The Brown

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I. Stephen Brown, D. D. S., Periodontics & Implant Dentistry Summer

From Our Office Peri-Implant Disease: to Yours... Causes, Prevention and Treatment

Peri-implant diseases are a grow- s with all periodontal dis- ber of years after restoration. Careful ing problem in implant dentistry. eases, early diagnosis of clinical monitoring of implants can Infectious in nature, they can be of the peri- find early changes in clinical parame- classified into two types: peri- A implant tissues adjacent to implants is ters. Clinical features of peri-implant implant mucositis and peri-implan- key to successful treatment. mucositis include, but are not limited titis. Peri-implant mucositis is an Radiographs should be taken at the to, , swelling of inflammatory lesion residing only in the peri-implant mucosa, increased the mucosa. Peri-implantitis affects time of implant insertion to determine both the peri-implant soft tissues baseline alveolar levels. probing depths (mainly pseudo-pock- and the supporting bone. Radiographs should also be taken at ets), and/or erythema of the surround- Although restorations of endos- the time of prosthesis delivery and ing tissues. seous implants have demonstrated one year later. These can then be Peri-implantitis can be character- a very high success rate, one study compared to future radiographs to ized by bleeding or suppuration upon found 80 percent of patients had determine if crestal or peri-implant probing, increased pocket depth and peri-implant mucositis in half their bone loss has occurred. swelling or fistula formation; and implants; and 56 percent of Peri-implant diseases often do not additionally pain on chewing and patients also had peri-implantitis in become clinically evident for a num- radiographic bone loss. 43 percent of their implants. This current summer issue of The PerioDontaLetter addresses the Figure 1. If not caught causes, prevention and treatment of in its early stages, peri- peri-implant disease. As periodon- implant disease can tists, our focus is the treatment and progress and destroy the stabilization of these conditions. entire bone support for As always, we welcome your an implant. questions and comments in our col- laboration to manage these com- mon conditions.

I. Stephen Brown, D. D. S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 Figure 2. One year after implant Figure 3. On flap reflection, Figure 4. The cement was placement, a fistula is forming excess cement appears to be the removed and a bone graft and a on the buccal of the upper etiology of the bone destruction. barrier membrane were placed to second premolar. attempt to regenerate the lost bone support.

Causes of Warrer et al found implants without than an attachment compared to the keratinized mucosa demonstrated attachment seen with Peri-Implant Disease significantly more recession and natural teeth. slightly more attachment loss than Recent technological developments Local iatrogenic factors can play a implants with an adequate zone of in collar design and abut- significant role in the development of attached gingiva. ments have demonstrated the ability to peri-implant disease. These include: One study suggested that implant sur- maintain stable crestal bone and biolog- • excess cement face characteristics (smooth vs. tex- ical width. • bacterial biofilm tured) also influence the progression of • incompletely-seated abutments peri-implant disease. • open crown margins Preventing Lindhe J et al found that because • occlusal overload Peri-Implant Disease • over-contouring of restorations, and there are biologic differences between • poorly positioned implants teeth and implants, the progression of Preventing the development of a Several studies have shown chronic infection around implants is some- biofilm and eliminating it from the periodontitis increases the risk of peri- what different than it is around natural implant surface should be the first steps implant disease along with parafunc- teeth. The inflammatory cell infiltrate in the preservation of peri-implant soft tional habits (bruxism and malocclu- around implants was reported to be sion), systemic diseases such as dia- larger and extend more apically when tissue health. This requires thorough betes and osteoporosis, and smoking. compared to a corresponding lesion in instruction and strict One study found that the found the gingival tissue around natural teeth patient compliance. at implant sites affected with peri- due to the lack of . Adequate control implantitis was almost identical to the In addition, the tissues around is also essential in the partially-edentu- bacteria found in periodontitis. implants are more susceptible to lous patient to prevent cross contamina- Other studies indicate the width of plaque-associated infections that tion from teeth to implants. Recent keratinized gingiva affects the health of spread into the alveolar bone primar- studies have found that the lack of pre- the supporting tissues around dental ily due to the lack of a periodontal ventive maintenance in individuals with implants. Bouri et al found implants ligament. pre-existing peri-implant mucositis was with narrow zones of keratinized tissue The routine soft tissue healing associated with a high incidence of peri- (less than 2mm) had more plaque and response to a majority of implant and implantitis. inflammation, were more prone to abutment surfaces is a parallel arrange- When restoring an implant, it is bleeding on probing, and presented ment of connective tissue fibers. This absolutely essential to ensure all excess with more bone loss. arrangement is described as a seal rather cement has been removed and the area is cleansable with an oral hygiene prod- local iatrogenic factors contributing to al steps, however minimal bone remod- uct such as an interproximal brush. the problem. eling is possible. Some success in well- Cement peri-implantitis is one of the If the disease has progressed to peri- contained four-wall defects has been most significant reasons for marginal implantitis and bone loss is evident, ini- achieved by removing the implant infection and bone loss. Studies by tial treatment is the same: mechanical crown and abutment and attempting Wilson, Cobb and Callan have , anti-microbials and strict bone regenerative procedures after described pathological changes associ- oral hygiene protocols, including cover screw replacement, grafting and ated with excess cement. Shapoff and . primary closure. Lahey have discussed numerous factors Administration of systemic or local leading to excess cement and discussed antibiotics should also be considered to Bone Regeneration and strategies to identify, diagnose and pre- reduce the number of pathogens pre- vent excess cement around implants. sent. Adjunctive local or systemic Reosseointegration Adjusting the prosthesis to open the antibiotics have been shown to reduce embrasure space will allow the patient bleeding on probing and probing depths Comparison of the various decontam- easy access during home oral hygiene. in combination with mechanical ination methods or their combined use Pontic areas should be convex rather debridement. Culturing and / or DNA did not show any significant differences than concave in the area over gingival probes will identify the pathogenic bac- in terms of bone regeneration and tissues to ensure plaque and food debris teria and define which antibiotic will reosseointegration. is easily cleansable. likely have the best result. Once the implant surface has been The basic goal in the treatment of decontaminated, the clinician can then Treating peri-implantitis is decontamination of consider whether to attempt to regen- the infected abutment or implant sur- erate the bone around the implant Peri-Implant Disease face. Unfortunately, to date, studies based on the amount of bone loss, the suggest that nonsurgical treatment of defect morphology and the patient’s Peri-implant mucositis is often a peri-implantitis is unpredictable and motivation. reversible condition and requires only the use of chemical agents alone such Access flap surgery in combination minimal intervention to treat. Tho- as chlorhexidine has only limited with decontamination of the implant rough mechanical debridement of the effects on clinical and microbiological surface seems to be the treatment area along with local anti-microbials parameters. modality that provides the best such as Chlorhexidine irrigation or Numerous methods are used to improvement of inflammation. Ad- Dentomycin or Arestin is usually suffi- debride a plaque-contaminated abut- ditional osseous recontouring of the cient to resolve the problem. A tho- ment or implant surface including bony architecture around the implant rough examination of the area should mechanical, sonic and ultrasonic could be helpful in arresting further also be completed to ensure there are no scalers; lasers; air-powder abrasion bone loss. Leonhardt et al found an and various chemical solutions such as citric acid, and saline. Beneficial effects of laser therapy on peri-implantitis have been shown, but this treatment needs to be further evalu- ated. Schwarz et al found the Er:YAG laser only improved peri-implant prob- ing pocket depth and clinical attach- ment level for about six months. Another study using access flap surgery with the application of a chemical agent (e.g., metronidazole gel) for decontamination showed Figure 5. Coronal bone loss on favorable results. Figure 6. Peri-implant disease this implant was the result of In most situations, clinical parameters can cause bone destruction from excess subgingival cement. of soft tissue peri-implantitis can be one implant to another. improved with a variety of intervention-

