Management of peri-implantitis, follow up and maintenance of implants

Question 1

Introduction

Peri-implantitis is

Answer 1

Peri-implantitis is a destructive inflammatory process affecting the soft and hard tissue surrounding the implant

• Alveolar bone loss
• Inflammation in the peri-implant connective tissue

Question 2

Introduction

Diagnosis of peri‐implantitis requires detection of both

Answer 2

• bleeding on probing (BoP) and
• bone loss on radiographs

Question 3

Introduction

Peri‐implantitis initially affects:

Answer 3

the marginal part of the peri‐implant tissues and the implant may remain stable and in function for varying periods of time

• Implant mobility is therefore not an essential symptom for peri‐implantitis , but may occur in the final stage of disease progression and indicates complete loss of integration

Question 4

Peri-implantitis: Management

How should the management start?

Answer 4

Peri -implantitis management should start with non-surgical treatment as first option and if the disease didn’t resolve proceed with surgical treatment

• However, depending on the severity of peri-implantitis such as moderate to severe form of peri-implantitis non- surgical procedure may be insufficient and ineffective to resolve disease but should always precede surgical therapy

Question 5

Peri-implantitis: Management

Methods of non surgical treatment:

Answer 5

Question 6

Laser

The commonly used lasers for the decontamination of implant surface are:

Answer 6

Question 7

Risk Factors

Answer 7

1. Peri-implantitis risk factors include periodontal disease , lack of maintenance , cigarette and smokeless tobacco use, hyperglycaemia and obesity .
2. Local risk factors include inadequate plaque control , mucositis , implant’s malposition and poorly designed prostheses or presence of excess cement .
3. Potential risk factors requiring additional research include genetic and systemic conditions , high doses of bisphosphonates and hormonal replacement therapy .
4. Occlusal overload , lack of keratinised tissue and local presence of titanium particles seem to aggravate peri-implant disease , but studies are still required prior to drawing definitive conclusions

Question 8

Prior to maintenance 10 points inspection.

Answer 8

1. Recession
2. Mobility
3. Occlusion
4. Contacts
5. Plaque and calculus assessment
6. Probing
7. Bleeding or suppuration
8. Percussion sensitivity
9. Radiographic assessment
10. Instrumentation

Question 9

Prior to maintenance 10 points inspection.

Points 1-3

Answer 9

1. Plaque and calculus assessment
   Presence or absence of plaque, calculus or cement should be noted. Oral hygiene should be reinforced at this stage.
2. Probing
   The implant should be probed at the same four points and angulations as the initial readings post restoration. If there has been an increase in probing then this may signify peri-implant mucositis or peri-implantitis.
3. Bleeding or suppuration
   A positive finding of bleeding indicates inflammation with or without bone loss. Suppuration may mean the presence of advanced peri-implantitis. Pressing the gingival margin may be better to detect suppuration over probing.

Question 10

Prior to maintenance 10 points inspection.

Points 4-7

Answer 10

4. Recession
   The presence of progressing recession may ether be a sign of progressive soft tissue changes or associated with mucositis or peri-implantitis.
5. Mobility
   Any mobility with an implant must be investigated. This suggests either a restorative complication (loose abutment or screw) or complete loss of integration.
6. Occlusion
   The occlusion of the implant should be kept light enough to allow three layers of shimstock to pass through with the patient in maximum intercuspation as well as in lateral excursions. Any facetting should be investigated.
7. Contacts
   This should be assessed with floss. A definitive contact point is ideal. A loose or open contact may lead to food impaction which subsequently causes biofilm development on the implant or adjacent tooth.

Question 11

Prior to maintenance 10 points inspection.

Points 8-10

Answer 11

8. Percussion sensitivity
   A positive finding may be indicative of a biological or restorative complication.
9. Radiographic assessment
   If findings from points 1-8 show the possibility of clinical changes relating to a peri-implant infection then a radiograph should be taken. This should be compared to previous radiographs to assess bone levels.
10. Instrumentation
    This is performed supra-gingivally with a prophy cup and prophy paste. Sub-gingivally a titanium scaler can be used to dislodge any plaque, calculus or cement. A glycine-based air polishing powder can also be used to decontaminate subgingivally, as well as threads of exposed implants. A cotton pledget soaked in Chlorhexidine to swab the area may be utilised as the final step.