Is there an accepted protocol for managing peri-implantitis?
(Content under development)
The following question was submitted by a practising dentist: Is there an accepted protocol for the treatment/management of peri-implantitis and associated bone loss?
JCDA Editorial Consultant Dr. Anastasia Cholakis of the University of Manitoba provided these initial comments for consideration:
At this time, prevention of peri-implantitis seems to be the safest bet. According to the latest consensus of the 7th European Workshop on Periodontology “clinical and radiographic data should routinely be obtained after prosthesis installation on implants in order to establish a baseline for the diagnosis of peri-implantitis during maintenance of implant patients.”
A proper in-office peri-implant maintenance protocol is extremely important. Once the diagnosis of peri-implantitis has been confirmed with increasing clinical probing depths, bleeding on probing and progressive bone loss the recommended treatment is varied.
According to Esposito’s 2012 Cochrane systematic review: “There is no reliable evidence suggesting which could be the most effective interventions for treating peri-implantitis.” The issue appears to be the high rate of recurrence reported between 50-100% at 1-5 years.
My 7 year clinical experience with treating peri-implantitis has been to remove the implant if more than 50% bone loss has occurred, or if the conditions for debridement and decontamination are poor (eg. proximity to other implants, severe angulations etc). I prefer a surgical approach in the treatment of peri-implantitis as this allows for better access to the implant surface and the bony defect.
Decontamination of the implant surface can vary. The use of local antimicrobials, antibiotics, implantoplasty, air abrasives or lasers have all been recommended. Once the implant surface has been cleansed either GBR is attempted or the flap is apically positioned leaving threads exposed. I will frequently also perform a connective tissue graft if no keratinized tissue is present.
At this point the evidence we have is empirical at best and should be adapted to a case-by-case situation. The patient should be advised of the possibility of recurrence.
Editorial Consultant Dr. Sylvia Todescan, also of the University of Manitoba, added the following:
There is not yet an accepted protocol. Nonsurgical therapy of peri-implantitis, such as scaling and root planning, has not been successful. Another nonsurgical option for the treatment of peri-implantitis is local administration of Arestin [minocycline hydrochloride microspheres 1 mg (Ora-Pharma, Horsham, PA)].That treatment led to slight improvements in clinical and microbiological parameters for up to 12 months.
Other treatments, such as erbium-doped yttrium aluminum garnet (Er:YAG) laser therapy or use of air abrasives or diode laser irradiation, have been investigated as methods to decontaminate the implant surface. However, only limited data are available in the literature, and so far there is no definitive evidence that any of these methods improve clinical conditions in cases of peri-implantitis.
Caution is advised if the practitioner uses techniques with an insufficient evidence base. Surgical interventions that have been used to treat peri-implantitis include resection associated with implantoplasty or regenerative therapy.
Surface decontamination is important during treatment of peri-implantitis, but decontamination alone will not lead to substantial re-osseointegration on a previously contaminated implant surface. So far, there is no consensus in the literature about which treatment is better for peri-implantitis. This information is from an article by Dr. Todescan, Dr. Cholakis and Professor Salme Lavigne on the topic of peri-implantitis, that will be published soon in the JCDA. Please look out for it.
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There are obviously patient specific and site variables that must be taken into account when assessing how to treat a site with peri-implantitis. I have had more consistent success in slowing/arresting bone loss when creating a site that is accessible for oral hygiene. I have many patients with implants that were placed 15-20 years ago where we have been able to arrest bone loss enabling preservation of the prosthesis even when there is less than 50% bone remaining. As with teeth I would say that the key variable in determining longevity of the implant is the rate of bone loss prior to and perhaps more importantly after surgical treatment to facilitate access. It is critical to verify that occlusion is not playing a role in the bone loss as this will doom all treatment.
Recent research presented at the corporate forum of the AAP 2012 by Dr. Chandur Wadhwani, NW Prosthodontics, indicated that up to 65% of cement restorations may have excess cement associated with the restorations and that many of the supposed ‘implant cements’ may promote bacterial growth and are not radiopaque whereas other cements such as Temp Bond and Zinc Phosphate are bacterial resistant and radiopaque allowing the clinician the ability to detect excess cement.
Also discussed were options for allowing porcelain to be baked on the abutment allowing for supragingival yet esthetic margins if cement retained restorations are decided upon where screw retained isn’t possible. Further research is needed.
Although case reports only, the Periolase has shown many significant clinical cases with substantial regeneration following periimplantitis in a minimally invasive technique (laser assisted periimplantitis procedure- LAPIP)without the use of bone grafts, membranes or other additional biomaterials, regenerative substances)
Dr. G. Romanos of Eastman Dental Center has also published several studies utilizing various lasers, including CO2 laser in conjunction with traditional regenerative procedures.