Current Understanding and Treatment Strategies of Peri-Implant Diseases - An Overview

Navjot Kaur¹, Tarun Nanda^2*, Baljeet Singh³, Sonia Nanda⁴

¹Associate Professor, Department of Dentistry, White Medical College and Hospital, Pathankot, Punjab, India
²Professor, Department of Periodontology, Bhojia Dental College and Hospital, Baddi, HP, India
³Principal, Department of Periodontology, Himachal Dental College and Hospital, Sundernagar, HP, India
⁴Professor, Department of Prosthodontics, National Dental College and Hospital, Dera Bassi, Punjab, India

^*Corresponding Author: Tarun Nanda, Professor, Department of Periodontology, Bhojia Dental College and Hospital, Baddi, HP, India; Email: [email protected]

Published Date: 24-09-2022

Copyright^© 2022 by Kaur N, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

As the general practitioners and specialists all over are placing dental implants with increased confidence and expertise, so are the diseases and complications associated with them have gained momentum. Peri-implant diseases consisting primarily of peri-implant mucositis and peri-implantitis consists of soft tissue and hard tissue inflammation resulting in increased clinical parameters such as pocket depth, clinical attachment loss, implant mobility  along with radiological findings of bone loss around the implant body and prosthesis. To manage these infections, various treatment strategies have propped up in dentistry that one can mix and match the different options according to the situation and do the needful. In this article, there is description of peri-implant diseases, signs and symptoms that are associated with them and the therapeutical options that can be applied to treat them. The goal of this article is to make the diagnosis and therapy easy and narratable with the help of flowcharts, so that the reader whether an academician or a clinician can understand the cause, effect of peri-implant diseases and can correct them for the benefit of the patients.

Keywords

Peri-implant Diseases; Peri-Implant Mucositis; Peri-implantitis; Non-surgical Therapy; Surgical Therapy

Abbreviation

VS: Visual Signs; BOP: Bleeding On Probing; PPD: Probing Pocket Depth; RBL: Radiographic Bone Loss; OHS: Oral Hygiene Status; NST: Non-Surgical Therapy; AMT: Anti-Microbial Therapy, AST: Antiseptic Therapy; RBD: Residual Bone Defect; EBL: Extensive Bone Loss; OFD: Open Flap Debridement; DC/DD: Decontamination/Detoxification; GBR: Guided Bone Regeneration; APF: Apically Positioned Flap

Introduction

With the advent of implants in today’s world, newer and wider possibilities have cracked up to replace the missing teeth in the patient’s oral cavity. Osseointegration of the implant structure with the alveolar bone has led to a predictable treatment outcome in most of the cases. But, on the same time, it has opened plethora of mechanical and biological complications which has decreased the success and survival rate of implants. These complexities can arise due to various factors out of which accumulation of biofilm causing inflammation of the soft and hard tissue around the implant presents a major reckoning component in implant’s abidance.

The inflammatory lesions surrounding the implant body falls into the category of peri-implant diseases, namely, peri-implant mucositis and peri-implantitis [1]. Peri-implant mucositis, contrary to gingivitis, is an inflammation of the mucosa surrounding a functional implant and peri-implantitis as in periodontitis is swelling of surrounding mucosa and bone loss beyond the initial bone remodeling after the placement of the implant [2]. In a systemic review done with metanalysis, the prevalence for peri-implant mucositis was reported at 43% ranging from 19% to 65%, whereas for peri-implantitis, it amounted to 22% ranging from 1% to 47% [3].

