14 PERI - IMPLANTITIS · of peri-implantitis. Both non-surgical and surgical methods are used to treat implant affected by peri-implantitis. Through this article, we attempt to review

ABSTRACT : Replacement of lost natural tooth by osseo-integrated implant has modernized the

practice of dentistry.Even though there is long shelf life of a dental implant, peri-implantitis signifies the

most important problem which can compromise the long-term success and survival of implant-supported

rehabilitations. The microflora of dental peri-implantitis comprises mainly of anaerobic gram-negative

cocci and bacilli that resemble the chronic periodontitis microflora.Elimination of risk factors likes

smoking, poor oral hygiene, diabetes etc. and long-term maintenance care is essential to reduce the risk

of peri-implantitis. Both non-surgical and surgical methods are used to treat implant affected by peri-

implantitis. Through this article, we attempt to review etiopathogenesis, risk factors, early diagnosis and

intervention which will contribute to more effective prevention and management of peri-implantitis.

1 2 3 4Vineeta Gupta, Sonia Gupta, Nutan Tyagi, Akansha Misra1Professor and Head, Department of Oral Pathology and Microbiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar2Post Graduate Student, Department of Oral Pathology and Microbiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar3Reader, Department of Oral Pathology and Microbiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar4Senior Lecturer, Department of Oral Pathology and Microbiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar

INTRODUCTION : Replacement of the lost teeth is essential to maintain the occlusal function, optimum oral health, esthetics, phonetics, facial support and masticatory needs. Various methods like removable partial denture, fixed partial denture, and complete denture are being used since decades for replacement of missing teeth with natural or synthetic substitute. But all the methods have some problems which has lead to a new era in oral rehabilitation with the introduction of osseointegrated dental implants. Nowa days, dental implants supporting fixed restoration have become a frequent replacement for missing teeth.Patient expectations have risen considerably seeing the possibility of avoiding removable prosthesis as a treatment option (1, 2).

Dental Implant is a prosthetic device made of inert, alloplastic materials implanted into the oral tissues beneath the mucosal layer within the bone to replace missing teeth which have been lost as a result of poor oral hygiene, trauma, sports injury, bruxism, neoplasia, traumatic occlusion, genetic

predisposition, congenital defect, systemic disease and lack of nutrients. It is also used as a support for fixed or removable dental prosthesis. The implant is not only biocompatible but attached to bone through a complex phenomenon known as osseointegration. This process occurs due to continuous modelling and remodeling of bone (3, 4).

Besides high survival success rate of dental implant, failures orcomplications associated with dental implant placement have been documented. On the basis of osseointegration concept(5) and chronology(6, 7), oral implant failures have been classified as shown in [Table1&2]:-

PERI-IMPLANT DISEASE : The 6th European workshop on periodontology held in 2008 defined peri-implant diseases as the inflammatory lesions that develop in the tissues around implants. Peri-implant disease includes peri-implant mucositis and peri-implantitisthat affect the mucosa and surrounding bone respectively (8, 9). Peri-implant mucositis is defined as a bacteria-induced

PERI - IMPLANTITIS : AN OVERVIEW

Keywords :Peri-implant disease, Implant failures, Peri-implant mucositis

Source of support : NilConflict of interest: None

Journal of Dental Sciences

University

University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 80

University J Dent Scie 2016; No. 2, Vol. 1

ReviewArticle

reversible inflammatory reaction which is confined to the soft tissues surrounding a functioning implantwithout signs of loss of surrounding bone and follows early bone remodeling during healing.Whereas,peri-implantitisis an inflammatory reactionaround an implant in function associated with loss of bone support and soft tissue inflammation (10, 11). The term peri-implantitis was first introduced in literature by Mombelli et al (12)in 1987. Zitzman et al in 2008 (10), based on the results of their study putforththat frequencies of peri-implant mucositis were estimated in 80% of the participants and 50% of implants and those of peri-implantitiswere 28-56% of the subjects and in 12-14% of implants. A study carried out by Atieh et al in 2013 (13) showed that peri-implant mucositis was observed in 63.4% of the patients and in 30.4% of implants, whereas peri-implantitis occurred in 18.8% of the patients and in 9.6% of implants.

