4.10.23 Hoda_Peri-implantitis

Question 1

What are the definitions of peri-implant health, peri-implant mucositis, peri-implantitis?

Answer 1

• Peri-implant health: Is the absence of perfuse bleeding, suppuration as well as not having signs of inflammation, deep pockets and bone loss after bone remodeling. (Araujo & Lindhe, 2018)
• Peri-implant mucositis: Is the presence of perfuse bleeding, with or without suppuration, visual signs of inflammation with or without deep pockets, absence of bone loss following remodeling. (Heitz-Mayfield & Salvi, 2018)
• Peri-implantitis: Is the presence of perfuse bleeding, with or without suppuration, deep pockets of 6 mm and bone loss of 2 mm (Berglundh et. al 2018)

Question 2

What are the various etiologies of peri-implantitis?

Answer 2

Sarmiento 2016
The primary etiology of peri-implantitis is bacterial plaque accounting for 78.8%, followed by iatrogenic factors accounting for 8.5%, followed by exogenous irritants accounting for 5.5%, then absence of keratinized mucosa accounting for 4.8%, and the least is extrinsic pathology accounting for 2.2%

Question 3

Why did the Derks-Tomasi study have such a high prevalence of peri-implantitis?

Answer 3

Derks and Tomasi 2015
Peri-implant mucositis prevalence is 43%, while peri-implantitis is 22%

Many of the implants studied were tissue-level.
The study was from the Nobel center in Sweden.

Dr. Wang says: Peri-implantitis (in his experience) is about 30%, mucositis is “50% or more”.

Question 4

What is the most common type of peri-implantitis defect, according to Schwarz?

Answer 4

Schwarz et. al. 2007 = human and dogs defects

The configuration of bone loss around implants was classified into:
✓ Class I, which is infrabony defect.
✓ Class II, Suprabony defect.
✓ a: Vertical, b: Horizontal, c: Circumferential.
✓ Prevalence of defects:
o Class Ie 55.3% = most common = circumferential infrabony defect
o Class Ib 15.8%
o Class Ic 13.3%
o Class Id 10.2%
o Class Ia 5.4%
✓ 79% of defects are a combination of class I & II

Question 5

What is the Monje classification for peri-implantitis defects?

Answer 5

Monje ‘19 = used CBCT. Creates beam hardening & scattering.

Class I = infraosseous defects
Class II = Supracrestal defects
Class III = combination of I and II.
Subclasses:
* (a) dehiscence.
* (b) 2-3 wall.
* (c) circumferential defect.
Severity: A: Advanced. M: Moderate. S: Slight.

Question 6

Do implants fail more often in patients with a history of periodontitis?

Answer 6

Karoussis ‘03 = used ITI rough surface implants
Compared:
* Group A: Patients with history of periodontitis
* Group B: Patients without history of periodontitis

Results:
- Survival rates (Group A vs Group B): 90.5 % vs 96.5%
- Group A had a significantly higher incidence of peri-implantitis than group B (28.6% vs. 5.8%).
- Success rates (Group A vs Group B): 52.4% vs 79.1%

Question 7

What are the classifications of implant surface roughness?

Answer 7

Albrektsson & Wennerberg
19 implants may be classified into 4 types according to surface roughness:
* Smooth (Sa , 0.5 mm);
* minimally rough (Sa between 0.5 and 1.0 mm),
* moderately rough (Sa between 1.0 and 2.0mm),
* rough (Sa 2.0 mm).

Question 8

Is peri-implantitis related to smoking?

Answer 8

Inconclusive evidence

Karoussis ‘03
Karoussis et. al. 2003 did a cohort study following up 53 pts:
* 41 non-smokers
* 12 smokers

Periimplantitis (back then) was defined differently than today:
PD ≥ 5mm
BOP +
Annual bone loss > 0.2 mm

Peri-implantitis incidence (Implant level)
* Smokers: 17.9%
* Non-smokers 6%

Question 9

Is peri-implantitis related to diabetes?

Answer 9

Inconclusive evidence

Tawii ‘08 = found an association between diabetes & peri-implantitis
Tawii et. al. 2008 did a cohort study of 1-12 year (mean: 3.5 years)
Peri-implantitis prevalence (implant level)
HbA1c level ≤ 7% is 0%
HbA1c level 7% - 9% is 4.3%
HbA1c level > 9% is 9.1%

Costa ‘12 = found no association between diabetes & peri-implantitis
Costa et. al. 2012 did a cohort study of 5 years, they included 80 patients with mucositis:
** * 69 were non-diabetic pts.
* 11 were diabetic.**
o Fasting blood glucose ≥126 mg/dL or intake of anti-diabetic med.
* Defined peri-implantitis as:
PD ≥ 5mm
BOP/SUP +
No threshold on bone level

Question 10

Does smoking affect the osseointegration of implants?

