The Role of Titanium Particles Periapical Lesions on Implants Peri-Implantitis Probing Depths Involved in Peri-Implantitis The majority of studies reported a direct The results from available studies Available evidence does not allow an correlation between retrograde peri- document that the peri-implant mucosa is The Brown evaluation of the role of titanium or metal implantitis and the existence of periapical about 3 to 4 mm high, and the epithelium particles in the pathogenesis of peri- endodontic lesions at adjacent teeth. is about 2 mm high. The zone of connective implant diseases. The scarce evidence available indicates tissue averaged 1.5 mm. In the absence that sites with periapical infections have of previous radiographs, radiographic The Risk of Peri-Implantitis in survival and complication rates similar to bone level loss of 3 mm or greater, and implants placed in non-infected sites. tm Cement-Retained Restorations vs. probing depths 6 mm or more. indicate PDL Screw-Retained Implants peri-implantitis. Occlusal Overload as a Risk Factor for Peri-Implantitis PerioDontaLetter Properly cemented restorations with no Conclusion: I. Stephen Brown, D.D.S., Periodontics & Implant Spring excess cement were not found to be at There is currently no evidence that higher risk for peri-implantitis when The Most Important occlusal overload constitutes a risk factor/ compared to screw-retained restorations. indicator for the onset or progression of Factors for Controlling Certain cements are radiopaque and they peri-implantitis. It did find that thin soft From Our Office The 2017 World Workshop on should be used. Periodontitis and tissues lead to increased marginal bone to Yours... Nevertheless, a systematic review loss compared to thick soft tissues at Peri-Implantitis and Implantology: emphasized the rough surface structure of implants. cement remnants may facilitate retention The Workshop concluded that In November 2017, 175 researchers, Essential New Clinical, Diagnostic educators and clinicians from around of the bacteria which causes peri- Discrepancies Between adequate motivation in the patient’s implantitis and biofilm formation. the world met in Chicago to update and Treatment Information Implants And Teeth Over Time own plaque control, and compliance and standardize the definitions, with maintenance protocols, appear to diagnosis and treatment of periodontal he first World Workshop on pathogenesis, natural history, and Lack of Keratinized Gingiva as a Discrepancies between teeth and be the most important factors in and peri-implant diseases that will periodontics since 1999 was treatment of the diseases and conditions. Risk Factor for Peri-Implantitis implants may develop due to wear, limiting or avoiding potential negative be used by dental professionals intended to account for the It agreed that and changes in the anatomy of the face and effects on the . around the world. T notable advancements in the diagnosis (BOP) should be the primary parameter While studies suggest that the absence or jaws, which occur continuously. It found there is evidence that poor They produced 24 reports in 320 and treatment of in to set thresholds for . It agreed a reduced width of keratinized gingiva may In one study, the maxillary arch length plaque control and lack of regular pages, which were collated and the past 18 years. that a patient with gingivitis can negatively affect self-performed decreased by an average of 5 mm, and the maintenance constitute risk factors/ published in July 2018 as the In addition, the proceedings, for the revert to a state of health, but a measures, there is limited evidence that this mandibular arch decreased by an average indicators for peri-implantitis. proceedings of The World Workshop first time, addressed the diagnosis and periodontitis patient remains a factor constitutes a risk for peri-implantitis. of 8 mm, between the ages of 13 and 45. on the Classification of Periodontal PDL tm treatment of peri-implant diseases and periodontitis patient for life, even and Peri-Implant Diseases and conditions within the classifications of following successful therapy, and Conditions. periodontal disease. requires life-long supportive care to This issue of The PerioDontaLetter The World Workshop agreed a new prevent recurrence of disease. summarizes the proceedings of the classification system for periodontal Studies investigated the predictive World Workshop. It is a “Cliff’s Notes” and peri-implant diseases and conditions values of absence of BOP as an indicator synopsis which includes answers to is necessary for clinicians to properly for periodontal stability. While the many of the most clinically-pertinent diagnose and treat patients, as well as positive predictive value remained rather questions the experts debated. The for scientists to investigate etiology, low for repeated BOP prevalence — copy is taken almost verbatim from the reports. Some of the findings are controversial, and even surprising. Figure 1. Acute Selipsky, in the International Journal necrotizing ulcerative Figure 5. A radiograph of Figure 6. Flap entry reveals Figure 7. Another example of of Periodontics and Restorative gingivitis with 3-4 mm peri-implantitis caused by the primary etiology is peri-implantitis caused by Dentistry, October 2018, stated: probing depth and 15% plaque? excess cement? subgingival cement which failure to remove excess “Current absence of evidence is not horizontal bone loss in necessarily evidence of absence. ? was not removed when the cement from the restoration. Scientific studies point the way, but a a 24-year-old male. (See Figure 6) was placed. wise therapist chooses the path.” (Stage 2, Grade B.)

