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MANAGEMENT OF PERI-IMPLANT DISEASE: A CURRENT APPRAISAL Oksana P. Mishler, RDH, MS, and Harlan J. Shiau, DDS, DMSc SORT SCORE ABSTRACT ABCNA While the clinical science of managing peri-implant diseases is progressing, careful SORT, Strength of Recommendation Taxonomy monitoring and preventive care of peri-implant tissue health during maintenance is paramount. LEVEL OF EVIDENCE 1 2 3 Background See page A8 for complete details regarding SORT and Implants have become a routine treatment option for missing dentition. The bio- LEVEL OF EVIDENCE grading system logical complications of restored dental implants and associated supra-structures share similarities with the biofilm infections of natural dentition. Our existing par- adigms of periodontal disease treatment can partially be applied to management of peri-implant disease. Approach A critical analysis of the peri-implant disease literature was conducted, anchored by â a search on the MEDLINE database (2005 to present) by way of Ovid Medline . Search terms peri-implantitis, peri-implant mucositis and peri-implant diseases were utilized. Select references within bibliographies of review articles were sought. Conclusion The dental team must play a critical role in educating patients to control plaque-biofilm associated with peri-implant tissues and associated restorations. Routine assessments at maintenance appointments allow early treatment intervention to prevent escalation of peri-implant disease. Given the infancy of clinical science surrounding peri- implantitis treatment, further, high-quality evidence based studies are expected. Department of Periodontics, Key words: Peri-implantitis, peri-implant University of Maryland Dental School, Baltimore, MD 21201, ith the unfavorable prognosis of a tooth, the clinician and patient may be USA Wconfronted with decisions of tooth replacement. Dental implants and asso- ciated restorations have become an increasingly common treatment option in clinical Corresponding author: Department of Peri- practice. A recent systematic review has determined the 5- and 10-year implant odontics, University of Maryland Dental School, 1 Room 4213, Baltimore, MD 21201, USA. survival rate to be 97.7% and 92.8%, respectively. Nevertheless, the osseointegrated Tel.: 11 410 706 7152; fax: 11 410 implant is susceptible to complications. Notably, implants may develop infections 706 7201. E-mail: [email protected] similar to the biological complications that afflict natural dentition. Biofilm infections J Evid Base Dent Pract 2014;14S: of the peri-implant tissues challenge epithelial health and connective tissue sur- [53-59] rounding the implant—and potentially the underlying, supporting bone. 1532-3382/$36.00 ª 2014 Elsevier Inc. All rights reserved. Peri-implant disease is classified in part by anatomical involvement: peri-implant http://dx.doi.org/10.1016/j.jebdp.2014.04.010 mucositis and peri-implantitis. These specific pathologies can develop subsequent to a normal implant wound healing phase and osseointegration. Peri-implant mucositis is characterized by inflammation of the gingival soft tissue surrounding the implant. Peri-implantitis is defined by loss of crestal bone surrounding the implant in addition to inflammation of the peri-implant tissues clinically noticeable as bleeding on probing. Additional clinic parameters associated with peri-implantitis include suppuration, deepened probing depths, and recession of mucosal tissues. In particular, 53 June 2014 JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE peri-implantitis refers to a post-osseointegration event, dis- peri-implant disease progression.7,8 Suppuration at peri- tinguishing it from dynamic bone level changes associated with implant pockets is associated with infection and implies an in- remodeling immediately following implant placement. flammatory reaction present in the peri-implant tissues. Sup- puration has also been correlated to implant bone loss. Peri-implant diseases represent a common finding in contem- porary clinical practice. Mombelli and colleagues reviewed peri- Periodontal probing and related attachment level changes implant disease occurrence, focusing on studies spanning a represent an essential means of diagnosing and monitoring minimum of 5 years; the prevalence of peri-implantitis was re- peri-implant disease. Increased pocket probing depth is a ported to be in 10% of implants and 20% of patients.2 The clinical sign consistent with a finding of peri-implantitis, though authors point out, similar to other systematic reviews, that this finding alone is insufficient to fully establish a diagnosis. heterogeneity in disease definitions in studies makes it difficult Nonetheless, the finding of a probing depth $5 mm should to offer an unequivocal statement