Peri implantitis
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The document discusses peri-implantitis, its prevalence, and treatment options, highlighting that up to 47% of implants may be affected. It contrasts peri-implant mucositis, characterized by inflammation without bone loss, with peri-implantitis, which involves inflammatory bone loss. The document emphasizes early detection, thorough maintenance, and tailored treatment strategies to effectively manage these complications in dental implant patients.
Peri implantitis
- 1. Peri-Implantitis: Prevalence, Practical Treatment and Prevention Prevalence, Practical Treatment and Prevention Dr. Scott K. Smith November 13, 2013
- 2. Scott K. Smith • Practicing Periodontist 20 years • Placed over 10,000 implants • HiOssen lecturer, teacher and Instructer
- 3. Objectivesand Peri• Define Peri-Implant Mucositis Implantitis • Prevalence of each • Pathogenesis vs. Periodontal Disease • Diagnostic Criteria • Treatment for mucositis and implantitis • Maintenance following treatment
- 4. Conflict of Interest • HiOssen - Clinical practice support and honorarium.
- 5. Dental Implant Success • 400,000 implants placed per year in US • 1 million implants placed per year in EU • $6.5 billion US industry • Failure Rate of Implants less than 5% • Industry and Research Focus on Initial Stabilization, enhancing supporting structure and Initial Esthetics.
- 11. The Dark Side • Incidence of Peri-implant mucositis and Peri-implantitis is as much as 47%!! • Failure of Implants by Chronic Inflammation include Functional loss, Phonetic and Esthetic Challenges • Professional Challenge
- 12. Similarity with Periodontal Diseases • Host Response to Bacterial Insult • Initial Event is Inflammation of Pocket Epithelium without CT or Bone Destruction - Reversible = Gingivitis • Chronic Inflammation and Risk Factors = Periodontitis
- 13. Implant Related Periodontal Diseases • Peri-Implant Mucositis • Peri-Implantitis
- 14. Peri-Implant Mucositis • The presence of inflammation confined to the soft tissues around the implant - No sign of bone loss. • Presence of probing >4mm with bleeding or suppuration • Reversible
- 15. Peri-Implantitis • Inflammatory process around and implant including soft tissue and progressive loss of supporting bone beyond biological bone remodeling. • Probing depth >4mm with bleeding, suppuration and radiographic bone loss
- 16. Peri-Implantitis Probing depths >4mm with bleeding, suppuration Radiographic loss of bone beyond remodeling
- 17. Prevalence: Peri-Implant Mucositis Peri-Implant Mucositis • Berglundh, Renvert: 48% of all implants over 9-14 yrs affected. • Prevalence may be higher - Previous Dogma of Not Probing around Implants Reduced Identification
- 18. Prevalence: Peri-Implantitis Peri-Implantitis • Wide Range: from 4.7% to 36.6% • The Threshold used is Bone Loss. No standarized radiographic analysis. • Additionally Factors such as Smoking, Diabetes, Previous Periodontal Disease create subpopulations and complicate comparisons of studies.
- 20. Anatomy of a Tooth • Junctional Epithelium has Hemidesmosomal attachment to enamel • Connective tissue array of 1mm thickness with attachment to Cementum • Alveolar Bone with Perpendicular Fibers attaching to Cementum overlying Dentin • Vast Source of Nutrients and Cells for Regeneration of Ligament, CT, Cementum, Bone
- 21. Cementum • Acellular and Cellular containing cementoblasts provide support on the tooth side to anchor sharpy’s fibers • Periodontal Ligament space provides nutrient supply and cells for Regeneration
- 22. Anatomy of an Implant • Junctional Epithelium attached to titanium surface by basal lamina and hemidesmosomes • At apical portion of sulcus is only a few cell layers thick and separated from bone by 12mm • No Cementum - Bone to Implant Contact • Connective tissue between JE and Bone few vascular structures and few Fibroblasts
- 23. Pathogenesis
- 24. Peri-Implant Mucositis • Plaque formation of titanium surface and formation of biofilm. Gram (-) Anaerobic • Inflammatory infiltration occurs in CT • Neutrophils, lymphocytes, macrophages in high numbers • Adaptation of JE to Inflammation
- 25. Peri-Implantitis Peri-Implantitis • Inflammatory - bacterial driven destruction of the implant supporting apparatus. • Chronic Inflammation starting as PIM • Inflammatory Cell Infiltrate more Severe with Implants vs. Teeth • Rate of Disease Progression Faster with Implants
- 26. Peri-Implantitis • The difference in collagen fiber orientation (parallel to implant and perpendicular with teeth) and less vasculature structure may explain the faster pattern of tissue destruction with peri-implantitis.
