Implants should only be inserted when periodontal conditions are stable
Biofilm is the most significant cause of inflammatory bone loss around teeth and implants. Diagnostics,
biofilm management and, where necessary, treatment help in patients with this problem.
The W&H No Implantology without Periodontology workflow concept should provide stable tissue prior to implantation through prevention, and implant success in the long term through aftercare – something that is advantageous to both the patient and the treatment team.
By Dr Jan H. Koch, Germany
Implant treatment can significantly improve quality of life after tooth loss.[1, 2] The long-term prognosis is generally good, but biological complications are common. Peri-implantitis and its preliminary stage, mucositis, occur in a substantial proportion of patients. As is the case for periodontitis and gingivitis, oral biofilm is the main cause.[5, 6] This microbial biocoenosis can also encourage the development of severe systemic disease in the event of pathological changes, such as endocarditis and inflammatory bowel disease.
The only difference in the microbial flora in periodontitis and peri-implantitis is in the detail. Compared with healthy conditions, the quantity and aggressiveness of the pathogenic microorganisms change in both diseases.[5, 6] Bone loss around implants is generally more rapid and leads to more extensive defects than when it occurs around teeth. Accordingly, preventative care is advised even before implant treatment.
Determining risks and providing periodontal treatment
Periodontitis is a key risk factor for peri-implant inflammation. This means untreated periodontitis patients have an increased risk of peri-implant inflammation through to implant loss. The risk is also higher when patients who are initially treated are not included in a supportive periodontitis treatment/recall programme.
Leading periodontists therefore recommend carrying out a screening procedure before implant treatment using, for example, the periodontal screening index or periodontal screening and recording. Bleeding on probing and pocket depths are determined at selected positions. An extensive check of the periodontal status should be carried out if the results are abnormal.
Taking a careful medical history, including previous systemic exposure, is also important. This provides important information about increased risk of inflammation, for example in patients with diabetes that is not being optimally managed. Furthermore, patients should be informed of the risks relating to implants.
Where necessary, initial periodontal treatment is carried out. First, professional tooth cleaning establishes healthy gingival conditions. In this procedure, calculus (Fig. 1) and biofilm (Fig. 2) are removed as far as the gingival sulcus. In combination with careful instruction on oral hygiene, this gives the patient the basis for long-term freedom from inflammation.
Removal of subgingival coatings (debridement) is carried out using sonic or ultrasonic devices and special periodontal tips as initial periodontal treatment (Fig. 3). Manual instruments can also be used. Further surgical and/or regenerative measures may be necessary, depending on the situation.
Periodontal aftercare for long-term success
In the periodontal aftercare subsequent to implantation, soft (biofilm) and hard coatings are regularly professionally and mechanically removed.[16, 17] In the subgingival and supragingival areas, ultrasonic devices are generally used for this (Fig. 4), in combination with manual instruments where necessary. Alternatively, subgingival air polishing can be used in combination with periodontal attachments and powders.
Checking for individual risk factors, such as smoking and diabetes, and working towards a healthy lifestyle are also recommended for a good long-term prognosis after periodontitis treatment.[13, 19] If the patient had severe periodontitis before the initial treatment, the recall frequency will be increased accordingly, partially to prevent peri-implant inflammation.
Proactive implant treatment
If the patient has received good preventative treatment and where necessary has received preliminary periodontal treatment, implant treatment can be planned. A suboptimal implant-supported prosthesis increases the likelihood of biofilm forming. In order to avoid this, the correct implant position, sufficient distances from adjacent teeth and an ideal axial alignment should be considered during the planning phase. A sufficiently sized bone site and soft tissue that is well supplied with blood are needed for successful implant healing and a good long-term prognosis. Prior or simultaneous augmentation may be needed to achieve this. In contrast to this, the time at which the implant is inserted and the treatment is provided plays a less significant role.[22, 23]
In order to support predictable and stable implant treatment, it is also necessary to prepare the implant bed using suitable methods and equipment. This can be achieved using high-performance implantology motors in combination with surgical contra-angle handpieces. Using a low speed and an ample supply of sterile cooling fluid is essential during preparation. Otherwise, the bone can overheat and affect the healing process.
