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PERI-IMPLANT INFECTIONS
Clinical periodontology and implant dentistry, 6th edition, Chapter 11
Presented by:
Mostafa Montazeri - Resident of Periodontics, IAU Tehran
Introduction
Peri-implant infections:
1. Peri-implant mucositis Clinical signs of inflammation (BOP)
without bone loss
2. Peri-implantitis
Concomitant loss of supporting bone
– Pocket depths ≥ 5mm
– Suppuration
Introduction
Risk factors for peri-implant infections:
1. Material surface characteristics
2. Local environment (Resident oral microbiota)
3. Reconstruction design (and its accessibility for oral hygiene)
Peri-implant biofilm formation
Endosseous part of implant:
1. Should ideally be surrounded by bone
2. Usually not exposed to biofilm
Transmucosal part of implant:
1. Exposed to oral cavity
2. Rapidly colonized by microorganisms They attach to
salivary proteins and peptides Form Pellicle (Contains
receptors for adhesins on the cell surface of bacteria
Peri-implant biofilm formation
Titanium pellicles:
High molecular weight mucins, α-amylase, secretory IgA,
proline-rich proteins
Enamel pellicles:
Cystatins, low molecular weight mucins
The differences between pellicles formed on titanium
surface or tooth enamel DO NOT influence the
bacterial composition of the biofilm
Peri-implant biofilm formation
Due to common ecologic environment Similar principles and
sequence of biofilm formation
Formation of biofilm:
1. Adhesion of early colonizers; S.sanguinis, A.naeslundii to
salivary pellicle
2. Early colonizers grow, modify the environment and promote
the adhesion of secondary colonizers via co-aggregation
3. The biofilm becomes Stable Forms a protective environment
1- Surface characteristics of the implant
Chemical composition, Surface free energy (SFE; wettability),
Surface roughness (Ra)
Surface roughness Greater bacterial adhesion and biofilm
accumulation
Ra≥ 0.2µm, SFE Facilitated biofilm formation
Teflon-coated abutments
1. Less mature biofilm
2. Higher cocci
3. Lower motile organisms & spirochetes(low SFE)
1- Surface characteristics of the implant
When all surface characteristics interact with each other,
surface roughness found to be predominant
The impact of surface roughness on biofilm formation:
1. The protection from shear forces
2. Increased area for adhesion
3. Difficulty in cleaning
Rapid regrowth of the biofilm (In supramucosal areas)
1- Surface characteristics of the implant
FrÖjd et al. 2011; The effect of surface characteristics on
biofilm formation
o After 2 hours Surfaces with increased surface roughness
Higher bacterial adhesion
o After 14 hours Similar volume of biofilm on all surfaces
1- Surface characteristics of the implant
Various restorative materials for implant components
Titanium, gold, ceramics, zirconium
Zirconia exhibit low biofilm accumulation (Bremer et al. 2011)
Zirconia vs. Titanium abutments (Salihoglu et al. 2011)
1. Lower SFE
2. No difference in the adhesion of A.a & P.gingivalis 5 weeks
after abutment connection
1- Surface characteristics of the implant
Based on the surface roughness value Sa (average 3D height
deviation):
1. Smooth Sa≤0.5µm
2. Minimally rough Sa:0.5-1.0µm
3. Moderately rough Sa:1.1-2.0µm
4. Rough Sa>2.0µm
Commercially available titanium implants: Moderately rough or
Rough If exposed, enhanced biofilm formation
1- Surface characteristics of the implant
If exposed to oral cavity, rough surface implants
(Titanium plasma sprayed TPS) are more likely develop
peri-implantitis than minimally rough implant surfaces
2- Local oral environment
Biofilm formation (oral hygiene) & peri-implant mucositis
Cause and effect relationship
Deeper pockets Greater number of pathogens
Sumida et al. 2002; isolate of P.gingivalis & P.intermedia
were identical at implant and teeth areas
Takanashi et al. 2004; 75% of all P.gingivalis and 100% of
all P.intermedia isolates in samples from one subject were
identical Primary source of bacteria is from remaining
dentition
2- Local oral environment
Edentulous patients (with the history of periodontitis)
1. Distinct patterns of microbial colonization on soft tissues and
saliva;
2. A.a and P.gingivalis detected in edentulous patients;
Previously thought that these microorganisms would no be
present following removal of all teeth
Lang & Berglundh 2011; Pathogenic conditions in the oral
environment Ecosystem alteration Colonization of
pathogenic microorganisms at implant sites
2- Local oral environment
1. Treatment of periodontal diseases prior to implant placement
2. Supportive periodontal/peri-implant maintenance care
Reduce the risk of peri-implant infections
3- Oral hygiene and accessibility
Poor oral hygiene Greater incidence of
peri-implant infections
Good compliance following treatment is
important:
1. Prophylaxis/supportive periodontal
therapy (SPT)
2. Maintaining full-mouth plaque score <20%
3- Oral hygiene and accessibility
No access for oral hygiene Higher risk for
peri-implantitis
Good access for oral hygiene Rarely
associated with peri-implantitis
Wilson 2009; Cemented prosthesis should be
designed with accessible cement margins
Excess luting in the sulcus Foreign body
Removal of excess cement 74%
reduction in clinical signs of infection
Microbiota associated with peri-implant mucosal health Peri-implant biofilm forms
within minutes of exposure to
oral cavity (similar to teeth)
It may take longer for a
mature biofilm to develop
at implant sites.
