Peri-Implantitis:

Prevalence, Practical Treatment and Prevention

Prevalence, Practical Treatment and Prevention

Dr. Scott K. Smith

November 13, 2013
 Scott K. Smith

• Practicing Periodontist 20 years

• Placed over 10,000 implants
• HiOssen lecturer, teacher and Instructer
 Objectives
• Define Peri-Implant Mucositis and Peri-
Implantitis
• Prevalence of each
• Pathogenesis vs. Periodontal Disease
• Diagnostic Criteria
• Treatment for mucositis and implantitis
• Maintenance following treatment
 Conflict of Interest

• HiOssen - Clinical practice support and

honorarium.
Dental Implant Success
• 400,000 implants placed per year in US
• 1 million implants placed per year in EU
• $6.5 billion US industry
• Failure Rate of Implants less than 5%
• Industry and Research Focus on Initial
Stabilization, enhancing supporting
structure and Initial Esthetics.
 The Dark Side
• Incidence of Peri-implant mucositis and
Peri-implantitis is as much as 47%!!
• Failure of Implants by Chronic Inflammation
include Functional loss, Phonetic and
Esthetic Challenges
• Professional Challenge
 Similarity with
Periodontal Diseases
• Host Response to Bacterial Insult
• Initial Event is Inflammation of Pocket
Epithelium without CT or Bone
Destruction - Reversible = Gingivitis
• Chronic Inflammation and Risk Factors =
Periodontitis
Implant Related Periodontal
Diseases

• Peri-Implant Mucositis
• Peri-Implantitis
Peri-Implant Mucositis
• The presence of inflammation
confined to the soft tissues around
the implant - No sign of bone loss.
• Presence of probing >4mm with
bleeding or suppuration
• Reversible
 Peri-Implantitis
• Inflammatory process around and implant
including soft tissue and progressive loss of
supporting bone beyond biological bone
remodeling.
• Probing depth >4mm with bleeding,
suppuration and radiographic bone loss
 Peri-Implantitis

Probing depths >4mm with bleeding, suppuration

Radiographic loss of bone beyond remodeling
 Prevalence:
Peri-Implant Mucositis
Peri-Implant Mucositis
• Berglundh, Renvert:
48% of all implants over 9-14 yrs affected.
• Prevalence may be higher - Previous
Dogma of Not Probing around Implants
Reduced Identification
 Prevalence:
Peri-Implantitis
Peri-Implantitis
• Wide Range: from 4.7% to 36.6%
• The Threshold used is Bone Loss. No
standarized radiographic analysis.
• Additionally Factors such as Smoking,
Diabetes, Previous Periodontal Disease
create subpopulations and complicate
comparisons of studies.
Periodontal Anatomy
 Anatomy of a Tooth
• Junctional Epithelium has Hemidesmosomal
attachment to enamel
• Connective tissue array of 1mm thickness with
attachment to Cementum
• Alveolar Bone with Perpendicular Fibers attaching
to Cementum overlying Dentin
• Vast Source of Nutrients and Cells for
Regeneration of Ligament, CT, Cementum, Bone
 Cementum

• Acellular and Cellular containing

cementoblasts provide support on the
tooth side to anchor sharpy’s fibers
• Periodontal Ligament space provides
nutrient supply and cells for Regeneration
 Anatomy of an Implant
• Junctional Epithelium attached to titanium
surface by basal lamina and hemidesmosomes
• At apical portion of sulcus is only a few cell
layers thick and separated from bone by 1-
2mm
• No Cementum - Bone to Implant Contact
• Connective tissue between JE and Bone few
vascular structures and few Fibroblasts
Pathogenesis
 Peri-Implant Mucositis

• Plaque formation of titanium surface and

formation of biofilm. Gram (-) Anaerobic
• Inflammatory infiltration occurs in CT
• Neutrophils, lymphocytes, macrophages in
high numbers
• Adaptation of JE to Inflammation
 Peri-Implantitis
Peri-Implantitis
• Inflammatory - bacterial driven destruction
of the implant supporting apparatus.
• Chronic Inflammation starting as PIM
• Inflammatory Cell Infiltrate more Severe
with Implants vs. Teeth
• Rate of Disease Progression Faster with
Implants
 Peri-Implantitis

• The difference in collagen fiber orientation

(parallel to implant and perpendicular with
teeth) and less vasculature structure may
explain the faster pattern of tissue
destruction with peri-implantitis.
 Influential Factors

