Peri implantitis and peri implant mucositis

1. SUCCESS IS AN ICEBERG

2. Peri-implantitis

3. Contents
Introduction
Peri-implant diseases
Classification of Peri-implantitis
Etiology
Prevelance
Risk factors
Pathology
Histopathology
Diagnosis
Prevention
Treatment
Conclusion
References

5. A Dental Implant is a prosthetic device made of
alloplastic material(s) implanted into the oral
tissues beneath the mucosal or periosteal layer
and on or within the bone to provide retention and
support for a fixed or removable dental
prosthesis.

6. Peri-implant mucosa Physiological periodontium
Desmosomes and hemidesmosomes of epithelium and junctional epithelium
(biological width) are linked with the contact surface
Direct bone-to-implant contact
Anchoring system of root cementum,
alveolar bone and desmodontic
fibers
Subepithelially more collagen fibers
and less fibroblasts/vessels
Subepithelially more fibroblasts and
vessels
Parallel collagen fibers in relation to
implant surface
Dentogingival, dentoperiostal,
circular and transseptal fiber
orientation
Comparison of peri-implant mucosa with physiological periodontium
PERPENDICULAR FIBERS
ANCHORING SYSTEM
CONNECTIVE TISSUE
FIBERS PARALLEL TO THE
IMPLANT
EPITHELIAL ATTACHMENT
IN CONTACT WITH THE
IMPLANT

7. Periimplant
Mucositis
• 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
beyond biological bone remodelling.
Peri-
Implantitis
• It is a progressive and irreversible inflammatory
disease of implant-surrounding hard and soft tissues
and is accompanied with bone resorption, decreased
osseointegration, increased pocket formation and
purulence.
PERI-IMPLANT DISEASES
POCKET FORMATION
BONE RESORPTION

9. Staging Definition
Stage I BoP and/or SUP and bone
loss ≤ 3 mm beyond
biological bone remodeling
Stage II BoP and/or SUP and bone
loss > 3 mm and < 5 mm
beyond biological bone
remodeling
Stage III BoP and/or SUP and bone
loss ≥ 5 mm beyond
biological bone remodeling
Stage IV BoP and/or SUP and bone
loss ≥ 50% of the implant
length
*
beyond biological
bone remodeling
BoP = bleeding on probing; SUP = suppuration
* Depending on implant length, if peri-implantitis can be classified as simultaneously
corresponding to more than one stage, the most advanced stage should be chosen.
PROPOSED CLASSIFICATION OF PERI-IMPLANTITIS

10. ETIOLOGY OF PERI-IMPLANTITIS
 Periodontal Pathogens
 ExcessiveTrauma – RETROGRADE PERI-IMPLANTITIS

11. Bacterial flora which are associated with periodontitis and peri-implantitis, are
found to be similar.
Studies have shown that the bacterial flora at the failing implant sites consist of
gram-negative anaerobic bacteria:
Prevotella intermedia
Prevotella nigrescens
Fusobacterium
Streptococcus constellatus
Aggregatibacter actinomycetemcomitans
Porphyromonas gingivalis
Treponema denticola
Tannerella forsythia
Peri-implantitis is a poly-microbial anaerobic infection
PERIODONTAL PATHOGENS

12. FACULTATIVE
ANAEROBIC COCCI
FACULTATIVE
ANAEROBIC RODS
GRAM ‘-’ve
52.8% 17.4% 7.3%
No Gingivalis and Spirochetes present
COCCOID MOTILE RODS SPIROCHETES
NATURAL
TEETH[CREVICES]
55.6% 4.9% 3.6%
PARTIALLY
EDENTULOUS
PATIENTS[IMPLANT
POCKETS]
65.8% 2.3% 2.1%
FULLY EDENTULOUS
PATIENTS
71.3% 0.4% 0
Implants in partially edentulous patients appear to be at a greater risk than
in fully edentulous patients

13. RETROGRADE PERI-IMPLANTITIS
 An infection at the apex of an implant deep in the bone.
 Fortunately such an infection is rare but it usually occurs very soon after implant
placement, typically within the first 3 weeks and results in an intense throbbing pain.
 ORIGIN : Chronic tooth abscess
Implant placement in freshly extracted socket
 No response to strong antibiotic therapy.
 Surgical decontamination is necessary.

