334 PERI-IMPLANT DISEASE • FERREIRA JR et al

Clinical, Histological, and Microbiological

Findings in Peri-Implant Disease:
A Pilot Study
Samuel Barros Ferreira, Jr., DDS,* Caio Márcio Figueiredo, DDS, MSc,†
Ana Lúcia Pompéia Fraga Almeida, DDS, MSc, PhD,‡ Gerson Francisco Assis, MSc, PhD,§ Thiago José Dionísio,储
and Carlos Ferreira Santos, DDS, MSc, PhD¶

eri-implant disease is defined as Objectives: This study is intended and the HI, except for the mPI on the

P an inflammatory process on the

soft tissues around implants.1
Dental implants do not have a periodon-
tal ligament2 and the connective tissue
around dental implants is differently ar-
ranged when compared with natural
teeth.3 Despite these differences, similar
characteristics between periodontal and
peri-implant diseases exist.4 Thus, clin-
ical indices used to assess periodontal
disease can also be used to monitor tis-
sues around dental implants.5 Although
some modifications in periodontal indices
may be necessary to allow a more accurate
evaluation of peri-implant disease,4,6 it is
important to assess the reliability of the
correlation between such clinical indices
and the real inflammatory condition as
revealed by histological findings.7–10
*Specialization Student, Section of Periodontology, Hospital for
Rehabilitation of Craniofacial Anomalies, University of São
Paulo, Bauru, Brazil.
†Instructor, Section of Implantodontology, Hospital for
Rehabilitation of Craniofacial Anomalies, University of São
Paulo, Bauru, Brazil.
‡Instructor, Section of Periodontology, Hospital for
Rehabilitation of Craniofacial Anomalies, University of São
Paulo, Bauru, Brazil.
§Associate Professor, Department of Biological Sciences,
Discipline of Histology, Bauru School of Dentistry, University of
São Paulo, Bauru, Brazil.
储Laboratory Technician, Department of Biological Sciences,
Bauru School of Dentistry, University of São Paulo, Bauru,
Brazil.
¶Associate Professor, Department of Biological Sciences,
Discipline of Pharmacology, Bauru School of Dentistry,
University of São Paulo, Bauru, Brazil.
Reprint requests and correspondence to: Carlos
Ferreira Santos, DDS, MSc, PhD, Bauru School of
Dentistry, University of São Paulo, Alameda Dr.
Octávio Pinheiro Brisolla, 9-75, Discipline of
Pharmacology, Bauru/São Paulo 17012-901, Brazil,
Phone: ⴙ55 14 32358282, Fax: ⴙ55 14 32234679,
E-mail: cebola@usp.br
ISSN 1056-6163/09/01804-334
Implant Dentistry
Volume 18 • Number 4
Copyright © 2009 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e3181a44fd8
to verify the correlation among clini-
cal indices of the peri-implant soft tis-
sues, the histological condition and
the presence of 3 pathogens commonly
associated with peri-implant diseases
(Aggregatibacter actinomycetem-
comitans, Porphyromonas gingivalis,
and Tannerella forsythia).
Materials: Four clinical indices,
Gingival Index (GI), Sulcus Bleeding In-
dex, GI modified by Mombelli, and
Plaque Index modified by Mombelli
(mPI) were evaluated around 1 dental
implant of each subject (n ⫽ 10). Sub-
gingival plaque was collected for
bacterial analysis (polymerase chain re-
action) and a biopsy of peri-implant soft
tissues for histological analysis was har-
vested. The clinical indices and detected
pathogens correlated with a developed
histological index (HI).
Results: There was no statistically
significant relationship between the
clinical indices (GI, Sulcus Bleeding
Index, and GI modified by Mombelli)
Visual inspection of the peri-
implant soft tissues may indicate
signs of disease as color alteration,
swelling, thickness,11 and bleeding
on probing by indices widely used
for evaluating the gingival dis-
ease.12,13 Inflammatory lesions may
exist in the absence of visual signs of
inflammation.14 Despite the healthy
aspect, an inflammatory infiltrate
may be present.11,15–17
central area of lingual aspects (r ⫽
0.85, P ⫽ 0.0029). There was a ten-
dency for a positive correlation
between the mPI on the central area of
buccal aspects and the HI (r ⫽ 0.63,
P ⫽ 0.0544). The counting of lympho-
cytes and plasmocytes correlated pos-
itively with HI, thus suggesting the
index reliability. The prevalence of A.
actinomycetemcomitans, P. gingivalis,
and T. forsythia did not present a sig-
nificant relationship with the HI.
Conclusion: Despite the small
number of samples and the poor sta-
tistical significance, the mPI seems to
be useful for evaluation of inflamma-
tory severity on soft tissue around den-
tal implants as demonstrated by its
relationship with the HI. Further stud-
ies are necessary to elucidate this sub-
ject. (Implant Dent 2009;18:334 –344)
Key Words: periodontal index, gingi-
val index, plaque index, bleeding
index, peri-implant disease
Several studies have been con-
ducted with the purpose of demon-
strating the correlation between the
clinical indices and the real histologi-
cal changes in the periodontal tissues.
The results are controversial since
some of these works demonstrated that
there is a positive correlation,18,19
whereas others did not.16,17,20
Furthermore, probing around
teeth has been demonstrated to be an

