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Dental Tribune Italian Edition

28 Speciale Perio Tribune Italian Edition - Ottobre 2015 < pagina 25 The prevalence of peri-implanti- tis has been reported to be up 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-implant lesions are similar to those found in deeper periodontal pockets2,3 and cross infection by periodontopathogens as a primary aetiology has been implicated as a possible pathway. However the wide variety of im- plant designs, surfaces etc. make the treatment of peri-implantitis much less predictable and sub- ject to much greater variability than periodontal 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 effica- cy of submucosal debridement us- ing ultrasonics or carbon fibre cu- rettes5 , while two others compared the effect of an Er:YAG laser against that of mechanical debridement and 2% chlorhexidine as a com- bined therapy6,7 . The first found similar results between laser and combined therapies, while the sec- ond concluded that the laser effect was limited to a six month period. A further study compared combi- nations of oral hygiene instruc- tion, mechanical debridement and topical minocycline with a similar regime which substitut- ed 0,1% chlorhexidine as the an- timicrobial8 . The former seemed to confer some benefit while the latter showed limited or no clini- cal improvements. Finally, a study comparing two bone regeneration procedures reported clinically sig- nificant 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-implantitis12 . Such a plethora of therapies makes it dif- ficult for the clinician to choose a regimen 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-implantitis. Recently, in a study published in the Journal of Clinical Periodon- tology, a clear association was demonstrated through multi-lev- el statistical analysis between risk of peri-implantitis and lo- cation, specifically the maxilla, while overt peri-implantitis was shown to be highly correlated to patients with a predisposing his- tory of periodontitis, and being male13 . Surprisingly in this par- ticular study no correlation was demonstrated with smoking, yet this has been a consistently cited risk factor in many other studies. Indeed in a study published in the Swedish Dental Journal in 2010, the percentage of implants with peri-implantitis was significantly increased for smokers compared to 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 interrelated with some prostheses making ef- fective oral hygiene untenable, while others present deep margins that make removal of excess ce- ment 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 con- dition is characterised by mucosal oedema, rubor and bleeding on probing (BOP). By definition it is not associated with purulence or bone loss. However this condition is often asymptomatic to the pa- tient and as such is typically only diagnosed at routine recall. Hence there is a need to recognise that when implant treatment is com- pleted the patient should remain on annual reviews for at least the first five years, and thereafter once every two years. On presenta- tion with mucositis a combina- tion of mechanical debridement and submucosal decontamination and antimicrobial therapy are in- dicated. The treatment should be repeated three times within a two week period, so called Triple Ther- apy (Norton M). The protocol is as follows: 1. mechanical scaling of implant surface with titanium or car- bon 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 implant. 3. Application of Minocycline Gel 2 % (Dentomycin, Henry Schein Ltd) at the deepest level of the po- cket on all sides of the implant. 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 po- tential confounding factors for the advance of the lesion due to biofilm formation and bacterial contami- nation of the surface which leads to bone loss and further surface ex- posure. With advancing bone loss it often results in colonisation of the deeper pockets with well known periodontopathogens and infection ensues. This then is peri-implan- titis. Peri-implantitis is character- ised by the presence of vertical or craterlike bone defects and sponta- neous purulence and bleeding 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 almost 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 dehis- cences, as well as the use of cement retained prostheses. Implants with a micro-roughened surface tex- ture have presented excellent long term data and until recently there has been very little published in the literature demonstrating a sus- ceptibility of these surfaces to this condition. 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 de- contamination16 . Ultimately, if left unchecked and untreated, it may become impossi- ble to arrest the condition, leading to wholesale failure of the case (Figs. 3 & 4). Such failures impose a tre- mendous strain and burden on the clinician (let alone the patient), de- stroying the confidence of a patient who has endured significant ex- pense and trauma and occasionally results in a breakdown of commu- nication between both parties that all too often sadly results in a legal claim of negligence. Such claims can be hard to defend for patients where no warnings and/or support- ive periodontal/peri-implant ther- apy have been undertaken. Treat- ment typically requires surgical access to excise any fibrous capsule and for direct access to the implant for surface decontamination. > pagina 29 Dr. Michael R. Norton Figg. 1-4 Peri-implantitis: is it a crisis?

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