Growing Problem of Peri-Implant Disease and What To Do About It

As dental practitioners, we constantly receive updates about the latest dental implants, new techniques and expanded indications. However, the complications that may arise with implant rehabilitation are less commonly advertised and understood.

Peri-implant disease is arguably one of the most significant risks associated with implants. It is a multifactorial disease, which if not diagnosed at an early stage, can ultimately lead to failure of the implant. As more and more implants are placed by clinicians of varying skill levels and clinical backgrounds, the number of patients presenting with the disease appears to be on the rise.

What Is Peri-Implant Disease?

Peri-implant disease is a condition that affects the tissues surrounding a functional implant; it includes both peri-implant mucositis and peri-implantitis. Peri-implant mucositis can be defined as reversible inflammatory reactions in the soft tissues surrounding a functioning implant. Peri-implantitis is characterized by inflammatory reactions with loss of supporting bone surrounding a functioning implant.

Peri-implantitis has much in common with chronic periodontitis. Both involve alveolar bone loss. However, there is a zone of connective tissues which is attached to the root surface in periodontitis. In contrast, connective tissue does not attach directly onto implants and there is no periodontal ligament. Therefore, the inflammatory lesion in peri-implantitis extends closer to the bone surface, which can be associated with a faster rate of progression and more aggressive consequences.

The prevalence of peri-implant disease is significant with peri-implant mucositis affecting up to 80% of implant patients and peri-implantitis affecting 25% of patients.

Causes and Risk Factors of Peri-Implant Disease

  • Bacterial infections play the most important role in the failure of dental implants. Bacterial flora that are associated with periodontitis and peri-implantitis are found to be similar.
  • Studies have shown that the bacteria at the failing implant site consists of gram-negative anaerobic bacteria, such as Porphyromonas gingivalis, Prevotella intermedia and Actinobacillus actinomycetemcomitans. The correlation between the presence of periodontitis and the development of peri-implantitis has been supported by a recent systematic review. Implants in partially dentate patients appear to be at a greater risk of peri-implantitis than implants in fully edentulous patients. There is a marked quantitative decrease in the number of periodontal pathogens around the implants in completely edentulous patients. It is possible that the natural teeth serve as reservoirs for periodontal pathogens from which colonization of the implant sites occurs. * Other patient-related risk factors include: inadequate oral hygiene, smoking, parafunctional habits and underlying systemic conditions such diabetes. Biomechanical factors, such as an occlusal overload, may play an important role in implant failure by resulting in progressive bone loss around the implant. The implants that suffer from traumatic failure have subgingival microflora representing a state of periodontal health.
  • Iatrogenic factors such as lack of primary stability, poorly positioned implants, premature loading during the healing period and poorly fitting abutments or restorations also appear to increase the likelihood of peri-implant disease.

Tips for Diagnosis

Early diagnosis and treatment is often the key to complete resolution of the problem. However, although advanced cases of the disease will be clearly identifiable, it is often a great challenge to diagnose early disease successfully.

Diagnosis of peri-implant disease relies on techniques commonly used for the diagnosis of periodontal disease. Swelling and redness of the peri-implant marginal tissues and plaque/calculus accumulation are important signs of peri-implant disease.

Inflammation of peri-implant tissues

Probing the peri-implant sulcus allows the assessment of: peri-implant probing depth, bleeding on probing and suppuration from the peri-implant space. Studies have shown that successful implants generally allow a probe penetration of approximately 3-4mm in the peri-implant sulcus. Bleeding on probing and suppuration are clear indications of disease.

Implant mobility is an insensitive measure in detecting early implant failure. More advanced peri-implantitis is characterized by mobility of the implant, indicating failure of osseo-integration.

How to Manage Peri-Implant Disease

Comprehensive treatment of peri-implant disease remains an enigma to most dentists but is largely dependent on the underlying etiology at play.

When the main etiological factor is bacterial infection, the first phase of treatment involves the control of acute infection and the reduction of inflammation. This involves the removal of plaque deposits and improved patient compliance with oral hygiene until a healthy peri-implant site is established. This may be sufficient to re-establish gingival health.

The implants that are affected with peri-implantitis are contaminated with soft tissue cells, microorganisms and microbial by-products. The defect must be debrided. Prophy jet and the use of a high pressure air powder abrasive has been advocated, as this removes the microbial deposits, but does not alter the surface topography and has no adverse effect on cell adhesion.

Various chemotherapeutic agents, such as contact with a supersaturated solution of citric acid have been used for the preparation of the implant surfaces. Soft tissue laser irradiation has also been used. Additionally, the systemic administration of antibiotics that specifically target gram-negative anaerobic organisms has shown an alteration in the microbial composition and a sustained clinical improvement.

A local delivery device with fibers containing polymeric tetracycline has been tried and this resulted in significantly lower total anaerobic counts.

Peri-implant bone defect (left) and use of regeneration (right)

When biochemical forces are considered as the main healing agent, improvement of the implant number and position and changes in the prosthetic design, can arrest progression.

Given the large number of implant placements each day around the world, a high prevalence of peri-implantitis can be anticipated, which stresses the necessity for a predictable therapy. Assiduous research is still required for the treatment of peri-implantitis, because there is still no standard protocol for its management.

Evidence suggests that early diagnosis and treatment leads to optimal treatment outcomes. Regular monitoring of dental implants during a comprehensive periodontal evaluation and proper maintenance is crucial to a patient’s implant health. Long-term success of any peri-implant treatment strategy requires a strict maintenance program at regular intervals.

If any of your patients shows signs of peri-implant disease, have them contact our office here [mailto:doctor@drgaryperlman.com] or call (904) 731-1324 to set up a consultation. Like periodontitis, I have had great success treating patients with peri-implant disease with LANAP.