PERI-IMPLANT DISEASES: THERAPY
PERI-IMPLANT DISEASES: THERAPY
1. Prevention
Prevention of peri-implant disease begins with patient education, which should be understood by the patient that peri-implant tissues respond to bacterial plaque accumulation, just as periodontal tissues do. Poor oral hygiene will lead to plaque accumulation, which will promote the development of peri-implant disease, which can ultimately impact the longevity of implants and implant-supported restorations.
a. Patient selection
Patient selection must take into account maintenance constraints. It is important for patients to understand, before implant placement, that the long-term outcome of implant therapy depends primarily on their cooperation. Patients must be educated about implant system maintenance and able to control the growth of bacterial plaque.
During the pre-implant consultation, peri-implant risk factors must also be taken into account. Indeed, as we have seen previously, certain behaviors significantly increase the risk of developing peri-implantitis. These include, in this case, tobacco and alcohol consumption. The clinician must then suggest that the patient discontinue their consumption in order to bring them into a lower-risk category.
b. Motivation for oral hygiene
Oral hygiene motivation techniques used in periodontology can, to a large extent, be used in implantology. During these oral hygiene motivation sessions, the practitioner will be able to provide the patient with the necessary instruments for plaque control (toothbrush, dental floss, interdental brushes). Highlighting the biofilm, thanks to the plaque revealer, will allow the patient to clearly visualize the areas to be cleaned.
c. Conditioning of the oral cavity
Periodontal therapy of the remaining teeth will be carried out before any implant insertion. Its objective will be the complete elimination of all latent or manifest states of periodontal disease. Resective or regenerative surgery after root planing will be performed in order to reduce or eliminate any bone lesions, the contents of which are likely to maintain bacterial accumulation and contaminate the implants.
d. Maintenance program
Prevention will also be based on rigorous periodontal and implant maintenance, during which the use of various diagnostic tools will allow monitoring of implant progress. During these sessions, oral hygiene instructions may be reinforced and non-surgical debridement may be performed. The frequency of these sessions will depend on the patient’s periodontal condition, their ability to control their oral hygiene, and the analysis of their risk factors.
– Conditioning of the oral cavity
Endodontic and prosthetic treatments will be performed to place implants in a completely healthy oral cavity. As implants are becoming increasingly common in the treatment of partial edentulism, it is important to carefully analyze their causes beforehand.
– Maintenance program
The frequency of these sessions will depend on the patient’s periodontal condition, their ability to control their oral hygiene and the analysis of their risk factors.
– Individual maintenance
In patients with removable or fixed implant-supported prostheses, hygiene procedures should focus on two distinct parts that will be cleaned separately: the prosthesis itself and the transmucosal connection abutments.
* Maintenance of the prosthesis
The prosthesis itself can be cleaned using most traditional oral hygiene methods. In the case of implant-supported prostheses, when space between the pontics and the mucosa allows, gauze strips are recommended. These strips, when moved, clean the cervical surfaces of the prosthetic teeth and the proximal surfaces of the connecting abutments. When space is limited, the pontics should be cleaned with braided and coated dental floss.
* Maintenance of transmucosal connecting abutments
Cleaning the abutments requires special attention, as an effort must be made to preserve their surface condition. The hygiene method aims to remove supragingival plaque using the rolling technique, and subgingival plaque using the BASS technique using a soft brush with a small head, possibly curved to access the lingual surfaces. The use of dental floss allows excellent plaque control around the abutments.
The use of interdental brushes facilitates the removal of bacterial plaque on the proximal surfaces, provided that the appropriately sized brush is used (neither too thin nor too wide). Brushes supported by braided wire should be avoided, as there is a risk of accidental damage to the titanium surface. Ideally, a brush with a flexible plastic stem should be used. The water flosser can complement these hygiene measures by promoting the removal of food debris, but it is insufficient on its own to eliminate supragingival plaque.
* Professional maintenance
This is referred to as supportive peri-implant care. The importance of this supportive care in maintaining the health of peri-implant tissues has been frequently noted.
Peri-implant marginal inflammation is, in fact, less pronounced when rigorous monitoring is carried out at regular time intervals.
Diagnostic phase
During these maintenance sessions, after assessing the quality of plaque control and possibly strengthening oral hygiene measures, it is advisable to carry out rigorous examinations of the peri-implant tissues (clinical and radiological assessment) in order to diagnose any lesions and intercept them early. Therapeutic interception is indicated as at the level of periodontal tissues when the presence of bleeding on probing of the peri-implant tissues is associated with an increase in pocket depth.
Therapeutic phase
Initial colonization by facultative anaerobic bacteria can be prevented by regular disorganization of supragingival plaque through the adoption of appropriate plaque control techniques and professional prophylaxis that can partially compensate for any lack of patient compliance.
