Peri-Implantitis:Prevalence, Practical Treatment and

Prevention

Dr. Scott K. SmithNovember 13, 2013

Scott K. Smith

•Practicing Periodontist 20 years

•Placed over 10,000 implants

•HiOssen lecturer, teacher and Instructer

Objectives•Define Peri-Implant Mucositis and

Peri-Implantitis

•Prevalence of each

•Pathogenesis vs. Periodontal Disease

•Diagnostic Criteria

•Treatment for mucositis and implantitis

•Maintenance following treatment

Conflict of Interest

•HiOssen - Clinical practice support and honorarium.

Dental Implant Success

•400,000 implants placed per year in US

•1 million implants placed per year in EU

•$6.5 billion US industry

•Failure Rate of Implants less than 5%

•Industry and Research Focus on Initial Stabilization, enhancing supporting structure and Initial Esthetics.

The Dark Side•Incidence of Peri-implant mucositis

and Peri-implantitis is as much as 47%!!

•Failure of Implants by Chronic Inflammation include Functional loss, Phonetic and Esthetic Challenges

•Professional Challenge

•Host Response to Bacterial Insult

•Initial Event is Inflammation of Pocket Epithelium without CT or Bone Destruction - Reversible = Gingivitis

•Chronic Inflammation and Risk Factors = Periodontitis

Similarity with Periodontal Diseases

Implant Related Periodontal Diseases

•Peri-Implant Mucositis

•Peri-Implantitis

Peri-Implant Mucositis

•The presence of inflammation confined to the soft tissues around the implant - No sign of bone loss.

•Presence of probing >4mm with bleeding or suppuration

•Reversible

Peri-Implantitis•Inflammatory process around and

implant including soft tissue and progressive loss of supporting bone beyond biological bone remodeling.

•Probing depth >4mm with bleeding, suppuration and radiographic bone loss

Peri-Implantitis

Probing depths >4mm with bleeding, suppurationRadiographic loss of bone beyond remodeling

Prevalence:Peri-Implant Mucositis

•Berglundh, Renvert: 48% of all implants over 9-14 yrs affected.

•Prevalence may be higher - Previous Dogma of Not Probing around Implants Reduced Identification

Prevalence:Peri-Implantitis

•Wide Range: from 4.7% to 36.6%

•The Threshold used is Bone Loss. No standarized radiographic analysis.

•Additionally Factors such as Smoking, Diabetes, Previous Periodontal Disease create subpopulations and complicate comparisons of studies.

Periodontal Anatomy

Anatomy of a Tooth

•Junctional Epithelium has Hemidesmosomal attachment to enamel

•Connective tissue array of 1mm thickness with attachment to Cementum

•Alveolar Bone with Perpendicular Fibers attaching to Cementum overlying Dentin

•Vast Source of Nutrients and Cells for Regeneration of Ligament, CT, Cementum, Bone

Cementum

•Acellular and Cellular containing cementoblasts provide support on the tooth side to anchor sharpy’s fibers

•Periodontal Ligament space provides nutrient supply and cells for Regeneration

Anatomy of an Implant•Junctional Epithelium attached to titanium

surface by basal lamina and hemidesmosomes

•At apical portion of sulcus is only a few cell layers thick and separated from bone by 1-2mm

•No Cementum - Bone to Implant Contact

•Connective tissue between JE and Bone few vascular structures and few Fibroblasts

Pathogenesis

Peri-Implant Mucositis

•Plaque formation of titanium surface and formation of biofilm. Gram (-) Anaerobic

•Inflammatory infiltration occurs in CT

•Neutrophils, lymphocytes, macrophages in high numbers

•Adaptation of JE to Inflammation

Peri-Implantitis

•Inflammatory - bacterial driven destruction of the implant supporting apparatus.

•Chronic Inflammation starting as PIM

•Inflammatory Cell Infiltrate more Severe with Implants vs. Teeth

•Rate of Disease Progression Faster with Implants

Peri-Implantitis

•The difference in collagen fiber orientation (parallel to implant and perpendicular with teeth) and less vasculature structure may explain the faster pattern of tissue destruction with peri-implantitis.

