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Perio Reports

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Perio Reports  Vol. 25, No. 2
Perio Reports provides easy-to-read research summaries on topics of specific interest to clinicians. Perio Reports research summaries will be included in each issue to keep you on the cutting edge of dental hygiene science.
Healing After Probing Implants - A Study in Dogs

Probing is an often-debated issue relating to implants. Some clinicians say yes while others emphatically say no. Researchers at the University of Berne in Berne, Switzerland, evaluated the histology of the tissue/implant interface on implants placed in foxhound dogs. A dog model has been used for many years to learn about the tissue/tooth interface. Evaluating the histology at the base of the sulcus over several days requires sacrifice of the dogs and removal of the implant and surrounding bone and soft tissue in a block section.

Mandibular premolar teeth were extracted from the three test dogs. Three months later, ITO dental implants were placed. The dogs received careful plaque control regularly throughout the study period. After another three months, the implants were osseointegrated and tissue appeared healthy with little, if any, bleeding. Clinical probing was performed on the mesial and distal sides of each implant. Facial and lingual surfaces were evaluated as unprobed controls. The probing was scheduled so that when the dogs were sacrificed, the implants were one to seven days after probing.

Probing caused separation between implant and epithelium, but did not enter the connective tissue. By day one after probing, a new epithelial attachment of 0.5mm was evident. By day two, it measured 1.12mm, day three is was 1.52mm. By day five, the epithelial attachment was complete at 1.92mm. Unprobed sites measured 1.69mm.

Clinical Implications: Based on this animal study, probing implants appears to be safe and any damage to the junction of tissue-to-implant is completely healed in five days

Etter, T., Hakanson, I, Lang, N., Trejo, P., Caffesse, R.: Healing after Standardized Clinical Probing of the Pei-Implant Soft Tissue Seal: A Histomorphometric Study in Dogs. Clin Oral Imp Res 13: 571-580, 2002.

Excess Cement Significant Risk Factor for Peri-Implantitis

In the past it was common to attach a crown or bridge to an implant with a screw, but problems with loosening, occlusal adjustments and cost made cementation a preferred choice. While the process is easier with cement, the risk of leaving excess cement is significant. Cement residue provides a retentive area for bacterial biofilm, leading to infection and inflammation.

A periodontist in private practice in Dallas, Texas, evaluated 39 consecutive patients with peri-implantitis around 42 single implants. In these same patients, 20 similar singletooth implants exhibited no clinical or radiographic signs of infection. These implants constituted the control group.

A periodontal endoscope was used to evaluate both the implant/crown margin and the adjacent tissue around diseased and control implants. Light and magnification identified cement with a characteristic white reflectance. Calculus appears brown or yellow with the endoscope. Bacterial biofilm appeared gray/blue in color and fluffy in nature. After recording the areas of excess cement, either a periodontist or dental hygienist used a hand instrument or power scalers to remove the cement. In three cases, a surgical flap was needed to accomplish complete removal.

Cement residue was found on 34 of the 42 infected implants. None was found on the healthy controls. At one month post-treatment, 33 of the 42 test implants were reevaluated with the endoscope. Peri-implantitis was resolved in 25 of the cases. No cause for continued infection in the other eight implants was found.

Clinical implications: Care must be taken when implant restorations are cemented. At the first signs of peri-implantitis, check for cement residue and remove it.

Wilson, T.: The Positive Relationship Between Excess Cement and Peri-Implant Disease: A prospective Clinical Endoscopic Study. J Perio 80:1388-1392, 2009.
Hand Instruments Versus Power Scalers on Implants

Overall, implants are successful, but in some cases, peri-implant infections do occur. Treatment focuses on reducing subgingival bacterial biofilm, with mechanical instrumentation, chlorhexidine on the curette tips and lasers. If non-surgical therapy doesn't work, a surgical flap procedure may be needed to gain sufficient access to remove biofilm and irritants.

Researchers at Kristianstad University in Kristianstad, Sweden, compared two non-surgical mechanical debridement methods in patients with peri-implantitis. Each of the 31 subjects completing the study had one, single-tooth implant with periimplantitis. Any periodontitis on natural teeth in the mouth was treated prior to treating the implant. Clinical measurements for probing and bleeding scores were measured using a plastic probe with a standard pressure of 0.2 newtons. Plaque samples were taken from subgingival areas for analysis.

Treatment instrumentation was with either titanium curettes (17 subjects) or an ultrasonic device (Vector System) with an implant tip (14 subjects). After the randomly assigned instrumentation, all implants were polished with rubber cups and polishing paste. Three in the curette group and one in the ultrasonic group were smokers. Average probing depths per implant varied from 2.8mm to 5.5mm.

Follow-up visits were at one week and one, three and six months. No differences were evident between treatment groups for bleeding, probing or subgingival microflora. Bleeding scores reduced insignificantly from 73 to 53 percent. Oral hygiene improved slightly, but remained poor for the entire study, despite repeated emphasis at each visit. Perhaps new approaches to biofilm control are needed.

Clinical Implications: Mechanical instrumentation alone is not sufficient to manage periimplantitis.

