As implant placement increases within all dental specialties, it is expected that the number of suboptimal results will increase, as well. The goal of this article is to provide clinicians with an outline of the management of periimplantitis cases, ranging from simple to complex. It will review signs and symptoms, diagnosis, case selection, and armamentarium. In addition, this chapter will discuss basic techniques which can be utilized at various stages to salvage the compromised implant.
Key points
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Increased dental implant placement equates to an increased number of long-term maintenance issues.
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Discussion of methods to avoid short- and long-term issues in relation to dental implants.
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Techniques for management of early, intermediate, and late stage issues that can arise from periimplantitis.
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Algorithm for when to attempt implant repair/salvage versus removal and replacement.
Introduction
Dental implants have been used to replace natural dentition since the 1960s. Branemark discovered that when titanium was implanted into a patient’s bone, it would lead to a process termed “osseointegration.” Gosta Larsson was the recipient of the first dental implant, placed by Branemark himself in 1965. When Larsson died in 2006, several implants were still in function. It can be assumed that he was a motivated patient who was diligent in maintaining his newly acquired dentition for decades. Many of the authors’ medical colleagues wonder how it is possible to implant a foreign body in the oral cavity without the constant risk of infection and rejection. The capacity of surgical grade titanium to promote bony fusion and acceptance is critical in the success of dental implants. The excellent vascularity of the head and neck area and rapid bony/oral epithelial turnover is also paramount. In addition, the constant flow of saliva, with its protective properties, is necessary in maintaining a healthy microbiological environment for the titanium and synthetic fixtures associated with the implant. It has been well established, however, that a significantly smaller amount of bacteria is needed to create inflammation, and subsequently infection, around a dental implant compared with a natural tooth.
Bacteria such as streptococci, lactobacilli, staphylococci, and corynebacteria along with large numbers of anaerobes, such as the bacteroides species, which normally make up the healthy oral flora of most humans, can turn into pathologic entities resulting in acute or chronic infection. The groves, threads, and irregularities, essential in osseointegration, could begin to harbor bacteria and then spill their toxic bioproducts into the periimplant space.
Diagnosis of periimplantitis
Unlike periodontal disease, which is well defined and organized into specific categories, periimplantitis is an ambiguous, and often controversial, term. It is typically used to describe any “less-than-ideal” condition surrounding a dental implant fixture. A survey by J. Thakkar and colleagues from the University of Michigan Department of Oral and Maxillofacial Surgery reported that approximately 62% of respondents considered periimplantitis a serious issue. Furthermore, 50% thought they did not receive sufficient training on this subject matter during residency. Many clinicians believe the most important criteria for a diagnosis of periimplantitis are exposure and gingival recession. Occasionally, a patient may present as asymptomatic with exposed implant threads, yet inflammation is minimal to nonexistent. This is often seen in patients who maintain excellent oral hygiene. Conversely, smokers with poor oral hygiene and a history of periodontal disease are particularly prone to developing periimplant issues.
In a recent article, Tolstunov describes a situation of progressive buccal bone loss, occurring in the anterior maxilla after implant placement. The clinical presentation is blueish in color and with granulation tissues or purulent discharge. In the absence of inflammation, this case does not meet the traditional definition of periimplantitis. Rather, Tolstunov refers to this presentation as “periimplantosis,” a noninflammatory diseased state.
The term periimplant mucositis can be used to describe a compromised implant in its earliest stage. It is often associated with exudate, increased pocket depth, and progressive bone loss. With early intervention, it may be possible to avoid severe bone loss, infection, and mobility leading to implant failure ( Fig. 1 , Table 1 ).
| Type | Subtype |
|---|---|
| Gingival diseases | Dental plaque-induced gingival diseases |
| Non–plaque-induced gingival lesions | |
| Chronic periodontitis (previously adult periodontitis) | Slight (1–2 mm CAL) |
| Moderate (3–4 mm CAL) | |
| Severe (>5 mm CAL) | |
| Localized (<30% of sites involved) | |
| Generalized (>30% of sites involved) | |
| Aggressive periodontitis (previously early onset periodontitis) | Slight (1–2 mm CAL) |
| Moderate (3–4 mm CAL) | |
| Severe (>5 mm CAL) | |
| Localized (<30% of sites involved) | |
| Generalized (>30% of sites involved) | |
| Periodontitis as a manifestation of systemic diseases | Associated with hematological |
| Disorders | |
| Associated with genetic disorders | |
| Not otherwise specified | |
| Necrotizing periodontal diseases | Necrotizing ulcerative gingivitis |
| Necrotizing ulcerative periodontitis | |
| Abscesses of the periodontium | Gingival abscess |
| Periodontal abscess | |
| Pericoronal abscess | |
| Periodontitis associated with endodontic lesions | Combined periodontic-endodontic lesions |
| Developmental or acquired deformities and conditions | Localized tooth-related factors that modify or predispose to plaque-induced gingival diseases/periodontitis |
| Mucogingival deformities/conditions around teeth | |
| Mucogingival deformities/conditions on edentulous ridges |
Contributing factors
Keratinized Tissue
The role of keratinized tissue, in relation to both natural dentition and dental implants, is a controversial topic among clinicians and the absolute necessity is still unknown. This type of tissue tends to be more resistant to abrasion and more resilient when considering its susceptibility to gingival recession. In many cases, its presence results in decreased probing depths and less plaque accumulation, which limits bacterial penetration into the periimplant space. Additional benefits include easier cleansability and increased patient comfort. Alternatively, there are several studies that confirm implant success in regions with little to no keratinized tissue. , , Therefore, it can be concluded that an implant with healthy keratinized tissue is preferable. Those without are not guaranteed to become compromised but it is more likely and even more diligent home care is required.