Supportive care also aims to prevent the development of biomechanical overloads that could be unduly exerted on the implant, by checking the quality of the prosthetic adaptation. The annual removal of the prosthetic elements will allow for more precise soundings and an assessment of actual mobility.
Determining the frequency of visits will depend on the following factors:
• The patient’s motivation and dexterity;
• The existence of factors unfavorable to good hygiene;
• The quality of peri-implant tissues;
• Natural teeth;
• Risk factors;
These supportive care sessions are generally recommended at a six-monthly frequency; quarterly in partially edentulous patients, as the terrain is considered more conducive to the development of peri-implantitis.
2. Purposes of processing.
The objective of the treatment is, on the one hand, to eliminate the bacterial flora that has colonized the implant surface and, on the other hand, to promote peri-implant bone regeneration and the reformation of an epithelial attachment around the implant.
* Non-surgical treatments.
chemical treatments
mechanical treatments
laser treatments
Chemical treatments, particularly topical Minocycline microspheres or systemic antibiotic therapy, provide significant reductions in bleeding on probing and pocket depth.
Chlorhexidine, at 0.1% to 0.5%, remains the most effective antiseptic. However, antiseptic treatments alone are not sufficient, even if they allow stabilization of clinical parameters such as bleeding on probing or pocket depth. They must be combined with mechanical or laser treatment for them to fully play their role. The laser-hydrogen peroxide combination makes it possible to obtain a particularly powerful antiseptic, in this case singlet oxygen.
Mechanical treatment seems to be the preferred method among authors, who most often prefer it. However, this method of decontaminating the implant surface must absolutely preserve the integrity of the implant surface.
The use of curettes, abrasive pastes, and air polishing powders must not damage the titanium oxide layer on the implant’s surface. As with chemical treatment, mechanical treatment alone is not sufficient. It is combined with chemical decontamination, whether antibiotic, antiseptic, or simply with saline solution.
Laser therapy has shown encouraging results, although it remains controversial. Studies show that laser therapy can be used successfully in patients with peri-implantitis, while in a literature review, Renvert et al., 2008, reported that the scientific data on laser therapy for peri-implantitis is incomplete and provides no benefit compared to mechanical treatment.
*Surgical treatments
Mechanical treatment appears to be insufficient in the localized management of peri-implantitis. Similarly, the addition of antiseptics or the use of laser without surgery will have only a limited effect on clinical and microbiological parameters.
Given the particularly low number of publications, it appears that the treatment of choice for peri-implantitis is surgical treatment, which should be preceded, if necessary, by a global non-surgical phase to reduce the bacterial load. This surgical treatment could make it possible to consider re-osseointegration around a previously contaminated implant surface.
-Surgical elimination of pockets by apical repositioning of the flap
-Surgical elimination of pockets by apical repositioning of the flap with osteoplasty
-Guided Bone Regeneration (GBR)
-Explantation
THERAPEUTIC STRATEGIES
1. Protocol A: mechanical debridement (Mombelli and Lang 2000)
Oral implants that present (Lang et al., 2000):
• Plaque, or tartar deposits adjacent to slightly inflamed peri-implant tissues
• An absence of suppuration;
• A drilling depth not exceeding 3 mm;
should be subjected to mechanical debridement. While tartar spicules can be removed using carbon fiber curettes, plaque is cleaned using rubber cups and polishing paste
2. Protocol B: Antiseptic treatment
Antiseptic treatment is used in situations where the probing depth is 4-5 mm, while the presence of plaque and bleeding on probing has been revealed. The presence of suppuration may be optional. Antiseptic treatment (Protocol B) is applied in conjunction with mechanical treatment (Protocol A).
Antiseptic treatment includes the application of the most powerful antiseptic, namely chlorhexidine digluconate, in the form of a 0.1%, 0.12% or 0.2% mouthwash or in the form of a gel to be applied to the desired site. Generally, it takes 3 to 4 weeks of regular administration to achieve positive results.
3. Protocol C: Antibiotic treatment
When the probing depth is 6 mm or more, plaque deposits and bleeding are frequently found upon probing. However, signs of suppuration are not necessarily found.
Such a peri-implant lesion is highlighted on radiography by the presence of a bowl-shaped radiolucent area around the implant. The highlighted pocket represents an ecological niche that leads to colonization by Gram-negative anaerobic periodontopathogenic microorganisms. Antibacterial treatment should then include antibiotics to eliminate, or at least reduce, these pathogens from the submucosal ecosystem. This will allow healing of the soft tissues, as demonstrated by Mombelli and Lang (1992)
4. Protocol D: resective or regenerative therapy
When the infection is controlled and the inflammation is reduced, periodontal surgery techniques can be considered.
PERI-IMPLANT DISEASES: THERAPY
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