfaces and large diameters require an substantial amount of oral hygiene to stay infection free.

In conclusion, these 2 stage implants with rough «endosseous» surface are quite unsuitable from the start for a large group of patients within the population. Additionally most conventional 2-stage implants provide enormous amounts of endosseous implant surface, much more than necessary for load transmission purposes. Since a lot of bonte-to-implant-contact requires functional stimuli, vertical bone loss along the implant is expected anyway.

Another general problem with conventional 2 stage implants is their utilization of the crestal cortical and underlying spongeous bone. These bone areas are already prone to resorption. This again leads to exposed implant surfaces that quickly hold a reservoir of bacterial and cause chronic infection and progressive bone loss. In this light most 2-stage implants are in principle a faulty design and should be forbidden or their indications severely reduced.

Treatment of Peri-Implantitis

Even by now there is no effective (final) treatment for this disease. All attempts at cleaning the infected areas remain ineffective due to oral bacteria multiplying hourly and perpetually creating millions of new bacteria at every moment. Attempts at «polishing» the rough surfaces in the mouth do not work either, as such polishing is not possible close to the bone since remnants of the polisher remain on the implant and in the deep pocket, fostering new inflammation.

In some cases peri-implantitis stops on its own when the bone loss reaches resorption-resistant «basal» bone areas.

It is generally admitted today that reliable and successful treatments for peri-implantitis are missing.

The only way to avoid this disease with 100% certainty is to remove the 2 stage implant.

Level of Awareness of Treatment Providers regarding Peri-Implantitis

Peri-implant diseases are inflammatory conditions affecting the soft and hard gum tissues around dental implants. Similar to a natural tooth, bacteria can build up on the base of the implant, below the gum line. Over time, the bacteria irritate the gum tissue, causing it to become inflamed, damaging the tissue and if not caught early, causing the bone structure below the implant to deteriorate.

Peri-implant diseases are classified into two categories.

In peri-implant mucositis, gum inflammation is found only around the soft tissues of the dental implant, with no signs of bone loss. Generally peri-implant mucositis is a precursor to peri-implantitis. Evidence suggests that peri-implant mucositis may be successfully treated and is reversible if caught early

Peri-implant mucositis

In peri-implantitis, gum inflammation is found around the soft tissue and there is deterioration in the bone supporting the dental implant. Peri-implantitis usually requires surgical treatment.

Peri-Implantitis

Peri-implantitis

Signs of peri-implant diseases are similar to symptoms of gum disease: red or tender gums around the implants, or bleeding when brushing. And just like your natural teeth, implants require regular tooth brushing and flossing and regular check-ups from a dental professional. Other risks factors for developing peri-implant disease include previous periodontal disease diagnosis, poor plaque control, smoking, and diabetes. It is essential to routinely monitor dental implants as part of a comprehensive periodontal evaluation.

The up sideto dental implants is they function just like your natural tooth. The down side is, they are capable of becoming diseased just like a natural tooth. With a proper oral health routine, your dental implant can last a lifetime.

 

 

Proper maintenance of the peri-implant soft tissue, including the evaluation and treatment of peri-implant inflammation and bone loss, plays a key role in ensuring the best possible long-term outcomes for implant therapy. With a clear understanding of peri-implant disease, how it develops, and the methods involved in preventing, diagnosing and treating the condition, its effects can be mitigated.

Peri-implant disease resembles periodontal disease in its structure, but has different criteria and treatment options. Peri-implant mucositis can advance to peri-implantitis around implants in a manner similar to the progression of gingivitis to periodontitis around natural teeth.1 Collectively, peri-implant mucositis and peri-implantitis are known as peri-implant disease.2,3 Early detection and treatment are essential for effective treatment of peri-implant inflammatory disease.

Peri-implant mucositis manifests itself in the soft tissue with signs of redness, swelling and generalized inflammation (Fig. 1). It mirrors the effects of gingivitis around natural teeth and is confined to the soft tissues only, with no evidence of radiographic bone loss. Mucositis is best treated when detected early, through elimination of the factors contributing to inflammation, regular in-office implant maintenance, and improved dental care at home.

Figure 1: Gingiva above tooth #9 exhibiting symptoms of peri-implant mucositis.

Figure 2: The inflammation and sulcular crevices forming around these maxillary implants are indicative of peri-implantitis.

Figure 3: The onset of peri-implant disease is illustrated by the saucer-shaped voids surrounding the maxillary implants near the surface of the gingiva in this radiograph.

Figure 4: The three-dimensional imagery offered by CBCT scanning facilitates detection of bony lesions on the facial, lingual and proximal aspects that are often not visible through conventional radiography.