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 less than 30 percent — the negative Staging was determined to be largely Summary of Occlusal Trauma and • Available evidence supports that Probing of peri-implant tissue with predictive value in the same studies was dependent upon the severity of disease at infringement is associated with light force was determined to be a safe nearly 100 percent. presentation, as well as on the complexity Additional Workshop inflammation and loss of periodontal and important part of a complete oral The Workshop agreed this demonstrated of disease management. Findings There is a lack of evidence from human support. examination. that absence of BOP at repeated Four stages, 1 through 4, are each to be studies implicating occlusal trauma in the examinations represented periodontal determined after considering several cause or progression of gingival recession. New Classification for A Common Finding in health and was a very reliable indicator for variables, including clinical attachment Evidence Regarding the Favorable Mucogingival Defects Infected Implants periodontal stability. loss, amount and percentage of bone loss, Influence of Periodontal Treatment The Association of Removable or Based on Interproximal probing depth, presence and extent of on Systemic Diseases Fixed Appliances with Bone Levels When compared with healthy implant angular bony defects, and furcation Periodontitis sites alone, peri-implantitis is associated A New Classification involvement, , and tooth Current evidence that effective treatment Mucogingival defects based on with higher counts of 19 bacterial species, System for loss due to periodontitis. of periodontitis can favorably influence The available evidence does not support interproximal bone levels were placed including Prophyromonas gingivalis and Grading was established to provide systemic diseases, although limited, is that optimal fixed or removable appliances into three new classifications. . Periodontal Disease supplemental information about biological intriguing and should definitely be assessed. are associated with periodontitis. • Recession Type 1 (RT1): Gingival Several consensus statements features of the disease, including a history- Several studies show that periodontitis However, evidence was found that recession with no loss of concluded: based analysis of the rate of disease contributes to the overall inflammatory prosthesis design can be associated with interproximal attachment. (This new • Suppuration is a common finding at The Workshop agreed that, consistent burden, which is strongly implicated in progression, assessment of the risk for plaque retention, gingival recession and classification combines Millers 1st sites diagnosed with peri-implantitis. with current knowledge on heart disease, stroke and diabetes. further progression, anticipated poor loss of periodontal support. and 2nd classifications.) • Anti-infective treatment strategies are pathophysiology, three forms of Periodontal diseases can no longer be outcomes of treatment, and assessment of • Recession Type 2 (RT2): Gingival successful in suppressing disease periodontitis can be identified, and considered simple bacterial infections: Occlusal Trauma and Abfractions the risk that the disease or its treatment recession associated with loss of progression. established the following new classification rather, they are complex diseases of may negatively affect the general health of interproximal attachment. (This system for periodontal disease: multifactorial nature involving an intricate There is no credible evidence to support the patient. classification is the same as Millers • Necrotizing periodontitis interplay between the subgingival the theory that occlusal trauma causes Three grades were established: 3rd classification.) • Periodontitis as a manifestation of microbiota, host immune and inflammatory abfractions. A possible cause of what • Grade A – low risk for progression • Recession Type 3 (RT3): Gingival systemic disease, and responses, and environmental modifying dentists have been calling lesions • Grade B – moderate risk for progression recession associated with a loss of • The forms of the disease previously factors. Bacteria are necessary, but not is toothpaste abuse, according to Peter • Grade C – high risk for progression interproximal attachment greater recognized as “chronic” or “aggressive” sufficient, to cause disease in all people. Dawson in Functional 2007. periodontitis, now grouped under a In addition to aspects related to the than the facial recession. (Miller’s 4th classification.) single category, “periodontitis”. progression of periodontitis, grading Occlusal Trauma and Keratinized Tissue and (Miller has questioned combining his In revising the classification system, the factors are to include general health status, Periodontitis Periodontal Health classifications I and II, saying this could Workshop agreed on a classification and other exposures, such as smoking or Minimal Bleeding Moderate Bleeding framework for periodontitis, which would level of metabolic control in diabetes. Occlusal trauma does not initiate Periodontal health can be maintained in be detrimental to the clinician attempting be further characterized by a Thus, grading will allow the clinician to periodontitis, and there is weak