by Lynne H. Slim RDH, BSDH, MSDH
I recently scheduled a periodontal maintenance appointment with my talented periodontal co–therapists, Laurie Cason, RDH, and periodontist Jeffrey S. Sherry, DDS. I trust them completely, enjoying our visits. Laurie recently lost an implant to peri–implantitis. Her implant was placed 10 years ago, and it was difficult for her to face the terminal inflammation and sudden loss of supporting bone.
I recently reviewed the literature on peri–implantitis. In addition, I consulted a good friend and clinician in Calgary, Catherine Fairfield, RDH, for some simple points to consider when providing supportive care around implants, and what to consider when confronted with a failing implant.
Our knowledge about peri–implantitis is generally limited. The inflammatory reactions that develop around implants are collectively known as peri–implant diseases.1 Most lesions are caused by oral biofilm colonization around the implant surface.2 There are two types of peri–implant disease: peri–implant mucositis that corresponds to gingivitis, and peri–implantitis that corresponds to periodontitis. Peri–implant mucositis and peri–implantitis are differentiated by the loss of supporting bone in peri–implantitis.1
There is a statistically significant higher incidence of peri–implantitis for implants placed in patients with a history of chronic periodontitis (28.6%) compared with periodontally healthy individuals (5.8%).3 The correlation between the presence of periodontitis and the development of peri–implantitis has been supported by a recent systematic review.4 Given the continually increasing number of implants placed in dental practices, it is obvious that today's periodontal therapists will be looking for predictable therapy to treat peri–implant diseases.
Another systematic review3 reports a less than adequate level of existing evidence for the clinical application of a therapeutic protocol for peri–implantitis, but does present some general guidelines:
• Submucosal debridement alone may not be adequate for the complete removal of bacterial load from the surfaces of implants with peri–implant pockets greater than or equal to 5 mm.3 A rmore ecent study5 reported that two methods of nonsurgical mechanical debridement of peri–implantitis (titanium hand–instruments or an ultrasonic device) achieved an improvement of plaque and bleeding scores (without significant differences in efficacy between them), but both equally failed to exert a significant effect on peri–implant probing pocket depth.
• The use of the Er:YAG laser can improve peri–implant clinical outcomes for about six months, but it is still unclear whether these positive short–term clinical outcomes can be maintained for a longer period of time.3
• The combination of minocycline microspheres and mechanical debridement appears to provide an improved treatment outcome when compared to the combination of chlorhexidine and mechanical debridement. The improvement in peri–implant pocket depths obtained by the adjunctive use of minocycline microspheres can be maintained for a period of 12 months.3 A more recent study6 additionally mentioned that the use of local antibiotic treatment with minocycline microspheres as an adjunct to mechanical debridement may possibly have to be repetitive in nature, in order to sustain its beneficial effect on a long–term basis.
• Guided bone regeneration or the application of a bone substitute (nanocrystalline hydroxyapatite) can provide improved clinical outcomes following six months of nonsubmerged healing.3 More recent studies7,8 have shown that the use of the bone substitute without a membrane tend to provide a less favorable outcome of healing than guided bone regeneration at two years7 and a poor long–term outcome at four years of follow–up.8 On the contrary, guided bone regeneration still continued to provide clinical improvement after four years.8 No randomized controlled clinical trials are available on the use of access flap surgery (open flap debridement) alone as an alternative therapy.3
I discussed clinical implications for peri–implant diseases with Catherine, who practices in both periodontal and prosthodontic disciplines, and lectures occasionally on peri–implant diseases. She shares some simple guidelines:
• In every recall examination (the time intervals should be individualized), peri–implant probing measurements are recommended, and it's important to detect bleeding on probing (BOP), suppuration, and changes in probing depths. Conventional probing using a light force (0.25N) does not damage the peri–implant tissues.2 Specially designed plastic nontraumatizing probes are commercially available for peri–implant probing.
• Routine periapical films are recommended — at time of placement of restorative component, six months later, and at the maximum every second year unless clinical parameters indicate they should be taken earlier.
• Light debridement should be performed as necessary to remove biofilm/calculus as needed on a routine basis. (Intervals to be determined by the clinician for optimal care.)
• If subgingival cement is present, it MUST be removed as soon as possible either surgically or nonsurgically, as this becomes a serious concern for the long–term stability and health of implants.
• Surgical intervention (access flap surgery) should be considered if there is no improvement in peri–implant health with the above nonsurgical protocol. Be aware that peri–implantitis is difficult to treat and the outcomes may not be predictable.2
Mobility of an implant indicates the lack of complete osseointegration and calls for its removal.2 Catherine concluded our conversation by saying that implant maintenance is easy in health and difficult when disease strikes! In other words, prevention of peri–implantitis is imperative, because therapy of peri–implantitis is difficult, to a large extent undiscovered until now, and, finally, unpredictable. Let's keep our eyes wide open!
- Zitzmann NU, Berglundh T. Definition and prevalence of peri–implant diseases. J Clin Periodontol 2008; 35 (Suppl. 8): 286–291.
- Lindhe L, Meyle J. Peri–implant diseases: consensus report of the sixth European Workshop on Periodontology. J Clin Periodontol 2008; 35 (Suppl. 8): 282–285.
- Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri–implantitis: a systematic review. J Clin Periodontol 2008; 35: 621–629.
- Renvert S, Persson GR. Periodontitis as a potential risk factor for peri–implantitis. J Clin Periodontol 2009; 36 (Suppl. 10): 9–14.
- Renvert S, Samuelsson E, Lindahl C, Persson GR. Mechanical non–surgical treatment of peri–implantitis: a double–blind randomized longitudinal clinical study. I: Clinical results. J Clin Periodontol 2009; 36: 604–609.
- Renvert S, Lessem J, Dahlén G, Renvert H, Lindahl C. Mechanical and repeated antimicrobial therapy using a local drug delivery system in the treatment of peri–implantitis: a randomized clinical trial. J Periodontol 2008; 79: 836–844.
- Schwarz F, Sculean A, Bieling K, Ferrari D, Rothamel D, Becker J. Two–year clinical results following treatment of peri–implantitis lesions using a nanocrystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane. J Clin Periodontol 2008; 35: 80–87.
- Schwarz F, Sahm N, Bieling K, Becker J. Surgical regenerative treatment of periimplantitis lesions using a nanocrystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane: a four–year clinical follow–up report. J Clin Periodontol 2009; 36: 807–814.
Lynne Slim, RDH, BSDH, MSDH, is an award–winning writer who has published extensively in dental and dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. She is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist.Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene–related topics.