z TRABAJO DE FIN DE GRADO Grado en Odontología

z

TRABAJO DE FIN DE GRADO Grado en Odontología

UPDATING TREATMENTS OF PERI-IMPLANTITIS

Madrid, curso 2020/2021

Número identificativo ¹⁶¹

Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology

Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008; 35 (Suppl. 8):

282–285. doi: 10.1111/j.1600-051X.2008.01283.x Abstract

Issues related to peri-implant disease were discussed. It was observed that the most common lesions that occur, i.e. peri-implant mucositis and peri-implantitis are caused by bacteria. While the lesion of peri-implant mucositis resides in the soft tissues, peri- implantitis also affects the supporting bone. Peri-implant mucositis occurs in about 80% of subjects (50% of sites) restored with implants, and peri-implantitis in between 28% and 56% of subjects (12–40% of sites). A number of risk indicators were identified including (i) poor oral hygiene, (ii) a history of periodontitis, (iii) diabetes and (iv) smoking. It was concluded that the treatment of peri-implant disease must include anti-infective measures. With respect to peri-implant mucositis, it appeared that non-surgical mechanical therapy caused the reduction in inflammation (bleeding on probing) but also that the adjunctive use of antimicrobial mouthrinses had a positive effect. It was agreed that the outcome of non-surgical treatment of peri-implantitis was unpredictable. The primary objective of surgical treatment in peri-implantitis is to get access to the implant surface for debridement and decontamination in order to achieve resolution of the inflammatory lesion. There was limited evidence that such treatment with the adjunctive use of systemic antibiotics could resolve a number of peri- implantitis lesions. There was no evidence that so-called regenerative procedures had additional beneficial effects on treatment outcome.

Key words: Consensus report; diagnostics;

infectious diseases; non-surgical treatment;

peri-implant diseases; peri-implantitis; peri- implant mucositis; prevalence; risk indicators;

surgical treatment

Accepted for publication 20 May 2008 Jan Lindhe¹, Joerg Meyle² on behalf of Group D of the European Workshop on Periodontologyⁿ

1Department of Periodontology, Faculty of Odontology, The Sahlgrenslea Academy at Go¨teborg University, Go¨teborg, Sweden;

2Department of Periodontology, Zentrum fu¨r Zahn-Mund-und Kieferheilkunde, Justus- Liebig-Universita¨t Giessen, Giessen, Germany

Conflict of interest and source of funding statement

Group D participants declared that they had no conflict of interests.

The 6^th European Workshop on Perio- dontology was supported by an unrestricted educational grant from Straumann AG.

The sponsor had no impact on the program or on the deliberations of the European Workshop.

nT. Berglundh, N. Claffey, H. De Bruyn, L.

Heitz-Mayfield, I. Karoussis, E. Ko¨no¨nen, J.

Lindhe, J. Meyle, A. Mombelli, S. Renvert, A.

van Winkelhoff, E. Winkel, N. Zitzmann.

J Clin Periodontol 2008; 35 (Suppl. 8): 282–285 doi: 10.1111/j.1600-051X.2008.01283.x

282 r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard

Periodontology 2000, Val. 17, 1998, 63-76

Printed in Denmark All rights reserved Copyright 0 Munksgaard 1998

PERIODONTOLOGY 2000 ISSN 0906-6713

The diagnosis and treatment of peri-implantitis

ANDREA MOMBELLI & NIKLAUS P. LANG

Peri-implantitis is defined as an inflammatory pro- cess affecting the tissues around an osseointegrated implant in function, resulting in loss of supporting bone (1st European Workshop on Periodontology (4)). The term peri-implant mucositis has been pro- posed for reversible inflammations of the soft tissues surrounding implants in function. The purpose of this chapter is to discuss the requirements for diag- nostic procedures to prevent and intercept these dis- eases and to outline the options for therapy at differ- ent stages. This will be based on the hypothesis that microbial colonization of dental implants and infec- tion of the peri-implant tissues can cause peri-im- plant bone destruction and may lead to implant fail- ure. (Disease conditions associated with implants not designed for osseointegration, and primary fail- ures to achieve tissue integration are not discussed in this chapter.)

Evidence for a microbial cause of peri-implant infections

Although it is clear that multiple factors can contrib- ute to implant failure, an increasing number of

studies point to the detrimental effect of anaerobic plaque bacteria on peri-implant tissue health. There are essentially five lines of evidence supporting the view that microorganisms play a major role in caus- ing peri-implantitis: (i) an experiment in humans, showing that deposition of plaque on implants can induce peri-implant mucositis, (ii) the demon- stration of distinct quantitative and qualitative dif- ferences in the microflora associated with successful and failing implants, (iii) placement of plaque-reten- tive ligatures in animals leading to shifts in the com- position of the microflora and peri-implantitis, (iv) antimicrobial therapy improving the clinical status of peri-implantitis patients, and (v) evidence that the level of oral hygiene has an impact on the long-term success of implant therapy (Table 1).