- 27. Influential Factors • Patient Related - systemic diseases, history of Periodontal Disease • Social Factors - Poor OH, Smoker, Heavy alcohol consumption • Parafunctional Habits - Bruxism, Malocclusion
- 28. Smoking • Baig and Rajan found in smokers significantly more marginal bone loss after placement and higher Peri-Implantitis percentages.
- 29. Previous Periodontitis • Significant correlation with increased prevalence of Peri-Implantitis
- 30. Genetic Factors • Significant correlation with Interleukin1gene polymorphism and PeriImplantitis. • Plagnat - proposed markers for Elastase and alkaline phosphatase may be helpful in future diagnosis of bone destruction.
- 31. Health Status • Diabetes Type I and II if uncontrolled lend to increased inflammatory Response and Peri-Implantitis
- 32. Occlusion • Non-axial forces, cantilevers, bruxism • H.L.Wang et al - occlusal overload positively associated with Peri-Implantitis • Likely excess strain causes microfracture within bone.
- 33. Additional Influential Factors -You’re to Blame • Implant Design • Prosthetic Connection • Mechanical Failures and Cement Contamination • Surgical Errors
- 34. Implant Design • Smooth titanium vs. Roughened surfaces • Smooth Cervical collar vs. Surface texture to coronal margin • Thread Design - aggressive vs. passive
- 35. Implant Design Connection • External Hex • Internal Hex • Morse Taper • Platform Switch
- 36. Platform Design • Crestal Bone loss begins when healing abutment is attached to implant at second stage surgery (Nobel implants - Ericsson J. Clin. Perio 1995) • Burglund and Lindhe identified 0.5mm inflammation above and below Branemark implants at abutment/implant junction after 2 weeks.
- 38. Microgap and Platform Switching • Move the microgap away from the implant platform and hence away from the crestal bone as a protective measure.
- 40. Restorative Problems • Excessive Cantilever • No Passive fit • Improper fit of abutment • Improper prosthetic design, occlusal scheme • Premature Loading, Overtorquing • Connecting implants to Natural teeth
- 45. Retained Cement
- 46. Surgical Placement • Off Axis Position - severe angulation, • Lack of Initial Stabilization • Infection from improper flap design • Overheating bone • Spacing too close to teeth or implants • Inadequate bone or attached gingiva • Too Buccal or Lingual and compromise bone
- 49. Space Between Teeth and Implants
- 50. Head of Implant
- 51. ANGULATION
- 53. Heat Generation • Eriksson and Albrektsson reported the critical temperature for implant placement was 47C for 1 minute. • Matthews and Hirsch demonstrated that temperature elevation was more a result of force applied rather than drill speed.
- 54. Diagnostic Criteria • Probe all implants - Plastic or Metal • Look for Bleeding and or Suppuration • X-rays should be taken yearly first two years and compared to base line placement • Evaluate Occlusion, Prosthetic Stability • Soft tissue evaluation - Attached Gingiva?
- 55. Probing
- 56. Probe Long Axis
- 57. Accessibility • Adjust Prosthesis • Plaque Control • Biofilm Removal
- 58. How do you Probe this?
- 60. Bone Level
- 62. Treatment Options • Early Detection is Key to Success and improved health! • Non-surgical Intervention • Surgical Intervention
- 63. Non-Surgical - Studies • Mechanical Debridement with plastic instruments and Chlorhexidine irrigation showed reduction of pocket and bleeding at six months - Schwartz • Antiseptic irrigation of pockets <4mm not effective, but over 5mm it has added effect. Renvert • Adjunctive use of generalized antibiotics did not improve the treatment results
- 65. Peri-Prosthetic
- 66. Peri-Prosthetic
- 68. Peri-implant Mucositis • Application of Minocycline spheres along with debridement provide some additional benefit to reducing bleeding and probing, but NEEDS TO BE REPEATED OFTEN. Renvert
- 69. Clinical Treatment of PIM • Mechanical Scaling of Implants with plastic or titanium instruments or Ultrasonic Plastic Tips. I-Brush if exposed threads. • Apply exposed implant surface with 0.2% Chlorhexidine gauze for 2 mins • Subgingival irrigation with 0.2% Chlorhexidine 5ml per implant • Minocycline Spheres or Gel
- 70. Peri-Implantitis Treatment Options Treatment Options • Visualization with open flap very effective with cementitits!
