Peri implant Diseases and its management

detail description about periimplant mucositis and periimplantitis and therapeutic measures for management

1. Peri-implant diseases and its management

2. D efinition Peri-implant disease- Peri-implant disease is a collective term for inflammatory processes in the tissues surrounding an implant - Albrektsson & Isidor 1993, 1 st EWP, Switzerland. Definition of Mombelli A, Lang N.P 1998- pathological inflammatory changes that take place in the tissue surrounding a load bearing implant

3. Normal v/s peri-implant tissues Periodontal Peri-implant

4. Difference in probing and clinical condition

5. Peri-implant mucositis Albrektsson & Isidor (1994 ) reversible inflammatory reactions in the soft tissues surrounding a functioning implant. According to Kostovillis (2008) Inflammatory changes which are confined to the soft tissue surrounding an implant with no signs of loss of supporting bone . Roos-Jansaker AM et al. prevalence is 48% of implants followed from 9 to 14 years

6. Clinical features Probing depth > 4mm BOP or suppuration

7. Histopathology Response to early plaque formation Pontoriero et al . (1994 )- Inflammation and probing depth change over a period of 3 weeks Zitzmann et al . (2001) also concluded that at the end of 3 weeks of plaque built-up, increase in size of peri-implant mucosa from 0.03 mm 2 at baseline to 0.2 mm 2 Proportions of neutrophills increased in CT

8. Response to long standing plaque formation Ericsson et al.- Inflammatory response same In gingival tissues amount of tissue breakdown that occurs during the 3 month interval is more or less fully compensated by the tissue built up during the subsequent phases of repair. In the lesion within the peri-implant mucosa, the tissue breakdown is not fully recovered by reparative events . (reduced tissue built up) Histopathology

9. Concluding remark Shares similarity with gingivitis in terms of host response and development of clinical signs. it represents an obvious precursor to peri-implantitis. Early detection is essential.

10. Peri-implantitis The term “Peri-implantitis” was introduced in the late 1980s ( Mombelli et al. 1987) and was subsequently defined as “an inflammatory process affecting the soft and hard tissues around a functioning osseointegrated implant, resulting in loss of supporting bone” (Albrektsson & Isidor 1994 ).

11. In the consensus report from the 6th European Workshop on Periodontology- peri-implant mucositis was an inflammatory lesion that resides in the mucosa, while peri-implantitis also affects the supporting bone”. ( Lindhe & Meyle 2008, Zitzmann & Berglundh 2008). Peri-implantitis- progressive loss of supporting bone beyond biological bone remodeling . Consensus report of Working Group JCP 2012

12. Retrograde peri-implantitis First described by McAllister and colleagues.

13. Etiopathogenesis Biofilm formation Staph. Aureus for initiation and host response is overwhelmed by gram – ve bacteria. The connective exhibit B-lymphocytes and plasma cell infiltration

14. Etiopath … The rate of disease progression and the severity of inflammatory signs different than periodontitis The increased susceptibility for bone loss around implants may be related to the absence of inserting collagen fibers into the implant spontaneous continuous progression of the disease with additional bone loss

15. Risk factors Previous periodontal disease Residual cement Smoking Genetic factors Diabetes mellitus Occlusal overload Emerging Risk factors Rheumatoid arthritis Premature loading Alcohol consumption

16. Clinical features

17. Classification Newman and Flemming (1992) have proposed a classification of non successful implants, based on the severity of peri-implantitis: “Compromised successful implant” characterized by inflammation, hyperplasia, fistula formation occurring near an otherwise fully osseointegrated implant. “Failing implant” characterized by progressive bone resorption, but the implant remains functional. “Failed implant” in which infection persists around an implant whose function is compromised.

18. Classifications Based on the % of bone loss Froum SJ, Rosen PS, 2012

19. Based on radiographic presentation of peri-implant bone loss as 5 main types: Zhang L, Geraets W, Zhou Y, et al, 2014

20. Diagnosis of peri-implantitis The examination of peri-implant tissues should include:- Evaluation of oral hygiene standard . Modified plaque index- Mombelli et al. Evaluation of peri-implant marginal tissues . Probing, bleeding and suppuration Evaluation of bone-implant interface Radiographs and mobility

21. Probing around implants Initial probing immediately before installing final restoration using 0.25N probing force Gentle probing resulting in bleeding suggests the presence of soft tissue inflammation presence of suppuration/ exudate indicates pathological changes Increasing probing depth and bleeding are indicators for additional radiographic examination

22. Radiographs IOPA following placement and then following the prosthesis installation should function as the baseline Bone loss can have a number of nonbacterial causes including surgical technique, implant design, implant position, crestal thickness of bone, loose prosthesis/abutment, and excessive occlusal force

23. Treatment approaches

24. Treatment Objectives in the therapy of peri-implantitis: The removal of bacterial plaque within the peri-implant pocket. The decontamination and conditioning of the implant surface. E limination of the sites that cannot be maintained plaque-free by oral-hygiene procedures. The establishment of an effective maintenance program.

