Peri-implantitis is a chronic inflammatory disease affecting the bone and gum tissue around implants. As the number of implants being placed increases and subjected to inflammatory and occlusal demands the incidence of problems associated with Peri-implantitis will also increase. It is essential for practitioners to understand the etiology of Peri-implantitis and their role in preventing, treating and maintaining this growing problem.

1. Peri-Implantitis:
Prevalence, Practical Treatment and Prevention
Prevalence, Practical Treatment and Prevention
Dr. Scott K. Smith
November 13, 2013

2. Scott K. Smith
• Practicing Periodontist 20 years
• Placed over 10,000 implants
• HiOssen lecturer, teacher and Instructer

3. Objectivesand Peri• Define Peri-Implant Mucositis
Implantitis
• Prevalence of each
• Pathogenesis vs. Periodontal Disease
• Diagnostic Criteria
• Treatment for mucositis and implantitis
• Maintenance following treatment

4. Conflict of Interest
• HiOssen - Clinical practice support and
honorarium.

5. Dental Implant Success
• 400,000 implants placed per year in US
• 1 million implants placed per year in EU
• $6.5 billion US industry
• Failure Rate of Implants less than 5%
• Industry and Research Focus on Initial
Stabilization, enhancing supporting
structure and Initial Esthetics.

11. The Dark Side
• Incidence of Peri-implant mucositis and
Peri-implantitis is as much as 47%!!
• Failure of Implants by Chronic Inflammation
include Functional loss, Phonetic and
Esthetic Challenges
• Professional Challenge

12. Similarity with
Periodontal Diseases
• Host Response to Bacterial Insult
• Initial Event is Inflammation of Pocket
Epithelium without CT or Bone
Destruction - Reversible = Gingivitis
• Chronic Inflammation and Risk Factors =
Periodontitis

13. Implant Related Periodontal
Diseases
• Peri-Implant Mucositis
• Peri-Implantitis

14. Peri-Implant Mucositis
• The presence of inflammation
confined to the soft tissues around
the implant - No sign of bone loss.
• Presence of probing >4mm with
bleeding or suppuration
• Reversible

15. Peri-Implantitis
• Inflammatory process around and implant
including soft tissue and progressive loss of
supporting bone beyond biological bone
remodeling.
• Probing depth >4mm with bleeding,
suppuration and radiographic bone loss

16. Peri-Implantitis
Probing depths >4mm with bleeding, suppuration
Radiographic loss of bone beyond remodeling

17. Prevalence:
Peri-Implant Mucositis
Peri-Implant Mucositis
• Berglundh, Renvert:
48% of all implants over 9-14 yrs affected.
• Prevalence may be higher - Previous
Dogma of Not Probing around Implants
Reduced Identification

18. Prevalence:
Peri-Implantitis
Peri-Implantitis
• Wide Range: from 4.7% to 36.6%
• The Threshold used is Bone Loss. No
standarized radiographic analysis.
• Additionally Factors such as Smoking,
Diabetes, Previous Periodontal Disease
create subpopulations and complicate
comparisons of studies.

19. Periodontal Anatomy

20. Anatomy of a Tooth
• Junctional Epithelium has Hemidesmosomal
attachment to enamel
• Connective tissue array of 1mm thickness with
attachment to Cementum
• Alveolar Bone with Perpendicular Fibers attaching
to Cementum overlying Dentin
• Vast Source of Nutrients and Cells for
Regeneration of Ligament, CT, Cementum, Bone

21. Cementum
• Acellular and Cellular containing
cementoblasts provide support on the
tooth side to anchor sharpy’s fibers
• Periodontal Ligament space provides
nutrient supply and cells for Regeneration

22. Anatomy of an Implant
• Junctional Epithelium attached to titanium
surface by basal lamina and hemidesmosomes
• At apical portion of sulcus is only a few cell
layers thick and separated from bone by 12mm
• No Cementum - Bone to Implant Contact
• Connective tissue between JE and Bone few
vascular structures and few Fibroblasts

23. Pathogenesis

24. Peri-Implant Mucositis
• Plaque formation of titanium surface and
formation of biofilm. Gram (-) Anaerobic
• Inflammatory infiltration occurs in CT
• Neutrophils, lymphocytes, macrophages in
high numbers
• Adaptation of JE to Inflammation

25. Peri-Implantitis
Peri-Implantitis
• Inflammatory - bacterial driven destruction
of the implant supporting apparatus.
• Chronic Inflammation starting as PIM
• Inflammatory Cell Infiltrate more Severe
with Implants vs. Teeth
• Rate of Disease Progression Faster with
Implants

26. Peri-Implantitis
• The difference in collagen fiber orientation
(parallel to implant and perpendicular with
teeth) and less vasculature structure may
explain the faster pattern of tissue
destruction with peri-implantitis.