evidence most patients under optimal oral root coverage, since different procedures multidimensional staging and grading incorporate individual patient factors into that it alters the progression of the disease. conditions, even with minimal amounts of are required to treat Class I and Class II system, and which could be adapted over the diagnosis, which are crucial to Reduction of tooth mobility may enhance keratinized tissue. gingival recession.) time as new evidence emerges. comprehensive case management. the effect of periodontal therapy. However, an increased risk for development or progression of gingival Peri-implantitis recession was found in cases presenting with thin periodontal phenotypes, The World Workshop defined peri- suboptimal oral hygiene, and requiring implantitis as a plaque-associated restorative or orthodontic treatment. pathologic condition occurring in the tissue around dental implants, Biologic Width Redefined characterized by inflammation in the Figure 4. Bleeding on peri-implant mucosa, and subsequent probing (BOP) should be the Biologic width was redefined as progressive loss of supporting “supracrestal tissue attachment,” and this bone. Peri-implant mucositis is assumed primary parameter to set question was addressed: What is the ideal to precede peri-implantitis. thresholds for gingivitis. dimension, and does infringement cause Peri-implantitis was found to be Minimal Bleeding: Twenty to loss of periodontal support? associated with poor plaque control, and thirty seconds after probing Fig. 2. Periodontal disease • Histologically, the dimension is with patients with a history of severe the mesial and distal sulci associated with local factors composed of periodontitis. The onset of peri- with a , a implantitis may occur early, following and uncontrolled diabetes in and supracrestal connective tissue single bleeding point is attachment. implant placement, as indicated by a 50-year-old male. Probing Fig. 3. Radiographic appearance of periodontitis in a 34-year-old observed. Moderate Bleeding: depth was 5-6 mm with 25% • The average dimensions for each radiographic data. Peri-implantitis, in female. Probing depths were 6-9 mm, with bone loss of 50% the absence of treatment, seems to A fine line of blood, or several horizontal bone loss. (Stage varies histologically from 0.5 to 1 mm. associated with secondary occlusal trauma. (Stage 4, Grade C.) • Since it varies considerably, it is progress in a non-linear and bleeding points, become 3, Grade C.) impossible to define a fixed biologic circumferential, and accelerating visible at the . width dimension. pattern.

PerioDontaLetter, Spring less than 30 percent — the negative Staging was determined to be largely Summary of Occlusal Trauma and • Available evidence supports that Probing of peri-implant tissue with predictive value in the same studies was dependent upon the severity of disease at Gingival Recession infringement is associated with light force was determined to be a safe nearly 100 percent. presentation, as well as on the complexity Additional Workshop inflammation and loss of periodontal and important part of a complete oral The Workshop agreed this demonstrated of disease management. Findings There is a lack of evidence from human support. examination. that absence of BOP at repeated Four stages, 1 through 4, are each to be studies implicating occlusal trauma in the examinations represented periodontal determined after considering several cause or progression of gingival recession. New Classification for A Common Finding in health and was a very reliable indicator for variables, including clinical attachment Evidence Regarding the Favorable Mucogingival Defects Infected Implants periodontal stability. loss, amount and percentage of bone loss, Influence of Periodontal Treatment The Association of Removable or Based on Interproximal probing depth, presence and extent of on Systemic Diseases Fixed Appliances with Bone Levels When compared with healthy implant angular bony defects, and furcation Periodontitis sites alone, peri-implantitis is associated A New Classification involvement, tooth mobility, and tooth Current evidence that effective treatment Mucogingival defects based on with higher counts of 19 bacterial species, System for loss due to periodontitis. of periodontitis can favorably influence The available evidence does not support interproximal bone levels were placed including Prophyromonas gingivalis and Grading was established to provide systemic diseases, although limited, is that optimal fixed or removable appliances into three new classifications. Tannerella forsythia. Periodontal Disease supplemental information about biological intriguing and should definitely be assessed. are associated with periodontitis. • Recession Type 1 (RT1): Gingival Several consensus statements features of the disease, including a history- Several studies show that periodontitis However, evidence was found that recession with no loss of concluded: based analysis of the rate of disease contributes to the overall inflammatory prosthesis design can be associated with interproximal attachment. (This new • Suppuration is a common finding at The Workshop agreed that, consistent burden, which is strongly implicated in progression, assessment of the risk for plaque retention, gingival recession and