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20 Revisione della Letteratura Implant Tribune Italian Edition - Marzo 2017 Before PPD > 5 mm as the reference (Fig. 2). A radiographic MBL ≥ 0.5–1 mm, > 1–2 mm, > 3–4 mm and ≥ 5 mm, taking prosthesis delivery as baseline, was considered as defining periimplantitis in 15%, 45%, 35% and 5% of the studies, re- spectively (Fig. 3). As such, it was speculated that a radiographic MBL < 1 mm should be considered as physiological bone remodeling. BOP and/or SUP were prerequisite in all of the analyzed studies. In most of the studies, the combina- tion of clinical and radiographic measurements were used for case definition. In two prospective studies,32,33 the radiographic MBL were not reported, and clinical measurements alone were used to assess biological complications. In these cases, the presence of BOP and/or SUP on probing and PPD ≥ 4 mm were prerequisite for a diagnosis of periimplantitis. In nine studies, one randomized controlled trial,34 three prospec- tive35–37 and five retrospective studies,38–42 BOP and radiograph- ic assessments were performed alone, without reporting any PPD measurements. In these cases, a MBL ranging from 0.5 mm39 to > 4 mm34 was considered to be associated with periimplantitis. 2012, changes in the level of crestal bone were either not defined or not clearly reported, making the diagnosis of periimplantitis difi- cult.6,8,32,33,41,43–49 However, even in studies that de- fined the entity of MBL, diferent diagnostic criteria were used. In one long-term study, periimplan- titis was defined as the presence of BOP, PPD ≥ 4 mm and MBL > 0.5 mm.39 How ever, another study used MBL > 4 mm as a reference value.34 Most of the studies considered MBL > 2 mm for the diagnosis of periimplantitis.36,50–54 Previously, our group used a radiographic MBL > 3 mm, from the baseline radiograph taken at the time of prosthesis delivery, to diagnose periimplantitis.19,55,56 In three other studies, MBL was considered in relation to the time that the prosthesis was in func- tion.35,57,58 All of the studies but five calculated MBL in millime- ters. In the other studies, the im- plant threads were used as refer- ence.36,42,58–60 Eight studies applied PPD > 5 mm for the diagnosis of periimplanti- tis. 43,44,47,53,59,61–63 Marrone et al. defined periim- plantitis as the presence of BOP, PPD > 5 mm and MBL > 2 mm.51 Charalampakis et al. applied the criteria of the presence of BOP and/or SUP, PPD ≥ 5 mm and MBL ≥ 1.8 mm after one year in func- tion.57 Zetterqvist et al. included cases of PPD > 5 mm and MBL ≥ 3 mm.62 Two other studies, one prospec- tive63 and one retrospective,64 ap- plied the presence of BOP and/or SUP, PPD > 5 mm and radiograph- ic signs of MBL, without specify- ing the baseline bone level. Posi- tive BOP and/or SUP, radiographic MBL ≥ 3 mm and PPD ≥ 6 mm were used by Koldsland et al. 47 At the 7th and 8th European Work- shop on Periodontology, periim- plant mucositis and periimplan- titis were described as follows: “Changes in the level of crestal bone, presence of bleeding on probing and/or suppuration; with or without concomitant deepen- ing of peri-implant pockets.”6,8 Periimplant mucositis was de- fined with positive BOP and/or SUP and periimplantitis with pos- itive BOP and/or SUP, in combi- nation with radiographic MBL ≥ 2 mm. The same parameters were used by Zitzmann and Berglundh to define periimplantitis.65 How- ever, Atieh et al. used the same criteria, plus PPD ≥ 5 mm, as the definition of periimplantitis in their systematic review paper. 4 Discussion Periimplant diseases present in two forms: periimplant muco- sitis and periimplantitis.10 Both are characterized by an inflam- matory reaction in the tissue sur- rounding an implant. Periimplant mucositis has been defined as a reversible inflammatory reaction in the soft-tissue surrounding an implant in function, whereas periimplantitis has been defined as a more profound inflamma- tory lesion characterized by a deepened periimplant pocket and loss of supporting bone around a functional implant.10,24 Studies published in early 2010 suggested that mucositis and periimplantitis are equivalent to periodontitis, since both are de- scribed as an imbalance between bacterial load and the host re- sponse.8,25 Based upon this, both diseases are closely related to the formation of a biofilm containing microbiota rich in Gram-negative bacteria in the presence of a susceptible host.66 However, it has been shown that microorganisms may be present, but are not a necessity for periim- plantitis.66 In addition, both periodontitis and periimplantitis share sever- al common systemic risk factors or indicators (e.g., smoking, poor oral hygiene, diabetes or histo- ry of periodontitis, osteoporo- sis).10,64,66,67 