27. Influential Factors
• Patient Related - systemic diseases, history
of Periodontal Disease
• Social Factors - Poor OH, Smoker, Heavy
alcohol consumption
• Parafunctional Habits - Bruxism,
Malocclusion

28. Smoking
• Baig and Rajan found in smokers
significantly more marginal bone loss after
placement and higher Peri-Implantitis
percentages.

29. Previous Periodontitis
• Significant correlation with increased
prevalence of Peri-Implantitis

30. Genetic Factors
• Significant correlation with
Interleukin1gene polymorphism and PeriImplantitis.
• Plagnat - proposed markers for Elastase
and alkaline phosphatase may be helpful in
future diagnosis of bone destruction.

31. Health Status
• Diabetes Type I and II if uncontrolled lend
to increased inflammatory Response and
Peri-Implantitis

32. Occlusion
• Non-axial forces, cantilevers, bruxism
• H.L.Wang et al - occlusal overload
positively associated with Peri-Implantitis
• Likely excess strain causes microfracture
within bone.

33. Additional Influential
Factors -You’re to Blame
• Implant Design
• Prosthetic Connection
• Mechanical Failures and Cement
Contamination
• Surgical Errors

34. Implant Design
• Smooth titanium vs. Roughened
surfaces
• Smooth Cervical collar vs. Surface
texture to coronal margin
• Thread Design - aggressive vs. passive

35. Implant Design Connection
• External Hex
• Internal Hex
• Morse Taper
• Platform Switch

36. Platform Design
• Crestal Bone loss begins when healing
abutment is attached to implant at second
stage surgery (Nobel implants - Ericsson J.
Clin. Perio 1995)
• Burglund and Lindhe identified 0.5mm
inflammation above and below Branemark
implants at abutment/implant junction after
2 weeks.

38. Microgap and Platform
Switching
• Move the microgap away from the implant
platform and hence away from the crestal
bone as a protective measure.

40. Restorative Problems
• Excessive Cantilever
• No Passive fit
• Improper fit of abutment
• Improper prosthetic design, occlusal scheme
• Premature Loading, Overtorquing
• Connecting implants to Natural teeth

42. Mehcanical Failures

43. Fractured Implants

44. Loosening of Screws

45. Retained Cement

46. Surgical Placement
• Off Axis Position - severe angulation,
• Lack of Initial Stabilization
• Infection from improper flap design
• Overheating bone
• Spacing too close to teeth or implants
• Inadequate bone or attached gingiva
• Too Buccal or Lingual and compromise bone

47. Inadequate Attached
Gingiva

48. Inadequate Buccal Bone

49. Space Between Teeth
and Implants

50. Head of Implant

51. ANGULATION

52. Buccally Positioned

53. Heat Generation
• Eriksson and Albrektsson reported the
critical temperature for implant placement
was 47C for 1 minute.
• Matthews and Hirsch demonstrated that
temperature elevation was more a result of
force applied rather than drill speed.

54. Diagnostic Criteria
• Probe all implants - Plastic or Metal
• Look for Bleeding and or Suppuration
• X-rays should be taken yearly first two
years and compared to base line placement
• Evaluate Occlusion, Prosthetic Stability
• Soft tissue evaluation - Attached Gingiva?

55. Probing

56. Probe Long Axis

57. Accessibility
• Adjust Prosthesis
• Plaque Control
• Biofilm Removal

58. How do you Probe
this?

59. Remove Prosthetic

60. Bone Level

61. Attached Gingiva?

62. Treatment Options
• Early Detection is Key to Success and
improved health!
• Non-surgical Intervention
• Surgical Intervention

63. Non-Surgical - Studies
• Mechanical Debridement with plastic instruments
and Chlorhexidine irrigation showed reduction of
pocket and bleeding at six months - Schwartz
• Antiseptic irrigation of pockets <4mm not
effective, but over 5mm it has added effect.
Renvert
• Adjunctive use of generalized antibiotics did not
improve the treatment results

64. Peri-Implant Mucositis Transmucosal
Transmucosal

65. Peri-Prosthetic

66. Peri-Prosthetic

68. Peri-implant Mucositis
• Application of Minocycline spheres along
with debridement provide some additional
benefit to reducing bleeding and probing,
but NEEDS TO BE REPEATED OFTEN.
Renvert