excellent way to access the health of
natural teeth by measuring the probing
depth, tissue consistency, bleeding,
and the presence of exudate. On the
other hand, probing around dental im-
plants has been of little value because
of the structural differences between
natural teeth and dental implants, as
well as the lack of scientific criteria.21
Thus, it is important to investigate the
correlation of clinical indices and the
real histological conditions.
The amount of plaque can be mea-
sured by different indices.12,22 Many
studies demonstrated the correlation of
gingivitis and mucositis with the
plaque index.12,23,24 Plaque is also con-
sidered the most important etiological
factor in peri-implant disease.6,25
The diagnosis of peri-implant dis-
ease also uses bacteriological examina-
tions, and nowadays techniques of DNA
identification, such as the polymerase
chain reaction (PCR) represent an im-
portant auxiliary instrument for the de-
tection of periodontal pathogens.26 –29
The microbiota commonly associated
with peri-implant diseases comprises the
following: Prevotella intermedia, Porphy-
romonas gingivalis, Aggregatibacter
actinomycetemcomitans (formerly Acti-
nobacillus actinomycetemcomitans), Tan-
nerella forsythia (formerly Bacteroides
forsythus), Treponema denticola, Pre-
votella nigrescens, and Fusobacte-
rium nucleatum.25,27,30,31
This study was carried out due to
the paucity of data in the literature
correlating clinical parameters and the
histological inflammatory findings on
soft tissues affected by peri-implant
disease. Therefore, the aims were to
evaluate (i) the correlation of gingival
and plaque indices with the histologi-
cal changes of peri-implant soft tissues
measured by a developed histological in-
dex (HI) and (ii) the correlation between
the prevalence of 3 periodontopathic bac-
teria (A. actinomycetemcomitans, P. gin-
givalis, and T. forsythia) and HI.
PATIENTS AND METHODS
Patient Selection
The institutional Ethics Commit-
tee approved the protocol of this study
(No 253/2006-SVAPEPE-CEP). All
patients provided written informed
IMPLANT DENTISTRY / VOLUME 18, NUMBER 4 2009
consent during the pretreatment
screening period.
Ten systemically healthy patients
of both genders aging from 33 to 73
years, wearing implant-supported
prostheses, and with indication of sur-
gical treatment of peri-implant pockets
caused by mucositis were selected at
our institution.
All patients included in this study
were nonsmokers, with the absence of
acute infection or hormonal alter-
ations, were not taking antibiotics,
anti-inflammatory medicines, or other
drugs during the previous 6 months,
and were not subjected to any situation
that could interfere with the clinical,
histological, or bacteriological results.
Clinical Procedures
Anamnesis, radiographic exami-
nation, peri-implant probing, determi-
nation of the adopted clinical indices,
subgingival plaque collection, and an
incisional biopsy of the peri-implant
soft tissues were performed for each
patient. One trained examiner con-
ducted all these procedures. To carry
out the biopsies, only 1 area with 1
implant per patient was selected, tak-
ing into account the amount of kera-
tinized mucosa.
Four indices were determined to
measure the degree of soft tissue in-
flammation (Gingival Index [GI],12 GI
modified by Mombelli [mGI],22 and
Sulcus Bleeding Index [SBI]13) and 1
measuring the presence of supragingi-
val plaque (Plaque Index modified by
Mombelli [mPI] 22 ). These indices
were adopted because they are widely
used to determine gingivitis severity.
mGI and mPI were adopted since they
are modifications from Löe GI and PI
used for dental implants.
The clinical indices and probing
depth were determined at 6 sites
around the implant: mesiobuccal, buc-
cal, distobuccal, mesiolingual, lingual,
and distolingual aspects (mb, b, db,
ml, l, and dl, respectively).
Subgingival plaque samples sur-
rounding the implants were collected
twice with sterile paper points (No.
40) that were inserted into the deeper
site at the buccal and lingual aspects.
To avoid contamination, before plaque
collection the implants were isolated
335
with sterile cotton rolls, and the su-
pragingival plaque was removed with
sterile cotton. After 15 seconds, the
paper points were removed from the
pockets and submersed in 0.5 mL of
sterile water in a microcentrifuge
tube,32 which was immediately stored
at ⫺20°C for further analysis.33
Biopsy in the measured area was
performed under local anesthesia by in-
cisions with conformity to excisional
new attachment procedure,34 1 mm dis-
tant of buccal and lingual edges. Peri-
implant tissues were gently removed
from the abutments and stored in 10%
buffered formaldehyde (pH 7.3) for 1
week. On completion of surgeries, the
surgical sites were thoroughly irrigated,
suctioned, and sutured.
Postoperative instructions and
medication were given to all patients,
who returned 1 week later for postop-
erative control.
Histological Procedures
Samples were properly treated
