Clie Ora imp Res 1994: 8: 254-259, Copyright © Munksgaerd 1996 CLINICAL ORAL. IMPLANTS RESEARCH Experimentally induced peri-implant mucositis A clinical study in humans Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP. Experimentally induced peri-implant mucositis. A clinical study in humans. Clin Oral Impl Res 1994: 5: 254-259, © Munksgaard, 1994 ‘The purpose of this study was to compare the clinical and microbiological (microscopic) parameters during the development of experimental gingigiv- itis and experimental peri-implant mucositis. Twenty partially edentulous patients were treated for moderate to advanced periodontal disease. Fol- lowing active periodontal therapy consisting of motivation, instruction in oral hygiene practices, scaling and root planing and periodontal surgery where indicated, IMZ oral implants were incorporated in posterior eden- tulous areas. After 3 months of healing, the prosthetic abutments were connected, and the patients were closely supervised for another 2 months of healing, At this time, baseline data were obtained. Re-examinations were scheduled at 3 and 6 months. Following this, the patients were asked to refrain from oral hygiene practices for 3 weeks. At all examinations including the end of the period of no oral hygiene, the following clinical parameters were obtained: Plaque Index, Gingival Index and Sulcus Bleed- ing Index, all modified by Mombelli et al. (1987), probing pocket depths and recession in mm. Furthermore, submucosal/subgingival plaque samples were obtained and analyzed using phase contrast microscopy. At the end of the 3-week period of plaque accumulation, optimal oral hy- giene was reinstituted. There were no statistically significant differences between the mean values of all parameters at implant compared to tooth sites at any observation periods. The period of no oral hygiene demon- strated a similar cause-effect relationship between the accumulation of bacterial plaque and the development of peri-implant mucositis as estab- lished for the gingival units by the experimental gingivitis model. R. Pontoriero, M. P. Tonelli, G. Camevale, A. Mombelli, S.R. Nyman, N. P. Lang University of Bere, Schoo! of Dental Medicine, Switzeriand Key words: implant ~ plaque ~ gingivitis ~ mucositis ~ bacterial morphotype Prof. Dr. Nklaus P Lang, University of Bere, School of Dental Medicine, Freiburgstrasse 7, CH-3010 Bors, Switzerand Accepted for publication 8 May 1904 Three decades ago, convincing evidence was pre- sented demonstrating that the accumulation of bacterial plaque at the dentogingival junction re- sulted in gingival inflammation (Lée et al. 1965). A true cause-effect relationship was presented in young dental student volunteers between a 3-week period of no oral hygiene, resulting in massive plaque accumulation and the subsequent develop- ment of gingivitis. Conversely, the reinstitution of optimal oral hygiene resulted in the re-establish ment of gingival health. Therefore, this experimen- tal gingivitis model forms the basis for prevention 254 of periodontal disease and successful periodontal therapy. Later, it was also demonstrated in animal studies that undisturbed plaque accumulation for a prolonged period of time may result in loss of attachment and alveolar bone (Lindhe et al. 1973. 1975). When endosseous implants are incorporated into oral tissues, a tight supracrestal mucosal tissue collar appears to seal off the oral environment from the tissues subjacent to the epithelial lining (Listgarten et al. 1991). It is reasonable to assumethat the body's host response will cope with bac- terial products originating from plaque accumu- lation in this mucosal tissue in a similar mode as the inflammatory response encountered in the gin- gival tissues. In fact, it has recently been shown in experimental animals (Berglundh et al. 1992) that de novo plaque formation on teeth and titanium implants provoked the establishment of an in- flammatory infiltrate of similar size in both mu- cosal regions. Human biopsies have also revealed the production of the same inflammatory me- diators in gingival and peri-implant mucosal tissues as a sequela of bacterial plaque accumu- lation (Schmid et al. 1992: Tonetti & Schmid 1994; Tonetti et al. 1994) Even though the development of plaque-induced gingivitis in humans has been extensively studied, little is known about the development of a plaque- induced inflammation of the peri-implant mucosal tissues in humans. The purpose of this study was to