Dental implants are increasingly regarded as the standard treatment for partial or complete edentulism. When correctly used, dental implants provide a high level of predictability and can be utilized in a range of treatment options. Although dental implants can present a long-term solution for tooth loss, it’s possible for complications to arise, sometimes years after the implants were originally placed. Peri-implant disease is a common complication.
Peri-implant disease has two distinct forms: peri-implant mucositis and peri-implantitis. Both diseases are identified by an inflammatory reaction in the tissues around the implant caused by bacterial buildup. Peri-implant mucositis is confined to the soft tissues surrounding the dental implant and doesn’t affect the supporting bone. Peri-implantitis is more serious, affecting the soft tissues and the bone supporting the implant. Without treatment, peri-implant mucositis can develop into peri-implantitis and may result in bone loss around the implant, ultimately leading to implant failure.
The inflammatory processes that cause peri-implant mucositis are similar to gingivitis. Once implants are placed, glycoproteins in saliva adhere to exposed titanium surfaces, forming a biofilm that plays an essential role in the development of infections in dental implants. Peri-implant disease has also been associated with anaerobic gram-negative bacteria, which are like the bacteria found in cases of severe and chronic periodontitis. Peri-implant mucositis is generally accepted as the precursor of peri-implantitis in a way that is very similar to the relationship between gingivitis and periodontitis. Just like gingivitis, peri-implant mucositis is reversible and need not develop into peri-implantitis. The main aim when treating peri-implant mucositis is to remove the biofilm from implant surfaces.
Peri-implant mucositis is estimated to occur in nearly half of implant cases, but the true figure may be higher as it is possible its prevalence may not always be reported. With early intervention the signs of peri-implant mucositis are reversible. A diagnosis can be made during a clinical examination. Signs include bleeding and sensitivity on probing, with probing depths in excess of 4 mm. Other signs of peri-implant mucositis include redness, hyperplasia, and edema. Sometimes pus may be discharged at the implant site, but gum recession isn’t always detectable, and radiological bone loss isn’t generally noticeable.
Peri-implantitis is diagnosed when the same parameters are present as for peri-implant mucositis but where there is also a clear loss of supporting bone. This diagnosis is made by comparing a baseline radiograph taken at the time of implant placement. With bone loss of 2 mm or more, it is possible that peri-implantitis has developed.
When assessing the patient’s suitability for dental implant treatment, it’s important to consider some of the most common risk factors for peri-implant disease. Patients who have previously suffered from periodontitis may be more at risk of developing peri-implant disease, although the survival rate may not be affected by their periodontal history.
One of the largest risk factors is poor plaque control, or poor oral hygiene. This may develop if the patient is unable to mechanically clean their dental implants using interdental brushes and dental floss. Sometimes this problem may develop due to implant positioning; the implant may have been inserted to meet the patient’s aesthetic concerns and help ensure proper functionality without considering hygiene and maintenance.
Another possible cause is residual cement, in which some cement is left sub-gingivally around the dental implants. With cement-retained implant crowns it can be difficult to completely remove the cement due to implant positioning and implant design. Residual cement could cause inflammation due to rough surface topography, which can provide a positive environment for bacteria.
Smokers are at increased risk for peri-implant disease, which is much more prevalent among people using tobacco products. A study found that 78% of implants in smokers were diagnosed with peri-implantitis, compared with just 64% of non-smokers.
Occlusal overload can cause microfractures within the jawbone and eventual bone loss, but studies have suggested that poor oral hygiene is still the key factor in peri-implant disease. Peri-implant disease may be prevalent, but it is preventable.
Including a Preventative Strategy in the Planning Stage
When planning implant treatment, it’s important to consider the possibility of peri-implant disease. Situating the implant in the correct location, and in vital and healthy bone increases the chances of a successful long-term outcome. In some situations it can be useful to use a custom abutment to help establish the proper emergence profile, which will make it easier for the patient to maintain good oral hygiene. When placing a cement-retained restoration, additional care should be taken to detect and remove any residual cement from any sub-gingival areas.
Minimizing the Patient’s Risk of Developing Peri-Implant Disease
Based on the patient’s risk factors for developing peri-implant disease, proper ongoing maintenance is imperative for the long-term success of dental implant treatment. The patient’s medical and dental history can help determine the appropriate preventative maintenance schedule. Their history should include the date of implant placement, the manufacturer of the implant, and the type and coronal design. The patient’s records should also show the type of restoration, when it was first loaded, and whether a screw or cement-retained restoration was chosen. Patients who have previously suffered from periodontitis may benefit from a shorter maintenance schedule. One of the problems with peri-implant disease is that it’s generally not painful. The patient may be unaware their implant has become inflamed or infected until more significant symptoms develop, at which stage the implant may have become mobile and will need to be removed.
The patient should be educated on proper oral care and advised of the potential risks if they choose to neglect their oral hygiene, as patients who have demonstrated a lack of oral hygiene may not be the best candidates for dental implant treatment. Oral hygiene instruction should be provided, including a demonstration of the correct interdental cleaning techniques and proper brushing techniques. A schedule of regular professional cleanings will allow their oral hygiene to be closely monitored and for ongoing treatment to be adjusted as required.
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