Experimentally induced peri-implant mucositis The experimental gingivitis model, originally de- scribed by Loe et al. (55) and representing the ulti- mate proof for a cause-and-effect relationship be- tween bacterial plaque accumulation and gingivitis, was duplicated with regard to the peri-implant situ- ation (74). Following a period of 6 months with

Table 1. Sources of evidence for a bacterial cause of peri-implantitis

Source References

Experimentally induced peri-implant mucositis: plaque accumulation on implants leads to peri-implant mucositis

Demonstration of distinct quantitative and qualitative differences in the microflora associated with successful and failing implants

Peri-implant microflora is established shortly after implant placement. Successful implants experience no shifts in microbial composition over time

12, 74

6, 9, 11, 26, 69, 80, 82, 86, 87 1, 7, 13, 47, 60, 65

-~

~ _ _ _ _

Periodontal pathogens may be transmitted from residual teeth to implants 7, 37, 38, 49, 64, 75 Induction of peri-implantitis by placement of plaque retentive ligatures in animals

Theraw aimed at a reduction of the Deri-implant microflora improves clinical conditions 41, 50 24, 25, 62 Edentulous patients with poor oral hygiene have more bone resorption around fixtures

than do subjects with good hygiene ⁵²

63

Peri-Implant Mucositis and Peri-Implantitis: A Current

Understanding of Their Diagnoses and Clinical Implications*

The American Academy of Periodontology (AAP) peri- odically publishes reports, statements, and guidelines on a variety of topics relevant to periodontics. These papers are developed by an appointed committee of experts, and the documents are reviewed and approved by the AAP Board of Trustees.

I. INTRODUCTION – PURPOSE

The use of dental implants has revolutionized the treat- ment of partially and fully edentulous patients today.

Implants have become a treatment approach for man- aging a broad range of clinical dilemmas due to their high level of predictability and their ability to be used for a wide variety of treatment options. While in many cases dental implants have been reported to achieve long-term success, they are not immune from compli- cations associated with improper treatment planning, surgical and prosthetic execution, material failure, and maintenance. Included in the latter are the biologic complications of peri-implant mucositis and peri-im- plantitis, inflammatory conditions in the soft and hard tissues at dental implants. It is the purpose of this paper to review the current knowledge concerning peri-im- plant mucositis and peri-implantitis to aid clinicians in their diagnoses and prevention. It is recognized that new information will continue to emerge, and as such, this document represents a dynamic endeavor that will evolve and require further expansion and reevaluation.

II. BACKGROUND – DIAGNOSES, PREVALENCE, AND INCIDENCE

Peri-implant diseases present in two forms – peri- implant mucositis and peri-implantitis. Both of these are characterized by an inflammatory reaction in the tissues surrounding an implant.^1,2 Peri-implant mucositis has been described as a disease in which the presence of inflammation is confined to the soft

tissues surrounding a dental implant with no signs of loss of supporting bone following initial bone re- modeling during healing. Peri-implantitis has been characterized by an inflammatory process around an implant, which includes both soft tissue inflam- mation and progressive loss of supporting bone be- yond biological bone remodeling.³While there may be some disagreement whether the soft tissues sur- rounding an implant are histologically consistent with mucosa or gingiva, this paper for the sake of consis- tency will retain the term mucositis as it has been historically used in the literature to describe this particular disease entity.

From a clinical standpoint, signs that determine the presence of peri-implant mucositis include bleeding on probing and/or suppuration, which are usually associated with probing depths‡4 mm and no evi- dence of radiographic loss of bone beyond bone re- modeling. Outcomes from reports^4,5 assessing the prevalence of peri-implant diseases revealed that peri-implant mucositis was present in 48% of im- plants followed from 9 to 14 years affected with this problem.⁵Since peri-implant mucositis is reversible with early intervention and removal of etiology,^6,7it is quite possible that its prevalence could be under- reported. However, when these same parameters are present with any degree of detectable bone loss fol- lowing the initial bone remodeling after implant placement, a diagnosis of peri-implantitis is made.⁸ This can only be applied for cases where there has been a baseline radiograph obtained at the time of su- prastructure placement. It has been recommended in those cases where this baseline radiograph is absent to use a threshold vertical distance of 2 mm from the expected marginal bone level following re- modeling post-implant placement as the threshold for diagnosing peri-implantitis.³

Distinct differences in the incidence and prevalence of peri-implantitis have been reported by a number of authors. Most recently, a publication discussed this problem and noted that a literature search of 12 studies in which bleeding on probing and/or pu- rulence were detected with concomitant radiographic bone loss, revealed eight different thresholds of

doi: 10.1902/jop.2013.134001

Volume 84 • Number 4

* This paper was developed under the direction of the Task Force on Peri- Implantitis and approved by the Board of Trustees of the American Academy of Periodontology in January 2013. Task Force members:

Dr. Paul Rosen, chair; Drs. Donald Clem, David Cochran, Stuart Froum, Bradley McAllister, Stefan Renvert, Hom-Lay Wang.

DISCLAIMER: This paper represents the views of the Academy regarding periodontal therapy and related procedures. It must be recognized, however, that decisions with respect to the treatment of patients must be made by the individual practitioner in light of the condition and needs of each specific patient. Such decisions should be made in the best judgment of the practitioner, taking into account all relevant circumstances.

436

THIEME

Review Article 1

Peri-implantitis Update: Risk Indicators, Diagnosis, and Treatment

Dinesh Rokaya^1,2 Viritpon Srimaneepong³ Wichaya Wisitrasameewon⁴ Manoj Humagain⁵ Pasutha Thunyakitpisal^2,6

1International College of Dentistry, Walailak University, Bangkok, Thailand

2Research Unit of Herbal Medicine, Biomaterials and Materials for Dental Treatment, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand

3Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand

4Department of Periodontology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand

5Department of Periodontics, Kathmandu University School of Medical Sciences, Dhulikhel, Kavre, Nepal

6Department of Anatomy, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand

Address for correspondence Viritpon Srimaneepong, DDS, MDSc, PhD, Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok 10330, Thailand (e-mail: [email protected]).