according to standard histological pro-
cedures. Each buccal and lingual sam-
ples were included in separate paraffin
blocks (total of 20 blocks—2 per pa-
tient). Serial sections (5 ␮m) parallel
to the longitudinal axis were obtained
from each sample and stained with
hematoxylin and eosin.
For each buccal (n ⫽ 10) and lin-
gual fragments (n ⫽ 10) of peri-
implant tissues, duplicates for the
mesial, central, and distal areas of the
fragments were prepared, thus com-
prising a total of 120 slides (60 slides
in duplicates).
Histological Analysis
A developed HI was used for
comparison with the clinical parame-
ters determined. The HI is expressed
by scores ranging from 0 to 3 (Table
1) based on the inflammatory condition
of both the connective and epithelial tis-
sues. These scores were established in
accordance with qualitative character-
istics of the inflammatory infiltrate
(extension, density, and predominant
cells), which corresponded to the in-
flammatory degree in the evolution of
gingivitis according to the classifica-
tion of Page and Schroeder35 and
Kinane and Lindhe.36
336 PERI-IMPLANT DISEASE • FERREIRA JR et al
Table 1. Histological Index
Score
0 Gingiva with normal
appearance or rare
and insignificant
inflammatory infiltrate
1 Gingiva with slight
inflammation
2 Gingiva with moderate
inflammation
3 Gingiva with intense
inflammation
Fig. 1. Localization of areas a, b, c, and d used as reference regions for histological analysis.
This division is part of the classification criteria (Table 1), with the objective to better visualize
and analyze the histological changes. Areas (a) and (c) represent the region next to the
peri-implant sulcus or pocket. Areas (b) and (d) represent the region next the oral epithelium.
Histological Features
Connective tissue: slight lymphocyte infiltrated, slightly near the epithelial areas, isolated cells,
or in small groups subjacent to connective or sulcus epithelium; normal vessels; absence of
edema.
Epithelial tissue: cellular disjunction is rare or absent at the basal layer; vacuolization of
cytoplasm is rare or absent; absence of hyperplasia.
Connective tissue: slight infiltration of lymphocytes/plasmocytes with obvious predominance of
lymphocytes near the epithelial tissue, in a continuous thin layer under the sulcus or pocket
epithelium; accumulation of cells in connective papillae areas between the epithelial
projections, but may be involving all of areas “a” and “c” of Figure 1; possible presence of
hyperemic vessels and edema; slight collagen degradation.
Epithelial tissue: slight disjunctions at the basal layer; slight cytoplasm vacuolization, possible
epithelial hyperplasia.
Connective tissue: diffuse infiltration of lymphocytes/plasmocytes, more evident that in the
condition described above, with predominance of lymphocytes, collagen degradation in
areas “a” and “c” of Figure 1, proliferation of infiltrated cells towards the oral epithelium with
large involvement of areas “b” and “d” of Figure 1; hyperemia of vessels with possible
capillary proliferation; increase of neutrophil migration toward the sulcus (and junctional
epithelium) or pocket epithelium; moderate edema; increase of collagen degradation.
Epithelial tissue: cellular disjunctions at the basal layer; cytoplasm vacuolization, hyperplastic
epithelium with some prominent crests; migration of leucocytes to epithelial tissues.
Connective tissue: Intense and diffuse infiltration of lymphocytes/plasmocytes, with
considerable number of plasmocytes, replacing the most part of collagen fibers, with large
degradation in areas “a,” “b,” “c,” and “d” of Figure 1; hyperemia of vessels more frequently
observed; edema; neutrophil migration to pocket epithelium and the remaining junctional
epithelium.
Epithelial tissue: cellular disjunctions at the basal layer and cytoplasm vacuolization more
frequently observed; acanthotic epithelium with prominent epithelial crests.
Each section evaluated was di-
vided into 4 areas (Fig. 1, a– d). This
division is part of the classification
criteria (Table 1), with the objective to
better analyze the different degrees of
histological changes based on quanti-
tative attributions of descriptive histo-
logical analysis adopted in this study.
The slides were evaluated in an
optical microscope, under magnifica-
tion of 40, 100, and 400⫻. The HI
score was determined for each mesial,
central, and distal areas of buccal and
lingual aspects through analyses of 2
slides of each area (in duplicates).
To offer additional support data to
allow a better understanding of the
inflammatory changes and to help the
classification of the slides with the HI
scores, a counting of inflammatory
cells considered in the index (lympho-
cytes and plasmocytes) was conducted
using a 40⫻ objective and a Zeiss kpl
8⫻ eyepiece containing a Zeiss II
integration grid (Carl Zeiss Jena
GmbH, Jena, Germany) resulting in an
area of 102,400 ␮m2. The grid image
was superimposed on 1 representative
 IMPLANT DENTISTRY / VOLUME 18, NUMBER 4 2009 337