Risk Factors

The causative factors which are responsible and increases the risk for the peri-implant diseases can be broadly classified into patient associated and implant site and prosthesis associated factors. The presence of microorganisms along with formation of biofilm causing infection plays a significant role in initiation and progression of patient linked peri-implant diseases. Outcomes from various animal and human studies have shown similarity in the composition of bacteria in peri-implant diseases and gingivitis along with periodontitis, i.e gram negative aerobes and anerobes [4,5]. Other aspects that can be linked to patient are poor plaque control, lack of maintenance therapy, history of periodontal disease, active usage of tobacco products, presence of systemic conditions in the form of diabetes mellitus, obesity, cardiovascular conditions and genetic factors [6].  In site specific factors, implant surface characteristics, type, prosthetic design, residual cement, peri-implant soft tissues and occlusal overload come into play [7]. It has been hypothesized that rough surface implants harbor more bacteria than the machined ones. Also, poor prosthetic design increases the risk of peri- implant diseases by manifold times. Cement retained restorations are 3.6 times more prone to peri-implantitis when compared with screw-retained prosthesis. Patients with insufficient soft tissue around the implants are more susceptible to peri-implant infections [8]. Recently, tribocorrosion, in which there is mechanical, microbial and chemical wear of the implant surface resulting in release of titanium particles into the surrounding area and tissues causing peri-implant diseases have become a heated topic over the years [9].

Case Definations of Peri-Implant Diseases

Coming to the diagnosis of peri-implant diseases, it is done through clinical, radiographical and microbiological examination at various intervals. Before that, one must understand that what constitutes peri-implant health. In health, there should be no visible signs of inflammation, lack of profuse (line or drop) bleeding on probing, probing pocket depth should not exceed ≤5 mm at any point of time and there should no further bone loss beyond the physiological bone remodeling of upto 2 mm after the placement of implant and prosthesis. So, clinically, any changes in the above said criteria’s will lead to peri-implant diseases [10]. The placement of prosthesis will serve as the baseline criteria that should be followed over time to see any changes in the clinical and radiographical level to diagnose the disease. The implant shoulder or implant-abutment connection point will be the reference point for assessing the changes in the interproximal bone level for peri-implantitis [11].

For peri-implant mucositis, clinically, there will be inflammation of the surrounding tissues in the form of redness, swelling, abnormal contour and consistency or form of the soft tissue. There will be the presence of bleeding on gentle probing with a constant force of 0.25 N cm and suppuration will be there on palpation [12]. The probing pocket depths will be increased as compared to baseline data and there will be absence of bone loss besides the initial remodeling of the alveolar bone radiographically [13]. To assign a case of peri-implantitis, the clinical picture of the site will demonstrate all the signs and symptoms of peri-implant mucositis i.e redness and swelling, presence of bleeding on probing. Along with this, there will be increased pocket depths and progressive bone loss after the placement of implant supported prosthesis. For this, one has to have the baseline recordings of the pocket depth and standardized periapical radiographs taken at baseline period and after 1 year or so [12].  If there is absence of baseline data, then radiographic evidence of bone loss ≥3 mm and/or probing depths ≥6 mm represents peri-implantitis [14].

Viability of implant can be assessed by mobility but existence of it merely does not indicate peri-implantitis. Lack of osseointegration and loss of it after insertion of implant can have variable causes such as improper placement, increased occlusal overload per SE. Due to infectious nature of the peri-implant diseases, one can assume that microbiological examination can be helpful in diagnosing the disease but so far it has been seen that there are no specific bacterial profile that can be matched to peri-implant infection; so this criteria can be useful in guidance of the treatment plan rather than in identifying the disease [15].  Genetically, there is inconclusive evidence of the gene polymorphism linked to increased susceptibility of peri-implantitis but in cases of smokers; there is seen positive correlation of peri-implantitis with interleukin-1 gene polymorphism [16].

Treatment Planning and Considerations

In both the peri-implant diseases, whether it is mucositis or implantitis, the treatment planning differs with respect to the type of disease. If the inflammation has just limited to the perimucosal area and not gone and involved the alveolar bone, then, the use of systemic antibiotics along with mechanical non-surgical therapy can suffice the disease. Otherwise, in cases of peri-implantitis, surgical therapy has been proposed and has shown promising results over the time [17]. As with gingivitis and periodontitis, long term and periodic maintenance therapy and care are necessary to sustain the results of non-surgical and surgical implant therapy (Fig. 1).