Despite the success rates of dental implants, peri-implantitis presents as the most common complication in implant dentistry. This review discusses various factors associated with peri-implantitis and various available treatments, highlighting their advantages and disadvantages. Relevant articles on peri-implantitis published in English were reviewed from August 2010 to April 2020 in MEDLINE/PubMed, Scopus, and ScienceDirect. The identified risk indicators of peri-implant diseases are plaque, smoking, history of periodontitis, surface roughness, residual cement, emergence angle >30 degrees, radiation therapy, keratinized tissue width, and function time of the implant, sex, and diabetes. Peri-implantitis treatments can be divided into non- surgical (mechanical, antiseptic, and antibiotics), surface decontamination (chemical and laser), and surgical (air powder abrasive, resective, and regenerative). However, mechanical debridement alone may fail to eliminate the causative bacteria, and this treatment should be combined with other treatments (antiseptics and surgical treat- ment). Surface decontamination using chemical agents may be used as an adjuvant treatment; however, the definitive clinical benefit is yet not proven. Laser treatment may result in a short-term decrease in periodontal pocket depth, while air powder abrasive is effective in cleaning a previously contaminated implant surface. Surgical elimination of a pocket, bone recontouring and plaque control are also effective for treating peri-implantitis. The current evidence indicates that regenerative approaches to treat peri-implant defects are unpredictable.

Abstract

Keywords dental implants peri-implantitis implant complications decontamination anti-infective agents periodontal debridement bone regeneration

DOI https://doi.org/

10.1055/s-0040-1715779 ISSN 1305-7456.

©2020 Dental Investigation Society

Introduction

The dental implant has revolutionized oral rehabilitation and become a part of routine treatment in prosthetic reha- bilitation.¹ There has been marked advancement in implant

design, materials used, and surgical protocols. A high implant survival rate (94.6%) has been reported over a 13.4-year follow-up.² Approximately 90% of patients who received an implant were satisfied with their chewing ability and Eur J Dent

Published online: 2020-09-03

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DOI: 10.1111/jcpe.12957

2 0 1 7 W O R L D W O R K S H O P

Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the

Classification of Periodontal and Peri-Implant Diseases and Conditions

Tord Berglundh¹ | ² | ³ | ⁴ |

Juan Blanco⁵ | ⁶ | ⁷ | ⁸ | ¹ |

Elena Figuero⁹ | ¹⁰ | ¹¹ |

Ba⁸ | ¹² | ¹³ | ¹⁴ | ¹⁵ |

16 | ¹⁷ | ¹⁸ | ¹⁹ |

Dennis Tarnow²⁰ | ¹ | ¹⁵ | ²¹

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Peri-implantitis: A Comprehensive Overview of Systematic Reviews

Miriam Ting, DMD, BDS, MS¹* James Craig, DDS, MSc² Burton E. Balkin, DMD² Jon B. Suzuki, DDS, PhD, MBA^2,3

The objective of this systematic review was to perform a comprehensive overview of systematic reviews and meta-analyses pertaining to peri-implantitis in humans, including the prevalence and incidence, the diagnostic findings, microbial findings, effects of systemic diseases, and treatment of peri-implantitis. Electronic databases were searched for systematic reviews and meta-analyses of peri-implantitis. In view of the limitations of the included systematic reviews, the outcome of this overview suggested that (1) occurrence of peri-implantitis was higher in patients with periodontitis, in patients who smoke, and after 5 years of implant function; (2) the microbial profile of peri- implantitis was different from periodontitis; (3) risk for peri-implantitis was higher in patients with uncontrolled diabetes and cardiovascular disease; (4) there was no strong evidence to suggest the most effective treatment intervention for peri-implantitis, although most peri-implantitis treatments can produce successful outcomes; and (5) postimplant maintenance may be crucial in patients with a high risk of peri-implantitis.

Key Words: dental implant, peri-implant, bone loss, peri-implantitis, systematic review

INTRODUCTION

D

97.1% over a follow-up period of 10 years indicated that dental implants were a valid treatment option for the dental rehabilitation of the partially and fully edentulous patient.^3,4 However, despite its high survival rates, dental implants were prone to biological complications like peri-implantitis.⁵ Peri- implantitis was described as a destructive inflammatory lesion affecting hard and soft tissues of the osseointegrated implant causing bone loss and peri-implant pocketing.⁶Peri-implantitis can be asymptomatic, showing only signs of bleeding on probing, attachment loss, and bone loss. Or peri-implantitis can manifest clinical signs of increasing probing depths, suppuration, draining sinus, and peri-implant mucosal swelling or recession.⁷ If peri-implantitis was not detected early and treated, the bony destruction could extend the whole lengthen of the implant, resulting in loss of implant stability.⁷Thus, early peri-implantitis detection and effective treatment is crucial in a practice that focuses on implant rehabilitation of the edentulous patient.

Some studies indicated that patients, who have lost 1

implant due to peri-implantitis, were more prone to implant failure.^8,9Patients with periodontal disease seemed to experi- ence more implant loss due to peri-implantitis than periodon- tally healthy patients.^10,11Patients who smoke were also at risk for peri-implantitis, but non-smoking patients can develop peri- implantitis, and not all smoking patients develop peri- implantitis.^12,13 Radiographically, patients with periodontitis and smokers have also reported significantly more marginal bone loss around their implants.¹⁴ Thus, these factors predisposing peri-implantitis should be closely examined when treatment planning the dental patient for implants.

