11- peri implantitis

How do hard vs soft tissues heal after inserting an implant?

Osseointegration

Establish peri implant mucosa- via JE and CT zone

Periodontal structures after implant?

No cementum

No PDL

No perpendicular ct, only vertical

What are the time periods after surgical insertion of an implant?

Integration period (Time for osteointegration)

Prosthesis placement (crown)

Acclimatisation- comfort, hygiene

Baseline moment- closure or definitive Cementation, take records

Healthy peri implant tissues characteristics?

No swelling or redness or BOP or pain

No increased PD

How do you clinically assess implant site for health?

Evaluate soft tissues and biofilm, BOP (due to inflammation not trauma), sulcus probing

Periodic reviews- visual inspection, digital palpation

Peri implant tissue probing (6)

Always use same perio probe

For healthy patients- range broader- no CT so pd deeper already

Determined by prosthesis emergence (angle at which prosthesis coming out)

Remove prosthesis for reliable measurements

Maybe resistance, compare to initial records, gentle force

Bleeding suggests instability, positive predicative value greater

How to radiographically assess implant site for health?

Use fixed, non variable points to monitor progression

OPG, periapical

CBCT- BUT only shows interproximal bone levels (need clinical exam to confirm)

6 Clinical characteristics of unhealthy peri implant tissues

Plate detection

Mobility

Sounding depth at 6 points

Redness, swelling, contour, consistency and gum shape changes

Photographic records

No specific bacteria and determine released mediators

How to diagnose unhealthy peri implant tissues with palpation, percussion, stability?

Vb/Pt, tissue traction to check adherence, look for inflammation, suppuration

Check for sounds

Individual for each implant

What is peri implant mucositis? (Prevalence, what is it, characteristics) general risk factors 3 local 5

50-80% Medium term

Inflammation of peri implant mucosa due to plaque, precedes peri implantitis

NO BONE LOSS

BOP +, swelling, erythema, increased catheterisation due to inflammation

What is periimplantitis?

25-50% medium term

Progressive loss of bone

BOP with SUPPURATION

Peri implantitis diagnosis is based on what?

Combo of BOP + and/or suppuration

PD 6mm or over, bone levels 3mm or over apical from most coronal intraossesous component of implant (logical reference point)

What is this?

Peri implantitis- suppuration

What are 4 non peri implantitis reasons for implant failure?

Failure of osseointegration- early implant loss

Deosteointegration- later implant loss, occlusal overload

Physiological bone remodeling-

• translocation (inevitable bacterial colonisation)

• specific tissue adaptation

• recover of hemostasis (biological width)

Iatrogenic-

• remnants of submucosal cement

• over contoured prosthesis

• implant malposition

10 Possible errors in implant treatment that can lead to peri implantitis

Inappropriate patient selection

Insufficient periodontal treatment

Incorrect implant placement

Insufficient bone thickness

Too apical or too coronal

Error in mesio-distal position

Post op care

Incorrect prosthesis

Lack/absence of maintenance

Lack of diagnosis and management of mucositis

3 Objectives for therapeutic approach

Disinfect tissues surrounding implant

Decontaminated exposed implant surface

Promote favorable conditions to minimise future problems

Treatment strategy to cure peri implantitis?

1st - Etiological treatment (eliminate the cause)

2nd - Corrective treatment of sequelae (attempt to correct the consequences of the infection)

What 5 clinical parameters are used in CIST (cumulative interceptive supportive therapy) to assess disease severity? What 4 treatments depending on severity?

Presence of plaque, BoP, suppuration

Increased drilling depth

Radiographic bone loss

What are the 2 types of treatments goals and what ways would you treat the contaminated surface?

Goal- reosseointegration- disinfect titanium surface without altering it so bone can attach

Resective approach- reshape defect and leave part of implant exposed to oral cavity- smooth metal surface (less retentive to plaque)

Aeropolishers initially developed for… risk/not recommended when? What material used? Avoid in (5)

For supragingival removal of plaque

Risk of emphysema during subgingival instrumentation

Glycine 24um and erythritol 14 um

Avoid if thin bio type, no KM, pockets beyond mucogingival junction, adjacent to extracted tooth, endo abscess

When is a titanium brush used? (4)

Highly adherent calcified deposits

Unchanged implant surfaces

Narrow diameter implant

Difficult to reach areas

What is an implantoplasty? Do using what? 4 indications- why?

Mechanical removal of thread coils and modified surface of rough implants to decontaminate and create smooth surface

Use tungsten carbide burs

Limited regeneration potential-

• Peri implantitis with suprabony defect

• Peri implantitis with wide or partially contained intrabony defects (2–3 missing walls)

• No need for aesthetics- e.g posteriors

• Patient wants to maintain prosthetic resto

Advantages of an implantoplasty?

Adequate cooling

Doesn’t increase strength in standard diameters

Doesn’t have increased rate of fractures

Doesn’t lead to inflammation due to titanium particles

How are lasers catergorised based on their MOA?

Deep penetration- diode or Nd:YAG

Superficial penetration- Er:YAG or CO2

Quick lasers for non surgical mechanical debridement of peri implant lesions

Diode- melanin affinity- pigmentated pathogens (many in peri implantitis)

Nd:YAG- ophthalmology, aesthetic med, oncology- thermal changes + damage bone + slow healing

CO2- good hemostatic effect but not recommended

Er:YAG- mainly absorbed by water- good to remove granulation tissue, bacterial decontamination without damage

B- antiseptic therapy

A + subgingival irrigation 0.2% chx rinses or gel (1x daily 30secs) for 14 days

Chx has non selective cytotoxicity- is to fibroblasts and osteoblasts (compromise healing)

Saline- not bactericide but reduces biomass of biofilm

Sodium hypochlorite 0.25-1.5%- reduce biofilm doesn’t affect host cells

Updated guideline of C- antibiotics therapy? When used? What drug?

Doesn’t recommend use of systemic ATB as an adjuvant to non surgical treatment

Only in more severe cases- pd over 7mm and extensive drainage, many implants affected

Metronidazole 50mg x 8hrs x7 days- avoid as palliative care for lost implants

Effectiveness of surgery influenced by? (10)

Depending of anatomy of bone defect and location of implant

Resective surgery allows (3)? Results influenced by (4)

Better access to surface, proper decontamination, adequate apical replacement of peri implant tissue

Operator skill, extent of bone loss, tobacco, plaque