Influential Factors

•Patient Related - systemic diseases, history of Periodontal Disease

•Social Factors - Poor OH, Smoker, Heavy alcohol consumption

•Parafunctional Habits - Bruxism, Malocclusion

Smoking

•Baig and Rajan found in smokers significantly more marginal bone loss after placement and higher Peri-Implantitis percentages.

Previous Periodontitis

•Significant correlation with increased prevalence of Peri-Implantitis

Genetic Factors

•Significant correlation with Interleukin1gene polymorphism and Peri-Implantitis.

•Plagnat - proposed markers for Elastase and alkaline phosphatase may be helpful in future diagnosis of bone destruction.

Health Status

•Diabetes Type I and II if uncontrolled lend to increased inflammatory Response and Peri-Implantitis

Occlusion

•Non-axial forces, cantilevers, bruxism

•H.L. Wang et al - occlusal overload positively associated with Peri-Implantitis

•Likely excess strain causes microfracture within bone.

Additional Influential Factors -You’re to

Blame

•Implant Design

•Prosthetic Connection

•Mechanical Failures and Cement Contamination

•Surgical Errors

Implant Design

•Smooth titanium vs. Roughened surfaces

•Smooth Cervical collar vs. Surface texture to coronal margin

•Thread Design - aggressive vs. passive

Implant Design - Connection

•External Hex

•Internal Hex

•Morse Taper

•Platform Switch

Platform Design•Crestal Bone loss begins when healing

abutment is attached to implant at second stage surgery (Nobel implants - Ericsson J. Clin. Perio 1995)

•Burglund and Lindhe identified 0.5mm inflammation above and below Branemark implants at abutment/implant junction after 2 weeks.

Microgap and Platform Switching

•Move the microgap away from the implant platform and hence away from the crestal bone as a protective measure.

Restorative Problems

•Excessive Cantilever

•No Passive fit

•Improper fit of abutment

•Improper prosthetic design, occlusal scheme

•Premature Loading, Overtorquing

•Connecting implants to Natural teeth

Mehcanical Failures

Fractured Implants

Loosening of Screws

Retained Cement

Surgical Placement•Off Axis Position - severe angulation,

•Lack of Initial Stabilization

•Infection from improper flap design

•Overheating bone

•Spacing too close to teeth or implants

•Inadequate bone or attached gingiva

•Too Buccal or Lingual and compromise bone

Inadequate Attached Gingiva

Inadequate Buccal Bone

Space Between Teeth and Implants

Head of Implant

ANGULATION

Buccally Positioned

Heat Generation

•Eriksson and Albrektsson reported the critical temperature for implant placement was 47C for 1 minute.

•Matthews and Hirsch demonstrated that temperature elevation was more a result of force applied rather than drill speed.

Diagnostic Criteria•Probe all implants - Plastic or Metal

•Look for Bleeding and or Suppuration

•X-rays should be taken yearly first two years and compared to base line placement

•Evaluate Occlusion, Prosthetic Stability

•Soft tissue evaluation - Attached Gingiva?

Probing

Probe Long Axis

Accessibility

•Adjust Prosthesis

•Plaque Control

•Biofilm Removal

How do you Probe this?

Remove Prosthetic

Bone Level

Attached Gingiva?

Treatment Options

•Early Detection is Key to Success and improved health!

•Non-surgical Intervention

•Surgical Intervention

Non-Surgical - Studies

•Mechanical Debridement with plastic instruments and Chlorhexidine irrigation showed reduction of pocket and bleeding at six months - Schwartz

•Antiseptic irrigation of pockets <4mm not effective, but over 5mm it has added effect. Renvert

•Adjunctive use of generalized antibiotics did not improve the treatment results

Peri-Implant Mucositis -

Transmucosal

Peri-Prosthetic

Peri-Prosthetic

Peri-implant Mucositis

•Application of Minocycline spheres along with debridement provide some additional benefit to reducing bleeding and probing, but NEEDS TO BE REPEATED OFTEN. Renvert

Clinical Treatment of PIM

•Mechanical Scaling of Implants with plastic or titanium instruments or Ultrasonic Plastic Tips. I-Brush if exposed threads.

•Apply exposed implant surface with 0.2% Chlorhexidine gauze for 2 mins

•Subgingival irrigation with 0.2% Chlorhexidine 5ml per implant

•Minocycline Spheres or Gel

Peri-ImplantitisTreatment Options

•Visualization with open flap very effective with cementitits!