Peri-implantitis begins with the same symptoms as mucositis and can be induced by occlusal stress, bacteria, excess cement or a combination of factors. A sulcular crevice develops around the implant-bone interface as a result of inflammation in the supra-alveolar gingival tissues (Fig. 2). This allows bacteria to migrate apically and an infection to develop, ultimately leading to bone loss. Radiographically, this phenomenon appears as a radiolucent saucer shape surrounding the implant (Fig. 3).

Peri-implantitis is often compared to periodontal disease, but there is one important difference: Peri-implantitis can develop on the facial and lingual aspects of the implant in a manner that may be undetectable by traditional radiographs. Studies have shown that cone-beam computed tomography (CBCT) technology is effective in identifying facial, lingual and proximal bony lesions around implants (Fig. 4).4 Diagnosis of peri-implantitis can be aided by obtaining baseline bone-level scans 360 degrees around the implant. This involves taking a CBCT scan prior to placement of the implant, at the time of implant placement and when the implant restoration is loaded. Then, if peri-implant disease is suspected, subsequent CBCT scans can be compared with the baseline scans for definitive diagnosis of alveolar bone loss, including the location and severity.4

Prevention

According to a statement released in 2013 by the American Academy of Periodontology (AAP) on the “current diagnoses and clinical implications of peri-implant disease,” there are risk factors that can increase the potential for peri-implant disease.5 These factors include previous periodontal disease, poor oral hygiene, residual cement from cement-retained restorations, smoking, genetic factors, poorly controlled diabetes and occlusal overload.5,6

Based on these risk factors, an updated medical and dental history is essential in determining the appropriate in-office maintenance schedule for each implant patient. The dental history should include the date of implant placement as well as the type, coronal design and manufacturer of the implant.

For the restoration, the record should indicate the date the implant was first loaded into occlusion and whether a screw- or cement-retained restoration was used. The detection and removal of residual cement from subgingival areas is helpful in preventing inflammation and peri-implantitis.

A key preventive measure is to place previous periodontal disease patients on a shorter implant maintenance interval — generally three to four months — to ward off peri-implant disease.

Diagnosis

According to Dr. Stuart Froum, “The diagnosis of peri-implantitis includes periodontal probe depths (PPD) of 5–6 mm or greater, bleeding on probing (BOP), exudate, and bone loss greater than 2–3 mm around the implant.”1 Treatment protocol depends on the extent of the probe depths and whether any radiographic bone loss is evident, making it essential for every implant maintenance appointment to begin with the hygienist or dentist gently probing around the implant with 0.15–0.20 N of threshold pressure.7,8 The guidelines below should be followed in the preliminary diagnosis of peri-implant disease.3

Clinical Signs of Peri-Implant Disease

Treatment

The primary method for the nonsurgical treatment of peri-implantitis involves the mechanical debridement of plaque from the surface of the implant using titanium implant scalers or ultrasonic magnetostrictive implant inserts to improve the health of the peri-implant soft tissue, alleviate inflammation and mitigate bleeding (Fig. 5).9 Note that submucosal debridement alone may not be adequate for the removal of the bacterial load from the surfaces of implants with a peri-implant pocket depth greater than 5 mm or more than 50 percent of the implant length.10 Early detection and treatment is critical for successful peri-implant disease outcomes.

Figure 5: Debriding plaque from the surface of the implant with a titanium implant scaler helps to alleviate subgingival bleeding, inflammation and the presence of bacteria.

Conclusion

Peri-implant disease is generally not painful, and patients may not be aware that they have inflammation or an infection surrounding their implant. Early detection involves leveraging a combination of diagnostic data to properly identify peri-implantitis, including BOP, presence of suppuration and radiographic changes in bone levels. The identification of bony lesions can be aided by CBCT scanning. For cement-retained implant restorations, cement residue is sometimes found around the circumference of the coronal portion of the abutment or implant. This makes early detection and removal of all cement residue crucial.10 Effective treatment of peri-implant disease begins with regular in-office comprehensive diagnostic exams and implant maintenance visits to protect the patient’s investment and ensure a healthy and successful implant restoration.

Prevention of peri-implant disease should begin prior to implant placement and continue on through the restorative phase of treatment. Placing the implant in its proper location and in vital bone sets up a successful restorative outcome. An ideal custom abutment should be fabricated that includes a properly located abutment-crown junction.11 The custom abutment should establish an esthetic emergence profile that facilitates optimal patient and professional cleaning. Utilizing a dental laboratory that will deliver the appropriate restorative components helps to meet these goals. By properly planning the restorative phase before the implant is placed, the biologic and cosmetic outcomes are maximized, and the risk of peri-implantitis is reduced.