Implant Tribune United Kingdom Edition

Implant Tribune United Kingdom Edition | 3/201520 TRENDS&APPLICATIONS In the US over 500,000 implants are placed each year, whilst in the UK that figure was around 140,000 for 2010.Theprevalenceofperi-implan- titis has been reported to be up to 29percent1 mostnotablyinpatients whose implants are placed within a partial dentition. This yields a potentially vast number of implants, possibly as many as 185,000 in the US and UK alone that might suc- cumb to some form of peri-implant disease on an annual basis. The bacteria found within peri- implant lesions are similar to those found in deeper periodontal pockets,2, 3 and cross infection by periodontopathogensasaprimary aetiology has been implicated as a possible pathway. However the wide variety of implant designs, surfaces etc. make the treatment of peri-implantitis much less pre- dictable and subject to much greater variability than periodon- tal disease, where natural teeth present a known anatomy and well defined surface structure. In 2008 a systematic review4 of the literature regarding peri- implantitis using PubMed and the Cochrane library revealed little consensus on the treatment of this troublesome condition. One study reported on the efficacy of sub- mucosal debridement using ultra- sonics or carbon fibre curettes5 , while two others compared the effect of an Er:YAG laser against that of mechanical debridement and 2 % chlorhexidine as a com- bined therapy.6, 7 The first found similar results between laser and combined thera- pies, while the second concluded that the laser effect was limited to a six month period. A further study compared combinations of oral hygiene instruction, mechanical debridement and topical minocy- cline with a similar regime which substituted0.1%chlorhexidineasthe antimicrobial.8 The former seemed to confer some benefit while the latter showed limited or no clinical improvements.Finally,astudycom- paringtwoboneregenerationproce- dures reported clinically significant improvementsmediatedbyboth.9 Nonetheless a multitude of other studies have also been pub- lished reporting on the efficacy of tetracycline10 , CO2 laser11 , and photocatalytic decontamination amongstothersinthetreatmentof peri-implantitis.12 Such a plethora of therapies makes it difficult for the clinician to choose a regimen that is both within the reach of the average clinician and has some documented reliability. Risk factors Therehavebeenanumberofrisk factors cited for peri-implantitis. Recently,inastudypublishedinthe Journal of Clinical Periodontology, a clear association was demon- strated through multi-level statis- tical analysis between risk of peri- implantitis and location, specifi- cally the maxilla, while overt peri- implantitis was shown to be highly correlated to patients with a pre- disposing history of periodontitis, and being male.13 Surprisingly in thisparticularstudynocorrelation was demonstrated with smoking, yet this has been a consistently cited risk factor in many other studies.Indeedinastudypublished in the Swedish Dental Journal in 2010, the percentage of implants with peri-implantitis was signifi- cantly increased for smokers com- paredtonon-smokers(p = 0.04).14 Other factors that have been implicated include excess cement, poor oral hygiene, and prosthesis design which are of course inter- related with some prostheses making effective oral hygiene un- tenable, while others present deep margins that make removal of ex- cess cement almost impossible. Warning signals Peri-implantitisrarelypresents unannounced unless of course the patient fails to be placed on a regular recall programme or fails to attend for regular review. Early signs are often apparent in the form of peri-implant mucositis. This condition is characterised by mucosal oedema, rubor and bleeding on probing (BOP). By definitionitisnotassociatedwith purulence or bone loss. However this condition is often asympto- matic to the patient and as such is typically only diagnosed at routine recall. Hence there is a need to recognise that when im- plant treatment is completed the patient should remain on annual reviews for at least the first five years, and thereafter once every two years. On presentation with mucositis a combination of mechanical debridement and sub-mucosal de- contamination and antimicrobial therapy are indicated. The treat- ment should be repeated three times within a two week period, so- called Triple Therapy (Norton M). The protocol is as follows: 1. Mechanical scaling of implant surface with titanium or carbon fibre curettes. 2. Sub-mucosal irrigation with 5–10 ml chlorhexidine (0.2 %) per site, at thedeepestlevelofthepocketon all sides of the implant. 3. Application of Minocycline Gel 2 % (Dentomycin, Henry Schein Ltd) at the deepest level of the pocketonallsidesoftheimplant. However once peri-implant mu- cositis has taken hold it is unfor- tunate that it is often exacerbated by the design of implants today. The presence of a rough surface, taken to the top of an implant, and the application of microthreads or grooves have been proposed as potential confounding factors for the advance of the lesion due to biofilm formation and bacterial contaminationofthesurfacewhich leads to bone loss and further sur- face exposure. With advancing bone loss it often results in coloni- sation of the deeper pockets with well known periodontopathogens and infection ensues. This then is peri-implantitis. Peri-implantitis is characterised bythepresenceofverticalorcrater- like bone defects and spontaneous purulence and bleeding on pal- pation (Figs. 1 & 2). It is typically associated with deep peri-implant pocketing > 5mm. This condition is undoubtedly of increasing concern due to some principle factors, such as the al- most exclusive use of roughened implant surfaces, the treatment of partially dentate patients with a history of periodontal disease, the placement of implants with inadequate bone volume resulting in facial dehiscences, as well as the use of cement retained prostheses. Implants with a micro-rough- ened surface texture have pre- sented excellent long-term data and until recently there has been very little published in the litera- ture demonstrating a susceptibil- ity of these surfaces to this con- dition. However recent work by Albouy et al 15, 16 has received wide- spread attention with concern for the evidence that suggests some modern micro-textured surfaces may be completely resistant to decontamination.16 Ultimately, if left unchecked and untreated,itmaybecomeimpossi- ble to arrest the condition, leading to wholesale failure of the case (Figs. 3 & 4). Such failures impose a tremendous strain and burden on the clinician (let alone the patient), destroying the confidence of a pa- tient who has endured significant expense and trauma and occasion- ally results in a breakdown of com- munication between both parties that all too often sadly results in a legalclaimofnegligence.Suchclaims can be hard to defend for patients where no warnings and/or sup- portive periodontal/peri-implant therapy have been undertaken. Treatment typically requires surgical access to excise any fi- brous capsule and for direct access to the implant for surface deconta- mination. The author’s preference until now has been to use chlor- hexidine and tetracycline solution for this purpose while others have reported the use of citric acid and hydrogen peroxide amongst oth- ers.17 The use of lasers has also been extensively reported.6, 7, 18–20 How- everinarecentsystematicreviewa meta-analysis could only be done for Er:YAG laser as the literature on all other laser types was weak or heterogenous.21 The author has recently com- pletedtheacquisitionandtreatment of 20 patients in an efficacy study using Er:YAG water laser (Morita, AdvErl Evo) and it is hoped that publication of the results will be forthcoming. Indeed promising data has already been published to date using this same machine.22, 23 Nonetheless this methodology remains outside the reach of most generalpractitionersandhasyetto be proven predictably effective. As such most attention therefore re- mainsfocusedonphysicaldebride- ment via surgical intervention and topical antimicrobial therapies. Peri-implantitis: Is it a crisis? By Dr Michael R.Norton,UK 1 3 2 4

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