ETIOPATHOGENESIS AND RISK FACTORS : Implant mucosa is bounded by a stratified squamous epithelium which is continuous with junctional epithelium and attached to the titanium surface by basal lamina and hemidesmosomes. The junctional epithelium which is non-keratinised is 2mm long and separated from alveolar bone in the apical region by 1-2mm of collagen rich connective tissue [Figure-1].This 3- 4 mm thickness forms a biological barrier and provides protection to the osseointegration zone from plaque and oral cavity (14, 15). In between, the junctional epithelium and alveolar bone, the connective tissue compartment consists of comparatively larger amount of collagen and a small number of fibroblasts along with scarcity of blood vessels. The fibroblasts-rich barrier formed in relation to titanium implant has a high turnover rate and fibroblasts play an important role in creating and maintaining mucosal seal (16).

Within few seconds after the placement of implant, a thin saliva-derived layer consisting of glycoproteins, proline-rich proteins, phosphoproteins and histidine-rich proteins becomes attached to the exposed surface of titanium along with colonization of bacteria (17, 18). Microbial colonization around the implant and subsequent inflammatory reaction are the key events involved in the pathogenesis of peri-implant diseases.This results in irreversible tissue destruction.Peri-implant mucositis corresponds to gingivitis around the natural teeth. Biofilm formation plays an important role in initiation and advancement of peri-implant disease and is necessary for the progression of infections around the dental implant. Peri-implant mucositis is the forerunner of peri-implantitis (19-23). Lipopolysaccharides present in the cell wall of gram-negative bacteria stimulate T-lymphocytes, monocytes and macrophages to release cytokines in local inflammatory tissue infiltrates which play an important role in the development of peri-implant disease. Cytokines are

glycoproteins and act as regulatory molecules at both local and systemic level. IL-1, IL-6, IL-8, IL-12 and TNF-á act as proinflammatory factors which are responsible for bone resorption whereas IL-10 has anti-inflammatory function (24, 25).

The microorganisms which are commonly associated with peri-implant diseases are the gram-negative anaerobes such as Prevotella intermedia, Porphyromonasgingivalis, A c t i n o b a c i l l u s a c t i n o m y c e t e m c o m i t a n s , B a c t e r i o i d e s f o r s y t h u s , Tr e p o n e m a d e n t i c o l a , Prevotellanigrescens, Peptostreptococcus micros and Fusobacterium nucleatum (26). Microbial shift(27) can be identified by comparing the microbiota in health, gingivitis and periodontitis and risk factors(3, 9, 28)associated withperi-implant diseases as shown in [Flowchart 1, 2].

CLINICAL FEATURES AND DIAGNOSIS : In the early stages, peri-implant lesions are asymptomatic and generally discovered on recall appointment. The clinical features of peri-implant mucositis are redness of mucosa, bleeding on probing, loss of clinical attachment i.e. distance from cementoenamel junction to the base of pocket <(less than) 3mm, pseudo-pocket formation on probing and no peri-implant radio-transparency. Pain, swelling, bleeding on probing, loss of clinical attachment >(more than) 3mm, pseudo-pocket formation on probing, suppuration and mobility (later) are the features associated with peri-implantitis (27, 29).

Diagnosis of peri-implant diseases includes (5, 8, 9, 30) probing parameters, radiographic assessment, peri-implant crevicular fluid and salivary analyses. These can be summarized as follows:-

1. Probing is an important tool for the analysis of peri-implant health and disease.

2. Periodontal probing [Figure-2] is done by means of a light force of 0.25N that doesn't cause injuryto the peri-implant tissues. This can be done by periprobe.

3. Presence of bleeding on probing or suppuration indicates inflammatory response of tissue due to the formation of biofilm and is used as an interpreter for tissue support loss.

4. Probing depth should be measured regularly by using light force of 0.25N for the diagnosis of peri-implant diseases.

5. Good quality of radiograph to determine the loss of surrounding bone.

6. Determination of biochemical markers in peri-implant fluid and saliva are not considered asimportant diagnostic tool for peri-implant diseases.