Alternatively, the implant bed can be prepared with piezo-surgical systems, for which special sets of instruments are available. Bone can be worked on in a gentle yet highly effective manner using other special instruments. Indications include alveolar ridge splitting, surgical tooth removal, and the preparation of bone blocks or lateral windows for augmentation. Highly advanced piezo-surgical devices are also minimally invasive in soft tissue.
Stability measurement and bone surgery
Once the implant has been screwed into its final position, the primary stability can be safely and precisely determined using resonance frequency analysis. The technology is available either separately or as an optional module in an implantology motor. If the ISQ (Implant Stability Quotient) value measured is 66 or higher, early intervention is possible, and if it is over 70, treatment must be provided immediately.
An exposure protocol based on the ISQ value improves the prognosis of treatment. Simply measuring the torque resistance, however, does not provide the same level of clinical safety. If reduced ISQ values are measured after the implant has been inserted, a two-phase protocol is generally chosen. After exposure, a new measurement can then be used to determine whether osseointegration has been successful (secondary stability) and loading will be predictable at this point.
The emergence region should be designed to ensure that it is atraumatic to the tissue for long-lasting implant restorations. The implant–abutment connection, material, surface and emergence profile must be biocompatible and mechanically resilient over the long term. The transgingival components should also be accessible for individual and professional cleaning and for probing.
Definitively integrating abutments or other components at implant level immediately (“one abutment, one time”) has also proved to be effective. In combination with good hygiene and correspondingly healthy tissue, this concept can probably be used to achieve a more stable attachment of the implant to the oral cavity than if the components have to be replaced several times - a requirement for peri-implant health.
Whether it is with crowns, bridges, partial or complete prostheses, the implant-supported superstructure should be designed so that the patient can maintain it without any difficulty. Additionally, a distance of at least 2 mm between the bone and the mucosal edge of the prosthesis appears to be advised to prevent infection and subsequent bone loss.
Experts recommend treatment immediately after the initial occurrence of symptoms of inflammation to avoid peri-implant bone loss from the start. Mucositis affects almost half of all implants, and since patients often have several implants, it occurs in a high percentage of patients. The prophylactic or periodontal recall programme established after the implant has been inserted should therefore be continued.[20, 33] At-home oral hygiene should be carefully tailored to the new prosthesis and the patient accordingly instructed on this. In combination with professional biofilm management, good preventative efficacy can be achieved in this way.
The risk of peri-implantitis decreases from 43.9 per cent (no recall) to 18.0 per cent if a patient receives a recall appointment carried out carefully each year, in other words by more than half. Ultrasonic systems with special instruments that do not affect the materials are suitable for this, such as those made of PEEK (Fig. 5), or appropriate manual instruments.
Mechanically preventing mucositis
As for periodontitis patients, peri-implant recall includes regular screening with a clinical check of both periodontal and peri-implant tissue for symptoms of inflammation, probing and, where necessary, radiographic diagnosis. A frequency of two to four times a year has proved to be effective. Deep probing values and bleeding occur more commonly in patients with peri-implantitis than in those with mucositis; pus secretion only occurs in patients with peri-implantitis.
If a patient has mucositis, professional supragingival and subgingival biofilm removal reduce the risk of the inflammation advancing to peri-implantitis. Local and systemic antibiotics used as supportive measures or air polishing, however, show no additional benefit.[20, 39]
Peri-implant bone loss can develop even if good preventative care is provided, for example if the patient’s oral hygiene is not sufficient. Most minimal defects should be treated in a non-surgical manner using peri-implant debridement. Mechanical removal of coatings using suitable ultrasonic systems, supported by Er:YAG lasers, antibacterial photodynamic treatment, air polishing, or treatment with local or systemic antibiotics, where appropriate, has shown promising results.
If closed treatment is no longer possible, the defect must be surgically exposed and carefully decontaminated. This is carried out after flap preparation by removing inflamed tissue and cleaning the surface of the implant using, for example, ultrasonic or piezo-surgical systems. Measures designed to regenerate the bone carried out after this procedure have been successful. Special piezosurgical instruments are available for the surgical treatment of periodontal defects.