The aim of this comprehensive review was to provide a systematically derived overview of systematic reviews pertaining to different aspects of peri-implantitis that will help the clinician understand and manage peri-implantitis in their practice.

MATERIAL ANDMETHODS

Focused questions

! What is the prevalence, incidence, or risk of peri-implantitis in periodontal health and disease?

! What factors are associated with peri-implantitis?

! What treatment intervention is most effective in treating peri-implantitis?

Literature and study design

A systematic search was conducted of PubMed, Embase, Web of Science, Cochrane library, and Google Scholar for systematic reviews and meta-analyses of peri-implantitis published from October 1989 until October 2016. The keywords used for the

1Kornberg School of Dentistry, Temple University, Philadelphia, Penn.

2Department of Periodontology and Oral Implantology, Kornberg School of Dentistry, Temple University, Philadelphia, Penn.

3Department of Microbiology and Immunology, School of Medicine, Temple University, Philadelphia, Penn.

* Corresponding author, e-mail: [email protected] DOI: 10.1563/aaid-joi-D-16-00122

Journal of Oral Implantology 225

LITERATUREREVIEW

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DOI: 10.1111/jcpe.12954

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Peri-implantitis

Frank Schwarz^1* | ^2* | ^3,4 | ⁴

1

Germany

2

Sweden

3

4

Germany.

Journal of Periodontology and Journal of Clinical Periodontology.

1)

2) 3) 4a) 4b) 4c) 5a)

5b)

6)

Peri-Implant Disease, a Consensus for Treatment: A Case Study

Nick Caplanis, DDS, MS¹ Edward Kusek, DDS²* Sam Low, DDS, MS³ Eric Linden, DMD, MSD⁴ Hamilton Sporborg, DDS⁵

The aim of this case report was to find common treatment with the use of laser energy to treat failing implants. This article discusses definition of peri-implantitis and how-to diagnosis peri-implantitis. The article shows a case report of treatment with the use of two different lasers.

Key Words: peri-implantitis, mucositis, photobiomodulation, Erbium, 9300 nm CO2laser, 10600 nm CO2laser

INTRODUCTION

P

When the breadth of the dental implant market is considered, peri-implantitis is potentially a significant global health care problem. In 2012, an estimated 1 260 000 dental implant procedures were performed in the United States alone, at with an estimated market value of $900 million. The dental implant market is expected to grow to more than $2 billion by 2021 in the United States and to $6.8 billion by 2024

worldwide.^6,7 If 28%–56% of all implant patients and 12%–

43% of all implants develop peri-implantitis, this potentially adds millions (if not billions) of dollars in additional treatment costs. More importantly, given our understanding of the potential adverse effects of periodontal disease on systemic health, peri-implantitis may also increase the risk for various systemic diseases, given its similarities with periodontitis.

This clinical problem is also exacerbated by the challenges in diagnosis as well as a lack of high quality and long -term treatment data. An accurate diagnosis is an absolute require- ment to successfully treat any clinical condition. Crestal bone loss around implants caused by peri-implantitis must be differentiated from bone loss that occurs from a variety of other reasons unrelated to plaque or inflammation. This includes physiologic bone remodeling,⁸ establishment of biologic width,⁹ occlusal trauma,^10,11 and faulty surgery.¹² Differentiation between bone loss caused by peri-implantitis and other potential etiologies is often difficult and can lead to inaccurate diagnosis and subsequent ineffective treatment protocols. Mucositis, for example, could be associated with an implant that has bone loss and deep pocketing caused by occlusal trauma but was instead misdiagnosed as peri- implantitis.¹¹ Treatment could therefore focus on surgically reducing deep pockets and removing plaque when the appropriate protocol may be prophylaxis and a minor occlusal adjustment.

DIAGNOSIS

Peri-implant mucositis is defined as a plaque-induced inflam- mation without associated progressive loss of crestal bone. The clinical findings include mucosal inflammation, bleeding on probing and suppuration, and pathologic pocket formation.

Clinical probing of the pocket is essential for making a diagnosis. along with radiographs, when deep pockets are

1Loma Linda University School of Dentistry, Loma Linda, Calif.

2College of Dentistry, University of Nebraska Medical Center, Lincoln, Neb; Department of Dental Hygiene, University of South Dakota, Vermillion, SD.

3College of Dentistry, University of Florida, Gainesville, Fla.

4Section of Oral, Diagnostic, and Rehabilitation Services, Division of Periodontics, College of Dental Medicine, Columbia University Irving Medical Center, New York, NY.

5Private practice, Mission Viejo, Calif.

* Corresponding author, e-mail: [email protected] https://doi.org/10.1563/aaid-joi-D-19-00043

Journal of Oral Implantology 371

RESEARCH

J Clin Periodontol. 2018;45(Suppl 20):S237–S245. | 237

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DOI: 10.1111/jcpe.12953

2 0 1 7 W O R L D W O R K S H O P

Peri-implant mucositis

Lisa J.A. Heitz-Mayfield^1,2 | ³

1

2

3

Correspondence

Journal of Periodontology and Journal of Clinical Periodontology.

Abstract

Methods

Findings

Conclusions

Is Marginal Bone Loss around Oral Implants the Result of a Provoked Foreign Body Reaction?

Tomas Albrektsson, MD, PhD, RCPSG;*^,†Christer Dahlin, DDS, PhD;*^,‡Torsten Jemt, DDS, PhD;^§,||

Lars Sennerby, DDS, PhD;^¶Alberto Turri, DDS, PhD cand;*^,||Ann Wennerberg, DDS, PhD^†

ABSTRACT

Background: When a foreign body is placed in bone or soft tissue, an inflammatory reaction inevitably develops. Hence, osseointegration is but a foreign body response to the implant, which according to classic pathology is a chronic inflam- matory response and characterized by bone embedding/separation of the implant from the body.