Table 2. Clinical and Histological Indices

GI mGI SBI mPI HI
Buccal Lingual Buccal Lingual Buccal Lingual Buccal Lingual Buccal Lingual
Patient M C D M C D M C D M C D M C D M C D M C D M C D M C D M C D
1 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 1 1 2
2 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4 4 1 1 1 1 1 1 1 2 2 1 1 1
3 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 1 1
4 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 3 3 3 0 0 0 1 0 0 1 1 1 1 1 1
5 1 1 1 2 2 2 0 0 0 2 2 2 0 0 0 3 3 3 0 0 0 0 0 0 1 1 2 1 1 1
6 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 0 0 0 0 0 0 1 1 1 1 1 1
7 2 2 2 1 1 1 1 1 1 0 0 0 4 4 4 0 0 0 0 0 0 0 0 0 2 1 1 1 0 2
8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 1
9 2 2 2 2 2 2 1 1 1 2 2 2 4 4 4 4 4 4 1 1 1 2 2 1 1 1 1 1 2 2
10 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4 4 1 1 1 2 2 2 2 1 1 1 2 1
M indicates mesial; C, central; D, distal; GI, gingival index (1967); mGI, gingival Index modified by mombelli (1987); SBI, sulcus bleeding index (1971); mPI, plaque index modified by mombelli (1987); HI,
histological index.

