Dental Clinical Articles
Posted: 8 December 2011
Peri-Implantitis: Causes, Treatment and Prevention
As implants become more widely used, so associated problems become more common. As a new centre is established specifically to treat peri-implant diseases, David Holmes looks at their causes and the treatment options available
Peri-implant disease is a growing problem in implant dentistry. Despite our best efforts to refine implant design and surface features the problem persists, and in some cases appears to be growing. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds the numbers of patients presenting with the disease seems to be increasing.
Peri-implant diseases are infectious in nature and can be broken into two types; peri-implant mucositis and peri-implantitis. Peri-implant mucositis describes an inflammatory lesion that resides in the mucosa, while peri-implantitis also affects the supporting bone1.
As with most things in dentistry, early diagnosis is often key to successful resolution of the problem. Adequate baseline radiographs should be taken at the time of insertion of the final prosthesis to determine the baseline alveolar bone levels. This can then be compared to future radiographs to determine if additional bone loss, beyond ‘normal’ has occurred.
Careful monitoring of implants should look for changes in clinical parameters such as bleeding on probing, suppuration on probing and increased probing depths. The clinician should then consider taking a radiograph to evaluate possible bone loss.
Local iatrogenic factors can often contribute to the initiation and/or maintenance of peri-implantitis. These can include excess cement, poorly fitting abutment/crowns, over contouring of restorations and poorly positioned implants2. Poorly controlled chronic periodontitis also increases the risk of peri-implant disease.
Peri-implant mucositis is a reversible condition and requires only minimal intervention to treat. Thorough mechanical debridement of the area along with local anti-microbials (Chlorhexidine irrigation, Dentomycin) is usually sufficient to resolve the problem. A thorough examination of the area should also be completed to ensure there are no local iatrogenic factors contributing to the problem.
If the disease has progressed further and bone loss is evident, the initial treatment phase is the same; anti-microbials (chlorhexidine, dentomycin), mechanical debridement and strict oral hygiene protocols, including chlorhexidine mouthwash. Administration of systemic antibiotics should also be considered to reduce the number of pathogens present. Numerous methods have been used to debride the plaque-contaminated implant surface including mechanical, sonic, and ultrasonic scalers, lasers, air-powder abrasion, and various chemical solutions such as chlorhexidine digluconate, citric acid, hydrogen peroxide, and saline3,4. At the Centre for the Treatment of Peri-implant Disease (CTPID) we use a combination of methods including chlorhexidine digluconate, tetracycline solution, saline and mechanical debridement. However, every case is unique and requires a tailored solution.
The clinician can then consider whether to attempt to regenerate the bone around the implant. This decision is made based on the amount of bone lost, the defect morphology and the patient’s response and motivation5. The goal here is to re-establish bone volume around the implant, however, there is ongoing debate about the ability to ‘re-osseointegrate’ the previously contaminated implant surface.
|PROTOCOL FOR TREATING PERI-IMPLANTITIS|
|1. Systemic antibiotics equivalent to metronidazole 400mg TDS for three days pre-operatively|
|2. Pre-operative one minute mouthwash with 0.2% chlorhexidine|
|3. Full-thickness flap elevation extending beyond the infected area to sound tissues (Figure 2)|
|4. Comprehensive debridement and curettage down to fresh bone. Mechanical curettage of implant surface with carbon fibre curettes (Figure 3)|
|5. Pack gauze strips soaked in 0.2% chlorhexidine around implant, into defect and under the mucoperiosteal flap. Leave in situ for five minutes|
|6. Remove gauze and wash defect with tetracycline solution 1g in 20ml of sterile saline (Figure 4)|
|7. Graft defect with synthetic, allogeneic, xenogenic graft material rehydrated in the tetracycline solution (Figure 5)|
|8. Overlay graft with double layer of resorbable collagen membrane, rehydrated in tetracycline solution (Figure 6)|
Preventing peri-implantitis requires thorough oral hygiene instruction, adequate surgical technique and the use of dental implants with appropriate moderately rough surfaces and implant thread and body design. Adequate periodontal disease control is also essential in the partially edentulous patient to prevent cross contamination from periodontal lesion to the implant surface. The presence of untreated chronic periodontitis has shown to increase the risk of implant failure by 5%.