Peri-Implantitis •Treatment to be determined by amount of

bone loss and esthetic impact of the implant in question

•If minimal bone loss (3 threads or less) Proceed with similar treatment as Peri-implant mucositis, but decontaminate prosthetic components as well. The use of various lasers has been suggested.

•If bone loss is advanced or progressive than surgical access with resective or regenerative components will need to be employed.

Peri-ImplantitisNon Surgical - Studies

•31 Subjects mean age 62

•One qualifying implant per patient

•PPD >4mm with bleeding or suppuration

•< 2.5mm bone loss

•J. Clin. Perio 2009 Renvert

Non-Surgical

•Titanium hand instrumentation

•Or Ultrasonic Debridement with plastic tip

•6 month results - minimal change with PD for either treatment modality

Laser Therapy Er:YAG

•SRP with plastic instruments and 0.2% chlorhexidine followed by Er:YAG 20sec disinfection per implant

•Control was only SRP and antiseptic rinse

•Six months later Equal Reduction of Pocket and Clinical Attachment

•Twelve months later both groups lost effect

Peri-Implantitis with Er:YAG vs. Air-Abrasive

device•42 Patients mean age 69

•Laser 55 implants

•Perio Flow 45 implants

•PPD >5mm with bleeding or suppuration

•> 3mm bone loss

•J. Clin Perio 2011, Renvert

Results

•Remove Supra-Structure from Implants!

•Significant difference in PD bleeding and Pus reduction for both groups at 6 months

•Both seem to have limited benefit in advanced cases

Open Flap - Resective

•Surgical flap access and resection of 1 or 2 wall defects combined with decontamination and antibiotic treatment was effective in just over half the cases over 5 years. Leonhardt 2003

•2008 Hitz-Mayfield with flap surgery and resection and antimicrobial treatment stopped the progression of the disease in 90% of cases up to one year - However, BOP continued in 50% of the lesions.

Regenerative Surgery

•Schwartz (2008) found combination bone grafting debridement and antibiotics had significant reduction of bone loss and BOP after 2 years.

•Froum (2012) Significant reduction of BOP, Pocket reduction, bone loss over 3-7 years.

Submerged Healing -

•16 implants in 12 patients

•Open Flap and 3% Hydrogen Peroxide

•Bone Graft and Membrane

•Submerged healing

•Roos-Janasker J. Clin Perio 2007

Submerged Surgical Results

•PD change 4.2mm

•Defect fill (threads) 3.8

•Defect Fill (mm) 2.3

•Recession (mm) 2.8

Implant Configuration and Decontamination•Implant contours and surface are a limitation to remove the biofilm

•Surface treatments including - mechanical, Er:YAG, photodynamic, air-abrasion, implantoplasty

•Romeo (2005, 2007) implantoplasty improved regenerative capability - reducing probings from 5.5 - 3.6mm and BOP.

Implantoplasty

Regenerative Treatment for Peri-Implantitis affected implant:Stuart J. Froum Clin Adv Perio

2013

•7 year follow up showed decrease pocket depths

•Technique successful in 51 cases (IJPRD 2012:32:11-20)

•Believes if any Elements of protocol not followed could compromise outcome

Protocol

•1 month prior to surgery: SRP of natural teeth; debride implant surface and OHI

•Requires 2 visits to accomplish this

Surgery: Exposure and Debridement

•2 gm Amox 1 hour prior to surgery

•FTF to expose area

•Debride defect with titanium and graphites

•Air-Power abrasives (Bicarbonate powder) for 60 secs

•60 secs irrigation with sterile saline

•60 secs application of Tetracycline strips

Surgical Protocol

•Second application of air-powder abrasive for 60-90 secs

•Application of CHX for 30 secs

•60-90 secs of sterile saline with air power device no powder

Surgical Protocol•EMD applied - avoid blood and saliva

•Defect filled with 1:1 Bioss/Puros rehydrated with gem 21

•2 ossix membranes placed to cover all surfaces

•Flap released and coronally advanced and sutured with Goretex and vicryl sutures