Table 3. Statistical Correlation Between Clinical Indices and HI

GI mGI SBI mPI
r P r P r P r P
Buccal
M 0.000 1.000 0.03858 0.9184 0.1118 0.7589 0.3536 0.3129
C ⫺0.1409 0.7072 0.1237 0.7330 ⫺0.1195 0.7330 0.6299 0.0544
D ⫺0.3953 0.2632 ⫺0.1543 0.6821 ⫺0.3727 0.2957 0.3536 0.3129
Lingual
M ⫺0.1443 0.6821 0.0000 1.0000 0.0000 1.0000 0.2887 0.4069
C 0.0643 0.8651 0.1739 0.6321 0.4033 0.2475 0.8487 0.0029*
D 0.0000 1.0000 ⫺0.04762 0.8916 ⫺0.1183 0.7330 ⫺0.08133 0.8382
*Statistically significant correlation (Spearman’s correlation test).

M indicates mesial; C, central; D, distal; GI, Löe gingival index (1967); mGI, mombelli gingival index (1987); SBI, Mühlemann and Son sulcus bleeding index (1971); mPI, mombelli plaque index (1987); HI,
histological index.

area of each 4 sections represented in sample, 5 ␮L of 10⫻ PCR buffer, 2.5
Figure 1. unit of Taq DNA polymerase, 0.2 ␮M
of each deoxyribonucleotides, 1.0 ␮M
DNA Extraction of each primer, and 1.5 ␮M of MgCl2.
The subgingival plaque samples As positive controls, isolated DNA from
were diluted 1:2 in sterile water and A. actinomycetemcomitans ATCC 29522,
collected by centrifugation at 10,000g P. gingivalis ATCC 33277, and T. for-
for 5 minutes in a microcentrifuge at sythia ATCC 43037 were tested with the
4°C. The supernatant was discarded species-specific primers. Ubiquitous prim-
and the resulting pellet was washed 2 ers were also used as a positive control for
more times with 1 mL sterile water.
the PCR amplification. For each set of
The pellet was reconstituted with 100
primers, PCR was performed on sterile
␮L of water and 100 ␮L of InstaGene
Matrix (Bio-Rad Laboratories, Inc., water to check for DNA contamination
Hercules, CA) and incubated at 56°C (negative controls).
for 30 minutes. The samples were then Specificities of all primers were
vortexed and boiled for 10 minutes. previously investigated38,39 and primer
After centrifugation to remove unbroken sequences were compared with similar
cells (10,000g for 3 minutes), the super- sequences of the reference organisms
natant was used for PCR analysis.37 by BLAST search (http://ncbi.nlm.
nih.gov/blast/). To further test the
PCR Conditions specificity of the primers, total DNA
A total of 50 ␮L of PCR reaction from all bacterial strains cited above
mixture contained 10 ␮L of DNA was used with each of the primer
pairs. The sequences of the primers
and the temperature profiles were pre-
viously described.40,41
PCR amplification products (9
␮L) were analyzed by 2% agarose
gel electrophoresis. The agarose gels
were stained with 0.5 ␮ g/mL
ethidium bromide and photographed
under ultraviolet light. A 100 bp
DNA ladder served as a molecular
weight marker.37
Data Analysis
The values for each of the 4 clin-
ical indices and the presence of 3
periodontopathic bacteria were cor-
related with the HI. The correlations
were performed using the values of
mesial, central and distal area of
buccal, and lingual aspects. The re-
sults of the counting of inflamma-
tory cells were correlated with the
attributed scores of HI. Spearman’s cor-
338 PERI-IMPLANT DISEASE • FERREIRA JR et al

Table 4. Inflammatory Cells by Area* of Histological Index

A-L A-P B-L B-P C-L C-P D-L D-P
Score 0
Mean 6.00 0.00 0.00 0.00 4.0 0.00 0.00 0.00
Std. error 0.58 0.00 0.00 0.00 0.58 0.00 0.00 0.00
Score 1
Mean 176.3 6.75 73.75 5.13 73.38 2.88 48.50 3.88
Std. error 39.54 1.05 16.84 0.74 14.72 0.64 14.84 3.31
Score 2
Mean 237.60 8.50 121.40 5.63 150.40 6.13 90.88 3.75
Std. error 37.76 1.04 18.25 1.21 28.51 1.32 19.58 0.65
Spearman’s correlation test. A, B, C, and D are the correspondent areas of Figure 1.

*Number of cells/102,400 ␮m2.

L indicates lymphocytes; P, plasmocytes.

