2.1Statements and Recommendations Obtained from the 4th and 5th ITI Consensus Conferences

2.1.1Proceedings of the 4th ITI Consensus Conference 2008

International Journal of Oral and Maxillofacial Implants 2009, Vol. 24 (Supplement): Consensus statements and recommended clinical procedures regarding risk factors in implant therapy (Cochran and coworkers 2009)

Introductory remarks

The group was asked to address the available evidence for potential risk factors in implant therapy. The authors were requested to prepare narrative reviews using a systematic approach, and were provided with general topics rather than specific research questions. The four reviews presented for discussion within the group addressed: (1) systemic conditions and treatments as risks for implant therapy, (2) history of treated periodontitis and smoking as risks for implant therapy, (3) mechanical and technical risks in implant therapy, and (4) local risk factors for implant therapy. The group’s participants critically reviewed each of the review papers produced by its members, and amendments were made following thorough discussion.

Systemic conditions and treatments

Clinical recommendations

With respect to systemic conditions and treatments as risk factors for implant therapy, the following recommendations can be made:

•A thorough medical history is essential to identify potential systemic risks.

•Risks for implant failure and risks for medical complications should be differentiated and evaluated. In some instances, conditions and their treatments may pose increased risks for implant failure, whereas the risk for the patient may be minimal. As an example, there are no data to support withholding implant treatment for patients with diabetes or osteoporosis. However, these patients need to be informed of the possibility of implant complications.

•Where there is a potential risk of a medical complication—for example, osteonecrosis of the jaw in patients taking oral bisphosphonates and patients undergoing radiotherapy—the option of implant therapy should be chosen restrictively, and the patient should be informed specifically, taking into account the current level of uncertainty with regard to the consequences. For patients with a life-threatening systemic disease, implant placement should be postponed until the patient’s medical condition is stabilized and has improved.

History of treated periodontitis and smoking

Clinical recommendations

With respect to a history of treated periodontitis and smoking, the following recommendations can be made:

•History of treated periodontitis. A history of treated periodontitis is not a contraindication for implant placement. However, patients with a history of treated periodontitis should be informed of an increased risk of implant failure and peri-implantitis. Patients with a history of periodontitis should receive individualized periodontal maintenance and regular monitoring of peri-implant tissue conditions.

•Smoking. Smoking is not a contraindication for implant placement. However, patients should be informed that the survival and success rates are lower in smokers. Heavy smokers should be informed that they are at greater risk of implant failure and loss of marginal bone. Patients who smoke should be informed that there is an increased risk of implant failure when sinus augmentation procedures are used.

•History of treated periodontitis and smoking combined. Patients who smoke and have a history of treated periodontitis should be informed that they have an increased risk of implant failure and peri-implant bone loss.

Mechanical and technical risks

Clinical recommendations

With respect to mechanical/technical risks, the following recommendations can be made:

•In general, implant reconstructions should be planned to minimize mechanical/technical risks.

•Patients receiving implant therapy should receive regular maintenance care in order to detect mechanical/technical complications early, particularly in patients with overdentures.

•Both cemented and screw-retained implant-supported reconstructions can be recommended.

•Patients should be evaluated for bruxism.

Local risk factors

Clinical recommendations

With respect to local risk factors, the following recommendation can be made:

•Special care should be taken in selection of implant diameter and design in areas with limited interdental space.

2.1.2Proceedings of the 5th ITI Consensus Conference 2013

International Journal of Oral and Maxillofacial Implants 2014, Vol. 29 (Supplement): Consensus statements and clinical recommendations for prevention and management of biologic and technical implant complications (Heitz-Mayfield and coworkers 2014)

Introductory remarks

Implant treatment is highly successful, as documented in a wealth of scientific literature. However, patients and clinicians should expect to see complications within their daily practice. The aim of the papers presented by this group was to address the prevention and management of technical and biologic complications in order to make recommendations both for clinical practice and future research. Three topics were chosen within the field of complications of implant treatment, and these addressed prevention and therapy of peri-implant disease and prevention of technical complications.

