Peri-implantitis:
- Introduction :
Fifty years after the first titanium implant was placed by Branemark in Sweden, we thought it would be appropriate to take stock of peri-implant maintenance and the means available to today’s practitioners to treat and prevent these complications that we will encounter more and more frequently.
Among these complications we find inflammatory complications of infectious origin occurring after osseointegration has been achieved and affecting the peri-implant tissue. This is called peri-implantitis.
- Definition of peri-implantitis:
Peri-implantitis was defined at the European Workshop on Periodontology as: “an inflammatory process of infectious origin that affects the hard and soft tissues around an osseointegrated and functioning implant, and that results in the loss of bone support”
The review of articles by Lang and Berglundh published in 2011 shows that the definition of peri-implantitis remains very variable according to the authors. For them, it corresponds to a probing depth greater than 6 mm associated with a bone loss of 2.5 mm objectified radiographically.
In conclusion, we will remember that peri-implantitis is an inflammatory process of infectious origin affecting the tissues around an osteointegrated and functioning implant.
- Classification:
- Schwarz et al classified peri-implant lesions based on the configuration of bone defects:
• Class 1: intraosseous defect.
• Class 2: supraalveolar defect in the crestal insertion of the implant.
This classification informs us that 2 classes and there is no obvious clinical and radiological interpretation.
- Another classification system requires the amount of bone loss along with the shape of the defect:
• Class I: slight horizontal bone loss with minimal peri-implant defects
• Class II: moderate horizontal bone loss with isolated vertical defects.
• Class III: moderate to advanced horizontal bone loss with large circular bone defects.
• Class IV: advanced horizontal bone loss with large circumferential vertical defects, as well as loss of the buccal or vestibular bone wall.
This classification reveals a horizontal bone defect as well as other types of bone defects around the implant, no clinical picture, no treatment modality and no prognosis are highlighted.
Peri-implantitis
- Diagnostic methods:
- Inspection of peri-implant tissue:
The visual aspect of the peri-implant soft tissues is important and before probing, the practitioner can already identify certain “dubious” signs: redness, edema, bleeding, suppuration, alteration of the contour shape or even loss of keratinized tissue. The presence of these clinical signs indicates a pathological, inflammatory or infectious situation, which should lead us to conduct more in-depth investigations.
- Assessment of inflammation:
In order to be able to make an unambiguous diagnosis, it is necessary to resort to classifications; among the numerous publications in this field, two classifications seem interesting:
The classification of (Mombelli et al., 1987) which includes 4 scores ranging from 0 to 3, is an adaptation of the classification of (Löe and Silness, 1963) which has been modified for peri-implant tissues.
The classification of (Apse et al., 1991) which also includes 4 scores ranging from 0 to 3 and which seems simpler to use in clinical practice
Assessment of implant inflammation according to Mombelli et al. (1987) and Apse et al. (1991)
Note: Once the inflammation is characterized, it will be necessary to identify the cause and attempt to correct it; the etiology can be multiple: lack of hygiene of the patient, but also persistence of sealing cement in the peri-implant groove, unscrewing of the abutment.
- Plaque assessment:
In order to assess the amount of plaque around implants, Mombelli and his colleagues proposed in 1987 a modification of the plaque index of (Silness and Löe, 1964) classically used in periodontology in order to adapt it to the peri-implant mucosa, it is a 4-level score ranging from 0 to 3, it is presented in the following table : peri-implant plaque index according to Mombelli et al. 1987
- Peri-implant survey:
Peri-implant probing is the main element in the diagnosis of peri-implant diseases. Studies on experimental peri-implantitis have shown that an increase in probing depth over time is always associated with loss of attachment, as well as marginal bone loss.
More recently, Professor Heitz-Mayfield has conducted a study of probing depth around an implant on which she induced experimental mucositis using a ligature. She found, after a few weeks of observation, that probing depth increased as inflammation increased and that beyond 1.6 mm depth, peri-implant inflammation was always associated with loss of attachment, as well as marginal bone loss.
The depth of the survey:
Several studies have shown that well-osseointegrated implants provide a probing depth of approximately 3 mm. The depth of penetration at peri-implant probing has been studied histologically. In dogs, the results indicated that the density of peri-implant tissues influences the depth of penetration. In the presence of peri-implant inflammation, the periodontal probe penetrates close to the bone level. In healthy sites, the tip of the probe is stopped by the adhesion of connective tissue to the implant neck. There are correlations between the bone level identified on radiography and the measurement of peri-implant probing.
Survey around an implant and a tooth:
Peri-implantitis
The type of probe used:
A graduated plastic or metal periodontal probe can be used. Some authors recommend a Teflon, polycarbonate or titanium probe to avoid scratching the implant surface, specially designed to take measurements around implants
Different types of periodontal probes:
- Presence of bleeding during probing:
Bleeding on probing is a clinical parameter defined by the presence of bleeding after penetration of the periodontal probe into the peri-implant sulcus. For this parameter to become a reproducible diagnostic criterion, it is necessary to standardize it, currently the authors recommend gentle probing with a force less than or equal to 0.25 N whether on natural teeth or around implants
- Presence of suppuration:
The presence of pus is sometimes encountered in cases of peri-implantitis, but it is never present in simple peri-implant mucositis. Therefore, the presence of pus is a pathognomonic sign of destruction of peri-implant tissues and peri-implantitis.