- 71. Peri-Implantitis • Treatment to be determined by amount of bone loss and esthetic impact of the implant in question • If minimal bone loss (3 threads or less) Proceed with similar treatment as Peri-implant mucositis, but decontaminate prosthetic components as well. The use of various lasers has been suggested. • If bone loss is advanced or progressive than surgical access with resective or regenerative components will need to be employed.
- 72. Peri-Implantitis Non Surgical - Studies Non Surgical - Studies • 31 Subjects mean age 62 • One qualifying implant per patient • PPD >4mm with bleeding or suppuration • < 2.5mm bone loss • J. Clin. Perio 2009 Renvert
- 73. Non-Surgical • Titanium hand instrumentation • Or Ultrasonic Debridement with plastic tip • 6 month results - minimal change with PD for either treatment modality
- 74. Laser Therapy Er:YAG • SRP with plastic instruments and 0.2% chlorhexidine followed by Er:YAG 20sec disinfection per implant • Control was only SRP and antiseptic rinse • Six months later Equal Reduction of Pocket and Clinical Attachment • Twelve months later both groups lost effect
- 75. Peri-Implantitis with Er:YAG vs. Air-Abrasive device • 42 Patients mean age 69 • Laser 55 implants • Perio Flow 45 implants • PPD >5mm with bleeding or suppuration • > 3mm bone loss • J. Clin Perio 2011, Renvert
- 76. Results • Remove Supra-Structure from Implants! • Significant difference in PD bleeding and Pus reduction for both groups at 6 months • Both seem to have limited benefit in advanced cases
- 77. Open Flap - Resective • Surgical flap access and resection of 1 or 2 wall defects combined with decontamination and antibiotic treatment was effective in just over half the cases over 5 years. Leonhardt 2003 • 2008 Hitz-Mayfield with flap surgery and resection and antimicrobial treatment stopped the progression of the disease in 90% of cases up to one year - However, BOP continued in 50% of the lesions.
- 78. Regenerative Surgery • Schwartz (2008) found combination bone grafting debridement and antibiotics had significant reduction of bone loss and BOP after 2 years. • Froum (2012) Significant reduction of BOP, Pocket reduction, bone loss over 3-7 years.
- 79. Submerged Healing • 16 implants in 12 patients • Open Flap and 3% Hydrogen Peroxide • Bone Graft and Membrane • Submerged healing • Roos-Janasker J. Clin Perio 2007
- 80. Submerged Surgical Results • PD change • Defect fill (threads) • Defect Fill (mm) • Recession (mm) 4.2mm 3.8 2.3 2.8
- 81. Implant Configuration and Decontamination • Implant contours and surface are a limitation to remove the biofilm • Surface treatments including - mechanical, Er:YAG, photodynamic, air-abrasion, implantoplasty • Romeo (2005, 2007) implantoplasty improved regenerative capability - reducing probings from 5.5 - 3.6mm and BOP.