Purpose: The aim of this paper is to suggest an alternative way of looking at the reason for marginal bone loss as a complication to treatment rather than a disease process.

Materials and Methods: The present paper is authored as a narrative review contribution.

Results: The implant-enveloping bone has sparse blood circulation and is lacking proper innervation in clear contrast to natural teeth that are anchored in bone by a periodontal ligament rich in blood vessels and nerves. Fortunately, a balanced, steady state situation of the inevitable foreign body response will be established for the great majority of implants, seen as maintained osseointegration with no or only very little marginal bone loss. Marginal bone resorption around the implant is the result of different tissue reactions coupled to the foreign body response and is not primarily related to biofilm- mediated infectious processes as in the pathogenesis of periodontitis around teeth. This means that initial marginal bone resorption around implants represents a reaction to treatment and is not at all a disease process. There is clear evidence that the initial foreign body response to the implant can be sustained and aggravated by various factors related to implant hardware, patient characteristics, surgical and/or prosthodontic mishaps, which may lead to significant marginal bone loss and possibly to implant failure. Admittedly, once severe marginal bone loss has developed, a secondary biofilm-mediated infection may follow as a complication to the already established bone loss.

Conclusions: The present authors regard researchers seeing marginal bone loss as a periodontitis-like disease to be on the wrong track; the onset of marginal bone loss around oral implants depends in reality on a dis-balanced foreign body response.

KEY WORDS: bone loss, dental implants, foreign body reaction, osseointegration, peri-implantitis

INTRODUCTION

Osseointegration was discovered when working with implants in research animals¹ at the very same labo- ratory of the Göteborg University where the senior authors behind this publication were once trained. The discovery was made around 1962, and it has meant an enormous advancement for clinical treatment of oral implants. The advent of osseointegration represented a true clinical breakthrough; for the first time ever, reli- able long-term clinical results of oral implants were reported.^1–3As a reflection of the substantial contribu- tion to clinical development we have seen with oral

*Department of Biomaterials, Göteborg University, Göteborg, Sweden;^†Department of Prosthodontics, Malmö University, Malmö, Sweden;^‡Department of Oral& Maxillofacial Surgery, NU Hospital Group, Trollhättan, Sweden;^§Department of Prosthetic Dentistry/

Dental Material Science, University of Göteborg, Göteborg, Sweden;

||The Brånemark Clinic, Public Dental Health Service, Göteborg, Sweden;^¶Department of Oral and Maxillofacial Surgery, Göteborg University, Göteborg, Sweden

Reprint requests: Professor Tomas Albrektsson, Department of Biomaterials, Sahlgrenska Academy, PO Box 412, Göteborg SE 405 30, Sweden; e-mail: [email protected]

© 2013 Wiley Periodicals, Inc.

DOI 10.1111/cid.12142

155

ImplantDentistry

596 DentalUpdate July/August 2017

Dental Implants: An Overview

Abstract: Dental implants are widely used and are considered to be one of several treatment options that can be used to replace missing teeth. A number of implant-supported treatment options have been used successfully to replace a single tooth and multiple teeth, as well as a completely edentulous jaw. However, as the number of patients who have dental implants is increasing, dental personnel are more likely to see patients with implant-supported restorations or prostheses. Nevertheless, dental implants may fail as a result of mechanical complications, such as screw loosening or due to biological causes like peri-implant diseases. As a result, dental personnel should be able to recognize these complications and the factors that have negative effects on the success of such implant-supported restorations or prostheses. Therefore, a basic knowledge of dental implants is necessary for every dental student, hygienist and dentist.

CPD/Clinical Relevance: Maintenance of implant-supported restorations and prostheses requires long-term follow-ups. It is the responsibility of the patient to maintain good oral hygiene and also of the dental personnel who look after the patient to ensure a durable restoration and prosthesis.

Dent Update 2017; 44: 596-620

implants is known as peri-implant tissue and is comprised of soft (mucosa) and hard (bone) tissues. The peri-implant soft tissue has similar features to the soft tissue that surrounds teeth.^7-10 It consists of a junctional epithelium and connective tissue. The junctional epithelium is attached to the implant and/or abutment surface through a hemi-desmosomal attachment. Connective tissue is present apical to the junctional epithelium and coronal to the crest of alveolar bone.¹⁰ Connective tissue fibres are found to be positioned close to the implant surface but not attached to it, and predominantly arranged in a circular manner. Connective tissue fibres also arise from the crest of alveolar bone and from the periosteum and are oriented parallel to the implant/

abutment surface and extend towards the oral epithelium. Thus, the junctional epithelium and connective tissue form a protective seal between the oral environment and the peri-implant bone which plays a vital role in the success of the implant treatment outcome. The junctional epithelium and the connective tissue are collectively known as the biologic width, which is comparable to that found around teeth.¹¹

Abdulhadi Warreth, BDentSc, MDentSc(TCD), PhD(TCD), MFD RCSI, Department Restorative Dentistry, Ajman University, Al–Fujairah Campus, United Arab Emirates, Najia Ibieyou, BDentSc, MDentSc(TCD), PhD(TCD), Postgraduate student, Institute of Molecular Medicine, Trinity College, Dublin, Ronan Bernard O’Leary, Fifth Year Dental Science, Matteo Cremonese, Third Year Dental Science, Dublin Dental University Hospital, Trinity College, Dublin and Mohammed Abdulrahim, BDentSc MDentSc(TCD), PhD(TCD), Oral Medicine Department, Faculty of Dentistry, Benghazi University, Benghazi, Libya.