compare the clinical and microbiological (microscopic) par- ameters during the development of experimental \givitis and experimental peri-implant mucositis 6 months following implant installation in humans. Material and methods ‘Twenty healthy. partially edentulous patients in the age range of 36-59 years were recruited from a pri- vate specialist center and treated for moderately advanced periodontal disease in the mandibular anterior and premolar regions. Periodontal treat- ment included motivation and instruction for proper oral hygiene practices, root debridement by scaling and root planing and, where indicated, periodontal flap surgery. Following completion of active periodontal ther- apy. titanium oral implants (IMZ. Friedrichsfeld, Mannheim, Germany) wete installed in the pos- terior, edentulous areas to serve as end abutments for conventional, fixed partial dentures. Implant insertion was performed according to the procedures described by Kirsch et al. (1989). After a healing period of 3 months during which the implants were submerged. a second surgical procedure was performed to expose the implants to the oral environment for prosthetic abutment connection. Oral hygiene instruction for proper plaque control around the implants and the re- maining dentition was reinforced, and professional supportive therapy (Axelsson & Lindhe 1974) was instituted once every 3 weeks. After a further 2-month period of healing and close supervision, a baseline examination was per- Experimental peri-implant mucositis formed, and re-examinations were scheduled 3 and 6 months after baseline. At the examinations the following parameters were assessed at the mesial, buccal, distal and lingual aspects of each implant (test) and adjacent natural tooth (control): 1. The presence of plaque was evaluated according to the criteria of the Plaque Index (PII: Sil- ness & Lée 1964) and adapted for oral implants (Mombelli et al. 1987). 2. The peri-implant mucosal and gin conditions were evaluated using the crite the Gingival Index (Gl: Lée & Silness 1963) and adapted for oral implants (Mombelli et al. 1987). 3. The Sulcus Bleeding Index was also determined (SBI: Mahlemann & Son 1971), 4. Probing pocket depths (PPD) were measured from the gingival or peri-implant mucosal mar- gin to the bottom of the sulcus or pocket and recorded to the nearest mm using a calibrated periodontal probe with a tip diameter of 0.4 mm and a standardized pressure (240 Niem*: van der Velden 1979). 5. The location of the peri-implant mucosal or gingival margin in relation to the inferior bor- der of the implant “healing cap”, the cemento- enamel junction or the margin of a tooth res- toration as fixed reference points was deter- mined to the nearest millimeter. 6. Evaluation of the composition of the subgingival and submucosal microbiota. was performed using phase-contrast microscopy. After the re- moval of the supragingival plaque with sterile cotton pellets, samples of the subgingival and submucosal plaque were obtained from one site at each implant and adjacent tooth according to the method described by Magnusson et al. (1985). Total bacterial counts as well as pro- portions of bacterial morphotypes were enumer- ated at a magnficiation of x1200 according to the criteria proposed by Listgarten & Helldén (1978). Following the 6-month re-examination. the patients signed consent forms and were asked to refrain from all oral hygiene for a period of 3 weeks and allow plaque accumulation around the implants and ad- jacent teeth according to the experimental gingivitis, ‘model proposed by Lée et al. (1965). At the end of the period of no oral hygiene. the parameters de- scribed were again assessed and analyzed. There- after, oral hygiene was reinstituted and prosthetic treatment completed. ‘An analysis of variance followed by the Scheffe post hoe procedure was performed to identify sig- nificant differences (P<0.05) between test and con- 255Pontoriero et al. trol sites as well as for significant longitudinal changes. Results Each of the 20 patients contributed to the study with one implant (test) and 1 adjacent tooth (con- trol) unit, resulting in a total of 80 peri-implant and 80 periodontal sites for the clinical and 20 peri-implant and 20 periodontal sites for the ‘obiological parameters. The means and stan- dard deviations of the clinical parameters at base- line, at 3 and 6 months and after 3 weeks of undis- turbed plaque accumulation are presented in Tables I-S. The mean PII values varied