Peri-Implant Diseases

Transcription

1 Peter Hesmn Zid Esmil nd Crig Brcly Peri-Implnt Diseses Astrct: Peri-implnt diseses re inflmmtory conditions tht ffect the soft nd hrd supporting tissues round implnt fixtures. Peri-implnt mucositis usully responds to orl hygiene instructions, scling nd prophylxis, ut peri-implntitis, which involves one resorption, hs less predictle tretment outcomes following non-surgicl mngement. Adjunctive tretment for decontminting sites my include the use of ntimicroils nd resistnt cses my sometimes e mnged with surgicl pproch. Clinicl Relevnce: As dentl implnt-retined prostheses ecome more populr the prevlence of peri-implnt complictions will lso increse. Dentl prctitioners nd cre professionls should pprecite their potentil roles in the mngement of these conditions. Dent Updte 2010; 37: Osseointegrted implnt-retined restortions nd prostheses hve ecome predictle tretment modlity for replcing missing teeth. An estimted one million endosseous dentl implnts re plced nnully worldwide nd pproximtely 110 different mnufcturers now produce over 440 implnt rnds. 1 Sles of dentl implnts nd utments rise y 15% nnully with projected worldwide mrket sle of $2 illion y In Europe, etween 1995 nd 2005, 21 million dentl implnts were plced with the clinicl need resulting from n incresing popultion of older ptients, n estimted 770 million people missing one Peter Hesmn, BDS, MDS, PhD, FDS RCPS(Glsg), MRD RCS(Edin), Professor of Periodontology, School of Dentl Sciences, Newcstle University, Newcstle, NE2 4BW, Zid Esmil, BDS, MFDS RCS(Edin), Generl Professionl Trinee, Newcstle Dentl Hospitl, NE2 4AZ nd Crig Brcly, BDS, FDS RCPS(Glsg), DRD RCS(Edin), MRD RCS(Edin), MPhil, PhD, Consultnt in Restortive Dentistry, Associte Postgrdute Den for Specilist Trining, University Dentl Hospitl of Mnchester, Higher Cmridge Street, Mnchester, M15 6FH. or more teeth y the ge of 65, round 20 million edentulous people nd chnging ptient preferences. 3 The long-term success of dentl implnts is dependent upon regulr follow-up nd mintennce regimes nd, s dentl implnts ecome more prevlent, the responsiility for providing this mintennce cre will fll incresingly on the generl dentl prctitioner. This rticle ims to leve the prctitioner etter informed out the potentil prolems tht my e encountered during follow-up of ptients with dentl implnts, how they my e dignosed, nd the options for clinicl mngement. Peri-implnt disese Dentl implnts, like nturl teeth, re susceptile to inflmmtory diseses tht re predominntly driven y the ccumultion of dentl plque. These conditions re ctegorized into those tht re limited to the peri-implnt soft tissues (peri-implnt mucositis) nd those tht lso ffect the lveolr one support (periimplntitis). Peri-implnt mucositis Peri-implnt mucositis is reversile, inflmmtory lesion ffecting the mrginl soft tissues tht surround osseointegrted dentl implnts ut does not involve the resorption of the supporting one (Figure 1). This condition corresponds to gingivitis round nturl teeth nd presents s redness nd swelling of the soft tissues. Bleeding on proing is the clinicl sign tht confirms dignosis (Figure 1). 4,5 As with chronic gingivitis, necrotizing ulcertive condition my develop when risk fctors such s smoking re present. Peri-implntitis Peri-implntitis is n inflmmtory lesion tht ffects the supporting one s well s the surrounding soft tissues of functioning implnt. 4-6 This condition rodly corresponds to periodontitis round the nturl teeth. In ddition to leeding on proing, ffected sites my exude pus (Figure 1c) nd re lwys ccompnied y mrginl one loss (Figure 1d). To distinguish pthologicl one resorption from physiologicl remodelling of the lveolr crest the loss of one height should involve 3 threds of the implnt fixture (1.8 mm) following the first yer in function. 7 Prevlence Although there re few long term dt on the prevlence of peri-implnt Octoer 2010 DentlUpdte 511