Abdulhadi Warreth

integration is influenced by several factors, such as implant material, bone quality and quantity, and the implant loading condition.^2,3

As the use of dental implants has become much more common, dental personnel are more likely to see patients who have implant–supported/retained restorations. Nevertheless, dental implants are affected by diseases in a similar manner to teeth and may also fail after several months or years in service.^4-6 Therefore, it is not unreasonable to suggest that the implant and the peri-implant tissue should be examined on a routine basis in a similar manner to that which is carried out for periodontal examination.⁷ So, when a deviation from the norm is found, the treatment may be carried out in practice or by a specialist, depending on the severity of the condition. Accordingly, the dentist should be equipped with basic knowledge of dental implants. Hence, it is the aim of this article to provide this basic information which is needed by every dental student and dentist alike.

Implant-soft tissue interface

The tissue that surrounds Dental implants (also known as oral or

endosseous implants) have been used to replace missing teeth for more than half a century. They are considered to be an important contribution to dentistry as they have revolutionized the way by which missing teeth are replaced with a high success rate.^1-3 This success depends on the ability of the implant material to integrate with the surrounding tissue. However, this

Najia Ibieyou, Ronan Bernard O'Leary, Matteo Cremonese and Mohammed Abdulrahim

Volume 32, Number 5, 2012

533

A Proposed Classification for Peri-Implantitis

Stuart J. Froum, DDS*

Paul S. Rosen, DMD, MS** Peri-implantitis was first introduced

as a term in the 1980s and then modified in the 1990s to describe an inflammatory disease that results in loss of supporting bone around an implant.^1,2 This entity has clearly been differentiated from mucositis, in which the inflammation in the mucosa around an implant is not accompanied by bone loss and is reversible.² The general term peri- implantitis has been often applied to any implant with varying degrees of bone loss if accompanied by probing depths (PDs) ≥ 4 mm and bleeding and/or purulent exudate on probing.^3,4 However, as noted in a literature review by Zitzmann and Berglundh,⁵ the clinical definition of peri-implantitis has differed in many studies. For example, Berglundh et al⁶ defined peri-implantitis as having a PD > 6 mm or attachment loss or bone loss of ≥ 2.5 mm.⁶ Although the pathogenesis of peri-implantitis has been described as the early le- sion, established lesion, and ad- vanced lesion, this peri-implantitis staging pertained to a histologic, not clinical, differentiation.⁷ To date, there have been no standardized The lack of a standardized classification to differentiate the various degrees of

peri-implantitis has resulted in confusion when interpreting the results of studies evaluating the prevalence, treatment, and outcomes of therapy. The purpose of this paper is to propose a classification for peri-implantitis based on the severity of the disease. A combination of bleeding on probing and/or suppuration, probing depth, and extent of radiographic bone loss around the implant is used to classify the severity of peri-implantitis into early, moderate, and advanced categories. The rationale and method of measurement for the classification are presented and discussed. This classification should help in communication between researchers and clinicians and thus provide a better understanding of peri-implantitis. (Int J Periodontics Restorative Dent 2012;32:533–540.)

* Clinical Professor and Director of Clinical Research, Department of Periodontology and Implant Dentistry, New York College of Dentistry, New York, New York; Private Practice, New York, New York.

** Clinical Associate Professor of Periodontics, Department of Periodontology, Baltimore College of Dental Surgery, University of Maryland, Baltimore, Maryland; Private Practice, Yardley, Pennsylvania.

Correspondence to: Dr Stuart J. Froum, 17 W. 54th Street, Suite 1C/D, New York, NY 10019; fax: 212-246-7599; email: [email protected].

© 2012 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

44

Review article

GUIDANCE FOR CLINICIANS

diseases and conditions.

characteristics of peri-implant health, peri-implant mucositis, and peri-implantitis.

peri-implant mucosa.

• Bone loss is used to differentiate between peri-implant mucositis and peri-implantitis.

• The progression of peri-implantitis is faster than that observed in periodontitis and occurs in a non-linear and accelerating pattern.

INTRODUCTION

ALTHOUGH A CLASSIFICATION of peri-implant diseases and conditions was addressed peri-implant diseases had previously been presented at several editions of the EFP’s European Workshop on Periodontology.

should provide the clinical guidelines for diagnosis (i.e. how to assess the condition).

PERI-IMPLANT HEALTH,

PERI-IMPLANT MUCOSITIS, AND PERI-IMPLANTITIS.

TORD BERGLUNDH.

Tord Berglundh. Professor and chair at the Department of Periodontology at the Institute of Odontology, Sahlgrenska Academy at the University of Gothenburg,

Sweden. He is co-editor of the textbook Clinical Periodontology and Implant Dentistry and associate editor of the journals Clinical Oral Implants Research and the EFP’s Journal of Clinical Periodontology. He is a member of the editorial board of the Journal of Dental Research and serves as a referee on several other journals. He has received numerous scientific awards and produced about 230 scientific publications within the field of dental implants, periodontal and peri-implant diseases, immunology, genetics, tissue integration, and regeneration.