Answer 10

Brian Mealy
If rough implant: No
If smooth (pure titanium): Yes

Question 11

How does Dr. Wang manage smokers & regeneration?

Answer 11

Cut the smoking amount to half, 2 weeks before and 2 weeks after the procedure.
= this reduces the cotinine level to half.
The body will rebound.

Question 12

Where does the probe stop when probing a healthy tooth vs. healthy implant?

Answer 12

Lang ‘94
Lang et. al. found that when we probe a health implant, the probe stops close to the coronal 1/3 of connective tissue, while** teeth on the other hand, it stops at the apical 1/3 of the junctional epithelium**. However, in cases of peri-implantitis the probe stops at the 1/3 of connective tissue. “Exceeded the CT by 0.5 mm” (Lang et. al. 1994)

Question 13

In periodontitis, how deep does the probe penetrate into the tissues?

Answer 13

Periodontitis: Probe stops in the apical 1/3 of the CT, or even 0.5 mm to the bone

Question 14

What is the probing difference between natural tooth vs. Implant?

Answer 14

Araujo & Lindhe
Difference between the JE and the CT attachment zone:
1 mm

Question 15

What is the difference between the biologic widths of the natural tooth vs. implant?

Answer 15

3mm in implant, 2mm in natural tooth
1 mm JE, 1mm CT = in natural tooth
2 mm JE, 1mm CT = in implant

Monje - looked at PD accuracy around implants both with vs. without the crown
Dukka - looked at BOP around implants

Question 16

What type of membrane should always be used when regenerating peri-implantitis defects?

Answer 16

Dr. Wang says: dPTFE
Collagen membrane does not work

Question 17

Should NSPT always be attempted before surgical tx of peri-implantitis?

Answer 17

Renvert ‘18 - yes
Non-Surgical therapy should always be attempted before surgical intervention, the aim of NST is to reduce bacterial colonization accumulated on the implant surface. In addition, it will enable the clinician to evaluate the patient’s oral hygiene.

Salvi et. al. 2007
Implants with bone loss and PD ≥ 5 mm
25 pts., 31 implants with peri-implantitis. Mechanical debridement + 0.2% CHX + locally delivered microencapsulated minocycline to sites with PD ≥ 5mm. 1 yr. FU
* Result: Reduction of BOP & PD up to 12 mos. of FU

Question 18

What is the long-term result of surgical tx of peri-implantitis?

Answer 18

Berglundh ‘18
Files and radiographs of 50 patients who had undergone surgical treatment for peri-implantitis were analyzed retrospectively.

Results
Average function time of implants at the time of therapy was 7.5 ± 3.8 years
Treatment was effective in reducing peri-implant probing depth and bleeding on probing scores, while preserving the crestal bone level.
Treatment outcomes were better at implants with non-modified surfaces than at implants with modified surfaces (SR: 9.3 vs. 5.7 years)
The probability of an implant exhibiting no further bone loss or bone gain after treatment was high when the peri-implant mucosa at the site had shallow pockets and no bleeding on probing at follow-up.

Question 19

How effective are resective treatments for peri-implantitis?

Answer 19

Stavropoulos ‘19
Systematic review, ≥ 5 years FU,
* The main goal of managing peri-implantitis with implantoplasty (removing the threads and polishing the implant surface) is to prevent bacterial plaque adhesion.
* Implantoplasty has a positive clinical and radiographic results (low BOP, shallow PDs, increased CAL, stable bone levels on the short‐ to medium‐term) (weak evidence)

Ravida ‘20
Sys. Review discussing possible treatment outcomes
* 3 Possible outcomes expected
After resective procedures:
* Peri-implant health W/ reduced support.
* Peri-implant mucositis W/ reduced support.
* Recurrent/refractory peri-implantitis.
After regenerative procedures:
* Same diagnosis W/ Addition of peri-implant health/mucositis after complete regeneration.p

Question 20

How are implantoplastied implants affected with regards to: Strength, Temperature, Ti particles?

Answer 20

Strength - Chan IJOMI
* 3.75 - 4.1 mm diameter implants may weaken with implantoplasty

Temperature increase - Sharon et al; De-Souza et al
* 1.8 degrees Celcius
* Doesn’t cause problems

Ti particles - no effect on outcomes
* Need histology to check cell initiation

Question 21

How does implantoplasty affect survival of implants, relative to the amount of starting bone loss?

Answer 21

Ravida
< 25%: “Baseline” (reference for odds ratios)
25-50%: 9X more likely failure than if 25% bone loss
> 50%: 18X more likely failure than if 25% bone loss

Question 22

What is the difference between recurrent vs. refractory peri-implantitis?

Answer 22

Ravida ‘20
Recurrent: period of stability followed by progressive bone loss w/signs of inflammation
Refractory: treatment failed to resolve peri-implantitis and progressive bone loss

Should wait at least 6 months after tx before determining if the treatment was successful