Table 5. Correlation Between Inflammatory Cells and HI Scores

A-L A-P B-L B-P C-L C-P D-L D-P
r 0.5943 0.6295 0.7095 0.4332 0.7386 0.6849 0.6194 0.4463
P 0.0073* 0.0039* 0.0007* 0.0639 0.0003* 0.0012* 0.0047* 0.0554
*Statistically significant correlation (Spearman’s correlation test). A, B, C, and D are the areas of Figure 1.

L indicates lymphocytes; P, plasmocytes.

relation test (P ⬍ 0.05), through the
software Statistica (version 5.1, Stat
Soft Inc., Tulsa, OK), was used for
data analysis.
RESULTS
A total of 120 slides (duplicates of
60 slides) were evaluated and used as
gold standard for comparison with the
other parameters in this study.
The results of clinical and histo-
logical indices and their statistical cor-
relations can be observed in Tables 2
and 3, respectively. The mPI showed a
statistically significant correlation
with the HI in the central area of lin-
gual aspect. No statistically significant
correlation was found for areas of the
buccal aspects and the other areas of
lingual aspect. No statistically signifi-
cant correlation was detected for the
other indices either.
The counting of lymphocytes and
plasmocytes in Figure 1, a– d is
depicted in Table 4. The positive cor-
relation between the counting of in-
flammatory cells and HI can be
obtained from Table 5.
For each patient, samples of sub-
gingival plaque were collected both in
buccal and lingual aspects, with a total
of 20 samples. A. actinomycetemcomi-
tans was detected in only 1 patient
(10%) and in 1 surface (5%), whereas
P. gingivalis was detected in 4 patients
(40%) and in 6 surfaces (30%). The
most prevalent bacterium was T. for-
sythia, which was detected in 5 pa-
tients (50%) and in 6 faces (30%). In 3
patients, none of the bacteria was de-
tected. The presence of the 3 peri-
odontopathic bacteria studied did not
correlate with the HI.
DISCUSSION
This study evaluated the correla-
tion of 3 clinical indices of gingival
inflammation, based on bleeding and
visual aspects (GI, mGI, and SBI), and
1 index of plaque accumulation (mPI)
with the histological condition,
through a developed HI. Such correla-
tion was analyzed to test the ability of
the clinical indices to show the real
inflammatory changes on the tissues
clinically evaluated. The aim of deter-
mining bacterial detection was to cor-
relate the presence of 3 common species
in peri-implant disease with the in-
flammatory degree of the tissues.
There are controversial findings in
the literature regarding the ability of
clinical indices to show the histologi-
cal condition of gingival tissues. Some
authors found positive results,18,19,42
whereas others do not agree since they
did not find positive association in
their studies.17,20 The positive correla-
tion of the counting of lymphocytes
and plasmocytes and HI found in this
study strongly suggest the reliability
of the HI.
The results found in this study for
the clinical indices based on visual and
bleeding conditions (GI, mGI, and
SBI), despite the nonstatistically sig-
nificant correlation, suggest that these
indices do not reflect the real inflam-
matory degree (HI) of the evaluated
tissues. Probably, the parameters of
GI, mGI, and SBI used in this study
are not exactly applicable to evaluate
the inflammation status in the peri-
implant tissues.
As far as the use of bleeding as a
diagnostic tool of peri-implant inflam-
mation is considered, some studies in-
dicate the use of bleeding indices
as a signal of inflammation,23,26,43,44
whereas others do not corroborate
these findings since a correlation with
the real inflammatory changes in the
tissues was not observed.23,45
Structural differences between
peri-implant and periodontal tissues
are mainly represented by the parallel
disposition of collagen fibers to the
implant surface and the absence of
connective tissue insertion.3 There-
fore, when probing the peri-implant
sulcus, the probe goes beyond the ep-
ithelial seal and causes injury to sub-

jacent connective tissue.21 This causes
bleeding even if the inflammation is
absent,46 thus affecting the results of
clinical examinations of inflammation,
as those used in this study.
There is evidence that the incom-
patibility of bleeding signal with the
histological inflammatory condition in
peri-implant tissues may result from
the small number of blood vessels in
these tissues when compared with the
periodontal tissues. 3,47 Because of
these differences, the clinical indices
that evaluate bleeding and visual as-
pects, which sometimes successfully
reflect the real inflammatory degree in
periodontal tissues, may not be appli-
cable to peri-implant tissues. This
could explain our divergent results for
the lack of correlation of GI, mGI, and
SBI with the HI.
The significant correlation be-
tween mPI and HI found in this study
suggests that plaque accumulation
may be a good parameter to monitor
peri-implant healthy. This was the only
index that positively correlated with the
histological changes (Table 3). These
results agree with others that found a
positive correlation between the plaque
index and inflammation.16,23,24
Despite the positive correlation
between mPI and HI, the bacterial
analysis in this work did not demon-
strate statistically significant correla-
tion between the 3 studied species
with the inflammatory degree, in con-
trast with studies that documented
these bacteria as key pathogens in
periodontal and peri-implant dis-
ease.27,48 –50 The bacterial composition
of plaque is accepted as its pathogenic
factor.51 In this study, the lack of cor-
relation between the prevalence of the
bacterial species in the subgingival
plaque with the HI (Table 5) may be
explained by the sample size.
CONCLUSION
In conclusion, within the limita-
tions of a pilot study, our results suggest
that mPI may be used as an indicator
of the real inflammatory status in peri-
implant disease. Other indices, such as GI,
mGI, and SBI, which depend on probing
of the implant sulcus, did not show statis-
tically significant correlations with the HI.
IMPLANT DENTISTRY / VOLUME 18, NUMBER 4 2009
Additional studies are necessary to better
elucidate these points.
ACKNOWLEDGMENTS
The authors thank Daniele Santi Ceolin
and Tânia Mary Cestari for the excellent
technical assistance. This research was
partially supported by FAPESP (Process
No 02/09380-6).
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2404-2412.