Implant Surface
A rough, hydroxyapatite-coated implant surface, combined with an absence of keratinized gingiva, has been associated with periimplantitis and subsequent bone loss. An insufficient amount of attached tissue leaves the rough surface exposed, increasing the chances of implant failure. , A meta-analysis by Esposito and colleagues revealed 20% fewer cases of periimplant complications among implants with smooth surfaces compared with those with rough surfaces.
Implant Location
It has been well established that posterior implants experience greater bone loss than their anteriorly placed counterparts. The difference amounts to 3.5 times more bone loss in the posterior, with these implants losing approximately 0.14 mm of bone annually. Conversely, anterior implants only lose 0.04 mm of bone on average. In addition, the amount of keratinized tissue more profoundly affects implants in the posterior in terms of soft tissue health.
Restorative Factors
Prosthetic design can play a significant role in both the short- and long-term health of an implant. Home care can prove to be challenging, even for patients with excellent oral hygiene, if the restoration is poorly designed. Bulky crowns and nonhygienic embrasures, for example, are extremely difficult to maintain. The crown-to-implant ratio must also be considered when treatment planning in order to avoid excessive occlusal and lateral forces. Clinicians should reevaluate the occlusal scheme and consider the placement of additional implants to decrease the occlusal loading if the fixture becomes compromised. The progression from periimplant mucositis to periimplantitis and to eventual implant failure is more gradual in cases with these unfavorable restorations. If recognized early, interventions to impede the periimplant disease process can be initiated ( Figs. 2–4 ).
Alcohol
The relationship between alcohol and periimplantitis was investigated by Carr and colleagues. He concluded that mild to moderate consumption led to fewer occurrences of periimplantitis (12% and 6%, respectively) than heavy consumption, which resulted in 42% of cases. Based on this study, it was presumed that mild to moderate alcohol consumption decreases inflammatory markers, leading to improved overall periimplant health. The investigators could not determine why heavy consumption of alcohol led to a nearly 3-fold increase in the rate of periimplantitis. Since the data were inconclusive, it remains uncertain whether a topical application of alcohol would be beneficial or if the improved periimplant environment was a systemic effect.
Prevention of periimplantitis
Education and Home Care
Implant candidate selection and patient education are paramount in the long-term success of the final restoration. Establishing realistic expectations with the patient before initiating implant therapy is extremely important. It must be made clear that health and maintenance of an implant is distinctly different from that of a natural tooth. For example, removal of supragingival plaque is even more critical in maintaining an implant. Oral hygiene instructions, including various brushing techniques, should be emphasized and demonstrated by the clinician. Certain anatomic presentations must also be taken into consideration. Posterior implants frequently lack adequate keratinized, which can make oral hygiene challenging for the patient. If this is the case, a pulsatile oral irrigation device should be provided. The patient must be instructed to use the lowest setting possible to removal all supragingival debris. The goal of this device is to decrease bacterial burden rather than remove intrasulcular calculus, which can be accomplished during hygiene visits.
In-Office Implant Maintenance
The hygiene team must understand the armamentarium and techniques necessary in maintaining dental implants. Instruments used in routine care, such as ultrasonic and metallic scalers, should be avoided as they have been proved to damage the delicate implant surface. Any imperfections created can promote bacterial growth, which subsequently results in periimplantitis, bone loss, and possible implant failure. Alternatively, ultrasonic scalers with plastic sleeves or nonmetallic tips are preferred for implant maintenance. Hand instruments made of graphite, nylon, or plastic, along with those coated in Teflon are also recommended. In addition, titanium curettes are appropriate for scaling, and the implant can be polished with a rubber cup and pumice. A smooth, flawless implant surface is important in the prevention of plaque accumulation and periimplant bacterial colonization.
In the case of the patient with clinically evident perimucositis, without associated bone loss, a deep pseudopocket often exists. Typically, the tissue is flaccid with poor tone, allowing food and plaque to collect along the implant surface. Unlike a healthy implant, which requires gentle maintenance, these pockets require a deeper, more extensive debridement, similar to scaling and root planing, with the instrumentation listed earlier. Once the deposits are removed, the desired outcomes are increased tissue tone, decreased bacterial burden, and elimination of a passage in which bacteria can accumulate. In some instances, however, tissue redundancy recurs and must be treated through surgical methods, such as gingivectomy or gingivoplasty ( Fig. 5 ).