Complex community of
multispecies develops within
weeks
Microbiota associated with peri-implant mucosal health De Boever 2006;
Increase in detection
frequency of
P.gingivalis &
T.forsythia over time
after implant
placement in subjects
with the history of
aggressive
periodontitis
Microbiota associated with peri-implant mucosal health Mombelli et al. 1987 1988 1990; The microbiota associated
with peri-implant health (similar to healthy periodontal subjects)
1. Predominantly G+ facultative cocci
2. High levels of Actinomyces & Veillonella
3. Low anaerobic counts
4. Low levels of G- anaerobic rods
5. Low proportions of F.nucleatum, Spirochetes, Fusiforms,
Motile curved rods
Microbiota associated with peri-implant mucosal health Low levels of Periodontal pathogens; A.a, T.forsythia,
P.gingivalis, T.denticola, P.micra, S.intermedius detected in
healthy peri-implant sulci in fully edentulous subjects
Patients with good oral hygiene and stable periodontal
condition Successful implants despite the presence of
periodontal pathogens
Microbiota associated with peri-implant infections Similar to that in chronic periodontitis; mixed anaerobic
infection dominated by G- bacteria
Some studies also found:
1. Enteric rods
2. Yeasts
3. Staphylococci (S.aureus and S.epidermidis)
4. Peptostreptococci
Microbiota associated with peri-implant infections
Microbiota associated with peri-implant infections Peri-implant mucositis microbiota
≈ Peri-implantitis microbiota
Maximo et al. 2009; In peri-
implantitis compared to
mucositis:
1. Higher levels of T.forsythia
2. Lower levels of A.gerencseriae
and C.ochracea
Microbiota associated with peri-implant infections Deeper peri-implant pockets Higher numbers of P.gingivalis
CMV and EBV Possible etiologic role in peri-implantitis
immune suppression overgrowth of periodontal pathogens
In peri-implantitis sites; Jankovic et al. 2011
CMV 65%
EBV 45%
CMV with EBV 33%
Microbiota associated with peri-implant infections 16S rRNA sequencing Identification and discovery of
previously unrecognized microorganisms in the oral cavity
Chloroflexi, Tenericutis, Synergistes
P.micra, P.stomatis, P.alactolyticus, S.moorei
Archaea (Methanobrevibacter oralis); Single-cell microorganisms that:
1. Produce methane
2. Associate with periodontal disease severity
Also found at peri-implantitis sites with higher rates than healthy sites
Patients at risk for peri-implant infections
1. History of treated periodontitis
In patients with advanced periodontitis Persistence of
pathogens following full-mouth extraction and implant
placement
Extraction of periodontally involved teeth Significant
reduction in periodontal pathogens (Not eliminated)
The pathogens could colonize the peri-implant sites
Patients at risk for peri-implant infections
2. Residual probing depths
≥ 6mm; Increased risk
≥ 5mm with BOP
3. Specific bacteria; Few studies available
Luterbacher et al. 2000; Positive DNA test of A.a, P.gingivalis,
P.intermedia, T.denticola Enhanced the diagnostic power of
the presence of bleeding on gentle probing to predict
progression of peri-implant disease
Anti-infective treatment and microbiologic effects Most studies have reported a reduction in the total bacterial
counts and pathogens in the first 3 months following treatment
Longer follow-up periods Gradual return to baseline
microbiota
Treatment strategies:
1. Non-surgical mechanical therapy
2. Non-surgical mechanical therapy and adjunctive microbial
agents
3. Surgical access and implant surface decontamination
Non-surgical mechanical therapy
In Peri-implant mucositis Effective alone
In Peri-implantitis Limited and unpredictable results due to
difficulty in gaining access to the biofilm
Transient changes in few microbial species
Return to baseline levels 6 months afterwards with no clinical
improvement
Limited improvement even with Er:YAG or air-abrasive polish
Non-surgical mechanical therapy and adjunctive microbial agents Mechanical debridement + Irrigation with 0.5% chlorhexidine
+ systemic administration of ornidazole 100mg/day for 10
days; at
10 days:
Dramatic reduction in total anaerobic microbiota
Mainly G+ facultative bacteria(95%)
Pathogens could not be recovered
After 12 months
Detection of F.nucleatum, A.odontolyticus significantly lower
Reduction in BOP and mean pocket depths
Non-surgical mechanical therapy and adjunctive microbial agents Local delivery of antimicrobials:
Non-resorbable tetracycline fibers and minocycline
hydrochloride microspheres
Microbiologic improvements up to 12 months
Gradual recolonization
Surgical access and implant surface decontamination Flap therapy + Decontamination
Chemicals; Citric acid, Hydrogen peroxide, saline,
chlorhexidine
Lasers; Nd:YAG, Er:YAG
Photodynamic therapy; reduction in periodontal pathogens
Mechanical approaches; Curettes, ultrasonic, air-abrasion
Surgical access and implant surface decontamination Charalampakis et al. 2012;
Treating peri-implantitis most with surgical access and various
antimicrobial agents (most amoxicillin+ metronidazole)
45% success
Conclusion
Treatment of peri-implantitis is challenging, but anti-infective approach is indicated
Goals: biofilm control, establishment of healthy local environment
Prevention of peri-implantitis
1. Identification of high-risk patients
2. Treatment of periodontitis prior to implant placement
3. Access for good oral hygiene
4. Avoidance of iatrogenic problems
5. Supportive care
THE END