Correspondence to:

Tord Berglundh

Tord Berglundh

New Classification

of periodontal and peri-implant diseases

S U P P L E M E N T A R T I C L E

Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants – Consensus report of working group 3

Stefan Renvert^1,2,3,4, Hideaki Hirooka^5,6, Ioannis Polyzois⁷, Anastasia Kelekis-Cholakis⁸, Hom-Lay Wang⁹and Working Group 3

1Oral Health Sciences, Kristianstad University, Kristianstad, Sweden;²School of Dental Science, Trinity College, Dublin, Ireland;³Blekinge Institute of Technology, Karlskrona, Sweden;⁴Faculty of Dentistry, The University of Hong Kong, Hong Kong City, Hong Kong;⁵Division of Advanced Prosthetic Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Miyagi, Japan;⁶Sweden Dental Center, Tokyo, Japan;⁷Department of Restorative Dentistry and Periodontology, Trinity College, Dublin Dental University Hospital, Dublin, Ireland;

8Division of Periodontics, Dr Gerald Niznick College of Dentistry, University of Manitoba, Winnipeg, MB, Canada;⁹Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA.

Abstract: The following consensus report is based on four background reviews. The frequency of maintenance visits is based on patient risk indicators, homecare compliance and prosthetic design. Generally, a 6-month visit interval or shorter is preferred. At these visits, peri-implant probing, assessment of bleeding on probing and, if warranted, a radio- graphic examination is performed. Diagnosis of peri-implant mucositis requires: (i) bleeding or suppuration on gentle probing with or without increased probing depth compared with previous examinations; and (ii) no bone loss beyond crestal bone level changes resulting from initial bone remodelling. Diagnosis of peri-implantitis requires: (i) bleeding and/

or suppuration on gentle probing; (ii) an increased probing depth compared with previous examinations; and (iii) bone loss beyond crestal bone level changes resulting from initial bone remodelling. If diagnosis of disease is established, the inflammation should be resolved. Non-surgical therapy is always the first choice. Access and motivation for optimal oral hygiene are key. The patient should have a course of mechanical therapy and, if a smoker, be encouraged not to smoke.

Non-surgical mechanical therapy and oral hygiene reinforcement are useful in treating peri-implant mucositis. Power-dri- ven subgingival air-polishing devices, Er: YAG lasers, metal curettes or ultrasonic curettes with or without plastic sleeves can be used to treat peri-implantitis. Such treatment usually provides clinical improvements such as reduced bleeding ten- dency, and in some cases a pocket-depth reduction of ≤ 1 mm. In advanced cases, however, complete resolution of the disease is unlikely.

Key words: Peri-implant diseases, peri-implantitis, peri-implant mucositis, non-surgical therapy, maintenance, supportive care

INTRODUCTION

Dental implants have long been used to replace missing teeth. Initially, it was believed that the possible draw- backs of dental implant treatment were minimal if the implants were fully integrated into the bone. Over the years, however, it has become clear that biological com- plications frequently occur. Biological complications associated with dental implants are mostly infections induced by a bacterial biofilm, resulting in an inflamma- tory response in the soft tissues and bone surrounding implants. The inflammatory lesions located in the soft tis- sues have been referred to as peri-implant mucositis. If

the inflammatory response progresses further and results in a loss of the bone beyond the initial bone remodelling, it is referred to as peri-implantitis^1,2.

The prevalence of peri-implant mucositis has, in a recent systematic review, been reported in the range of 19%–65% and the prevalence of peri-implantitis in the range of 1%–47%³. The wide range may be dependent on the different patient populations investi- gated in the studies included in the review, but it may also reflect differences in diagnostic criteria. In a paper using different levels of severity, a substantial variance in disease prevalence was highlighted⁴. The differences in criteria used to characterise peri-implant

12 International Dental Journal 2019; 69 (Suppl. 2): 12--17

©2019 FDI World Dental Federation. Published by John Wiley & Sons Ltd International Dental Journal 2019; 69: 12–17

doi: 10.1111/idj.12490

de la Sociedad Española de Periodoncia

Época I, nº 1

Director: Ion Zabalegui

2015 / 1

periodoncia clínica

ENFERMEDADES PERIIMPLANTARIAS

Director Invitado:

Juan Blanco

1

© Springer Nature Switzerland AG 2020

Y. Ogata (ed.), Risk Factors for Peri-implant Diseases,

Prevalence and Etiology for Peri- implant Diseases

Yorimasa Ogata

Contents

Introduction 1

Prevalence of Peri-implant Mucositis and Peri-implantitis 2 Risk Factors/Indicators for Peri- implant Diseases 2

Pathogenesis of Peri-implant Diseases 6

Structure and Composition of Periodontium and Peri-implant Tissue 7

Conclusion 8

References 8

Introduction

Peri-implant diseases are present in two forms:

peri-implant mucositis and peri-implantitis [1–

4]. Peri-implant mucositis represents a revers- ible inflammatory reaction of the soft tissues surrounding dental implants in the absence of loss of supporting bone [3]. Peri-implantitis is characterized by inflammation in the connective tissues and progressive loss of supporting bones around dental implants [4]. They are the most frequent complications of dental implants [1, 5, 6]. However, the lack of widely accepted diag- nostic criteria for peri-implant diseases makes interpretation of the published prevalence

very difficult [1, 7, 8]. Consensus of the 2017 World Workshop described that diagnosis of peri-implant mucositis requires the presence of peri-implant signs of inflammation and bleed- ing and/or suppuration on gentle probing with or without increased probing depth compared to previous examinations and the absence of bone loss beyond crestal bone level changes resulting from initial bone remodeling [5, 6]. Moreover, diagnosis of peri-implantitis requires the pres- ence of peri-implant signs of inflammation and bleeding and/or suppuration on gentle probing with increased probing depth compared to pre- vious examinations and the presence of bone loss beyond crestal bone level changes result- ing from initial bone remodeling. If there is no data of previous examination, diagnosis of peri-implantitis can be based on the combina- tion of presence of bleeding and/or suppuration on gentle probing, probing depth of ≥6 mm, and Y. Ogata ( )