on prevalence of peri- be further assessed by the clinician, utilizing current and past implantitis. Another concern is whether the convenience radiographs. Note that major epidemiological studies have samples of clinical studies can be generalized to the overall used peri-implantitis definitions that incorporate a probing population seeking implant therapies. Overall, the prevalence of depth (either a 4 or 5 mm threshold), radiographic criteria of peri-implant mucositis is higher than that of peri-implantitis; it bone loss, and an inflammatory measure (bleeding on prob- occurs in about 50% of implants and just under 80% of patients.3 ing, or suppuration).2 Studies have allayed fears that probing would cause long-term damage to the peri-implant tissues. Peri-implant diseases are generally thought to represent Gingival mucosa surrounding a dental implant differs from that inflammatory conditions in response to bacterial plaque. Other of natural dentition. The peri-mucosal seal that forms after factors, such as aberrant occlusal forces, may also contribute to surgical placement provides a barrier against bacterial invasion the initiation and/or progression of peri-implant disease but from the oral cavity but is lacking some strength of attachment remain incompletely understood. The composition of these when compared to a natural sulcus. Thus, a plastic probe with biofilms is similar to the subgingival bacteria of chronic peri- minimal force (0.25 N) is recommended around an implant to odontitis, dominated by Gram-negative bacteria. Notably, avoid long-term damage to the peri-implant tissue. Etter et al studies have generally reported Porphorymonas gingivalis and verified that a complete reformation of the peri-mucosal seal other red complex bacteria at higher frequencies in peri- 9 – resulted at 5 days following gentle probing. Caution must be implantitis sites than healthy sites.4 6 In healthy implants with applied to probing measurements, as they alone are not stable probing depths of 5 mm or less the flora is characterized by indicative of disease around an implant. The presence of gram-positive cocci and small number of gram-negative species.6 prosthetic reconstructions attached to the implant—the While the objective of this article is to present the current profile of abutments or associated crowns may increase treatment options for peri-implant disease, it should be probing depth readings. Radiographic interpretation should prefaced by a discussion on assessment and diagnosis. What either confirm or dispute peri-implant diagnosis when will be apparent is that many treatment and management bleeding or inflammation is associated with increased probing paradigms are in their infancy; consequently, implementing depth. Use of a radiograph, in conjunction with periodontal strategies of early detection and maintenance of implants probing will greatly aid the clinician in interpreting a ‘large’ becomes essential. probing depth; for example, a radiograph that displays a sig- nificant amount of implant supra-structure cantilevered off of IS THE IMPLANT HEALTHY? ASSESSMENT OF the implant should alert the clinician to cautiously consider ‘ ’ PERI-IMPLANT CONDITION large clinical probing depth results. The clinical assessment tools used in monitoring periodontal Mobility of an implant is a terminal clinical sign—removal of health of natural teeth are used in monitoring peri-implant the failed implant is warranted. The osseointegrated dental tissues, though some considerations must be made given implant does not have any connective tissue fiber attachments the obvious structural differences (Figure 1). between the bone and the implant. As a result, mobility is a concerning finding suggesting the loss of direct bone-implant fl Assessment of mucosal in ammation is primarily made by contact that leads to the loss of stability. There is minimal observing bleeding following light probing (0.25 N) of the clinical science at this time indicating any ability to achieve a implant sulcus/pocket. As with periodontitis, the absence of stable long-term therapeutic outcome from treating implant — bleeding on probing has a high negative predictive value mobility. providing the clinician a predictor of stable peri-implant con- ditions. A prospective study detailed the utility of this param- Radiographic assessment is important in identifying bone loss eter during the maintenance phase of restored dental implants. associated with peri-implantitis. Again, in conjunction with Bleeding on probing at implant sites during more than 50% of probing, radiographs aid in developing a proper picture of the recall visits over a two-year period was strongly associated with underlying osseous topography of putative peri-implantitis Volume 14, Supplement
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