Evaluating and Managing Peri-Implantitis: Part 2
In this article, you will read:
- Key Points
- What's the problem?
- Risk Factors
- Prevention and Management
This content is based on the article "Peri-implantitis Evaluation and Management" published in Dental Clinics of North America (April 2020)
- Because of their prevalence and potential impact on outcome, peri-implant mucositis and peri-implantitis are important complications of implant placement.
- Clinicians placing and/or restoring implants must be familiar with the diagnostic features of these conditions and monitor their patients carefully.
- Management strategies should take into account local and systemic factors and should be as evidence-based as allowed by available data.
Peri-implantitis presents with bleeding on probing. In addition, probing depths will reflect progressive bone loss indicating that the disease progress is irreversible. consensus seems to exist around a probing depth of equal to or greater than 4 or 5 mm. The emphasize is on the need to record baseline probing depths as soon as the prosthesis has been completed. Baselines are to be measured on all 6 surfaces of each implant to have an accurate reference point for monitoring. Bleeding that occurs on light probing is an indicator of loss of peri-implant attachments and supporting tissue.
Peri-implant disease is also diagnosed using radiographic imaging. Periapical radiographs should be taken to help evaluate the bone margins around the implant. A 2-mm vertical bone loss from the estimated baseline bone level is considered the threshold for diagnosis of peri-implantitis. A marginal bone loss of more than 0.44 mm per year is an indicator of progressive peri-implantitis.
Prevention and Management
Patients should be advised to maintain a strict home oral hygiene program, particularly around implants, and should be provided with any necessary instructions and oral hygiene aids. The use of patient-administered plaque control modalities has been shown to reduce inflammation. Consistent follow-up appointments with the dentist and/or dental hygienist should include clinical examination with recording of probing depths and radiographs when indicated. Adjunctive techniques, including antiseptics, local and systemic antibiotics
and abrasive devices did not impact on reduction of inflammation.
The goals of treatment should be to clinically reduce the peri-implant pocket depths, reduce bleeding on probing, and radiographically
demonstrate bone consolidation. As with currently available treatment modalities, it may only be possible to arrest the disease.
A combination of surgical, open debridement, and antimicrobial treatment has been advocated for the treatment of peri-implantitis. Surgical intervention is required once a patient has bleeding on probing, greater than 5 mm of probing depth, and severe bone loss beyond that expected with remodeling.
When necessary, surgical procedures may be used in conjunction with detoxification of the implant surface by mechanical devices, such as high-pressure air powder abrasion or laser. Implantoplasty may be associated with higher implant survival rate than was noted when comparably affected fixtures were treated with an apically positioned flap. Implantoplasty, or resective procedures, may be selected when there is horizontal bone loss. This approach involves smoothing the implant surface and the implant threads with a high-speed diamond or carbide burr to create a polished implant surface with the goal of limiting plaque retention.
Recent studies have reported that the ER:YAG laser can remove the bacterial contaminated titanium oxide layer, promoting re-osseointegration and healthy soft tissue adaptation around the compromised implant. However, lasers have limitations and have not been shown to be more effective than other methods of decontamination.
Implant removal must be considered along with procedures designed to prolong the life of implants with peri-implantitis. Depending on the status of the fixture and its attachment, as well as any relevant host factors, a case-specific risk/benefit analysis should be formulated and shared with the patient. A balanced presentation outlining potential risks and benefits of the reasonable treatment options allows the patient to make an appropriate, informed decision. When implant retention is chosen, clinician experience and preference must play a role as data are lacking at this time for fully evidence-based procedure selection.