Department of Periodontology, Nihon University School of Dentistry at Matsudo, Chiba, Japan e-mail: [email protected]

Treatment of pathologic peri-implant pockets

S^{T E F A N} RE N V E R T & IO A N N I S PO L Y Z O I S

The peri-implant mucosa has a number of features similar to the gingival tissues surrounding teeth. It is a well-keratinized oral epithelium and creates a cuff- like barrier that has been proven to adhere to the implant’s collar by a hemidesmosomal attachment originating from the junctional epithelium cells (80, 83) (Fig. 1). The collagen fibers, originating at the level of the crestal bone, are parallel to the implant surface and as they cannot insert into the body of the implant, this makes them more susceptible to trauma. After the installation of titanium fixtures, a predominantly gram-negative subgingival anaerobic microflora is established on their surface (36). This bacterial aggregation in contact with the peri-implant mucosa leads to inflammation and bone loss. Simi- larly to the process seen around natural teeth, inflam- mation and bone loss will eventually lead to increased probing depths (48).

It has been demonstrated that an inflammatory lesion develops in the mucosa around teeth and implants as a reaction to de novo plaque formation (4). These lesions are localized in the marginal por- tion of the soft tissue between the keratinized oral epithelium and the junctional epithelium (4). If no treatment is provided and the lesion progresses, a large B-cell lymphocyte infiltrate develops. A number of studies demonstrated similarities in the host-cell response at implants diagnosed with peri-implantitis and at teeth with periodontitis (5, 6, 47). However, differences exist, and elastase-producing cells have been reported to be more common in peri-implanti- tis. This finding suggests that peri-implantitis is a more acute type of inflammation (23).

Peri-implant lesions progress in an apical direction and do not seem to be encapsulated by collagen fibers, as are periodontitis lesions (1, 37) (Fig. 2). His- tology data acquired from human biopsy specimens have identified an inflammatory infiltrate consisting of plasma cells, lymphocytes, macrophages and

numerous polymorphonuclear leukocytes in approxi- mately 65% of the connective tissue around implants with peri-implantitis. This finding could explain the increased amounts of elastase found in peri-implanti- tis lesions compared with the lesions around teeth.

Further observations suggest that the inflammatory infiltrate in peri-implantits lesions is in direct contact with the alveolar bone and can extend into the alveo- lar bone marrow spaces (37, 82). In periodontal lesions the inflammatory infiltrate does not spread to the bone but is separated from it by noninflamed connective tissue, the thickness of which is about 1 mm. Finally, the cytokine profile differs somewhat between peri-implant and periodontal sites. Cytoki- nes with the potential to activate osteoclasts have been found in both sites but their profile differs in that interleukin-1alpha appears to be the most preva- lent cytokine in peri-implantitis, whereas tumor necrosis factor-alpha is the most common cytokine in chronic periodontitis (33).

The majority of diagnostic methods conventionally used in periodontics have been adopted by clinicians and researchers to diagnose peri-implant diseases as well as to assess the health status of peri-implant tis- sues. These methods include clinical, radiographic and laboratory examinations. The periodontal probe has been an invaluable tool over the years in assessing the clinical status and depth of the periodontal pocket and the level of the marginal crest of the mucosa. Addition- ally, bleeding on probing or suppuration following probing have been considered as standard clinical evaluations (Fig. 3). Concerns about the accuracy of probing around implants as a result of the design of the supragingival implant components and the posi- tion of the implants has led the periodontal commu- nity to recommend a more flexible plastic probe for examination of the peri-implant pockets (Fig. 4).

Another reason why it would be prudent to question the ability of the periodontal probe to lend its

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1

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Carta al editor

Treatment of peri-implantitis with laser: a promising future?

Tratamiento de la periimplantitis con láser: ¿Futuro prometedor?

Javier Basualdo Allende¹ https://orcid.org/0000-0003-2369-2882 Alfredo von Marttens¹ https://orcid.org/0000-0002-7026-9334 Eduardo Fernández Godoy^2,3* https://orcid.org/0000-0002-2616-1510

1Universidad de Chile, Facultad Odontología, Especialidad de Implantología Buco Máxilo Facial.

Santiago, Chile.

2Universidad de Chile, Facultad Odontología, Departamento de Odontología Restauradora.

Santiago, Chile.

3Universidad Autónoma de Chile, Instituto de Ciencias Biomédicas. Santiago, Chile.

Autor para correspondencia: [email protected]

Recibido: 23/03/2020 Aceptado: 31/03/2020

Dear Editor:

Dental implants are widely used worldwide for tooth replacement and have become the gold standard in dentistry.^(1,2) However, with increased use as come more complications.⁽³⁾ Recent studies have reported that between 2.7 % and 47.1 % of all implants have peri-implantitis.^(4,5) Two types of inflammatory problems can occur around an implant due to infection: mucositis and periimplantitis. Mucositis is an inflammation of the mucosa surrounding the dental implant with no signs of bone loss after the initial process of bone remodeling. If mucositis is not well resolved, then it can progress to periimplantitis –an inflammatory process in both the mucosa