Abstract Translations
GERMAN / DEUTSCH
AUTOR(EN): Samuel Barros Ferreira, Jr., DDS, Caio Már-
cio Figueiredo, DDS, MSc, Ana Lúcia Pompéia Fraga
Almeida, DDS, MSc, PhD, Gerson Francisco Assis, MSc,
PhD, Thiago José Dionísio, Carlos Ferreira Santos, DDS,
MSc, PhD.
Klinische, histologische und mikrobiologische Untersu-
chungsergebnisse bei Erkrankungen im das Implantat um-
lagernden Gewebe: Eine Pilotstudie
ZUSAMMENFASSUNG: Zielsetzungen: Diese Studie hebt
darauf ab, den Zusammenhang zwischen den klinischen Ken-
nzahlen in Bezug auf das Weichgewebe im das Implantat
umlagernden Bereich, der histologischen Grundvorausset-
zung und dem Vorhandensein von 3 unterschiedlichen Patho-
genen zu bestätigen, die Allgemeinhin mit Erkrankungen im
Bereich um das Implantat herum in Verbindung gebracht
werden [Aggregatibacter actinomycetemcomitans, Porphy-
romonas gingivalis sowie Tannerella forsythia]. Materialien
und Methoden: Vier klinische Kennziffern, der Zahn-
fleischindex (GI), der Sulcus-Blutungs-Index (SBI), der
Mombelli-Zahnfleischindex (mGI) und der Mombelli-
Plaque-Index (mPI), wurden bei jedem Patienten um ein
Zahnimplantat herum bewertet (n ⫽ 10). Unter dem Zahn-
fleisch liegende Plaque wurde zum Zweck der bakteriellen
Analyse (PCR) gesammelt. Außerdem wurde eine Biopsie
der Weichgewebsteile um das Implantat herum für eine his-
tologische Analyse erhoben. Die klinischen Kennziffern
sowie entdeckten Pathogene wurden mit einem eigens en-
twickelten histologischen Index (HI) in Verbindung gebracht.
Ergebnisse: Außer beim mPI im zentralen Bereich der lin-
gualen Seiten ergab sich keinerlei statistisch maßgebliche
Verbindung zwischen den klinischen Kennzahlen (GI, SBI
and mGI) und dem HI (r ⫽ 0.85, P ⫽ 0.0029). Allerdings war
eine Tendenz hinsichtlich einer Positivverbindung zwischen
dem mPI im zentralen Bereich der bukkalen Seiten und dem
HI (r ⫽ 0.63, P ⫽ 0.0544) zu beobachten. Eine Zählung der
 IMPLANT DENTISTRY / VOLUME 18, NUMBER 4 2009
Lymphozyten und Plasmozyten korrelierte positiv mit dem
HI. Man kann daher von einer Zuverlässigkeit des Index
ausgehen. Das Vorherrschen von A. actinomycetemcomitans,
P. gingivalis und T. forsythia ergab keine bedeutsame
Verbindung mit dem HI. Schlussfolgerungen: Trotz der
geringen Anzahl an Proben und der nur geringfügigen statis-
tischen Bedeutung scheint der mPI in der Bewertung unter-
schiedlicher entzündlicher Tendenzen im Weichgewebe um
das Implantat herum hilfreich zu sein. Dies wird durch dessen
Beziehung zum HI unter Beweis gestellt. Weitere Studien
sind zur nötig, um dieses Thema weiter zu verfolgen.
SCHLÜSSELWÖRTER: Peridontaler Index, Zahnfleischin-
dex, Plaque-Index, Blutungsindex, Erkrankung des das Im-
plantat umlagernden Gewebes
SPANISH / ESPAÑOL
AUTOR(ES): Samuel Barros Ferreira, Jr., DDS, Caio Márcio
Figueiredo, DDS, MSc, Ana Lúcia Pompéia Fraga Almeida,
DDS, MSc, PhD, Gerson Francisco Assis, MSc, PhD, Thiago
José Dionísio, Carlos Ferreira Santos, DDS, MSc, PhD.
Conclusiones clínicas, histológicas y microbiológicas en la
enfermedad periimplante: Un estudio piloto
ABSTRACTO: Propósito: Este estudio tiene por objeto veri-
ficar la correlación entre índices clínicos de los tejidos suaves
periimplante, la condición histológica y la presencia de 3
patógenos generalmente asociados con las enfermedades per-
implante [Aggregatibacter actinomycetemcomitans, Porphy-
romonas gingivalis y Tannerella forsythia]. Materiales y
Métodos: Cuatro índices clínicos, el índice gingival (GI por
sus siglas en inglés), el índice de sangramiento gingival (SBI
por sus siglas en inglés), índice gingival modificado por
Mombelli (mGI por sus siglas en inglés) y el índice de placa
modificado por Mombelli (mPI por sus siglas en inglés),
fueron evaluados alrededor de un implante dental de cada
sujeto (n ⫽ 10). Se recolectó la placa subgingival para el
análisis bacteriano (PCR por sus siglas en inglés) así como
una biopsia de los tejidos suaves perimplante para el análisis
histológico. Los índices clínicos y patógenos detectados se
correlacionaron con un índice histológico creado (HI por sus
siglas en inglés). Resultados: No existió una relación estadís-
ticamente significativa entre los índices clínicos (GI, SBI y
mGI) y el HI, excepto que el mPI en la zona central de los
aspectos linguales (r ⫽ 0,85, P ⫽ 0,0029). Existió una
tendencia a la correlación positiva entre el mPI en la zona
central de los aspectos bucales y el HI (r ⫽ 0,63, P ⫽
0,0544). La cantidad de linfocitos y plasmacitos se correla-
cionó positivamente con el HI, sugiriendo la confiabilidad del
índice. La prevalencia de A. actinomycetemcomitans, P. gin-
givalis y T. forsythia no presentó una relación significativa
con el HI. Conclusiones: A pesar de la pequeña cantidad de
muestras y el pobre significado estadístico, el mPI parece ser útil
ско
соолог, Caio Márcio Figueiredo,
para evaluar la severidad inflamatoria en el tejido suave alred-
ско
соолог, гс
341
edor de implantes dentales tal como lo demuestra su relación con
el HI. Se necesitan más estudios para aclarar este tema.
PALABRAS CLAVES: índice periodóntico, índice gingival, índice
de placa, índice de sangramiento, enfermedad periimplante
PORTUGUESE / PORTUGUÊS
AUTOR(ES): Samuel Barros Ferreira, Jr., Cirurgião-
Dentista, Caio Márcio Figueiredo, Cirurgião-Dentista, Mestre
em Ciência, Ana Lúcia Pompéia Fraga Almeida, Cirurgiã-
Denista, Mestre em Ciência, PhD, Gerson Francisco Assis,
Mestre em Ciência, PhD, Thiago José Dionísio, Carlos
Ferreira Santos, Cirurgião-Dentista, Mestre em Ciência, PhD.
Achados clı́nicos, histológicos e microbiológicos na periim-
plantite: estudo piloto.
RESUMO: Objetivo: Este estudo teve por objetivo verificar
a correlação entre ı́ndices clı́nicos de tecidos moles periim-
plantares, a condição histológica e a presença de 3 patógenos
comumente associados a periimplantites (Aggregatibacter
actinomycetemcomitans, Porphyromonas gingivalis, and
Tannerella forsythia). Materiais e Métodos: Foram avaliados
quatro ı́ndices clı́nicos, ı́ndice gengival (GI), ı́ndice de san-
gramento do sulco, GI modificado por Mombelli e ı́ndice de
placa modificado por Mombelli (mPI) ao redor de um im-
plante dentário de cada indivı́duo (n ⫽ 10). Placa subgengival
foi coletada para realização de análise bacteriana (reação em
cadeia da polimerase) e biópsia de tecidos periimplantares foi
retirada para análise histológica. Foi realizada análise de
correlação dos ı́ndices e patógenos detectados com um ı́ndice
histológico desenvolvido (HI). Resultados: Não foi encon-
trada correlação estatisticamente significativa entre os ı́ndices
clı́nicos (GI, ı́ndice de sangramento do sulco e GI modificado
por Mombelli) e o HI exceto para o mPI na área central das
superfı́cies linguais (r ⫽ 0,85, P ⫽ 0,0029). Houve tendência
de correlação positiva entre o mPI na área central das super-
fı́cies vestibulares e o HI (r ⫽ 0,63, P ⫽ 0,0544). A contagem
de linfócitos e plasmócitos correlacionou-se positivamente
com o HI, sugerindo assim a confiabilidade do ı́ndice. A
prevalência de A. actinomycetemcomitans, P. gingivalis, e T.
forsythia não apresentou correlação positiva com o HI.
Conclusões: Apesar do pequeno número de amostras e a
fraca significância estatı́stica, o mPI parece ser útil para
avaliar a gravidade da inflamação no tecido mole ao redor de
implantes como demonstrado pela correlação com o HI. Es-
tudos futuros são necessários para elucidar este assunto.
PALAVRAS-CHAVE: ı́ndice periodontal, ı́ndice gengival,
ı́ndice de placa, ı́ndice de sangramento, periimplantite.
RUSSIAN /