Post Surgery

•2 weeks remove sutures and polish

•Pt to brush area 4x/day with 1:1 Peroxide and rinse with salt water 4x/day

•Return monthly for 12 months for post op and every 6-8 weeks for maintenance

Treating Peri-Implantitis

•Systemic Antibiotics for three days prior to treatment

•2 mins pre-operative rinse with Chlorhexidine

•Full Thickness Mucoperiosteal Flap to one tooth beyond diseased site

•Thorough Debridement circumfirentially with plastic or titanium or Ultrasonic plastic tips

Treating Peri-Implantitis

•Pack Gauze Strips soaked with CHX around implants and in defects for 5 mins

•Remove Gauze and irrigate with CHX or Tetracycline 250mg/5cc

•Graft Defect with FDBA, BioOss

•Apply Collagen Membrane

•Closure of Flap and Regular Post op Intervals

Detoxify

•HCL Acid

•Tetracycline

•EDTA

•Hydrogen Peroxide

•Er:YAG and Diode

Graft Material

•Need OsteoInductive Material as there is minimal Osteoprogenetor cells

•FDBA, DBA, Acel, OsteoCel, BMP2, Gem-21, PRP, Emdogain

•Collagen Matrix Necessary

•Tacks to hold membrane if necssary

Mechanical Debridement

I-Brush

Retrograde

LAPIP

•Nd:YAG laser with LANAP protocol to address peri-implantitis

•Closed access

•First pass to decontaminate and selectively eliminate infected tissue

•Debride with Piezon and CHX

•Second pass with laser to provide fibrin clot

LAP-IP

LAP-IP

LAP-IP

LAP-IP

Peri-Implantitis Effects

•Loss of implant and functioning prosthetics

•Esthetic Challenges

•Phonetic Challenges

•Maintenance Challenges

Prosthetic and functional failure

Prevention Is The First Step:

•Avoid conditions that contribute to poor results

•Choose cases where you have excellent chance for implant and prosthetic success.

•Anticipate and Diligently observe for implant and restorative problems.

•Once Perio-Implant Disease identified act quickly and with purpose to effectuate the situation

What I see •Retained Cement

•Inadequate attached gingiva

•Position of implant - Too Buccal

•Position of implant - Too Close to others

•Occlusal Overload

•Loss of Attached Gingiva Anterior

•Poor Oral Hygiene - Inability to get access

Hybrid Screw Retained Vs.

Implant Denture

Accessibility

Access for patient?

Proximity Issues

Implant Maintenance

•Needs to be Individually Determined

•Needs to be Enforced by Doctor and Hygienist

•Patient Needs to assume Responsibility

Low Risk Patient

•Highly motivated

•Excellent Oral Hygiene

•One or Two implants

•No associated Risk Factors

Moderate Risk Patient

•Loss of Motivation

•Fair Oral Hygiene

•3-6 implants

•Moderate Smoker (half pack)

•Controlled Medical Issues

High Risk Patient•Unmotivated

•Poor Oral Hygiene

•Previous Periodontitis

•>6 implants

•Smokes more than half Pack

•Poorly Controlled Systemic Disease(s)

Maintenance Recall

•Low Risk Patients - every 6 months

•Moderate Risk - every 3 months

•High Risk - every 2-3 months

•Note - Oral Hygiene signficantly influences the category the patient is placed.

Mechanical Debridement

Hand Scalers and Ultrasonics

Maintenance•Plastic, titanium, graphite instruments

for visual debridement from prosthetics and sulcus.

•Ultrasonics with plastic tips at low to moderate settings are excellent

•Individual or multiple implants with fixed crowns or bridges screw or cemented assess and debride as you would teeth.

Maintenance

•For Fixed Hybrid cases Remove at least Twice a year and assess and debride Transmucosal and Prosthetic underside

•O rings Remove Denture and address abutments directly

Maintenance

•Polish with soft rubber tip and non-abrasive paste - aluminum oxide, tin oxide, fine pumice

•Irrigate with CHX with endodontic syringe or piezon on low setting.

Ancillary Homecare

•Periostat - Doxycycline 20mg b.i.d.

•Evorapro - Especially for Dry Mouths

•Perio-science AO gel and rinse

•Listerene if no dry mouth 2x/day

•Biotene if dry mouth 2x/day

Likely Cause?

Etiology?

Thank You