• Patient Related - systemic diseases, history

of Periodontal Disease
• Social Factors - Poor OH, Smoker, Heavy
alcohol consumption
• Parafunctional Habits - Bruxism,
Malocclusion
 Smoking

• Baig and Rajan found in smokers

significantly more marginal bone loss after
placement and higher Peri-Implantitis
percentages.
Previous Periodontitis

• Significant correlation with increased

prevalence of Peri-Implantitis
 Genetic Factors

• Significant correlation with

Interleukin1gene polymorphism and Peri-
Implantitis.
• Plagnat - proposed markers for Elastase
and alkaline phosphatase may be helpful in
future diagnosis of bone destruction.
 Health Status

• Diabetes Type I and II if uncontrolled lend

to increased inflammatory Response and
Peri-Implantitis
 Occlusion

• Non-axial forces, cantilevers, bruxism

• H.L.Wang et al - occlusal overload
positively associated with Peri-Implantitis
• Likely excess strain causes microfracture
within bone.
 Additional Influential
Factors -You’re to Blame

• Implant Design
• Prosthetic Connection
• Mechanical Failures and Cement
Contamination
• Surgical Errors
 Implant Design

• Smooth titanium vs. Roughened

surfaces
• Smooth Cervical collar vs. Surface
texture to coronal margin
• Thread Design - aggressive vs. passive
 Implant Design -
Connection
• External Hex
• Internal Hex
• Morse Taper
• Platform Switch
 Platform Design
• Crestal Bone loss begins when healing
abutment is attached to implant at second
stage surgery (Nobel implants - Ericsson J.
Clin. Perio 1995)
• Burglund and Lindhe identified 0.5mm
inflammation above and below Branemark
implants at abutment/implant junction after
2 weeks.
Microgap and Platform
Switching

• Move the microgap away from the implant

platform and hence away from the crestal
bone as a protective measure.
 Restorative Problems

• Excessive Cantilever
• No Passive fit
• Improper fit of abutment
• Improper prosthetic design, occlusal scheme
• Premature Loading, Overtorquing
• Connecting implants to Natural teeth
Mehcanical Failures
Fractured Implants
Loosening of Screws
Retained Cement
 Surgical Placement
• Off Axis Position - severe angulation,
• Lack of Initial Stabilization
• Infection from improper flap design
• Overheating bone
• Spacing too close to teeth or implants
• Inadequate bone or attached gingiva
• Too Buccal or Lingual and compromise bone
Inadequate Attached
Gingiva
Inadequate Buccal Bone
Space Between Teeth
and Implants
Head of Implant
ANGULATION
Buccally Positioned
 Heat Generation

• Eriksson and Albrektsson reported the

critical temperature for implant placement
was 47C for 1 minute.
• Matthews and Hirsch demonstrated that
temperature elevation was more a result of
force applied rather than drill speed.
 Diagnostic Criteria
• Probe all implants - Plastic or Metal
• Look for Bleeding and or Suppuration
• X-rays should be taken yearly first two
years and compared to base line placement
• Evaluate Occlusion, Prosthetic Stability
• Soft tissue evaluation - Attached Gingiva?
Probing
Probe Long Axis
 Accessibility

• Adjust Prosthesis
• Plaque Control
• Biofilm Removal
How do you Probe
this?
Remove Prosthetic
Bone Level
Attached Gingiva?
 Treatment Options

• Early Detection is Key to Success and

improved health!
• Non-surgical Intervention
• Surgical Intervention
 Non-Surgical - Studies
• Mechanical Debridement with plastic instruments
and Chlorhexidine irrigation showed reduction of
pocket and bleeding at six months - Schwartz
• Antiseptic irrigation of pockets <4mm not
effective, but over 5mm it has added effect.
Renvert
• Adjunctive use of generalized antibiotics did not
improve the treatment results
Peri-Implant Mucositis -
Transmucosal
Transmucosal
Peri-Prosthetic
Peri-Prosthetic
Peri-implant Mucositis

• Application of Minocycline spheres along

with debridement provide some additional
benefit to reducing bleeding and probing,
but NEEDS TO BE REPEATED OFTEN.
Renvert
 Clinical Treatment of PIM
• Mechanical Scaling of Implants with plastic or
titanium instruments or Ultrasonic Plastic
Tips. I-Brush if exposed threads.
• Apply exposed implant surface with 0.2%
Chlorhexidine gauze for 2 mins
• Subgingival irrigation with 0.2%
Chlorhexidine 5ml per implant
• Minocycline Spheres or Gel
 Peri-Implantitis
Treatment Options
Treatment Options