- Mobility:
Implant mobility scale:
Peri-implantitis
Note: The implant mobility scale was developed in 1998, and assesses implant mobility in the horizontal and vertical directions by applying a vestibulo-lingual force of 500g on the implant held between 2 rigid instrument handles.
- The radiological examination:
Radiographic assessment is essential to estimate bone loss around an implant and to diagnose peri-implantitis in addition to clinical signs of deepening of the peri-implant groove and bleeding on probing. However, bone remodeling and physiological resorption observed during the first year following implant placement must be taken into account.
(Albrektsson and Isidor, 1994) defined at the 1st European Workshop on Periodontology that acceptable bone loss is less than 1.5 mm during the first year following implant placement and function, then less than 0.2 mm per year in subsequent years.
More recent data consider peri-implantitis to be any bone loss greater than or equal to 1 mm in the first year and 0.2 mm or more from the following year (Prathapachandran and Suresh, 2012)
- Radiographic characterization of peri-implantitis:
Radiologically, peri-implantitis is characterized by bone loss that is always circumferential, i.e. in the shape of a bowl or crater, at the point of emergence of the implant.
Note: Today we have three-dimensional imaging techniques with CT and cone beam computed tomography (CBCT). These modern techniques make it possible to overcome the limitations of 3-dimensional imaging, namely: visualizing the bone level only at the interproximal spaces but neither vestibularly, nor palatal or lingually due to superpositions
- Microbiological diagnosis:
The idea of successfully identifying biochemical markers that can monitor peri-implant health and detect peri-implant diseases early using non-invasive and reliable diagnostic tests is very attractive, which is why many research teams are working on these topics.
These biochemical markers which are mediators of inflammation are secreted in the peri-implant crevicular fluid, as well as in saliva, the detection of which would make the technique even easier to implement and non-invasive.
- Positive diagnosis:
Diagnosis of peri-implantitis requires:
- Visual inspection with assessment of the presence of classic signs and symptoms of inflammation (redness, swelling, pain).
- Presence of bleeding and/or suppuration on probing.
- Increased pocket depth and/or recession of the mucosal margin.
- Bone loss visible on x-ray in addition to initial bone remodeling.
In the absence of previous examinations, the diagnosis may be based on the combination of:
– Radiographic bone level > 3 mm in the major coronal portion of the intraosseous part of the implant.
– Presence of bleeding and/or suppuration.
– Loss of attachment > 6 mm.
- Differential diagnosis:
- Peri-implant mucosity: It is identified clinically by redness and bleeding of the soft tissues without destruction of the bone support (periodontal probing <5mm)
Treatment consists of plaque removal and rigorous oral hygiene with or without antiseptic. Similarly; the literature review by Renvert et al. confirms that non-surgical mechanical treatment and the use of antimicrobial mouthwash improve treatment outcomes.
- Occlusal overload
- Factors associated with occlusal overload or occlusal trauma probably consist of excessive expansion of the prosthesis in the posterior region; deviation of the implant axis from the axis of function; a large crown/implant length ratio.
Occlusal loading can cause complete bone destruction of an osseointegrated implant
- Etiological diagnosis:
Bacterial biofilms have been proven to be the main etiological factor in the development of inflammatory lesion of periodontal tissues. Several animal studies have demonstrated the mechanisms of inflammatory lesion development around dental implants.
A similar response was also observed, namely the establishment of biofilms in implants and teeth, with increased inflammatory infiltration and substantial collagen loss. The peri-implant lesion was considerably larger and the apical extension of the peri-implant mucosa was greater than that of the teeth
Multiple other variables can influence the progression of peri-implant disease. A variable can be characterized as a true risk factor for the progression of peri-implant disease once it has been studied in longitudinal studies and its negative impact has been established. Variables impacting the progression of peri-implant disease, which have been identified in retrospective and cross-sectional studies, can only be identified as risk indicators.
- Therapeutics for peri-implantitis:
- Purpose of processing:
The main goal of treatment is to maintain the functional implant and prevent the recurrence of peri-implant infection. To do this, it will be necessary to eliminate the granulation tissue adhering to the implant, to recreate a local environment favorable to the patient’s hygiene and to arrange the osteomucosal profile in order to facilitate its healing or even its regeneration.
Peri-implantitis
- Principle of treatment:
Treatment of peri-implantitis is based on:
- Cleaning the implant environment through impeccable patient hygiene and appropriate professional maintenance.
- Implant surface decontamination. This is the main aspect of peri-implantitis treatment. This procedure has been made more difficult by the appearance of rough implant surface conditions. Various decontamination techniques have been proposed, without there being any consensus on the subject. The main techniques are the use of carbon or titanium curettes, air polishing, laser, specific ultrasonic inserts, etc. These techniques are often associated with an antiseptic surface treatment (often with hydrogen peroxide).