25. CIST Cummulative interceptive and supportive therapy Cumulative therapy depending on the clinical and radiographic diagnosis

26. Nonsurgical approach Mechanical debridement Hand Instruments coated with titanium, carbon fiber, polytetrafluoroethylene, plastic, polyetheretherketone , or silicon. Ultrasonic tips or polishing cups coated with carbon fiber or plastic Air abrasive systems that use low abrasive amino acid, glycine powder

27. Occlusal therapy An analysis of the fit of the prosthesis Prosthesis design changes, improvement in implant number and occlusal equilibration can contribute to the arrest of peri-implant tissue breakdown progression

28. 3. Antimicrobial therapy Systemic antibiotic Amoxicillin-CV 625mg BID Metronidazole 200mg TID Local antimicrobial Minocycline microspheres (1mg Arestin ) doxycycline hyclate gel Tetracycline fiber ( Actisite ) Implant surface decontamination: Saline, citric acid, hydrogen peroxide, EDTA

29. Laser The commonly used lasers for the decontamination of the implant surface are: Nd:YAG (1064 nm), Erbium:yttrium-aluminium garnet( Er:YAG )(2940 nm), Diode (660 nm), and Carbon dioxide (10600 nm) lasers Er:YAG laser could remove the bacterial-contaminated titanium oxide layer, thus promoting reosseointegration Nevins M, Nevins ML, Yamamoto A, et al . 2014

30. Photodynamic therapy The activation of these dyes, such as toluidine blue-O, using specific wavelength of light (630– 700 nm) causes the release of oxygen radicals that will decimate periodontal pathogens. Konopka K, Goslinski T. 2007

31. Surgical interventions ACCESS FLAP The objective of the access flap is to gain access to submucosal implant surface for debridement and decontamination

32. 2. Implantoplasty Clinical trial reported that implants treated with implantoplasty had a higher implant survival rate compared with those that were treated with an apically positioned flap only Romeo E, Ghisolfi M, Murgolo N, et al, 2005

33. 2 gm amox 1 hr prior to surgery FTF to expose the area Debride the defect with titanium or plastic curettes Air powder abrasive (Bicarbonate powder) for 60 Sec 60 sec irrigation with sterile saline 60 sec application of tetracycline Defect filled with Bone Graft Membranes are placed to cover all surfaces Flap released and coronally advanced and sutured . REGENERATIVE APPROACH

34. The effectiveness of 4 surgical procedures (access flap and debridement alone, Surgical resection, regeneration with bone grafts, and guided bone regeneration) were studied in a systematic review and meta-analysis Each of the 4 procedures yielded roughly 2 to 3 mm PD reduction 2-mm increase in bone height was associated with the regenerative procedures in a systematic review Chan HL, Lin GH, Suarez F, et al 2014

35. There is no single superior antiinfective method available. Surgical interventions achieved greater probing depth reduction and clinical attachment gain compared with nonsurgical Access flap surgery shows resolution in only 58% of the lesions. The combination of resective and regenerative surgical techniques seemed to have favorable treatment outcomes in the management of periimplantitis . Reosseointegration of a previously contaminated implant surface is possible but highly variable and unpredictable.

36. Summery & Conclusion Similarity between periodontal and peri-implant diseases Early diagnosis of peri-implantitis is imperative Several risk factors exist for the development of peri-implantitis, which can guide patient selection and treatment planning . Treatment of peri-implantitis should be tailored to the severity of the lesion ( as outlined by the CIST protocol), which ranges from non surgical to surgical approach

37. Refrences Rosen P, Clem D, Cochran D, et al. Peri-implant mucositis and peri-implantitis: a current understanding of their diagnoses and clinical implications. J Periodontol 2013;84(4 ):436–43. Froum SJ, Rosen PS. A proposed classification for peri-implantitis. Int J Periodontics Restorative Dent 2012;32(5):533–40. Schwarz F, Herten M, Sager M, et al. Comparison of naturally occurring and ligature-induced peri-implantitis bone defects in humans and dogs. Clin Oral Implants Res 2007;18(2):161–70. Zhang L, Geraets W, Zhou Y, et al. A new classification of peri-implant bone morphology: a radiographic study of patients with lower implant-supported mandibular overdentures. Clin Oral Implants Res 2014;25(8):905–9.

38. Padial -Molina M, Suarez F, Rios HF, et al. Guidelines for the diagnosis and treatment of peri-implant diseases. Int J Periodontics Restorative Dent 2014;34(6):e102–11 . Saaby M, Karring E, Schou S, et al. Factors influencing severity of peri-implantitis. Clin Oral Implants Res 2014 . Heitz -Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators. J Clin Periodontol 2008;35(8 Suppl ):292–304 . Jia -Hui Fu, Hom -Lay Wang. Can Periimplantitis Be Treated? Dent Clin N Am.2015:59;951–980 .