2 c d Figure 1. () Peri-implnt mucositis: gingivl inflmmtion nd enlrgement round two mndiulr implnts. () Clinicl ppernce of peri-implntitis with circumferentil inflmmtion round the implnt t the LR3 site. (c) Clinicl ppernce of peri-implntitis with suppurtion t the mesil uccl site fter gentle proing with TPS plstic proe. Note how the flexiility of the proe llows it to follow closely the contour of the crown nd the long xis of the implnt fixture. (d) Rdiogrphic ppernce of fixture seen in (). There is extensive one loss on the mesil nd distl surfces of the fixture. In situ, the one involvement ffected the entire circumference of the fixture. diseses, those dt tht re ville re reltively consistent. Cross-sectionl studies of implnts tht hve een in function for 9 yers or more suggest tht peri-implnt mucositis ffects pproximtely 50% of implnts nd 80% of ptients; 7 periimplntitis, gin for implnts tht hve een in function for 9 11 yers, ffects 28 56% of ptients nd 12 43% of implnt sites. 6-8 Whilst these dt clerly indicte need for sustined supportive cre, it is ressuring to oserve tht overll survivl rte over the sme period is round 96%. Of the implnts tht re lost, the mjority fil erly, either efore plcement of the suprstructure, or within the first yer of loding. 9 Identifying ptients t risk For ptients with periodontl diseses it is crucil tht ssocited risk fctors re identified, modified or eliminted if the enefit of tretment is to e mximized. The sme strtegy pplies to ptients with peri-implnt diseses nd, lthough it might e nticipted tht risk fctors re ddressed dequtely efore the plcement of implnts, this my not lwys e the cse. Ptients who re unle to chieve good stndrd of plque control re t incresed risk of peri-implnt disese with n odds rtio of 2.9 for peri-implnt mucositis nd 14.3 for peri-implntitis, 10 nd the ssocition etween plque nd disese is dose-dependent. The ility of ptients to clen effectively round implnt fixtures, however, my not e ssumed from their ility to chieve high stndrd of plque control round the nturl dentition. 11 Therefore creful instruction in plque control mesures round implnts in the immedite post-plcement period is essentil. There is lso n incresed prevlence of peri-implntitis in ptients with history of periodontitis when compred to non-periodontitis ptients, 12,13 lthough the extent to which this might impct on overll implnt survivl in the long-term is uncler. 14,15 A history of periodontitis does not preclude the plcement of implnts, ut the disese should e stilized with high level mintennce to minimize the opportunity for periodontl pthogens from periodontlly-ctive sites to colonize peri-implnt tissues. 16 It is importnt to pprecite, however, tht the risk for peri-implnt infection is still present even when implnts re plced in edentulous ptients; n implnt will still provide fvourle ecologicl niche for coloniztion y commensl orl cteri. 17 Indeed, numer of cteril species such s Peptostreptococcus stomtitis, Mycoplsm slivrium nd Pseudormicter lctolyticus, tht re not linked with helthy implnt sites or periodontl disese, hve een identified t sites of periimplntitis. 18 Smoking is known risk fctor for periodontl diseses nd there is sustntil evidence se of long-term studies tht implicte the hit s risk fctor for peri-mucositis, peri-implntitis nd totl implnt filure. 12,19,20 These ssocitions hve een sustntited unequivoclly y systemtic review nd met-nlysis 20 nd, whilst there re few dt to suggest otherwise, it must e ssumed tht cigrette smoking will impct negtively on ttempts oth to prevent nd mnge peri-implnt disese in the longterm. Dignosis of peri-implnt disese Clinicl ssessment Visul ssessment lone will revel n inflmed gingivl cuff, lthough scr rections in the soft tissues, for exmple fter one grfting nd tissue mnipultion, my msk inflmmtory rections of the mucos. Proing is essentil nd my e undertken circumferentilly or t four sites round n implnt fixture. A plstic (TPS or WHO 621) proe hs greter flexiility thn metl counterprt, my cuse less contmintion nd dmge to the implnt surfce, nd is potentilly more ccurte s it cn dpt more redily to the utment-suprstructure junction (Figure 2). A light proing force of round N is recommended; 21 the sence of gingivl connective tissue fires ttched to the implnt surfce mens tht there is miniml resistnce to proing. In the presence of peri-implntitis there is n extensive, unencpsulted neutrophil infiltrte nd the periodontl proe is likely to penetrte the entire depth of the 512 DentlUpdte Octoer 2010

