While there is recognition worldwide of the need to prevent and treat peri-implant diseases in their earliest stages, there is a difference in how such treatments are carried out. In this Q&A, Iain Chapple, PhD, BDS, FDSRCPS, FDSRCS, CCST (Rest Dent), discusses the European Federation of Periodontology’s (EFP) Perio Prevention Workshop guidelines for addressing peri-implant diseases.
What treatment does the EFP recommend for early peri-implant disease, or peri-mucositis?
The evidence base for managing peri-implant mucositis is immature, and study results should be interpreted with caution. There is no “gold standard,” but patient-administered daily mechanical plaque control with or without chlorhexidine gel (not currently available in the United States) has shown promising results.1 Professional involvement is typically essential and should include personalized oral hygiene instructions, professional monitoring of self-care, and mechanical debridement by an oral health professional. A variety of hand or powered instruments and/or polishing tools have been employed, and there is no consensus on what’s most effective. However, studies reveal that these reduce clinical signs of inflammation, although complete resolution of bleeding on probing was not always achieved.2,3 So far, adjunctive measures (antiseptics, local and systemic antibiotics, air polishing devices) have not been found to dependably reduce clinical signs of inflammation. It is important to keep in mind, however, that a lack of supportive evidence does not disprove the effectiveness of well-reasoned clinical tactics. In other words, first use those approaches for which evidence exists, and, if unsuccessful, consider other approaches that may help on a site-by-site basis.
Specifically, when a dental hygienist sees signs of inflammation around an implant with slightly increased pocket depths, no suppuration, no discomfort, and no bone loss associated with increases in pocket depth, what treatment does the EFP recommend?
Peri-implantitis is regarded as a 1 mm or greater increase in bone loss after the first year of implant placement, together with bleeding and/or suppuration.4 The workshop dealt with primary prevention, and so focused on the management of mucositis. However, from previous workshops, it is clear that there is again no gold standard for managing periimplant mucositis. For slightly increased pocket depths, but with no suppuration or bone loss, then the condition is peri-implant mucositis and should be managed as described in the previous answer. In shallow pockets, subgingival prophylaxis for biofilm removal will probably suffice.
At what point is surgical intervention indicated?
The choice of surgical intervention or nonsurgical management will depend on many factors, such as the amount of bone loss; patient compliance with hygiene protocols (if oral hygiene remains poor, palliative nonsurgical management may be the best option); adjacent tissue health; financial considerations; medical considerations; and perhaps even a patient’s age/frailty.
Essentially, the criteria for surgical intervention are similar to those for chronic periodontitis— namely circumstances that bode poorly for long-term success. This comprises consistent bleeding on probing, increasing pocket depths, suppuration, and bone loss. Generally, surgical management may lead to healing by bone formation onto the implant, but this may not be re-osseointegration. Successful nonsurgical management leads to a healthy epithelial attachment to the implant surface. Ideally, if amenable to surgery, disinfection and regenerative surgery with bone substitutes and membranes, including complete burial of the implant for 3 months to 4 months, gives the implant the best chance for recovery. However, this is costly, in terms of fees and time, and typically requires special expertise and referral. Furthermore, if many implant threads are exposed, these efforts are unlikely to succeed. Meticulous plaque control via self-care regimens is essential for sustainable success.
What is an adequate zone of attached keratinized gingiva around an implant?
It is generally accepted that keratinized tissue around the implant is more desirable than nonkeratinized tissue, and many will graft a recipient site prior to implant placement in order to create a keratinized tissue cuff around the implant. However, many patients with meticulous oral hygiene can maintain implant health when there is a nonkeratinized tissue margin. The decision about managing a nonkeratinized marginal tissue should be clinical, and based on the presence or lack of signs of inflammation.
Should soft tissue grafting be recommended when there is less than a minimum amount of tissue?
If inflammation is present and a lack of keratinized tissue is considered potentially etiological, the patient should be referred for an opinion about grafting. If the patient is coping and there is no bone loss, no suppuration, and no bleeding on probing, surgery is not indicated.
What are your thoughts on smoking behaviors in implant patients?
Evidence that smoking is a modifiable risk factor for implant failure is consistent and convincing. I do not believe implants should be placed in smokers, unless these patients are fully aware and accepting of the increased likelihood of implant failure.5 This is part of the informed consent process.
- Spivakovsky S, Keenan A. The effect of anti-plaque agents on gingivitis. Evid Based Dent. 2016;17:48–49.
- Krishna R, De Stefano JA. Ultrasonic vs. hand instrumentation in periodontal therapy: clinical outcomes. Periodontol 2000. 2016;71:113–127.
- Heitz-Mayfield LJ, Lang NP. Surgical and nonsurgical periodontal therapy. Learned and unlearned concepts. Periodontol 2000. 2013;62:218–231.
- Sanz M, Chapple IL, Derks J. Clinical research on peri-implant diseases: consensus report of Working Group 4. J Clin Periodontol. 2012;39:202–206.
- Chrcanovic BR, Kisch J, Albrektsson T, Wennerberg A. Factors influencing early dental implant failures. J Dent Res. 2016;95:995–1002.
From Dimensions of Dental Hygiene. September 2016;14(09):21-22.