Peri-implantitis

Thanwadee Immsombatti

Jan 8th,2014

Background

• Peri-implant disease : An inflammatory reaction around the tissue surrounding an implant consist of two forms

• Peri-implant mucositis

• Peri-implantitis

Mombelli A. et al. Periodontol 2000 1998;17:63-76.The Sixth European Workshop on Periodontoloy 2008

Peri-implant mucositis

• The presence of inflammation

• Confine to the soft tissue

• No signs of loss of supporting bone following initial bone remodeling

• Reversible condition : early intervention and remove etiology

San M. et al. J Clin Periodontol 2012;39(Suppl.12):202-206.

Peri-implant mucositis

• Clinical findings• Bleeding on probing / gingival redness

• Probing depth ≥ 4 mm

• No radiographic bone loss

• Prevalence : 48% of implants

San M. et al. J Clin Periodontol 2012;39(Suppl.12):202-206.

Roos-Jansaker AM. J Clin Periodontol 2006;33:290-295.

Peri-implant mucositis

Peri-implantitis

• An inflammatory process

• Soft tissue inflammation, Bleeding on probing

• Probing depth ≥ 5 mm

• Suppuration

• Progressive loss of supporting bone beyond biological bone remodeling• Mean crestal bone loss of 0.9-1.6 mm in first post-surgical year

• Then annual bone loss of 0.02-0.15 mm

• In case of no baseline radiograph, 2 mm vertical distance from expected marginal bone level

• Prevalence : varied from 11%-47% depending on the threshold used

Peri-implantitis

Koldlands OC. et al. J Periodontol 2010;81:231-238.

San M. et al. J Clin Periodontol 2012;39(Suppl.12):202-206.

Peri-implantitis

Etiologies

• Formation of biofilm

• Gram-negative anaerobic bacteria : similar to natural teeth in periodontal disease• Peri-implant mucositis – Gingivitis

• Peri-implantitis – Periodontitis : S.aureus could be found as the initiation of peri-implantitis

Heit-Mayfield LJ. et al. Periodontol 2000 2010;53:167-181.Leohardt A. et al. Clin Oral Implants Res 1999;10:399-345.

Factors associated Peri-implantitis• History of periodontitis : two times

• Smoking : 3-4 times increased risk for peri-implantitis

• Residual cement : Rough area beneath gingival margin Bacterial attachment

• Implant position and design : inability to clean

Mombelli A. et al. Clin Oral Implants Res 2012;23(Suppl.6):67-76.

Linkevicius T. et al. Clin Oral Implants Res 2012 published online

Treatment

• Primary goals • Resolve inflammation

• Arrest the progression of disease

Treatment

Non-Surgical treatment

• Mechanical debridement• Ultrasonic scaler

• Hand instruments : Plastic curette

• Rubber cup & pumice

• Plaque control

• Effective in Peri-implant mucositis• carbon fibers curette, rubber cup, pumice

• In peri-implantitis, mechanical debridement alone was found not to be effective

Non-Surgical treatment

• Use in conjunction with mechanical debridement and chemical disinfection

• Local : high concentration, reduce side & adverse effect • Tetracyclin HCL (Actisite® )

• Minocyclin

• Systemic : ornidazole 1000 mg daily, metronidazole, amoxicillin

Antibiotic

Antibiotic

Surgical approach

• Surgical approach• Access surgery : apically positioned flap, surface modification

• Resective

• Regenerative : guided tissue regeneration, bone grafting

• Surface decontamination

Surface decontamination

• Chemical agents • hydrogen peroxide, citric acid, 35% phosphoric acid

• Photodynamic therapy• Photosensitizer + high energy laser light -> destroy bacterial cells

• Laser treatment • combined with Chemical agents to archieve higher re-

osseointegration

Anti-infective protocol

• Peri-implantitis VS Periodontitis• Eiology

• Treatment

• Anti-infective protocol have been adopted to treat peri-implantitis• Open flap debridement

• Implant surface decontamination

• Systemic antibiotic : Amoxicillin (500 mg) + Metronidazole (400 mg) 7-10 days

Anti-infective protocol

Conclusions

• Non-surgical treatment alone was found to be effective in peri-implant mucositis : carbon fibers curette, rubber cup, pumice

• Peri-implantitis with mild bone loss : Mechanical debridement, Antiseptic(CHX mouthwash), Systemic/Local Antibiotic, Resective surgery

• Peri-implantitis with moderate bone loss : Mechanical debridement, Antiseptic(CHX mouthwash), Systemic/Local Antibiotic, Open flap debridement, Surface decontamination, Regenerative surgery

Mechanical debridement

Anti-septic mouthwash

Local/systemic antibiotic

Resective surgery

Surface decontamination

Regenerative surgery

Peri-implant mucositis (<3mm)

Peri-implant mucositis (>3mm)

Peri-implantitis with mild bone loss

Peri-implantitis with moderate bone loss

Conclusions

• Bone fill & Re-osseointegraion• Regenerative procedure > Open flap debridement

• Membrane did not improve treatment outcome in comparison to the use of autogenous bone alone

• Systemic antibiotic (Amoxicilin plus metronidazole) and antiseptic mouthrinse(CHX) : improved clinical outcomes

Conclusions

• No single method of surface decontamination(Chemical agents, air abrasive, lasers) was found to be superior

• Citric acid(40%,30-60 sec) has proved to be most effective agent for bacterial growth reduction on HA surfaces

• The simplest method of surface decontamination; gauze soaked alternately in CHX and saline, should be preferred when combined with membrane-covered autogenous bone graft