3 Figure 2. Plstic TPS proe tht cn e used for proing round dentl implnts. The flexiility of the proe my enle more precise proing of irregulr defects thn would metl proe. Figure 3 () Gross deposits of plque nd clculus on n implnt-retined r. () The resultnt inflmmtion nd mssive gingivl overgrowth cused y the inility of the ptient to clen the suprstructure effectively. soft tissues nd extend to the level of the lveolr one. 22 Bleeding following gentle proing is the chrcteristic sign for peri-implnt mucositis nd suppurtion following proing is indictive of periimplntitis. Proing depth my e influenced y the implnt system nd the suprstructure used: gingivl cuff with proing depth of 5 mm ut with no leeding on proing my e consistent with helth. If initil proing depths re recorded out one month fter implnt plcement, then future mesurements, recorded for exmple on n nnul sis, cn e compred to the seline record. Any moility within yer of plcing n implnt nd/or its suprstructure is more likely to e sign of lck of osseointegrtion, frcture of the implnt or moility nd frcture of the suprstructure rther thn n erly sign of peri-implntitis. The only relile method for ssessing moility (other thn for single tooth implnt) is to dismntle the suprstructure so tht the implnt fixture(s) cn e ssessed independently. Lte moility of successfully integrted implnt, however, my e n dditionl sign of dvnced or progressing peri-implntitis. Rdiogrphic ssessment High qulity, long cone peripicl rdiogrphs re the films of choice for ssessing implnt fixtures. The idel exposure will revel the externl configurtion of the implnt nd the thred profile is likely to e visile unless there is verticl discrepncy of 15 from the perpendiculr etween the em nd the film surfce. 23 The norml one density round osseointegrted fixtures ws descried originlly s hving perifixturl trecultions rditing from the implnt surfce 24 nd rdiogrphic evidence of one trough extending piclly to the first thred my e consistent with helth eing mnifesttion of one remodelling nd re-estlishment of the iologic width of peri-implnt tissues. A rdiogrphic oservtion of one resorption mesil nd distl to the implnt of 3 threds will confirm dignosis of peri-implntitis. 7 If seline rdiogrph is tken t the time of plcement of the suprstructure, then further films cn e exposed t 6 nd 12 months t the time of gretest remodelling of one nd when complictions re most prevlent, nd then t 2-3 yer intervls therefter. More frequent exposures on n nnul sis re indicted when there re persistent clinicl signs of peri-implnt disese nd when there is n incresed risk of complictions, such s when implnts re plced in ptient with history of periodontl disese. It must, however, lwys e rememered tht this type of rdiogrphy is purely two dimensionl nd therefore gives no indiction s to ny potentil uccl one loss tht my hve occurred. Tretment of peri-implnt disese Comprehensive reviews 25,26 of the tretment of peri-implnt diseses hve mde importnt conclusions: n Tht mechnicl, non-surgicl therpy my e effective in the tretment of periimplnt mucositis nd tht the djunctive use of ntimicroil mouthrinses my enhnce the clinicl outcomes; n Tht non-surgicl therpy for periimplntitis is not predictle tretment even with djunctive chlorhexidine mouthrinse. Adjunctive locl or systemic ntiiotics, however, my e effective in reducing proing depths nd resolving leeding on proing; n Adjunctive Listerine mouthrinse cn reduce dentl plque nd mrginl leeding nd my provide some enefit in the mngement of peri-implnt mucositis. The reltively superficil nture of peri-implnt mucositis is the most likely reson tht this condition responds fvourly to intensive orl hygiene instruction, scling, prophylxis nd mouthrinsing with chlorhexidine. As lesions develop, however, their locl ntomy, the complex morphology of the exposed fixture nd the profile of suprstructure-implnt fixture design will inevitly compromise the ility of the clinicin to deride the site effectively nd the ility of the ptient to mintin the re free from dentl iofilm (Figure 3). 27 Mechnicl, non-surgicl tretment (using specificlly designed titnium curettes nd the Vector ultrsonic system with tips designed for tretment round dentl implnts) is effective in reducing dentl plque deposits nd soft tissue leeding, lthough the effects on proing depths nd the pthogenic sugingivl microflor re limited. 27 Titnium curettes re less likely thn conventionl instruments to lter or dmge the implnt surfce, ut their restricted ility to work horizontlly nd circumferentilly etween the threds on the prt of fixture exposed through periimplntitis will limit effectiveness. Similrly, 514 DentlUpdte Octoer 2010