classification combines Millers 1st sites diagnosed with peri-implantitis. with current knowledge on heart disease, stroke and diabetes. further progression, anticipated poor loss of periodontal support. and 2nd classifications.) • Anti-infective treatment strategies are pathophysiology, three forms of Periodontal diseases can no longer be outcomes of treatment, and assessment of • Recession Type 2 (RT2): Gingival successful in suppressing disease periodontitis can be identified, and considered simple bacterial infections: Occlusal Trauma and Abfractions the risk that the disease or its treatment recession associated with loss of progression. established the following new classification rather, they are complex diseases of may negatively affect the general health of interproximal attachment. (This system for periodontal disease: multifactorial nature involving an intricate There is no credible evidence to support the patient. classification is the same as Millers • Necrotizing periodontitis interplay between the subgingival the theory that occlusal trauma causes Three grades were established: 3rd classification.) • Periodontitis as a manifestation of microbiota, host immune and inflammatory abfractions. A possible cause of what • Grade A – low risk for progression • Recession Type 3 (RT3): Gingival systemic disease, and responses, and environmental modifying dentists have been calling abfraction lesions • Grade B – moderate risk for progression recession associated with a loss of • The forms of the disease previously factors. Bacteria are necessary, but not is toothpaste abuse, according to Peter • Grade C – high risk for progression interproximal attachment greater recognized as “chronic” or “aggressive” sufficient, to cause disease in all people. Dawson in Functional Occlusion 2007. periodontitis, now grouped under a In addition to aspects related to the than the facial recession. (Miller’s 4th classification.) single category, “periodontitis”. progression of periodontitis, grading Occlusal Trauma and Keratinized Tissue and (Miller has questioned combining his In revising the classification system, the factors are to include general health status, Periodontitis Periodontal Health classifications I and II, saying this could Workshop agreed on a classification and other exposures, such as smoking or Minimal Bleeding Moderate Bleeding framework for periodontitis, which would level of metabolic control in diabetes. Occlusal trauma does not initiate Periodontal health can be maintained in be detrimental to the clinician attempting be further characterized by a Thus, grading will allow the clinician to periodontitis, and there is weak evidence most patients under optimal oral root coverage, since different procedures multidimensional staging and grading incorporate individual patient factors into that it alters the progression of the disease. conditions, even with minimal amounts of are required to treat Class I and Class II system, and which could be adapted over the diagnosis, which are crucial to Reduction of tooth mobility may enhance keratinized tissue. gingival recession.) time as new evidence emerges. comprehensive case management. the effect of periodontal therapy. However, an increased risk for development or progression of gingival Peri-implantitis recession was found in cases presenting with thin periodontal phenotypes, The World Workshop defined peri- suboptimal oral hygiene, and requiring implantitis as a plaque-associated restorative or orthodontic treatment. pathologic condition occurring in the tissue around dental implants, Biologic Width Redefined characterized by inflammation in the Figure 4. Bleeding on peri-implant mucosa, and subsequent probing (BOP) should be the Biologic width was redefined as progressive loss of supporting “supracrestal tissue attachment,” and this bone. Peri-implant mucositis is assumed primary parameter to set question was addressed: What is the ideal to precede peri-implantitis. thresholds for gingivitis. dimension, and does infringement cause Peri-implantitis was found to be Minimal Bleeding: Twenty to loss of periodontal support? associated with poor plaque control, and thirty seconds after probing Fig. 2. Periodontal disease • Histologically, the dimension is with patients with a history of severe the mesial and distal sulci associated with local factors composed of junctional epithelium periodontitis. The onset of peri- with a periodontal probe, a implantitis may occur early, following and uncontrolled diabetes in and supracrestal connective tissue single bleeding point is attachment. implant placement, as indicated by a 50-year-old male. Probing Fig. 3. Radiographic appearance of periodontitis in a 34-year-old observed. Moderate Bleeding: depth was 5-6 mm with 25% • The average dimensions for each radiographic data. Peri-implantitis, in female. Probing depths were 6-9 mm, with bone loss of 50% the absence of treatment, seems to A fine line of blood, or several horizontal bone loss. (Stage varies histologically from 0.5 to 1 mm. associated with secondary occlusal trauma. (Stage 4, Grade C.) • Since it varies considerably, it is progress in a non-linear and bleeding points, become 3, Grade C.) impossible to define a fixed biologic circumferential, and accelerating visible at the gingival margin. width dimension. pattern.