Similarly, periimplantitis, as oc- curs with periodontitis, seems to be influenced by a particular genetic profile (i.e., interleukin-1 polymorphism).68 Others have rejected the descrip- tion of a disease comparable to periodontitis, 22,69,70 because of the anatomical diferences that exist between periodontal and periimplant structures (e.g., dif- erent collagen fiber orientation [perpendicular vs. horizontal], vascularity or repair capacity, and the mechanical resilience provided by the periodontal lig- ament).71 > pagina 21 Fig. 1 - PRISMA lowchart of search strategy. < pagina 19 presented Like periodontitis, the etiopatho- genesis of periimplantitis was shown to be triggered by bacteri- al infection that activates a cyto- kine cascade, leading to inflam- matory bone loss.7 “Periimplantitis” became an ac- cepted term in the consensus re- port from the 1st European Work- shop on Periodontology in 1993.26 It has been described as an irre- versible inflammatory destruc- tive reaction around implants in function that results in loss of supporting bone.26 The 6th European Workshop on Periodontology a modified definition, not only to acknowledge that periimplanti- tis is a treatable condition, but also to include the collective term of “periimplant disease” for both periimplant mucositis and periimplantitis.10 In order to improve the quality of research on periimplant diseases, the 7th European Workshop on Periodon- tology recommended the use of unequivocal case definitions: changes in the level of crestal bone and presence of BOP and/ or SUP, with or without concom- itant deepening of periimplant pockets.8 Finally, the American Academy of Periodontology in 2013 defined “periimplantitis” as an inflammatory reaction associ- ated with the loss of supporting bone beyond the initial biological bone remodeling around an im- plant in function.7 The extent and severity of periim- plant diseases have been rarely reported.27,28 Froum and Rosen proposed a combination of BOP and/or SUP, PPD and extent of radiographic MBL around the im- plant to classify periimplantitis into early, moderate or advanced disease categories.28 Likewise, Decker et al. proposed a prognosis system based on the di- agnosis for each category follow- ing the Kwok and Caton prognosis classification for natural denti- tion.27 In their study, the authors stated that PPD, extent of radio- graphic MBL, presence of SUP and implant mobility were found to be the most critical factors for categorizing cases as having a favorable, questionable, unfavor- able or hopeless prognosis.27 Recently, Albrektsson et al. modi- fied the concept of periimplanti- tis as a loss of bone surrounding an implant as a clinically unfa- vorable, disbalanced foreign-body reaction, specifically stating that osseointegration is a process whereby bone reacts to the den- tal implant by forming a calcified structure adjacent to it.22 Indeed, at times, this foreign-body reaction may actually result in osteoclastic activity that may de- stroy the supporting bone.22 The authors believe that the term “periimplantitis” is quite appro- priate, because it is not a prima- ry disease, but a complication of a clinically unfavorable, disbal- anced foreign-body reaction that is the starting point of the patho- logical process and consequent tissue sequelae.22 Currently, as foreseen by the con- sensus of the 7th European Work- shop on Periodontology,8 it is assumed that the infection itself is always caused by plaque and its products; However, numerous risk factors are recognized as be- ing specifically associated with periimplantitis, such as surgical- or prosthetic-related factors,19,20,29 implant characteristics,21 smok- ing30 and host response.30,31 Definition of periimplantitis with clinical and radiographic diagnosis Thirty-one manuscripts (Table 2) were selected and data were ex- tracted. Informations from 1,711 patients with 5,432 implants were analyzed. The term “periimplantitis” has generally been used to describe any implant with varying degrees of bone loss, and a clear defini- tion was either not presented or was extracted directly from the terminology. Four main charac- teristics have been used to define “periimplantitis”. Interestingly, all of the authors consider BOP and SUP as indicators of periim- plantitis. This approach considers pure- ly plaque- and foreign-body-in- duced periimplantitis, where an inflammatory response is often triggered by the biofilm or its products and/or foreign sub- stances, such as residual cement. Moreover, 22 studies clearly re- ported PPD as a crucial parameter for determining periimplantitis. No study considered PPD < 3 mm as indicative of periimplantitis. While the vast majority (64%) of the studies defined PPD = 3–5 mm as indicative of periimplantitis, the remaining 36% considered