• Visualization with open flap very effective

with cementitits!
 Peri-Implantitis
• Treatment to be determined by amount of bone
loss and esthetic impact of the implant in question
• If minimal bone loss (3 threads or less) Proceed
with similar treatment as Peri-implant mucositis,
but decontaminate prosthetic components as well.
The use of various lasers has been suggested.
• If bone loss is advanced or progressive than
surgical access with resective or regenerative
components will need to be employed.
 Peri-Implantitis
Non Surgical - Studies
Non Surgical - Studies
• 31 Subjects mean age 62
• One qualifying implant per patient
• PPD >4mm with bleeding or suppuration
• < 2.5mm bone loss
• J. Clin. Perio 2009 Renvert
 Non-Surgical

• Titanium hand instrumentation

• Or Ultrasonic Debridement with plastic tip
• 6 month results - minimal change with PD
for either treatment modality
Laser Therapy Er:YAG
• SRP with plastic instruments and 0.2%
chlorhexidine followed by Er:YAG 20sec
disinfection per implant
• Control was only SRP and antiseptic rinse
• Six months later Equal Reduction of Pocket
and Clinical Attachment
• Twelve months later both groups lost effect
Peri-Implantitis with Er:YAG vs.
Air-Abrasive device
• 42 Patients mean age 69
• Laser 55 implants
• Perio Flow 45 implants
• PPD >5mm with bleeding or suppuration
• > 3mm bone loss
• J. Clin Perio 2011, Renvert
 Results

• Remove Supra-Structure from Implants!

• Significant difference in PD bleeding and
Pus reduction for both groups at 6 months
• Both seem to have limited benefit in
advanced cases
Open Flap - Resective
• Surgical flap access and resection of 1 or 2 wall
defects combined with decontamination and
antibiotic treatment was effective in just over
half the cases over 5 years. Leonhardt 2003
• 2008 Hitz-Mayfield with flap surgery and
resection and antimicrobial treatment stopped
the progression of the disease in 90% of cases
up to one year - However, BOP continued in
50% of the lesions.
 Regenerative Surgery

• Schwartz (2008) found combination bone

grafting debridement and antibiotics had
significant reduction of bone loss and BOP
after 2 years.
• Froum (2012) Significant reduction of BOP,
Pocket reduction, bone loss over 3-7 years.
Submerged Healing -

• 16 implants in 12 patients
• Open Flap and 3% Hydrogen Peroxide
• Bone Graft and Membrane
• Submerged healing
• Roos-Janasker J. Clin Perio 2007
 Submerged Surgical
Results
• PD change 4.2mm
• Defect fill (threads) 3.8
• Defect Fill (mm) 2.3
• Recession (mm) 2.8
Implant Configuration
and Decontamination
• Implant contours and surface are a limitation
to remove the biofilm
• Surface treatments including - mechanical,
Er:YAG, photodynamic, air-abrasion,
implantoplasty
• Romeo (2005, 2007) implantoplasty improved
regenerative capability - reducing probings
from 5.5 - 3.6mm and BOP.
Implantoplasty
 Regenerative Treatment for Peri-
Implantitis affected implant:
Stuart J. Froum Clin Adv Perio 2013
Stuart J. Froum Clin Adv Perio 2013

• 7 year follow up showed decrease pocket

depths
• Technique successful in 51 cases (IJPRD
2012:32:11-20)
• Believes if any Elements of protocol not
followed could compromise outcome
 Protocol

• 1 month prior to surgery: SRP of natural

teeth; debride implant surface and OHI
• Requires 2 visits to accomplish this
 Surgery:
Exposure and Debridement
Exposure and Debridement
• 2 gm Amox 1 hour prior to surgery
• FTF to expose area
• Debride defect with titanium and graphites
• Air-Power abrasives (Bicarbonate powder) for
60 secs
• 60 secs irrigation with sterile saline
• 60 secs application of Tetracycline strips
 Surgical Protocol

• Second application of air-powder abrasive

for 60-90 secs
• Application of CHX for 30 secs
• 60-90 secs of sterile saline with air power
device no powder
 Surgical Protocol
• EMD applied - avoid blood and saliva
• Defect filled with 1:1 Bioss/Puros
rehydrated with gem 21
• 2 ossix membranes placed to cover all
surfaces
• Flap released and coronally advanced and
sutured with Goretex and vicryl sutures
 Post Surgery

