Dental Tribune Middle East & Africa Edition | 5/2019 IMPLANT TRIBUNE C3 Prevention 0: The best way to prevent peri-implant disease? Figs. 1a & b: Implant in position #14 affected by peri-implantitis: peri-implant probing a) with the prosthetic crown in situ and b) after prosthetic crown removal. Fig. 2: Radiographic examination of the implant Fig. 3: Excess resin cement around the implant. By Prof. Magda Mensi, Timothy Ives & Dr Gianluca Garzetti, Italy The philosophy of prevention in all medical professions is increasing from a global perspective. In fact, prevention of chronic non-commu- nicable diseases, the major burden of illness and disability in almost all countries in the world, has been strengthened in recent years.1 The motivation is to ensure a better qual- ity of life for people and to reduce public health expenditures. In dentistry, periodontitis is one of the major chronic non-communica- ble diseases. World experts in peri- odontics and science have published several principles regarding the pre- vention of periodontal diseases.2 by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone.3 The main reasons for concerns in this area are an aetiology in which several risk factors can play a determining role4 and a lack of a gold standard therapy. Primary and secondary preventative measures are really important to prevent mucositis and peri-implantitis and to avoid recur- rences, but there are many details to consider before placing implants to mitigate iatrogenic problems. There are many different prosthetic solu- tions besides implants that dental professionals could propose to pa- tients if consideration is given from the beginning to the entire situation. Implants may not always be in the best interest of the patient. Peri-implantitis is a twenty-first- century version of periodontitis and increasing in occurrence as implant placement is increasing (Figs. 1–3). Like periodontitis, it is a biofilm-as- sociated pathological condition, but instead of affecting periodontal liga- ments and bone, it is characterised For these reasons, every clinician, before placing an implant, should consider not only patient- and site- specific aspects, but also surgeon, prosthodontist, dental hygienist and dental technician skills in order to minimise the possibility of peri- implantitis in the future. The following should be considered before primary and secondary pre- vention, and it is the proposal of the au- thors that this approach be called “Prevention 0”. Patient-specific considerations When deciding to rehabilitate a pa- tient with dental implants, before surgical planning, we have to careful- ly inform the patient about the char- acteristics of this procedure. It is im- portant to underline that personal daily maintenance at home and ap- propriate compliance regarding fol- low-up controls and dental hygiene therapies are effective preventative measures.5 Procedure awareness and compliance are the foundation for success, but the clinician must also inform the patient about the impact of systemic disorders (osteogenesis imperfecta, ectodermal dysplasia, diabetes), medications (bisphos pho- nates), therapies (radiotherapy in the jawbone), habits (smoking, poor bio- film control) and a history of aggres- sive periodontitis6 as being relevant risk factors for peri-implant disease.7 Site-specific considerations The healing process after tooth loss leads to a variable reduction of the alveolar process, inducing hard- and soft-tissue deficiencies. The clini- cian must evaluate carefully all sites exposed to the following factors, because they have the potential for major healing deficiencies: loss of periodontal support, endodontic in- fections, longitudinal root fractures, thin buccal bone plates, buccal/ lingual tooth position in relation to the arch, extraction with additional trauma to the tissue, injury, pneu- matisation of the maxillary sinus, medications and systemic diseases reducing the amount of naturally formed bone, agenesis of teeth and pressure from soft-tissue-supported removable prostheses. Other site considerations relate to anatomical knowledge and in respect to the suitable anatomical structure of the area (maxillary sinus, inferior alveolar nerve), endodontic and peri- odontal health of adjacent teeth, and patient phenotype. According to Linkevicius et al. there is significant evidence that thin soft tissue leads to increased marginal bone loss com- pared with thick soft tissue around implants.3,8 Lack of bone has led to the development of various alter- native surgical techniques to avoid large bone regenerations or grafts, such as short implants, tilted im- plants, pterygoid implants and pala- tal implant mesh, with questionable results, but definitely decreasing the cleanability and maintainability of implants and prostheses. Dental hygienist skills and devices This professional figure plays a key role in disease prevention and oral health promotion.9 Dental hygien- ists should not limit their activities to being an oral cleaner, but act as the patient’s dental coach or person- al oral trainer, motivating patients not only in dental habits but also in lifestyle, for example regarding smoking cessation and diet. This is ÿPage C4 Figs. 4a–c: Peri-implant home care with a) AirFloss (Philips), b) X-Floss (ROEN) and c) interdental brush (TePe). Figs. 5a–c: Professional peri-implant biofilm removal by a) AIRFLOW with erythritol powder (PLUS powder, EMS), b) PERIOFLOW with PLUS powder and c) with PEEK tip (PI, EMS).