- Surgical removal of residual pockets. This strategy, as in periodontology, can leave aesthetic after-effects because it sometimes leads to exposure of the neck, or even of the implant coils.
- In some cases, the morphology of peri-implant alveolysis requires bone reconstruction techniques. These techniques are indicated when a deep infra-osseous lesion is present around the implant, or in the aesthetic sectors, in order to preserve the peri-implant tissue volumes. This reconstruction is most often done using a xenograft, with or without an autograft. A resorbable membrane can also be used to protect the graft.
Individual maintenance:
- The dental plaque revealer: it represents a real educational tool for the patient. It allows him to detect the presence of dental plaque, to eliminate it perfectly and to realize that the use of the toothbrush alone is not sufficient for an optimal cleaning
- Brushing:
The toothbrush must be adapted to the peri-implant tissues, it can be:
→ Manual: flexible with strands with a diameter of 20/ 100th
→ Electric: with a sensitive head and equipped with a pressure sensor.
The technique recommended in France by the UFSBD is the BROS technique:
B: Brush bottom and top separately.
A: Roller or rotating motion to brush teeth and gums, from pink to white.
O: Oblique, the brush is inclined 45° on the gum.
S: Follow a path to brush all sides of all teeth without forgetting the top
- Mouthwash:
It is now accepted that, in addition to a standard hygiene protocol, the use of a mouthwash (based on Chlorhexidine, herbs or essential oils) provides additional benefit in plaque control (Prasad – 2016).
In order to optimize the antiseptic action of Chlorhexidine, it would be preferable to delay its use by at least 30 minutes after brushing with toothpaste. Indeed, it is a cation whose action can be annihilated by the anions contained in the toothpaste.
Professional maintenance:
Recently, Favril produced a summary of the elements to check during a professional maintenance session:
- Update medical history: ask about any changes in health status and medication use
- Control the stability of marginal tissues (recession) and the width of the keratinized mucosa
- Check oral hygiene (presence of plaque) and clinical signs of inflammation (bleeding, suppuration), compare with previous visits. Do not hesitate to repeat oral hygiene instructions, insist on the need for peri-implant hygiene.
- Check the 4-point probe of the implant with gentle probing and compare the values with those noted during previous visits
- Check the occlusion between the implant and the opposing teeth, rebalance if necessary in case of overload
- Check for absence of mobility: sign of loss of integration, implant fracture or restorative complication (loosening – fracture of the screw or abutment)
- Check the contact point with floss: a loose contact point can lead to plaque buildup
- Take a retro-alveolar X-ray every year during the first 5 years then every 3 years unless there is a clinical change,
- Prophylactic cleaning: supra- and infra-gingival mechanical debridement if necessary using titanium insert, followed by polishing.
Peri-implantitis
- Curative treatment:
Non-surgical treatment:
Current published studies on nonsurgical treatment of peri-implantitis include mechanical debridement; adjunctive antibiotic therapy; adjunctive antiseptic therapy; and laser-assisted therapy.
However, in cases where non-surgical treatment results in complete healing of peri-implantitis the patient should be placed on a supportive maintenance program; otherwise if the disease is not resolved surgical therapy or even removal of the implant is required.
- Antibiotic therapy: The choice of antibiotic is made according to:
– Where the bacteria are known to be responsible for the infection.
– The known activity of the antibiotic molecule on the target germ.
– The presence of the antibiotic at the site of infection.
– The land
– Contraindications Before initiating antibiotic therapy, it is preferable to carry out a bacteriological analysis in order to use the molecule whose spectrum of action best targets pathogenic germs.
Peri-implant lesions are local lesions; therefore local treatment seems logical; the use of debridement alone does not seem to be sufficient and there seems to be a need for local antibiotics as adjunctive therapy in the treatment of peri-implantitis.
Local treatment with tetracycline shows that suppression of pathogens such as P.gingivalis; P.intermedia and AAC can be achieved 12 months after training (Mombelli et al.2001).
- Mechanical debridement:
The main problem with removing plaque and tartar from implant surfaces is related to the possible damage to the implant surface by using various instruments. These instruments must allow the removal of bacterial deposits otherwise their biocompatibility will be affected.
Various debridement methods are therefore unanimously recommended due to their safety with regard to the implant surface and the biological properties of the material.
Surgical treatment:
Multiple surgical procedures have been advocated for the surgical treatment of peri-implantitis, and the choice of intervention may depend largely on the configuration of the peri-implant defect
Surgical Procedures Armamentarium:
Peri-implantitis
In summary:
When peri-implantitis cannot be stopped by non-surgical means, two types of surgical techniques can be proposed.
The first is to move the gum so that the surface of the implant affected by peri-implantitis becomes accessible for brushing. When possible, the surface of the implant is also polished to make bacterial colonization less easy. This is called an apicalized flap and implantoplasty.
The second aims to regenerate bone destroyed by peri-implantitis through the use of regenerative materials (membranes, bone materials) and/or bone grafts.
The choice of surgical technique depends mainly on the shape of the bone defect created by peri-implantitis
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