• 2 weeks remove sutures and polish

• Pt to brush area 4x/day with 1:1 Peroxide
and rinse with salt water 4x/day
• Return monthly for 12 months for post op
and every 6-8 weeks for maintenance
Treating Peri-Implantitis
• Systemic Antibiotics for three days prior to
treatment
• 2 mins pre-operative rinse with
Chlorhexidine
• Full Thickness Mucoperiosteal Flap to one
tooth beyond diseased site
• Thorough Debridement circumfirentially with
plastic or titanium or Ultrasonic plastic tips
Treating Peri-Implantitis
• Pack Gauze Strips soaked with CHX around
implants and in defects for 5 mins
• Remove Gauze and irrigate with CHX or
Tetracycline 250mg/5cc
• Graft Defect with FDBA, BioOss
• Apply Collagen Membrane
• Closure of Flap and Regular Post op Intervals
 Detoxify

• HCL Acid
• Tetracycline
• EDTA
• Hydrogen Peroxide
• Er:YAG and Diode
 Graft Material
• Need OsteoInductive Material as there is
minimal Osteoprogenetor cells
• FDBA, DBA, Acel, OsteoCel, BMP2, Gem-
21, PRP, Emdogain
• Collagen Matrix Necessary
• Tacks to hold membrane if necssary
 Mechanical
Debridement
I-Brush
Retrograde
 LAPIP
• Nd:YAG laser with LANAP protocol to
address peri-implantitis
• Closed access
• First pass to decontaminate and selectively
eliminate infected tissue
• Debride with Piezon and CHX
• Second pass with laser to provide fibrin clot
LAP-IP
LAP-IP
LAP-IP
LAP-IP
Peri-Implantitis Effects

• Loss of implant and functioning prosthetics

• Esthetic Challenges
• Phonetic Challenges
• Maintenance Challenges
 Prosthetic and
functional failure
Prevention Is The First
Step:
• Avoid conditions that contribute to poor
results
• Choose cases where you have excellent chance
for implant and prosthetic success.
• Anticipate and Diligently observe for implant
and restorative problems.
• Once Perio-Implant Disease identified act
quickly and with purpose to effectuate the
situation
 What I see
• Retained Cement
• Inadequate attached gingiva
• Position of implant - Too Buccal
• Position of implant - Too Close to others
• Occlusal Overload
• Loss of Attached Gingiva Anterior
• Poor Oral Hygiene - Inability to get access
Hybrid Screw Retained
Vs. Implant Denture
Accessibility
Access for patient?
Proximity Issues
 Implant Maintenance

• Needs to be Individually Determined

• Needs to be Enforced by Doctor and
Hygienist
• Patient Needs to assume Responsibility
 Low Risk Patient

• Highly motivated
• Excellent Oral Hygiene
• One or Two implants
• No associated Risk Factors
Moderate Risk Patient

• Loss of Motivation
• Fair Oral Hygiene
• 3-6 implants
• Moderate Smoker (half pack)
• Controlled Medical Issues
 High Risk Patient
• Unmotivated
• Poor Oral Hygiene
• Previous Periodontitis
• >6 implants
• Smokes more than half Pack
• Poorly Controlled Systemic Disease(s)
 Maintenance Recall
• Low Risk Patients - every 6 months
• Moderate Risk - every 3 months
• High Risk - every 2-3 months

• Note - Oral Hygiene signficantly influences

the category the patient is placed.
 Mechanical
Debridement
Hand Scalers and Ultrasonics
 Maintenance
• Plastic, titanium, graphite instruments for
visual debridement from prosthetics and
sulcus.
• Ultrasonics with plastic tips at low to
moderate settings are excellent
• Individual or multiple implants with fixed
crowns or bridges screw or cemented
assess and debride as you would teeth.
 Maintenance

• For Fixed Hybrid cases Remove at least

Twice a year and assess and debride
Transmucosal and Prosthetic underside
• O rings Remove Denture and address
abutments directly
 Maintenance

• Polish with soft rubber tip and non-abrasive

paste - aluminum oxide, tin oxide, fine
pumice
• Irrigate with CHX with endodontic syringe
or piezon on low setting.
 Ancillary Homecare

• Periostat - Doxycycline 20mg b.i.d.

• Evorapro - Especially for Dry Mouths
• Perio-science AO gel and rinse
• Listerene if no dry mouth 2x/day
• Biotene if dry mouth 2x/day
Likely Cause?
Etiology?
Thank You