When restoring an implant it is absolutely essential to ensure all excess cement has been removed and the area is cleansable with an oral hygiene product. My preferred device is the TePe interproximal brush. I always make sure that the restoration is cleansable with at least the smallest brush. If necessary I will adjust the prosthesis to open the embrasure space to allow easy access by the patient during their home oral hygiene routine. Pontic areas should also be convex in the area over gingival tissues, rather than concave, to ensure that plaque and food debris is easily cleansable.
Peri-implant disease remains a controversial subject in implant dentistry. There is ongoing debate over the exact cause and ideal treatment for this persistent disease. Prevention, early diagnosis and referral to specialist care if necessary remain the key to successful management of the disease.
|PROTOCOL FOR TREATING PERI-IMPLANT MUCOSITIS|
|1. Mechanical scaling of implant surface with carbon fibre curettes|
|2. Buffing of exposed implant surface with gauze strips soaked in chlorhexidine (0.2%)|
|3. Sub-mucosal irrigation with 5ml chlorhexidine (0.2%) per site, at the deepest level of the pocket on all sides of the implant|
|4. Application of minocycline gel 2% (Dentomycin, Blackwell Supplies Ltd)|
The Centre for the Treatment of Peri-Implant Disease
A new opportunity for referral has been created specifically to address complications with implants. The Centre for the Treatment of Peri-Implant Disease (CTPID) will focus on providing a service to help patients who are encountering problems with their implants, whilst providing a much needed avenue for referral for dentists who struggle to deal with the ravages of peri-implantitis, chronic mucositis and other implant related biological and mechanical complications.
'It can be really upsetting for a patient to be told that their expensive implants are now infected or failing, and equally difficult for the clinician who is now faced with increasing chair time spent fire fighting a problem that he or she may be ill-equipped to deal with and keen to outsource,' says the centre's director, Dr Michael Norton.
'Our intention is to provide an outlet that allows referral to a centre of excellence where we can off-load the burden from the treating dentist and hopefully provide some hope for the patient.' The need for greater knowledge was highlighted by the ADI masterclass, Focus on Peri-implantitis in 2009, for which Dr Norton was the Scientific Chairman, and it remains as urgent today as ever.
'The centre is a win-win situation for all. The patient gets the hope of effective expert treatment, the dentist has an outlet for referral and we get the opportunity to further research the condition and build on our understanding of what does and does not work,' adds Dr Norton.
1. Lindhe, J. & Meyle, J. (2008) Peri-implant diseases: Consensus report of the Sixth European Workshop on Periodontology. Journal of Clinical Periodontology 35 (Suppl. 8), 282–285.
2. Lang, N. P., Bosshardt, D. D. & Lulic, M. (2011) Do mucositis lesions around implants differ from gingivitis lesions around teeth? Journal of Clinical Periodontology 38 (Suppl. 1), 182–187.
3. Schou, S., Berglundh, T. & Lang, N.P. (2004) Surgical treatment of peri-implantitis. International Journal of Oral & Maxillofacial Implants 19 (Suppl.): 140–149.
4. Schou, S., Holmstrup, P., Jrgensen, T., Skovgaard, L.T., Stoltze, K., Hjorting-Hansen, E. & Wenzel, A. (2003) Implant surface preparation in the surgical treatment of experimental peri-implantitis with autogenous bone graft and ePTFE membrane in cynomolgus monkeys. Clinical Oral Implants Research 14: 412–422.
5. Parlar A, Bosshardt DD, C¸ etiner D, Schafroth D, U¨ nsal B, Haytac¸ C, Lang NP. Effects of decontamination and implant surface characteristics on re-osseointegration following treatment of peri-implantitis. Clin. Oral Impl. Res. 20, 2009; 391–399.