О: Samuel Barros Ferreira Jr., доко
уг
доко уг
342 PERI-IMPLANT DISEASE • FERREIRA JR et al

сс ук, Ana Lúcia Pompéia Fraga Almeida, к окуг уб ло,
о бло
доко уг
ско соолог, гс одосоо го ос с
сс ук, доко флософ, Gerson Fran- окл HI. Дл об&с дого фк
cisco Assis, гс сс ук, доко обод дл % сслдо.
флософ, Thiago José Dionísio, Carlos Ferreira Santos,
доко уг
ско соолог, гс КЛ $ СЛО
: одол дкс,
сс ук, доко флософ. дс дкс, дкс убого к, дкс ко-
ул  клск, гсологск  оо
ос, ло бол
кобологск сслдо  
л  о  бол : д ло
сслдо 
TURKISH / TÜRKÇE
 !:
л. До сслдо  л YAZARLAR: Samuel Barros Ferreira, Jr., DDS, Caio Márcio
одд кол ду кл
ск Figueiredo, DDS, MSc, Ana Lúcia Pompéia Fraga Almeida,
окл л гк к , DDS, MSc, PhD, Gerson Francisco Assis, MSc, PhD, Thiago
гсолог
ск сосо  л
 3 José Dionísio, Carlos Ferreira Santos, DDS, MSc, PhD.
ог коого, с с Peri-implant hastalığında klinik, histolojik ve mikrobiy-
л бол [Aggregatibacter olojik bulgular: Bir pilot çalışma
actinomycetemcomitans (A.a), Porphyromonas gingivalis
(P.g.)  Tannerella forsythia (T.f.)]. !  л  ÖZET: Bu çalışma, peri-implant yumuşak dokularının klinik
од.  кл
ск окл: дс indeksleri, histolojik durum ve yaygın olarak peri-implant
дкс (GI), дкс кооо
ос дсо hastalıkları ile bağlantılı 3 patojenin [Aggregatibacter actino-
боод (SBI), дс дкс, одфо mycetemcomitans, Porphyromonas gingivalis and Tannerella
облл, (mGI)  дкс убого к, одф- forsythia] varlığı arasındaki korrelasyonu araştırmak am-
о облл, (mPI) олс окуг acıyla hazırlandı. Gereç ve Yöntem: Her bir hastanın bir
одого убого л у кдого у
ск dental implantı için dört klinik indeks değerlendirildi (n ⫽
сслдо (n ⫽ 10). Бл соб об 10). Bunlar Gingiva İndeksi (Gİ), Sulkus Kanama İndeksi
оддсого убого к дл бклого (SKİ), Mombelli tarafından değiştirilen Gingiva İndeksi
л (PCR),  к од бос (mGİ) ve Mombelli tarafından değiştirilen Plak İndeksi (mPİ)
л гк к дл idi. Bakteri analizi (PCR) için subgingivadan plak örneği
гсолог
ского л. Кл
ск окл alındığı gibi, histolojik analiz için peri-implant yumuşak
 л ог коог бл dokularından biyopsi de alındı. Klinik indeksler ve bulunan
соос с д гсолог
ск patojenlerin arasındaki korrelasyon, geliştirilmiş histolojik
окл (HI). ул . " удлос об- bir indeksle (Hİ) incelendi. Bulgular: Klinik indeksler (Gİ,
у сс
ск 
о ос ду SKİ, ve mGİ) ile Hİ arasında istatistiksel açıdan önemli bir
кл
ск окл (GI, SBI  mGI)  bağlantı bulunmadı. Buna tek istisna, merkezi lingual alanın
окл HI,  скл
 дкс mPI  mPİ değeri idi (r ⫽ 0.85, P ⫽ 0.0029). Merkezi bukkal
ло облс  
 соо (r ⫽ 0,85; alandaki mPİ ile Hİ arasında olumlu bir korrelasyon eğilimi
p ⫽ 0,0029). Бл л д к saptandı (r ⫽ 0.63, P ⫽ 0.0544). Lenfosit ve plazmosit
ололо кол ду дксо mPI  sayımları, Hİ ile olumlu korrelasyon göstererek indeksin gü-
ло облс  #
 соо  venilirliğine işaret etti. A. actinomycetemcomitans, P. gingi-
окл HI (r ⫽ 0,63; p ⫽ 0,0544). Кол
со valis ve T. forsythia patojenlerinin yaygınlığı Hİ ile önemli
лфоо  лоо ололо düzeyde bir bağlantı göstermedi. Sonuç: Örnek sayısının ve
кололос с окл HI,
о оол istatistiksel açıdan önemin az olmasına rağmen mPİ, dental
доло дос окл. Уо implantların etrafındaki enflamasyonun düzeyini değer-
сос ог коого A.a, lendirmek açısından mPİ’nin Hİ ile ilişkisinden de görüldüğü
P.g.  T.f.  ол 
о ос с gibi yararlı bulundu. Bu konunun açıklığa kavuşturulması
окл HI. од. "со  бол%о için daha fazla sayıda çalışmalar gerekmektedir.
кол
со об  ку сс
ску 
-
ос, о-доу, дкс mPI о окс ANAHTAR KELİMELER: periodontal indeks, gingiva in-
ол дл ок сос осл гк deksi, plak indeksi, kanama indeksi, peri-implant hastalığı
 IMPLANT DENTISTRY / VOLUME 18, NUMBER 4 2009 343

JAPANESE /

CHINESE /
344 PERI-IMPLANT DISEASE • FERREIRA JR et al

KOREAN /