Renvert, S., Samuelsson E., Lindahl, C., Persson, G.: Mechanical Non-Surgical Treatment of Peri-Implantitis: A Double-Blind Randomized Longitudinal Clinical Study. I: Clinical Results. J Clin Perio 36: 604-609, 2009.

Classifying Peri-Implant Disease

The American Dental Association endorsed dental implants in 1986. U.S. estimates suggest that more than 400,000 implants are now placed each year. Success rates for most dental implant systems are reported to be more than 90 percent, but with the increasing numbers of implants being placed today, there may be an increase in peri-implant disease. Two periimplant diseases have been identified: peri-implant mucositis, affecting only mucosa, and peri-implantitis, affecting both mucosa and supporting bone. Peri-implant mucositis occurs in 50 percent of implant sites and peri-implantitis occurs at 12-40 percent of sites, depending on the study. Diagnosis includes probing to identify bleeding/suppuration and radiographs to determine bone loss.

A proposed prognostic system might help clinicians predict implant success after treatment, based on the extent of periimplant disease (Fig. 1).

Clinical Implications: This simple prognostic system will provide clinicians who treat peri-implant disease with a system to anticipate outcomes of their treatment.

Nogueira-Filho, G., Iacopino, A., Tenenbaum, H.: Prognosis in Implant Dentistry: A System for Classifying the Degree of Peri-Implant Mucosal Inflammation. J Can Dent Assoc 77:b8, 2010.
Therapy for Peri-Implant Diseases, I

The term "peri-implantitis" was introduced in 1987 by Dr. Mombelli and his research team in Switzerland. The primary etiology of peri-implantitis is the same as periodontitis: bacterial biofilm. People with periodontitis are more likely to experience periimplantitis than those who are periodontally healthy when implants are placed. As the number of implants increases, so does the need for treatment of periimplantitis. The research on peri-implantitis treatment options is accumulating with no clear indication as to which therapies are the most effective.

Researchers at the University of Athens in Athens, Greece, systematically reviewed the published research on treatment of peri-implantitis. Although many studies are available, only five studies met the inclusion criteria of being randomized, controlled trials evaluating peri-implantitis treatments.

Four treatment approaches were evaluated: nonsurgical debridement alone, non-surgical debridement with local application of chlorhexidine, non-surgical debridement with locally applied antibiotics, Er:YAG laser alone or regenerative surgery. Mechanical instrumentation alone was the least predictable for longterm health. Another review in this issue demonstrates that instrumentation using a periodontal endoscope is an effective treatment of peri-implantitis in most cases. Using the laser or combining instrumentation with chlorhexidine or locally delivered minocycline provided predictable results for 12 months. Regenerative surgical procedures using bone substitute can be effective treatments.

Preventing peri-implantitis is the best approach, but when peri-implant infection is encountered, a variety of treatments are available, depending on the patient, the implant itself and the preferences of the treating clinician.

Clinical Implications: There is no established gold standard for treating peri-implantitis, but several viable options can be considered.

Kotosovili, S., Karousis, I., Trianti, M., Fourmousis, I.: Therapy of Peri-Implantitis: A Systemic Review. J Clin Perio 35:621-629, 2008.

Therapy for Peri-Implant Diseases, II

Inflammation around implants is similar to infection and inflammation found around natural teeth. As with natural teeth, bacterial biofilm is responsible for peri-implant diseases. Nearly 65 percent of all infectious diseases are caused by bacterial biofilms. Staphylococcus aureus is associated with peri-implantitis. This is interesting since foreign body infections are also colonized by S. aureus. It seems S. aureus favors titanium. Treatment of peri-implantitis follows traditional treatments of periodontitis.

The screw shape and design of implants might enhance biofilm formation and the crowns and bridges attached to the implant might hinder effective biofilm disruption in the area. Mechanical treatment is the primary approach, but with the challenges implants pose for instrumentation, antibiotics, antimicrobials and lasers have been suggested.

Researchers from Kristianstad University in Sweden, and Trinity College in Dublin, Ireland, collaborated on a literature review of treatments of peri-implant mucositis and periimplantitis. From 437 studies, 24 were included in the review.

Mechanical non-surgical therapy was effective when treating peri-implant mucositis (soft tissue involvement), but not as effective used alone to treat peri-implantitis (soft tissue and bone involvement). Adjunctive use of local and systemic antibiotics improved outcomes. Lasers provided minor benefits, but too few studies are published on lasers to conclude they are the treatment of choice. Additionally, antimicrobial mouthrinses were found to enhance the treatment outcome of mechanical instrumentation. As with natural teeth, it is easier to treat gingivitis than advancing periodontitis with moderate bone loss.

Clinical Implications: Just as with periodontitis, a variety of treatment approaches are available for peri-implantitis, and can be combined together for best results.

Renvert, S., Roos-Jansaker, A., Claffey, N.: Non-Surgical Treatment of Peri-Implant Mucositis and Peri-Implantitis: A Literature Review. J Clin Perio 35 (Suppl 8):305-315, 2008b.
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