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today EAO Stockholm 24 September 2015

science & practice8 EAO Annual Scientific Congress 2015 · 24 September In the US over 500,000 implants are placed each year, whilst in the UKthatfigurewasaround140,000 for2010.Theprevalenceofperi-im- plantitishasbeenreportedtobeup to 29 per cent1 most notably in pa- tients 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 succumb to some form of peri-implant disease on an an- nual basis. The bacteria found within peri- implantlesionsaresimilartothose found in deeper periodontal pock- ets,2, 3 and cross infection by peri- odontopathogensasaprimaryaeti- ology has been implicated as a pos- sible pathway. However the wide variety of implant designs, sur- faces etc. make the treatment of peri-implantitis much less pre- dictable and subject to much greater variability than periodon- tal disease, where natural teeth presentaknownanatomyandwell 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 ther- apies, while the second concluded that the laser effect was limited to asixmonthperiod.Afurtherstudy compared combinations of oral hygiene instruction, mechanical debridement and topical minocy- cline with a similar regime which substituted 0.1 % chlorhexidine as the antimicrobial.8 The former seemed to confer some benefit while the latter showed limited or no clinical improvements. Finally, astudycomparingtwoboneregen- eration procedures reported clini- cally significant improvements mediated by both.9 Nonetheless a multitude of other studies have also been published reporting on the effi- cacy of tetracycline10 , CO2 laser11 , and photocatalytic decontamina- tion amongst others in the treat- ment of peri-implantitis.12 Such a plethoraoftherapiesmakesitdiffi- cultforthecliniciantochooseareg- imen that is both within the reach of the average clinician and has some documented reliability. Risk factors There have been a number of risk factors cited for peri-implanti- tis.Recently,inastudypublishedin the Journal of Clinical Periodontol- ogy,aclearassociationwasdemon- strated through multi-level statisti- cal 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 citedriskfactorinmanyotherstud- ies. Indeed in a study published in the Swedish Dental Journal in 2010, the percentage of implants with peri-implantitis was significantly increasedforsmokerscomparedto non-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-implantitis rarely presents unannounced unless of course the patient fails to be placed on a regu- lar recall programme or fails to at- tend for regular review. Early signs are often apparent in the form of peri-implant mucositis. This condi- tion is characterised by mucosal oedema, rubor and bleeding on probing(BOP).Bydefinitionitisnot associated with purulence or bone loss.Howeverthisconditionisoften asymptomatic to the patient and as such is typically only diagnosed at routinerecall.Hencethereisaneed to recognise that when implant 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 timeswithinatwoweekperiod,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 the deepest level of the pocket on all sides of the im- plant. 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 bythedesignofimplantstoday.The presence of a rough surface, taken to the top of an implant, and the application of microthreads or grooves have been proposed as po- tential confounding factors for the advanceofthelesionduetobiofilm formationandbacterialcontamina- tion of the surface which leads to bone loss and further surface expo- sure.Withadvancingbonelossitof- ten results in colonisation of the deeperpocketswithwellknownpe- riodontopathogens and infection ensues.Thisthenisperi-implantitis. Peri-implantitis is charac- terised by the presence of vertical or crater-like bone defects and spontaneous purulence and bleed- ing on palpation (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 inade- quate bone volume resulting in fa- cial 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 al15, 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,ifleftuncheckedand untreated, it may become impossi- 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 thatalltoooftensadlyresultsinale- galclaimofnegligence.Suchclaims can be hard to defend for patients wherenowarningsand/orsupport- ive periodontal/peri-implant ther- apy have been undertaken. Treatment typically requires surgical access to excise any fi- brouscapsuleandfordirectaccess Peri-implantitis:Is it a crisis? By Dr Michael R.Norton,UK 1 2 3 4 DrMichaelNortonrunsapracticededicated to implant & reconstructive dentistry in Lon- don in the UK. This afternoon, he will mode- rate a satellite industry symposium on cur- rent strategies for limited bone situations sponsored by DENTSPLY Implants. 12 34

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