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24 Dental Tribune Middle East & Africa Edition | January-February 2016 implant Tribune > Page 25 Evaluation of dental implant therapy – peri-implantitis By Dr. Olivier Carcuac, UAE P eri-implantitis is one of the most common com- plications affecting pa- tients with dental implants. The condition is characterised by an inflammation in peri- implant soft tissue and loss of supporting bone. Despite several similarities in clinical features with its counterpart at teeth, the disease progres- sion of peri-implantitis is faster than that of periodontitis. Peri- implant mucositis is the pre- cursor to peri-implantitis as is gingivitis to periodontitis. Clinical and experimental studies demonstrated that peri-implant mucositis and gingivitis lesions are similar in size and cell composition (Lang et al 2011). Both lesions may progress and thereby in- fluence supporting tissues at teeth and implants. Estab- lished peri-implantitis lesions exhibit critical histopatho- logical differences when com- pared to periodontitis lesions (Berglundh et al 2011). Pre- clinical in vivo studies com- paring the two lesions have used experimental techniques to induce periodontitis and peri-implantitis. In one such study, Carcuac et al (2013) demonstrated that disease progression differed at teeth and implants over a six-month period. Bone loss was more pronounced at implants with modified surfaces compared to teeth and implants with non- modified surfaces. Histologi- cal analysis also demonstrated that periodontitis lesions were well contained and separated from the alveolar bone by a zone of non-inflamed connec- tive tissue, while a similar bor- der between the lesion and the supporting bone was absent in peri-implantitis sites (Figure 1). In addition, the most api- cal part of the peri-implantitis lesion was open towards the biofilm in the pocket, as the pocket epithelium only cov- ered about 60-70 % of the le- sion. The lateral and apical portions of the peri-implantitis lesion extended to the bone crest, the surface of which was lined with osteoclasts. The histopathological discrepan- cies between the two types of lesions may be explained by the structural differences in the supporting tissues at teeth and implants. In a comprehen- sive study based on human soft tissue biopsies obtained from 40 patients with severe periodontitis and 40 patients suffering from severe peri- implantitis, Carcuac et Ber- glundh (2014) reported further differences between periodon- titis and peri-implantitis le- sions. In contrast to periodon- titis samples, peri-implantitis lesions were more than twice as large and contained sig- nificantly larger area propor- tions, numbers, and densities of macrophages, plasma cells and neutrophil granulocytes than periodontitis lesions (Fig- ure 2). These findings indicate a more severe disease charac- ter for peri-implantitis, which may, in part, explain the high- er rate of progression. Peri-implantitis is diagnosed, as is periodontitis, in the pres- ence of bleeding on probing and loss of supporting tissues. The discussion regarding the diagnosis of peri-implantitis usually focused on radio- graphic thresholds of bone loss. In this context, recom- mendations for clinical re- search and diagnostic guide- lines for everyday clinical Figure 1: Buccal-lingual ground section from a tooth site exhibiting periodontitis (a) and from an implant site exhibiting peri-implantitis (b). Note the large inflammatory process in the connec- tive tissue and an extensive osseous defect around the implant, an ulcerated pocket epithelium, which lined the inflamed part of the mucosa toward the pocket compartment, and a large area of biofilm and calculus, which occupied the implant surface. Figure 2: Sections prepared from periodontitis and peri-implanti- tis sites. Pocket area located to the left. Plasma cell, macrophages and neutrophils granulocytes markers. Magnification x25 and x400. Note that the estimated total number of inflammatory cells within the lesion is significantly larger in peri-implantitis than in periodontitis sections. Note also that the numbers and density of Plasma cell, macrophages and neutrophils granulocytes are sig- nificantly larger in peri-implantitis than in periodontitis lesions.