Histopathological observations of biopsy material show abundant amount of mixed inflammatory cell infiltrate in the peri-implant mucosa that extend to the apical portion of pocket epithelium.In about 60% of the lesions, inflammatory cells are presentamongst which plasma cells predominate [Figure 3]. Various authors have reported that polymorphonuclear cells are evident in the connective tissue areas adjacent to the epithelium of pocket and in the perivascular zone in the more central regions of the inflammatory cells infiltrate (14, 31).

Immuno-histochemical analyses reveal that significantly larger and greater proportions of B cells (CD19) and elastase-positive cells are present in the peri-implantitis lesions than mucositis lesions. Peri-implantitis sites constantly showed the presence of elastase-positive cells in the central portions of the infiltrate as compared to the sites with mucositis (32).

Table 1: Osseointegration concept of oral implant failures [5]

Table 2: Chronological basis of dental implant failures [6, 7]

Figure 1: Schematic diagram showing relation of implant mucosa (OE- Oral epithelium, JE- Junctional epithelium, I- Implant, AB- Alveolar bone, CT-Connective tissue)

Flow chart 1: Microbial shift during disease

Flowchart 2: Risk factors for peri-implantitis and peri-implant mucositis

Figure 2: Schematic diagram showing peri-implant probing (A- Abutment, PP- Periprobe, I-Implant, B-Bone, AL- Attachment level, PD-Probing depth)

Types of failure

1. Biological a. Early or primary (before loading) b. Late or secondary (after loading

2. Mechanical

3. Iatrogenic

4. Inadequate patient adaptation

Effects

Failure to establishosseointegrationFailure to maintain the achieved osseointegration

Failure of implants, connecting screws, bridge frameworks, coatings etc.

Nerve damage, wrong alignment of implant, sinus perforation, devitalization of adjacent teeth etc.

Phonetical, aesthetical, psychological problems etc.

Types of failure

1. Early

2. Late

Cause

Surgical trauma, inadequate bone volume, lack of primary stability, intraosseous infection and bacterial contamination of receptor zone

Microbiological (peri-implantitis) and biomechanical changes (occlusal overload)

OE

CT

AB

I

JE

A

PP

I

B

PD

AL



Figure 3(A&B): Schematic sketch of a peri-implant lesion. Note the apical extension of ICT (inflammatory cell infiltrate). B) Photomicrograph section from experimental implantitis lesion showing the outlined area in A. See the inflammatory cells close to the bone and the osteoclasts on the bone surface [14].

TREATMENT :The treatment protocols followed takes into consideration the points mentioned below:-

1. Debridement or detoxification of implant surface(33-37) are essential to eradicate infection, resolve inflammation and make the implant surface favorable for bone regeneration and re-osseointegration by means of

a. Mechanical agents such as abrasive air powders, implantoplasty with rotary instrumentation, curettes, power instrumentation with specialized plastic tips etc.

b. Chemical agents like chlorhexidine, local and systemic antibiotics etc.

c. Photodynamic therapy and lasers like Er:YAg (Erbium-Doped Yttrium Aluminium Garnet), Co2 (Carbon dioxide) and diode lasers

2. Surgical procedures like open flap debridement with osseous recontouring and apical flap positioning are essential for the decontamination and smoothening of the implant surface (38).

3. Use of bone grafts and its substitutes with or without the use of barrier membranes like e-PTFE (expanded polytetrafluoroethylene) act as an adjuvant to surgical treatment (38).

CONCLUSION : The goal of modern dentistry is to rehabilitate the patient oral health in a predictable fashion. Dental implants have been reported to be successful means of rehabilitation in patients with tooth loss, but the amount of crestal bone loss followed by implant placement should be taken into account. For patients who are at risk for peri-implantitis, appropriate maintenance protocol should be pursued. It is advisable to diagnose implant mucositis lesions at an early stage otherwise this lesion can progress to peri-implantitis. If not properly managed, this will result in loss of function and esthetics.

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CORRESPONDENCE AUTHORS :Dr. Sonia GuptaPost Graduate StudentDepartment of Oral pathology and microbiology; IDST College, Kadrabad Modinagar, -201201Email- [email protected]



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14 PERI - IMPLANTITIS · of peri-implantitis. Both non-surgical and surgical methods are used to treat implant affected by peri-implantitis. Through this article, we attempt to review