between 0.5 and 0.8 at the implant and between 0.3 and 0.4 at the tooth sites in the pre-experimental 6 months period. The 3-weeks of no oral hygiene resulted in a mean PII= 2.4 for implants and PII=2.0 for teeth. This in- crease was statistically highly significant (P<0.001) for both test and control sites, although there was no significant difference between the 2 types of units at any of the observation times (Table 1) The mean GI values varied between 0.2 and 0.5 in the pre-experimental period with no statistically different differences between test and control sites. Following a 3-week period of plaque accumu- lation, the mean GI increased (P<0.001) to 1.6 and 1,9, respectively (Table 2). Table 3. Mean Sulcus Bleeding Index scores (standard deviation) at baseline, after 3 and 6 months and after 3 weeks of "experimental plaque accumulation Implants (test) Teeth (control) Baseline 03201 3 months 02201 6 months 03-01 3 weeks = plaque accumulation Ns 16202 ** 0.001. NS: no statistically significant dtferences between test and control units Table 4, Mean probing pocket depth (mm; standard deviation) at base lng, afer 3 and 6 months and the “experimental plague accumlation period examinations Implants (test) Teeth (control) Basle 28208 26205 3 months 27204 25-04 6 months 25203 24203 3 weeks i plaque accumulation 37205 NS 31z04 * P<0.05. NS: no statistically significant diferences between test and control units Table 5. Location of the peri-mplant mucosal and gingival margins in relation to a fixed reference (mim; =standard deviation) at baseline, after 3 and 6 months and after 3 weeks of “experimental plaque accumu- lation’ Implants (test) Teeth (control) Table 1. Mean Plaque Index scores (=standard deviation) at baseline, Baseline 18205 1304 after 3 and 6 months and after 3 weeks of “experimental plaque accumu- 3 months 20205 18202 tation” 6 months 21204 17203 wees a G Implants (test) Teeth (control) plaque accumulation 07203 NS 09+02 Baseline 0803 0,001, NS: no satisicaly significant citfrences betwoen test and 3 months control units 68 months 3 weeks oS plaque accumulation 24204 NS ** P<0.001. NS: no statistically significant ferences between test and control units Table 2. Mean Gingival Index scores (=stanéard deviation) at baseline, after 3 and 6 months and ater 3 weeks of “experimental plaque accumu lation’ Implants (lst) Tea (contot) Baseline 04205 3 months 04=03 & months 05=03 3 weeks a aque accumulation 16209 NS ** P<0.001. NS: no statistical signicant differences between test and contro units The Sulcus Bleeding Index scores followed the pattern of the GI scores (Table 3), increasing sig- nificantly for both types of units during the 3-week period of plaque accumulation. Probing pocket depths varied between 2.4 and 2.8 mm during the pre-experimental period, with no statistically significant differences between test and control units (Table 4). Following the 3-week period of no oral hygiene, the probing depths in- creased (P<0.05) to 3.7 and 3.1 mm for test and control units, respectively. The peri-implant mucosal and gingival margins were located 1.3 to 2.1 mm apical to the fixed refer- ences during the pre-experimental 6-month period, with no statistically significant differences between test and control sites (Table 5). The increasing mu-Tale 6, Distribution of bacterial morphotypes in submucosalsubgingval plaques at implant at agjacent tooth sites at baseline, after 6 months and afer 3 weeks of “experimental plaque accumulation” (mean proportions standard error) Implants Teeth (test) (control) Baseline cocooid cells % motile rods % spirochetes 4% coccoid cols 79:3--4.16 6 months % motile rods 2.4071 % spirochetes 1.2051 3 weeks % coceoid cals §4.3.680 4733.65, plaque accumulation % motile ods 174=221 NS 192+211 622180 7822.23 spirochetes ** Pe0.05, NS: no statistically signticantdiferenoes between test and contro units cosal and gingival inflammation during the experi- mental period resulted in a slight but significant (P<0.01) coronal displacement of the peri-implant mucosal (1.4 mm) and gingival (0.8 mm) margins as a sequelae of oedema. The results of the phase-contrast_microscopic analysis are summarized in Table 6. Only data on 14 patients were evaluated. Basically, there were no statistically significant differences in the compo- sition of the submucosal microbiota at implant sites in comparison with that of the subgingival microbiota at tooth sites at any of the observation times. However, there were significantly