In context of peri-implant mucositis, if there is inflammation around the implants and natural teeth in the oral cavity, then, one should focus on the oral hygiene status, smoking habits or presence of any systemic condition such as diabetes mellitus and try to eliminate it. But, if the infection is limited to one or more implants and the prosthesis is cemented, then, one should look for the residual cement under the prosthesis and remove it and if there is any flaw in the design of the prosthetic construction, then it should be taken off and fabricated again [18]. Use of systemic antibiotics such as amoxicillin  and metronidazole is validated in cases of abundant suppuration, existence of sinus or fistula and when the inflammation of the peri-implant area has reached the mucogingival line. To further reduce the bacterial load, one should proceed with the mechanical therapy in the form of scaling and implant therapy equivalent to scaling and root planing done in teeth but with a different approach [19]. In implants, since we have the titanium surface to clean upon, so the materials used are to be softer than it. So, instead of stainless steel, one can use plastic Teflon, carbon, gold-coated and titanium scalers and curettes. If one is using ultrasonics, then, the tips should be covered with plastic PEEK (Polyetheretherketone) and for polishing; there are rubber polishers, low-abrasion fluoride-free and pumice-free prophylaxis paste or high-pressure jets of glycine particles [20].

The mechanical therapy used on the implant surface is optimal for removing soft deposits, supragingival plaque and calculus along with free floating bacteria in the peri-implant sulcus. But, with the formation of biofilm tightly adhered to the surface of the implant body, it is not possible to completely eliminate the local deposits and microorganisms. So, in addition to scaling, one can use adjunctive therapies in the form of antimicrobial mouthwashes such as chlorhexidine and essential oils, submucosal irrigation with antiseptics and disinfectants such as 10% povidine iodine, topical application of antibiotics in the form of local drug delivery systems such as tetracycline fibres, sustained release of doxycycline, minocycline and use of lasers or photodynamic therapy in the area concerned.  Lastly, if the access to the peri-implant area is inadequate, then one should remove the prosthetic superstructure and then proceed with the therapy [21].

In cases of peri-implantitis, where there is bone loss in addition to soft tissue changes, non-surgical therapy as described above is insufficient to resolve the infection. So, here one has to resort to surgical methods to achieve desired results. The type and extent of peri-implantitis also determines the surgical therapy to be executed. For early cases of peri-implantitis (i.e bone loss <25% of the implant length), non-surgical therapy along with adjunctive use of antiseptics and systemic antibiotics with regular follow-up of patients’s compliance can be a useful treatment option. For moderate and advanced lesions of peri-implantitis (i.e bone loss 25 to 50% and >50% of the implant length), surgical therapeutical decisions are to be made accordingly [22]. There are 3 to 4 general approaches to correct the peri-implant disease. One can do an access surgery in the form of full-thickness flap elevation to access the implant surface and then debridement of the surface and the bone defect [23].

Detoxification of the implant surface has to be done to achieve re-osseointegration of the implant with the bone. For mechanical debridement, specially designed scalers are to be used. For chemical cleaning, one has to decontaminate the surface with different chemicals such as citric acid (40%), hydrogen peroxide, saline, tetracycline etc to decrease the bacterial load [24]. Although, these methods are effective in controlling the infection, yet, no mechanical or chemical detoxification method can fully remove the biofilm form the surface and have proven to be superior over the others. Another way to decontaminate the implant surface is by Implantoplasty i.e elimination of the threads of the exposed part of the implant to reduce the rough area and to achieve a smooth and polished surface [25]. Diamond burs are used to remove the threads followed by ceramic and metal polishers that are applied for smoothening. In this, one can stop the progressive bone loss although the major drawback of this technique is the marginal recession of the tissues that can be unaesthetic especially in the anterior areas [26]. Therefore, if the peri-implant disease is concentrated to aesthetic areas with shallow bony defects, then access therapy along with antiseptics, antibiotics and antimicrobials will be the treatment of choice and if it is present in the area not esthetically important along with suprabony component defects, then resective surgery along with apically positioned flap and removal of soft and hard deposits on the implant surface is to be performed diligently. In this way, probing pocket depths are also reduced and one section of the implant will be exposed for assisting in patient’s hygiene. This is the second approach to stop and correct the peri-implant infection.  This treatment option is generally carried out along with implantoplasty to enhance the results [27].