PerioDontaLetter, Spring The Role of Titanium Particles Periapical Lesions on Implants Peri-Implantitis Probing Depths Involved in Peri-Implantitis The majority of studies reported a direct The results from available studies Available evidence does not allow an correlation between retrograde peri- document that the peri-implant mucosa is The Brown evaluation of the role of titanium or metal implantitis and the existence of periapical about 3 to 4 mm high, and the epithelium particles in the pathogenesis of peri- endodontic lesions at adjacent teeth. is about 2 mm high. The zone of connective implant diseases. The scarce evidence available indicates tissue averaged 1.5 mm. In the absence that sites with periapical infections have of previous radiographs, radiographic The Risk of Peri-Implantitis in survival and complication rates similar to bone level loss of 3 mm or greater, and implants placed in non-infected sites. tm Cement-Retained Restorations vs. probing depths 6 mm or more. indicate PDL Screw-Retained Implants peri-implantitis. Occlusal Overload as a Risk Factor for Peri-Implantitis PerioDontaLetter Properly cemented restorations with no Conclusion: I. Stephen Brown, D.D.S., Periodontics & Implant Dentistry Spring excess cement were not found to be at There is currently no evidence that higher risk for peri-implantitis when The Most Important occlusal overload constitutes a risk factor/ compared to screw-retained restorations. indicator for the onset or progression of Factors for Controlling Certain cements are radiopaque and they peri-implantitis. It did find that thin soft From Our Office The 2017 World Workshop on should be used. Periodontitis and tissues lead to increased marginal bone to Yours... Nevertheless, a systematic review loss compared to thick soft tissues at Peri-Implantitis Periodontology and Implantology: emphasized the rough surface structure of implants. cement remnants may facilitate retention The Workshop concluded that In November 2017, 175 researchers, Essential New Clinical, Diagnostic educators and clinicians from around of the bacteria which causes peri- Discrepancies Between adequate motivation in the patient’s implantitis and biofilm formation. the world met in Chicago to update and Treatment Information Implants And Teeth Over Time own plaque control, and compliance and standardize the definitions, with maintenance protocols, appear to diagnosis and treatment of periodontal he first World Workshop on pathogenesis, natural history, and Lack of Keratinized Gingiva as a Discrepancies between teeth and be the most important factors in and peri-implant diseases that will periodontics since 1999 was treatment of the diseases and conditions. Risk Factor for Peri-Implantitis implants may develop due to , limiting or avoiding potential negative be used by dental professionals intended to account for the It agreed that bleeding on probing and changes in the anatomy of the face and effects on the periodontium. around the world. T notable advancements in the diagnosis (BOP) should be the primary parameter While studies suggest that the absence or jaws, which occur continuously. It found there is evidence that poor They produced 24 reports in 320 and treatment of periodontal disease in to set thresholds for gingivitis. It agreed a reduced width of keratinized gingiva may In one study, the maxillary arch length plaque control and lack of regular pages, which were collated and the past 18 years. that a patient with gingivitis can negatively affect self-performed oral hygiene decreased by an average of 5 mm, and the maintenance constitute risk factors/ published in July 2018 as the In addition, the proceedings, for the revert to a state of health, but a measures, there is limited evidence that this mandibular arch decreased by an average indicators for peri-implantitis. proceedings of The World Workshop first time, addressed the diagnosis and periodontitis patient remains a factor constitutes a risk for peri-implantitis. of 8 mm, between the ages of 13 and 45. on the Classification of Periodontal PDL tm treatment of peri-implant diseases and periodontitis patient for life, even and Peri-Implant Diseases and conditions within the classifications of following successful therapy, and Conditions. periodontal disease. requires life-long supportive care to This issue of The PerioDontaLetter The World Workshop agreed a new prevent recurrence of disease. summarizes the proceedings of the classification system for periodontal Studies investigated the predictive World Workshop. It is a “Cliff’s Notes” and peri-implant diseases and conditions values of absence of BOP as an indicator synopsis which includes answers to is necessary for clinicians to properly for periodontal stability. While the many of the most clinically-pertinent diagnose and treat patients, as well as positive predictive value remained rather questions the experts debated. The for scientists to investigate etiology, low for repeated BOP prevalence — copy is taken almost verbatim from the reports. Some of the findings are controversial, and even surprising. Figure 1. Acute Selipsky, in the International Journal necrotizing ulcerative Figure 5. A radiograph of Figure 6. Flap entry reveals Figure 7. Another example of of Periodontics and Restorative gingivitis with 3-4 mm peri-implantitis caused by the primary etiology is peri-implantitis caused by Dentistry, October 2018, stated: probing depth and 15% plaque? excess cement? subgingival cement which failure to remove excess “Current absence of evidence is not horizontal bone loss in necessarily evidence of absence. occlusal trauma? was not removed when the cement from the restoration. Scientific studies point the way, but a a 24-year-old male. (See Figure 6) crown was placed. wise therapist chooses the path.” (Stage 2, Grade B.)

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