69. Clinical Treatment of PIM
• Mechanical Scaling of Implants with plastic or
titanium instruments or Ultrasonic Plastic
Tips. I-Brush if exposed threads.
• Apply exposed implant surface with 0.2%
Chlorhexidine gauze for 2 mins
• Subgingival irrigation with 0.2%
Chlorhexidine 5ml per implant
• Minocycline Spheres or Gel

70. Peri-Implantitis
Treatment Options
Treatment Options
• Visualization with open flap very effective
with cementitits!

71. Peri-Implantitis
• Treatment to be determined by amount of bone
loss and esthetic impact of the implant in question
• If minimal bone loss (3 threads or less) Proceed
with similar treatment as Peri-implant mucositis,
but decontaminate prosthetic components as well.
The use of various lasers has been suggested.
• If bone loss is advanced or progressive than
surgical access with resective or regenerative
components will need to be employed.

72. Peri-Implantitis
Non Surgical - Studies
Non Surgical - Studies
• 31 Subjects mean age 62
• One qualifying implant per patient
• PPD >4mm with bleeding or suppuration
• < 2.5mm bone loss
• J. Clin. Perio 2009 Renvert

73. Non-Surgical
• Titanium hand instrumentation
• Or Ultrasonic Debridement with plastic tip
• 6 month results - minimal change with PD
for either treatment modality

74. Laser Therapy Er:YAG
• SRP with plastic instruments and 0.2%
chlorhexidine followed by Er:YAG 20sec
disinfection per implant
• Control was only SRP and antiseptic rinse
• Six months later Equal Reduction of Pocket
and Clinical Attachment
• Twelve months later both groups lost effect

75. Peri-Implantitis with Er:YAG vs.
Air-Abrasive device
• 42 Patients mean age 69
• Laser 55 implants
• Perio Flow 45 implants
• PPD >5mm with bleeding or suppuration
• > 3mm bone loss
• J. Clin Perio 2011, Renvert

76. Results
• Remove Supra-Structure from Implants!
• Significant difference in PD bleeding and
Pus reduction for both groups at 6 months
• Both seem to have limited benefit in
advanced cases

77. Open Flap - Resective
• Surgical flap access and resection of 1 or 2 wall
defects combined with decontamination and
antibiotic treatment was effective in just over
half the cases over 5 years. Leonhardt 2003
• 2008 Hitz-Mayfield with flap surgery and
resection and antimicrobial treatment stopped
the progression of the disease in 90% of cases
up to one year - However, BOP continued in
50% of the lesions.

78. Regenerative Surgery
• Schwartz (2008) found combination bone
grafting debridement and antibiotics had
significant reduction of bone loss and BOP
after 2 years.
• Froum (2012) Significant reduction of BOP,
Pocket reduction, bone loss over 3-7 years.

79. Submerged Healing • 16 implants in 12 patients
• Open Flap and 3% Hydrogen Peroxide
• Bone Graft and Membrane
• Submerged healing
• Roos-Janasker J. Clin Perio 2007

80. Submerged Surgical
Results
• PD change
• Defect fill (threads)
• Defect Fill (mm)
• Recession (mm)
4.2mm
3.8
2.3
2.8

81. Implant Configuration
and Decontamination
• Implant contours and surface are a limitation
to remove the biofilm
• Surface treatments including - mechanical,
Er:YAG, photodynamic, air-abrasion,
implantoplasty
• Romeo (2005, 2007) implantoplasty improved
regenerative capability - reducing probings
from 5.5 - 3.6mm and BOP.

82. Implantoplasty

83. Regenerative Treatment for PeriImplantitis affected implant:
Stuart J. Froum Clin Adv Perio 2013
Stuart J. Froum Clin Adv Perio 2013
• 7 year follow up showed decrease pocket
depths
• Technique successful in 51 cases (IJPRD
2012:32:11-20)
• Believes if any Elements of protocol not
followed could compromise outcome

84. Protocol
• 1 month prior to surgery: SRP of natural
teeth; debride implant surface and OHI
• Requires 2 visits to accomplish this

85. Surgery:
Exposure and Debridement
Exposure and Debridement
• 2 gm Amox 1 hour prior to surgery
• FTF to expose area
• Debride defect with titanium and graphites
• Air-Power abrasives (Bicarbonate powder) for
60 secs
• 60 secs irrigation with sterile saline
• 60 secs application of Tetracycline strips

86. Surgical Protocol
• Second application of air-powder abrasive
for 60-90 secs
• Application of CHX for 30 secs
• 60-90 secs of sterile saline with air power
device no powder

87. Surgical Protocol
• EMD applied - avoid blood and saliva
• Defect filled with 1:1 Bioss/Puros
rehydrated with gem 21
• 2 ossix membranes placed to cover all
surfaces
• Flap released and coronally advanced and
sutured with Goretex and vicryl sutures