PerioDontaLetter, Summer

judgment call which needs to be made by the clinician. Greenstein and Cavallaro suggest there are situations where it seems logi- cal that augmentation of keratinized gingiva would be beneficial: 1. Chronically inflamed sites where altering the gingival topography would make hygiene easier. 2. Locations with ongoing recession or continued loss of clinical attachment or bone, regardless of periodontal thera- py and good oral hygiene. 3. Sites where the patient complains of soreness when brushing, despite the appearance of gingival health. 4. Dental history suggesting predis- position to periodontitis or recession. 5. Patients noncompliant with peri- odic professional maintenance. Conclusion

Prior to implant placement, control of periodontal disease in other areas of the Figure 7. Improperly seated crowns can create a plaque trap leading to mouth is critical to preventing cross- peri-implant disease and bone loss. infection of the implant. It is also important to manage occlusal forces. open flap surgical procedure combined Modifying the surface of the contami- Retention of excess cement around with mechanical debridement of the nated implant surface topography can the dental implant collar is a major rea- implant surface was successful in be used in combination with resective son for peri-implantitis that does not decontaminating 58 percent of implants osseous surgery to correct the anatomi- become clinically evident immediately for five years. cal architecture of bone. Results after crown placement. In addition, If bone loss extends beyond half of showed that implant reshaping resulted recognition of excess cement is difficult the implant fixture length, it is often in better improvement when compared and not always evident on radiographs. recommended the implant be removed, with the control group (ie, flap debride- Improved methods of cementation the site reconstructed, and then an ment, systemic antibiotic, full mouth technique, shallow subgingival margins implant replaced after successful bone disinfection). with the use of custom abutments and augmentation. Guided bone regenera- early and frequent follow-up visits in a tion using a bone graft and membrane Augmentation of shared maintenance approach will mini- has demonstrated the best success in Keratinized Tissue mize the irreversible effects of cement achieving bone fill of the defects asso- peri-implantitis. ciated with peri-implantitis. Treatment of peri-implantitis can Some patients may need augmenta- improve soft tissue health; however, Studies show, however, that it is tion of keratinized tissue to maintain crestal bone loss around dental implants very difficult to regain osseointegra- peri-implant health. But in the is difficult to correct. tion and obtain healthy peri-implant absence of data which reliably pre- The best method is prevention. tissues once significant bone loss has dicts who would benefit from tissue PDL tm occurred. augmentation, ultimately this is a

I. Stephen Brown, D. D. S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660