higher pro- portions of spirochetes and motile rods and lower proportions of coccoid cells after the 3 weeks of no oral hygiene in both test and control sites. This study followed a group of partially edentu- lous patients for a period of 6 months after active periodontal and subsequent implant therapy dur- ing which proper plaque control was assured by good patient compliance and supplemented by rei ular professional maintenance care. As a result of optimal supportive therapy (Lang & Nyman 1994), very low plaque levels and peri-implant mucosal and gingival health concomitant with shallow sulei were maintained. Furthermore, the composition of the subgingival microbiota closely resembled that associated with gingival and periodontal long- term success and maintenance of periodontal health (Listgarten & Helldén 1978). These con- ditions provide optimal prerequisities for health and implant stability. Similar clinical and micro- biological results as found in the present study Experimental peri-implant mucositis have been presented for partially edentulous and edentulous patients treated with tooth- and/or im- plant-supported bridgework and maintained on proper plaque control for up to 5 years (Apse et al. 1989; Bower et al. 1989: Mombelli & Merieske- Stern 1990: Quirynen & Listgarten 1990), During the 3-week period of no oral hygiene. the clinical index values increased significantly at both implant and tooth sites. This is in agreement with the oral original experimental model pre- sented by Lée et al. (1965). The fact that these values increased to a similar level at implant and tooth sites suggests that plaque accumulates and ‘matures at similar rates in both types of units. Mi- crobial colonization studies of osseointegrated t tanium implants (Mombelli et al. 1988) have indi- cated that the pattern of bacterial colonization and plaque maturation on implants very closely re- sembles that known for tooth surfaces. It is there- fore not surprising that the peri-implant mucosal reactions to plaque paralleled the increased gingi- val inflammatory response at tooth sites. The soft tissue reactions to de novo plaque formation on implant surfaces have recently been compared with the gingival reactions in a study in beagle dogs (Berglundh et al. 1992). Biopsies from peri-implant and gingival tissues after a period of 3 weeks re- vealed similar histometric and morphometric re- sults for the 2 types of units. In particular, the size of the area occupied by the inflammatory infiltrate and the volumetric density of connective tissue components, such as collagen, vascular structures and fibroblasts, showed no statistically significant differences between the developing lesions at im- plant and tooth sites. Since the present study has demonstrated a simi- lar cause-effect relationship between the accumu- lation of bacterial plaque and the development of peri-implant mucositis as established for the gingi- val unit by the experimental gingivitis model. the need for supportive therapy at implant sites and tooth sites is of equal importance. Le but de l'étude présente été de comparer les paramétres cliniques et microbiologiques (microscopiques) durant le déve- Joppement d'une gingivite expérimentale et d'une inflammation ‘muqueuse paro-implasitaire expérimentale. Vingt patients par~ tiollement édentés onit été traités pour une parodomite modérée & avancée. Suivant le traitement parodontal acti consistant en Ja motivation, instruction en hygiene buccale, le détartrage et fe lissage radiculaire tla chirurgie parodontale lorsqu'elle etait indiquée. des implants buecaux IMZ ont été incorporés dans le Zones postérieures dentées. Aprés trois mois de guérison. les superstructures prothetiques ont et€ connectées et les patients font &é suivis de prés pendant les deux mois suivants. A ce ‘moment les données de base ont été prises, De nouveaux exa: zens ont é4& faits & trois et six mois. Apres ceci. les patients cont du arréter toute hygiéne buecale pendant trois semaines. 