88. Post Surgery
• 2 weeks remove sutures and polish
• Pt to brush area 4x/day with 1:1 Peroxide
and rinse with salt water 4x/day
• Return monthly for 12 months for post op
and every 6-8 weeks for maintenance

90. Treating Peri-Implantitis
• Systemic Antibiotics for three days prior to
treatment
• 2 mins pre-operative rinse with
Chlorhexidine
• Full Thickness Mucoperiosteal Flap to one
tooth beyond diseased site
• Thorough Debridement circumfirentially with
plastic or titanium or Ultrasonic plastic tips

91. Treating Peri-Implantitis
• Pack Gauze Strips soaked with CHX around
implants and in defects for 5 mins
• Remove Gauze and irrigate with CHX or
Tetracycline 250mg/5cc
• Graft Defect with FDBA, BioOss
• Apply Collagen Membrane
• Closure of Flap and Regular Post op Intervals

96. Detoxify
• HCL Acid
• Tetracycline
• EDTA
• Hydrogen Peroxide
• Er:YAG and Diode

97. Graft Material
• Need OsteoInductive Material as there is
minimal Osteoprogenetor cells
• FDBA, DBA, Acel, OsteoCel, BMP2, Gem21, PRP, Emdogain
• Collagen Matrix Necessary
• Tacks to hold membrane if necssary

101. Mechanical
Debridement
I-Brush

109. Retrograde

117. LAPIP
• Nd:YAG laser with LANAP protocol to
address peri-implantitis
• Closed access
• First pass to decontaminate and selectively
eliminate infected tissue
• Debride with Piezon and CHX
• Second pass with laser to provide fibrin clot

118. LAP-IP

119. LAP-IP

120. LAP-IP

121. LAP-IP

122. Peri-Implantitis Effects
• Loss of implant and functioning prosthetics
• Esthetic Challenges
• Phonetic Challenges
• Maintenance Challenges

125. Prosthetic and
functional failure

126. Prevention Is The First
Step:
• Avoid conditions that contribute to poor
results
• Choose cases where you have excellent chance
for implant and prosthetic success.
• Anticipate and Diligently observe for implant
and restorative problems.
• Once Perio-Implant Disease identified act
quickly and with purpose to effectuate the
situation

127. What I see
• Retained Cement
• Inadequate attached gingiva
• Position of implant - Too Buccal
• Position of implant - Too Close to others
• Occlusal Overload
• Loss of Attached Gingiva Anterior
• Poor Oral Hygiene - Inability to get access

130. Hybrid Screw Retained
Vs. Implant Denture

131. Accessibility

132. Access for patient?

135. Proximity Issues

139. Implant Maintenance
• Needs to be Individually Determined
• Needs to be Enforced by Doctor and
Hygienist
• Patient Needs to assume Responsibility

140. Low Risk Patient
• Highly motivated
• Excellent Oral Hygiene
• One or Two implants
• No associated Risk Factors

141. Moderate Risk Patient
• Loss of Motivation
• Fair Oral Hygiene
• 3-6 implants
• Moderate Smoker (half pack)
• Controlled Medical Issues

142. High Risk Patient
• Unmotivated
• Poor Oral Hygiene
• Previous Periodontitis
• >6 implants
• Smokes more than half Pack
• Poorly Controlled Systemic Disease(s)

143. Maintenance Recall
• Low Risk Patients - every 6 months
• Moderate Risk - every 3 months
• High Risk - every 2-3 months
• Note - Oral Hygiene signficantly influences
the category the patient is placed.

145. Mechanical
Debridement
Hand Scalers and Ultrasonics

146. Maintenance
• Plastic, titanium, graphite instruments for
visual debridement from prosthetics and
sulcus.
• Ultrasonics with plastic tips at low to
moderate settings are excellent
• Individual or multiple implants with fixed
crowns or bridges screw or cemented
assess and debride as you would teeth.

147. Maintenance
• For Fixed Hybrid cases Remove at least
Twice a year and assess and debride
Transmucosal and Prosthetic underside
• O rings Remove Denture and address
abutments directly

148. Maintenance
• Polish with soft rubber tip and non-abrasive
paste - aluminum oxide, tin oxide, fine
pumice
• Irrigate with CHX with endodontic syringe
or piezon on low setting.

149. Ancillary Homecare
• Periostat - Doxycycline 20mg b.i.d.
• Evorapro - Especially for Dry Mouths
• Perio-science AO gel and rinse
• Listerene if no dry mouth 2x/day
• Biotene if dry mouth 2x/day

150. Likely Cause?

152. Etiology?

153. Thank You