4 Figure 4. Plstic scling instruments re effective suprgingivlly ut my e less effective in removing hrd deposits from within exposed threds of implnts. plstic mnul instruments which my e useful for scling in the suprgingivl environment my e less effective when ttempting to remove deposits from etween the threds (Figure 4). Becuse of the prolem with ccess to the ffected prt of the fixture, the Implntic Derider hs een recently introduced (Figure 5). This rottory instrument clens down to the titnium surfce etween the threds of the exposed fixture t 400 rpm with copious wter cooling, ut the suprstructure must e dismntled to llow ccess (Figure 5). Er-YAG Lsers hve lso een used for decontminting peri-implntitis ffected implnt surfces, 28,29 ut gin, ccess hs proven chllenging nd the outcome dt from reltively smll studies hve yet to demonstrte significnt enefit when compred to conventionl mechnicl therpy. 25 Ultrsonic instruments with plstic tips (SoftTip, Dentsply PA, USA) re lso conceptully ttrctive for use on implnt surfces nd, lthough their efficcy in removing deposits from ffected surfces hs yet to e determined, there is evidence to suggest tht they inflict fr less dmge on the titnium surfce thn do conventionl metl ultrsonic instruments (Figure 6). 30 The ojective of tretment of peri-implntitis is to reduce or eliminte the cteril lod nd so llow heling to occur. When there is evidence of one crtering nd thred exposure, nd when mechnicl therpy lone my e effective, then djunctive ntimicroil therpy my e n option. Minocycline microspheres (Arestin, Orphrm, Johnson nd Johnson) dhere to the wlls of peri-implnt pockets nd re retined in high enough concentrtions to e effective ginst iofilm. They pper to e vlule djunct to mechnicl deridement in ptients with periimplntitis. 31,32 When peri-implntitis sites pper to e unresponsive to non-surgicl mngement, pockets continue to leed or suppurte nd there is one loss of 2mm (involving 3 or more threds of the implnt fixture), then referrl to specilist my e indicted for considertion of surgicl pproch to chieve etter ccess for decontmintion, nd perhps consider regenertive procedures in the longer term. Peri-implnt supportive cre It is crucil tht ny ptient with n implnt-retined prosthesis is enrolled into n individully-tilored progrmme of supportive cre, with the emphsis eing on preventive pproch to potentil peri-implnt prolems nd erly dignosis of developing peri-implnt disese. Risk ssessment should e ongoing, for exmple to estlish smoking sttus (hs n ex-smoker relpsed?) nd the overll mintennce of ptients who hve history of periodontl disese. The design of suprstructures should fcilitte orl hygiene prctices nd the use of soft ristle toothrushes (mnul or powered) should e reviewed. Single-tufted, interspce rushes, nd interdentl tpe nd rushes with plstic-coted wire hus re essentil for clening round fixtures nd eneth the suprstructure. Scling nd prophylxis should e undertken with plstic mnul or ultrsonic instruments with view to minimizing the deposit of clculus, disrupting nd removing iofilm nd ensuring n environment tht is consistent with peri-implnt helth. Figure 5. () The Implntic Derider designed to remove deposits from exposed threds of implnts ffected y peri-implntitis. Reproduced y kind permission of Dr Jn Nilsson, Implntic. () The Implntic Derider in vivo. (Reproduced y kind permission of Dr Jn Nilsson, Implntic. Figure 6. Ultrsonic hndpiece with SoftTip plstic tips which re n ttrctive option to hnd instruments for scling round dentl implnts. (Reproduced y kind permission of Dentsply PA, USA.) Conclusion Peri-implnt diseses re likely to ecome more prevlent s the populrity of implnt-retined prostheses continues to increse. Prevention is the optiml strtegy ut erly identifiction of peri-implnt complictions is essentil if inflmmtion in the supporting soft tissues is to e resolved. Peri-implntitis, however, is more chllenging condition nd Octoer 2010 DentlUpdte 515

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