- 82. Implantoplasty
- 83. Regenerative Treatment for PeriImplantitis affected implant: Stuart J. Froum Clin Adv Perio 2013 Stuart J. Froum Clin Adv Perio 2013 • 7 year follow up showed decrease pocket depths • Technique successful in 51 cases (IJPRD 2012:32:11-20) • Believes if any Elements of protocol not followed could compromise outcome
- 84. Protocol • 1 month prior to surgery: SRP of natural teeth; debride implant surface and OHI • Requires 2 visits to accomplish this
- 85. Surgery: Exposure and Debridement Exposure and Debridement • 2 gm Amox 1 hour prior to surgery • FTF to expose area • Debride defect with titanium and graphites • Air-Power abrasives (Bicarbonate powder) for 60 secs • 60 secs irrigation with sterile saline • 60 secs application of Tetracycline strips
- 86. Surgical Protocol • Second application of air-powder abrasive for 60-90 secs • Application of CHX for 30 secs • 60-90 secs of sterile saline with air power device no powder
- 87. Surgical Protocol • EMD applied - avoid blood and saliva • Defect filled with 1:1 Bioss/Puros rehydrated with gem 21 • 2 ossix membranes placed to cover all surfaces • Flap released and coronally advanced and sutured with Goretex and vicryl sutures
- 88. Post Surgery • 2 weeks remove sutures and polish • Pt to brush area 4x/day with 1:1 Peroxide and rinse with salt water 4x/day • Return monthly for 12 months for post op and every 6-8 weeks for maintenance
- 90. Treating Peri-Implantitis • Systemic Antibiotics for three days prior to treatment • 2 mins pre-operative rinse with Chlorhexidine • Full Thickness Mucoperiosteal Flap to one tooth beyond diseased site • Thorough Debridement circumfirentially with plastic or titanium or Ultrasonic plastic tips
- 91. Treating Peri-Implantitis • Pack Gauze Strips soaked with CHX around implants and in defects for 5 mins • Remove Gauze and irrigate with CHX or Tetracycline 250mg/5cc • Graft Defect with FDBA, BioOss • Apply Collagen Membrane • Closure of Flap and Regular Post op Intervals
- 96. Detoxify • HCL Acid • Tetracycline • EDTA • Hydrogen Peroxide • Er:YAG and Diode
- 97. Graft Material • Need OsteoInductive Material as there is minimal Osteoprogenetor cells • FDBA, DBA, Acel, OsteoCel, BMP2, Gem21, PRP, Emdogain • Collagen Matrix Necessary • Tacks to hold membrane if necssary
- 109. Retrograde
- 117. LAPIP • Nd:YAG laser with LANAP protocol to address peri-implantitis • Closed access • First pass to decontaminate and selectively eliminate infected tissue • Debride with Piezon and CHX • Second pass with laser to provide fibrin clot
- 118. LAP-IP
- 119. LAP-IP
- 120. LAP-IP
- 121. LAP-IP
- 122. Peri-Implantitis Effects • Loss of implant and functioning prosthetics • Esthetic Challenges • Phonetic Challenges • Maintenance Challenges
- 126. Prevention Is The First Step: • Avoid conditions that contribute to poor results • Choose cases where you have excellent chance for implant and prosthetic success. • Anticipate and Diligently observe for implant and restorative problems. • Once Perio-Implant Disease identified act quickly and with purpose to effectuate the situation
- 127. What I see • Retained Cement • Inadequate attached gingiva • Position of implant - Too Buccal • Position of implant - Too Close to others • Occlusal Overload • Loss of Attached Gingiva Anterior • Poor Oral Hygiene - Inability to get access
- 130. Hybrid Screw Retained Vs. Implant Denture
- 131. Accessibility
- 132. Access for patient?
- 135. Proximity Issues
- 139. Implant Maintenance • Needs to be Individually Determined • Needs to be Enforced by Doctor and Hygienist • Patient Needs to assume Responsibility
- 140. Low Risk Patient • Highly motivated • Excellent Oral Hygiene • One or Two implants • No associated Risk Factors
- 141. Moderate Risk Patient • Loss of Motivation • Fair Oral Hygiene • 3-6 implants • Moderate Smoker (half pack) • Controlled Medical Issues
- 142. High Risk Patient • Unmotivated • Poor Oral Hygiene • Previous Periodontitis • >6 implants • Smokes more than half Pack • Poorly Controlled Systemic Disease(s)
- 143. Maintenance Recall • Low Risk Patients - every 6 months • Moderate Risk - every 3 months • High Risk - every 2-3 months • Note - Oral Hygiene signficantly influences the category the patient is placed.
- 145. Mechanical Debridement Hand Scalers and Ultrasonics
- 146. Maintenance • Plastic, titanium, graphite instruments for visual debridement from prosthetics and sulcus. • Ultrasonics with plastic tips at low to moderate settings are excellent • Individual or multiple implants with fixed crowns or bridges screw or cemented assess and debride as you would teeth.
- 147. Maintenance • For Fixed Hybrid cases Remove at least Twice a year and assess and debride Transmucosal and Prosthetic underside • O rings Remove Denture and address abutments directly
- 148. Maintenance • Polish with soft rubber tip and non-abrasive paste - aluminum oxide, tin oxide, fine pumice • Irrigate with CHX with endodontic syringe or piezon on low setting.
- 149. Ancillary Homecare • Periostat - Doxycycline 20mg b.i.d. • Evorapro - Especially for Dry Mouths • Perio-science AO gel and rinse • Listerene if no dry mouth 2x/day • Biotene if dry mouth 2x/day
- 150. Likely Cause?
- 152. Etiology?
- 153. Thank You