If the lesion around the implant is circumferential intrabony crater-like (also known as patellar defect), then, the 3^rd approach i.e regenerative surgery in the form of biomaterials, grafts, bone substitutes along with barrier membranes are to be used to recover the lost bone tissue and stabilize the implant. Although, there is no evidence of the superiority of a specific bone grafting substitute in terms of long-term benefits, yet, whatever is used, there is approximately maximum reduction of about 5 mm in pocket depth and 2 mm of bone filling with regenerative therapy and if the patient compliance is good, then, one can expect good clinical results with passage of time [28]. Last but not the least, the approach used in cases of advanced lesions of peri-implant disease is explantation i.e implant removal. This can be done through various implant removal kits, implant drivers, reverse screw devices and bone trephine systems. These procedures are invasive in nature resulting in loss of soft and hard tissue around the implant but if the prognosis is poor and feasibility of keeping the structure in the mouth is not appropriate, then, it is better to explant the implant as soon as possible [29].

Figure 1: Decision tree/flow chart for diagnosing and treating peri-implant diseases.

Peri-Implant Mucosa and Maintenance Therapy

In any of the above given situations, it is generally said that a healthy masticatory mucosa of about 2 mm around the implant offers protection against the bone loss and also improves the aesthetic results in long-term [30]. Even though, many studies have pointed no difference in prognosis for implants with good keratinized mucosa or not, still, it is better to have a good surrounding mucosa for adequate oral hygiene levels and maintenance [23,31,32]. After the placement, implant monitoring and supportive therapy is equally significant to improve the results of the treatment done. Recall visits should be planned according to the patient’s risk profile, clinical indices and the placement and design of the implant prosthesis. Based on the presence of bleeding on probing, suppuration, biofilm, pocket depth and radiographic evidence of bone loss, a systematic protocol as developed by Mombelli and Lang, known by the name of Cumulative Interceptive Supportive Therapy (CIST) should be invoked and followed for the implant survival [33]. Also, one can go along with the Peri-implant Index of Treatment Needs (PIITN) as proposed by BuitragoVera PJ and Enrile De Rojas FJ, in 2016 that would facilitate decision-making when there is requirement for any of the complications associated with peri-implant health [21].

Conclusion

All said and done, there is no ideal situation where one can straight way follow and treat the disease according to the guidelines. Many a times, there is a requirement of combined therapies involving non-surgical, surgical and implantoplasty to prolong the life span of the implant fixtures in the patient’s mouth. Nonetheless, as there is increased acceptance of the implants in the dentistry all around, so, are the complications and problems associated with it. In the end, we can say that, starting from diagnosis and pre-evaluation of the patient, every step is important for achieving long lasting results and success. In any given state, right protocols should be followed to curtail the peri-implant disease and if it occurs, it should be treated with utmost priority and expertise based on the patient’s clinical scenario and the best option possible for it. Reciprocating the facts, it can be stressed that routine monitoring and evaluation of the implants at regular intervals can reduce the effects of risk factors associated with the disease and will lead to favorable prognosis in the patient’s mouth.

Conflict of Interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the manuscript.

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Article Type

Review Article

Publication History

Received Date: 23-08-2022
Accepted Date: 17-09-2022
Published Date: 24-09-2022

Copyright© 2022 by Kaur N, et al. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation: Nanda T, et al. Current Understanding and Treatment Strategies of Peri-Implant Diseases – An Overview. J Dental Health Oral Res. 2022;3(3):1-10.

Figure 1: Decision tree/flow chart for diagnosing and treating peri-implant diseases.