Three systematic reviews were conducted and formed the basis for discussion of working group 5. The discussions led to the development of statements and recommendations determined by group consensus based on the findings of the systematic reviews. These were then presented and accepted following modifications as necessary at plenary sessions.

Effects of anti-infective preventive measures on biologic implant complications and implant loss

Consensus statements

The aim of the review by Salvi and Zitzmann (2014) was to systematically appraise whether anti-infective protocols are effective in preventing biologic implant complications and implant loss after a mean observation period of at least ten years following delivery of the prosthesis. Out of fifteen included studies, only one comparative study assessed the effects of adherence to supportive periodontal therapy (SPT) on the occurrence of biological complications and implant loss. In view of the lack of randomized trails, observational studies including adherence and lack of adherence to SPT were considered valuable in order to estimate the effects of SPT on implant longevity and the occurrence of biological complications.

•Overall, the outcomes of this systematic review indicated that high long-term survival and success rates of dental implants can be achieved in partially and fully edentulous patients adhering to supportive periodontal therapy (SPT).

•Long-term implant survival and success rates are lower in patients with a history of periodontal disease adhering to SPT compared with those without a history of periodontal disease.

•The findings of this systematic review indicate that pre-existing peri-implant mucositis in conjunction with lack of adherence to SPT was associated with a higher incidence of peri-implantitis.

Treatment guidelines

Preventive measures before implant placement

•Residual periodontal pockets are a risk for peri-implant disease and implant loss. Therefore, completion of active periodontal therapy aiming for elimination of residual pockets with bleeding on probing should precede implant placement in periodontally compromised patients.

•In cases of residual probing depths (PD) ≥ 5 mm with concomitant bleeding on probing, full-mouth plaque scores > 20%, and associated risk factors, re-treatment and periodontal reevaluation are recommended before implant placement.

•In subjects diagnosed with aggressive periodontitis, an SPT program with shorter intervals is a prerequisite.

•During implant treatment planning, factors to be considered that may result in biological complications include: insufficient keratinized mucosa and bone volume at the implant recipient site, implant proximity, three-dimensional implant position, and design and cleansability of the prosthesis. Alternative restorative solutions should be considered according to a patient’s individual circumstances.

Preventive measures after implant placement

•All oral healthcare providers, including undergraduate students, should be trained to recognize clinical signs of peri-implant pathology and maintain or reestablish peri-implant health.

•After delivery of the definitive implant-supported prosthesis, clinical and radiographic baseline measurements should be established.

•During SPT, an update of medical and dental history and a clinical inspection of the implant-supported prosthesis including the evaluation of iatrogenic factors (e.g. cement remnants, misfit of prosthesis, implant proximity with insufficient access for interproximal oral hygiene) should constitute the basis of a proper diagnostic process.

•Regular diagnostic monitoring of the peri-implant tissues includes assessment of presence of plaque, probing depth (PD), bleeding on gentle probing (approx. 0.25 N), and/or suppuration.

•Changes in PD from a fixed landmark should be assessed regularly and compared to previous examinations.

•In the presence of clinical signs of disease, an appropriate radiograph is indicated in order to detect radiographic bone-level changes compared to previous examinations.

•A diagnosis of peri-implant health is given in the absence of clinical signs of inflammation. A recall frequency of at least once per year is recommended unless systemic and/or local conditions require more frequent intervals. In cases of peri-implant health, professional cleaning including reinforcement of self-performed oral hygiene is recommended as a preventive measure.

•A diagnosis of peri-implant mucositis is given in the presence of individual clinical signs of soft tissue inflammation (e.g. redness, edema, suppuration) and bleeding on gentle probing. If mucositis is diagnosed, in addition to reinforcement of self-performed oral hygiene, mechanical debridement with or without antiseptics (e.g. chlorhexidine) is delivered. The use of systemic antibiotics for the treatment of peri-implant mucositis is not justified. Therapy of peri-implant mucositis should be considered as a preventive measure for the onset of peri-implantitis.