257Pontoriero et al. Durant tous les examens, y compris la période sans hygiéne, les paramétres cliniques suivants ont ét€ obtenus: PII (Silness & Lae 1964), GI (Loe & Silness 1963) et SBI (Malblemann & Son 1971) tous modifies par Mombelli et al. en 1987, les profor- seurs de poche au sondage et la récession en mm. Des échantil lons sous-muqueux et sous-gingivaux de plaque dentaire ont également &1& prélewts et analyses sous un microscope & fond noir (Listgarten et Heldén 1987). Suite la gingivite expérimen- tale, une hygiéne buccale optimale @ été rétablie. IL n'y avait aucune difference significative entre les valeurs moyennes de tous les paramétres au niveau des implants comparées & celles au niveau des dents, et cect pour toutes les périodes d'observa- tion, La période d'arrét de Ihygiéne buccale a mis en évidence tune relation de cause a effet entre l'accumulation de plaque dentaire et Te développement d’inflammation de la muqueuse paro-implantaire semblable & celle qui avait &é établie au ni- vveau des gencives par le modéle de la gingivite expérimentale, ily a trente ans deja Zurammenfassung Ziel dieser Studie war es, die klinischen und microbiologischen (mikroskopischen) Parameter bei der Entstehung einer experi- ‘mentellen Gingivitis und einer experimentellen periimplantiren ‘Mukositis 2u vergleichen. 20 telbezahnte Patienten wurden we- gen ihrer mitteren bis fortgeschrittenen Parodontalerkrankung. ‘behandelt. Nach der aktiven Parodontaltherapie, die aus Moti- vation, Mundhygieneinstruktion, Scaling und Warzelglattenso- ‘wie Parodontalchirurgie (wo indiziert) bestand, wurden IMZ— Implantate im posterioren zahnlosen Bereichen cingesetzt Nach Absehluss der 3-monatigen Heilphase wurden die fur die prosthetische Rekonstruktion adaquaten Sekundarteile einge- Schraubt und die Heilung wahrend weiteren zvet Monaten streng Uberwacht. Am Ende dieser Periode wurden die Basisda- ten erhoben. Nachuntersuchungen fahrte man nach 3 und 6 Monaten durch. Ansehliessend forderte man die Patienten, auf ‘walhrend 3 Wochen jegliche Mundhygiene 2u unterlassen. Bei simtlichen Untersuchungen wurden folgende Klinischen Para- meter aufgenommen: PIL (Silness & Loe 1964), GI (Loe & Sil- ness 1963) und SBI (Mahlemann & Son 1971), alle modifiziert rach Mombelli et al. (1987); Sondierungstiefen und Rezessio- ren in mm, Zusitzlich wurden submukose/subgingivale Plaqu- eproben entnommen und mitels Phasenkontrastmikroskopie (Lisigarten & Helldén 1987) analysiert. Nach Abschluss der dreiwochigen Plaqueakkumulationsphase kehrte man 2u opti maler Mundhygiene 2uruck. Es wurden bei keinem der ver- schiedenen Untersuchungssegmente staistsch signifikante Un- terschiede det Mitielwerte aller erhobenen Befunde zwischen Implantaten und Zahnen gefunden. Die Phase mit vernachlas: sigier Mundhygiene zeigte einen ahnlichen Zusammenhang, zwischen bakterieller Plaqueakkumulation und Entwicklung e' ner periimplantaren Mukositis, wie dies seit langer Zeit vom cexperimentellen Gingivitismodell her fr die gingivale Finheit bekannt war. La intencién del presente estudio fue la de comparar los pard- ‘metros clinicos y microbiolégicos (microscépicos) durante el desarrollo de gingivitis experimental y mucositis peri-implanta- ria experimental Se trataron veinte pacientes edéntulos por en. fermedad periodontal desde moderada hasta avanzada. Tras ‘una terapia periodontal activa consistente en motivacién, ins- truccién en practicas de higiene oral, rascado y alisado radicul- ar y cirugia periodontal donde se indicd, se incorporaron im- plantes orales [MZ.en areas edéntulas posteriores. Tras tres me- ‘08 de cicatrizacién, se conectaron los pilares protéticos y los pacientes fueron supervisados estrechamente por otros dos me- 258 ses de cicatrizacién, En este momento se tomaron datos basa: les, Se programaron revisiones a los 3 y 6 meses. Tras esto se solicto a los pacientes que abandonaran la practica de higiene ‘oral durante tres semanas. En todos los eximenes incluyendo el final del periodo sin higiene se obtuvieron los siguientes paré- ‘metros clinicos: Pil (Silness & Le 1964). GI (Loe & Silness 1963) y SBI (Muhlemann & Son 1971) todos modificados por Mombelli et a. (1987), sondaje de bolsas y recesién en mm. ‘Ademas se obtuvieron muestras de placa submucosa/subgingi- val y analizadas usando microscopio de campo oscuro (Listgar- ten & Helldén 1987), Al final del periodo de las tres semanas de acurnulacién de placa se resituy6 Ia higiene oral 6ptima. No se encontraron diferencias estadisticamente significativas entre ls valores medios de todos los pardmetros tomados en los im- plantes o en los dientes en cualquier periodo de observacion. El periodo sin higiene oral demonstr6 una similar relacion cau- sa efecto entre la acumulacién de placa bacteriana y el desarro- llo de mucositis peri-implantaria como se establecié para las tunidades gingivales por el modelo de gingivitis experimental References Apse, P, Ellen, R. P. 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