14. RISK
FACTORS
Occlusion and
bone loss
Genetic
factors
Smoking &
oral hygiene
Parafunctional
habits
Iatrogenic causes
History of
periodontitis
Surface
modifications
of implant
Improper
prosthetic
design

16. PREVELANCE
There are several reports on the prevalence of mucositis and peri-implantitis
that differ between 5% and 63.4%. This enormous range is mainly based on
varying study designs and population sizes with different risk profiles and
statistic profiles
Zitzmann et al.
•patients with a
history of
periodontitis
•10% to 50% of the
dental implants
showed signs of
peri-implantitis
Consensus Report of
the Sixth European
Workshop in
Periodontology, Lin
dhe & Meyle
•incidence of peri-
implantitis
between 28% and
56%
Mombelli et al.,
•peri-implantitis in
20% of all
implanted
patients
•10% of all
inserted implants

17. Peri-implantitis with increased probing depth
(12 mm).
PERI-IMPLANTITIS - PATHOLOGY
[Peri-around,Implant,Itis-inflammation]
Clinical features:
 Bleeding on probing
 Redness
 Edema
 Suppuration
 Increased Probing depth
 Mobility
 Radiographical bone loss
Pain is an unusual feature, which, if present, is usually
associated with an acute infection.
SUPPURATION

19. DIAGNOSIS OF
PERI-IMPLANT DISEASES

20. DIAGNOSTIC PARAMETERS
 Clinical Indices
 Peri-implant probing using a rigid plastic probe
 Bleeding on Probing[BOP]
 Suppuration
 Mobility
 Peri-implant radiography
 Microbiology

21. PREVENTION OF PERI-IMPLANTITIS
Attention has to be paid, in particular to the following:
1. Refrain from smoking
2. Stay healthy
3. Maintain oral hygiene
By using mechanical plaque control (with manual or
powered toothbrushes)
Regular check upsNumbers of check-ups (cu) annually for different patient collectives
cu = 1 cu = 2 cu > 3
Oral hygiene and
hygienic ability of
the implant
well middle bad
Smoking status / in history in presence
Periodontitis,
mucositis (with
history)
/ / in presence
Other risk factors / /
e.g. systemic
diseases, history
of an non-
successful implant
insertion

22. Management of peri implantitis

24. Non-Surgical
[Conservative]
Manual
Treatment
Drug Therapy
Laser Therapy
Photodynamic
Therapy
Surgical
Resective Therapy
Regenerative
Approaches
The procedures include:

25.  Basic manual treatment can be provided by teflon-, carbon-, plastic- and
titanium curettes
 Material of the tip should be softer than titanium
 It is possible to reduce bleeding on probing scores by cleaning
with piezoelectric scalers as well as with hand instruments.
MANUAL TREATMENT:
CONSERVATIVE THERAPY
The use of a carbon
curette
Detoxification using an air
polishing device with glycin
powder.

26. Qualitative effectiveness (x: yes/o: no) of different cleaning methods depending on implant surface
Smooth surface
Sandblasted and acid-etched surface
(SLA)
Plasma sprayed surface
Rubber cap o o o
Metalic curette, rotating
titanium brush
o x x
Plastic curette o o o
Ultrasonic systems with
metalic tips
x (polished)
Ultrasonic systems with
plastic tips
o x x
Air polishing x x x
The results of air polishing systems are depending on the used medium and are significantly
better in the following order:
Hydroxylapatite/tricalcium phosphate > hydroxylapatite > glycine > titanium dioxide
> water and air (control group) > phosphoric acid
 An abrasive air polishing medium can modify the surface of implants
thereby:
Reducing the pocket depth and bleeding on probing
Re-osseointegration of titanium implants (39%-46%)
Increaisng clinical implant attachment
Reduction in pocket depth

27. DRUG THERAPY:
The following therapies can be distinguished:
 Antiseptic rinses in relation to different parameters.
 Application of systemic and locally delivered antibiotics in
relation to pocket depth or different parameters.
Systemic and Local Antibiotics:
A. Tetracyclines
B. Doxycycline
C. Amoxicillin
D. Metronidazole
E. Minocycline
F. Ciprofloxacin
G. Sulfonamides+Trimethoprim