•A diagnosis of peri-implantitis is given in the presence of mucositis in conjunction with progressive crestal bone loss. When peri-implantitis is diagnosed, early implementation of appropriate therapy is recommended to prevent further progression of the disease.

Therapy of peri-implantitis

Consensus statements

The focused question for the review by Heitz-Mayfield and Mombelli (2014) was: In patients with osseointegrated implants diagnosed with peri-implantitis, how successful is treatment aimed at resolution of the disease?

Currently, there is no standard of care for treating peri-implantitis. Various clinical protocols for treating peri-implantitis have been proposed, including mechanical debridement, the use of antiseptics and local and systemic antibiotics, as well as surgical and regenerative procedures. In view of the lack of comparable randomized controlled trials (RCTs), this review has taken a broader approach to capture as many relevant studies as possible, including randomized and observational studies, but with consideration to the strengths and limitations of the included research.

The ideal goal of the treatment of peri-implantitis would be the resolution of disease, i.e. no suppuration or bleeding on probing, no further bone loss, and the re-establishment and maintenance of healthy peri-implant tissues. A composite outcome to reflect this would include absence of peri-implant PD ≥ 5 mm with concomitant bleeding on probing and no suppuration, in addition to no further bone loss. If these criteria are met, it can be assumed that no further intervention other than nonsurgical maintenance care would be required, and the treatment outcome would therefore be regarded as successful. Unfortunately these data were rarely reported in the literature and therefore a compromise composite criterion for successful treatment outcome was employed, i.e. implant survival with mean PD < 5 mm and no further bone loss. Although there is no consensus in the literature on whether a 5-mm peri-implant PD alone represents health or disease, this threshold was adopted for the purposes of the review. This review was based on 33 studies reported in 43 papers including case-series of at least 5 patients treated with the same protocol and comparative studies. No studies were found comparing surgical and nonsurgical protocols. Based on this literature, the following conclusions were drawn:

1.The case definition of peri-implantitis remains unclear and varies substantially between studies.

2.There is a great variety of treatment protocols for both nonsurgical and surgical treatment.

a.Nonsurgical therapy included: debridement with hand and powered instruments, air-powder abrasive devices, laser treatment, and local and systemic antimicrobial agents.

b.Surgical therapy included: elevation of a mucoperiosteal flap and removal of granulation tissue to gain access to the implant and defect surfaces, decontamination of the implant surface (various techniques) with or without implant surface modification. Some studies also evaluated resective therapy or a variety of regenerative procedures. The majority of the studies employed systemic antimicrobial administration.

3.The following elements are common to most protocols for peri-implantitis therapy:

a.Pretreatment phase including establishment of good oral hygiene.

b.Anti-infective treatment including implant surface cleaning achieved by nonsurgical/surgical access.

c.Supportive maintenance care.

4.The available evidence does not allow recommendation of specific treatment options for peri-implantitis. However, improvement of clinical parameters was reported for the majority of patients, although complete resolution according to a composite success criterion was not usually achieved for all patients. Favorable short-term outcomes were reported in many studies; however, lack of disease resolution as well as progression or recurrence of disease and implant loss, despite treatment, were also reported.

5.Interpretation of the results of studies is complicated by unclear or high risk of bias, heterogeneity of study design, and difficulty of generalizing outcomes to practice settings due to frequent exclusion of patients who smoke, those with poorly controlled diabetes, and other conditions that may affect clinical outcomes.

6.There are no data investigating patient-reported outcomes and economic analysis of therapy.

7.Peri-implantitis therapy was associated with soft-tissue recession, which was most evident following surgical treatment. Postsurgery complications including membrane exposure and infection were also reported.

Treatment guidelines

1.As peri-implantitis is an infection associated with the presence of a submucosal bacterial biofilm around implants, the primary goal of therapy must be the resolution of the infection, which is achieved by the disruption of the biofilm, the removal of calculus and/or overhanging restoration margins, and the prevention of recurrence of the disease.

2.