28. Antibiotic Resistance
Clindamycin 46,7%
Amoxicillin 39,2%
Doxycycline 25%
Metronidazole 21,7%
Amoxicilin & metronidazol 6,7%
Antibiotic resistance of Prevotella intermedia , Prevotella
nigrescens and Streptococcus constellatus
New methods:
Metronidazole release from Poly-ϵ-Caprolacton/Alginat-ring - Lan et al
Fluorouracil release from Poly-ϵ-Caprolacton ring – Hou et al

29. LASER THERAPY:
Following lasers have bactericidal mode of action
o CO2
o Diode-, Er:YAG- (erbium-doped: yttrium-aluminum-garnet)
o Er,Cr:YSGG- (erbium, chromium-doped: yttrium-scandium-gallium-garnet)
lasers
LAPIP® treatment promises results. As an altered
version of LANAP® – the laser gum disease
treatment – the Laser Assisted Peri-Implantitis
Procedure is designed to preserve implants and
protect the surrounding tissue from further decay.

30. PHOTODYNAMIC THERAPY:
 Photodynamic therapy generates reactive oxygen species by multiplicity
with help of a high-energy single-frequency light (e.g. diode lasers) in
combination with photosensitizers (e.g. toluidine blue).
Wave length range = 580 to 1400 nm , toluidine blue-concentrations =between 10 and 50 ug/ml
 Aggregatibacter actinomycetemcomitans
 Porphyromonas gingivalis
Prevotella intermedia
Streptococcus mutans
Enterococcus faecalis
 Bactericidal against;
Manual treatment by titanium curettes &glycine air powder + adjunctive photodynamic
therapy
Reduction of periopathogenic bacteria & IL-1 BETA
12 MONTHS Basseti et al

31. SURGICAL THERAPY
Non-surgical therapy + Resective/Regenerative therapy
RESECTIVE THERAPY:
Patients with active peri-implant disease surgical pocket elimination and bone re-contouring in
combination with plaque control before and after surgery represents an effective treatment.
- SERINO ET AL
Peri-implantitis with granulation tissue. Peri-implantation 1 week after resective therapy.
 Ostectomy and osteoplasty combined with implantoplasty represent an
effective therapy to reduce or even stop peri-implantitis progression
In a radiographic study with 3 years follow-up,marginal bone loss after resective surgery with
implantoplasty was significantly lower than after resective therapy only.
- ROMEO ET AL

32. Regenerative therapy– defect after degranulation
Regenerative therapy– defect fill with a xenograft material
(BioOss ® , Geistlich, Switzerland)
Membrane application (BioGide ® ,
Geistlich, Switzerland) Preoperative radiograph of the
peri-implant defect.
Postoperative radiograph 12 months
after regenerative therapy
REGENERATIVE APPROACHES:
o The results of studies using a combination of membranes and bone graft materials
were superior to those using membranes or bone grafts alone and tend to give the
best results.
o There is a tendency that xenograft materials in combination with a resorbable
membranes might have advantages in terms of re-osseointegration.

33. conclusion
 No “ideal peri-implantitis therapy” have been described.
 Therefore, prevention is the most important factor.
 Continuous check-up intervals with professional teeth and implant
cleaning is necessary.
 Risk factors such as smoking and active or previous periodontitis.
 In non-surgical therapy, combinations of mechanical cleaning with
curettes and air polishing systems are recommendable.
 Adjuvant antiseptic rinses and local or systemic antibiotics are effective.
 Surgical therapy with resective and augmentative procedures completes
the treatment options.
 Proper awareness must be created by understanding the condition.

34. References
Carranzas-Clinical periodontology (12th edition)
Peri-implant tissue remodelling-by Luigi Canullo,
Roberto Cocehetto, Ignazio Loi
Journal of international clinical dental research
organisation
Journal of inter disciplinary dentistry
Peri-implant tissue-dear doctor (dentistry&oral health)
Head and face medicine (biomed central)
Journal of dental implantology
US national library of medicine