After treatment, the patient is once again intensively instructed on oral hygiene and made aware of the need for continual recall. If necessary, the frequency can be selected to be higher than previously in line with periodontal aftercare. If biofilm management is carried out consistently, the implantological results can remain stable for several years even after the periodontitis, mucositis or peri-implantitis has healed.[33, 39]
No Implantology without Periodontology
Successful implant treatment requires consistent, long-term preventative thinking. In each phase, this includes regular periodontal and peri-implant screening in combination with individually tailored risk management, oral hygiene training and professional biofilm management where possible for every patient.
Ideally, this preventative workflow should start well before each restorative measure, before periodontitis can develop. It is essential if implant prosthetic treatment is planned or has already been integrated. Patients will be pleased with the long-term success of the treatment and will be pleased to return to a practice or clinic they trust.
- Boven GC, Raghoebar GM, Vissink A, Meijer HJ. Improving masticatory performance, bite force, nutritional state and patient's satisfaction with implant overdentures: a systematic review of the literature. J Oral Rehabil 2015;42:220-233.
- Derks J, Hakansson J, Wennstrom JL, Klinge B, Berglundh T. Patient-reported outcomes of dental implant therapy in a large randomly selected sample. Clin Oral Implants Res 2015;26:586-591.
- Albrektsson T, Donos N, Working G. Implant survival and complications. The Third EAO consensus conference 2012. Clinical Oral Implants Research 2012;23:63-65.
- Derks J, Schaller D, Hakansson J, Wennstrom JL, Tomasi C, Berglundh T. Effectiveness of Implant Therapy Analyzed in a Swedish Population: Prevalence of Peri-implantitis. Journal of dental research 2016;95:43-49.
- Lafaurie GI, Sabogal MA, Castillo DM, Rincon MV, Gomez LA, Lesmes YA, et al. Microbiome and Microbial Biofilm Profiles of Peri-Implantitis: A Systematic Review. J Periodontol 2017;88:1066-1089.
- Hajishengallis G. Immunomicrobial pathogenesis of periodontitis: keystones, pathobionts, and host response. Trends in immunology 2014;35:3-11.
- Han YW, Wang X. Mobile microbiome: oral bacteria in extra-oral infections and inflammation. Journal of dental research 2013;92:485-491.
- Rakic M, Grusovin MG, Canullo L. The Microbiologic Profile Associated with Peri-Implantitis in Humans: A Systematic Review. The International journal of oral & maxillofacial implants 2016;31:359-368.
- Salvi GE, Cosgarea R, Sculean A. Prevalence and Mechanisms of Peri-implant Diseases. Journal of dental research 2017;96:31-37.
- Veitz-Keenan A, Keenan JR. Implant outcomes poorer in patients with history of periodontal disease. Evidence-based dentistry 2017;18:5.
- Tan WC, Ong MM, Lang NP. Influence of maintenance care in periodontally susceptible and non-susceptible subjects following implant therapy. Clin Oral Implants Res 2017;28:491-494.
- Lindhe J, Karring T, Lang N. Clinical Periodontology and Implant Dentistry: Blackwell Munksgaard, 2003.
- Tonetti MS, Eickholz P, Loos BG, Papapanou P, van der Velden U, Armitage G, et al. Principles in prevention of periodontal diseases. Journal of Clinical Periodontology 2015;42:S5-S11.
- Taylor JJ, Preshaw PM, Lalla E. A review of the evidence for pathogenic mechanisms that may link periodontitis and diabetes. Journal of Clinical Periodontology 2013;40:S113-S134.
- Newton JT, Asimakopoulou K. Managing oral hygiene as a risk factor for periodontal disease: a systematic review of psychological approaches to behaviour change for improved plaque control in periodontal management. Journal of Clinical Periodontology 2015;42:S36-S46.
- Trombelli L, Franceschetti G, Farina R. Effect of professional mechanical plaque removal performed on a long-term, routine basis in the secondary prevention of periodontitis: a systematic review. Journal of Clinical Periodontology 2015;42:S221-S236.
- Sanz M, Bäumer A, Buduneli N, Dommisch H, Farina R, Kononen E, et al. Effect of professional mechanical plaque removal on secondary prevention of periodontitis and the complications of gingival and periodontal preventive measures. Journal of Clinical Periodontology 2015;42:S214-S220.
- Wennstrom JL, Dahlen G, Ramberg P. Subgingival debridement of periodontal pockets by air polishing in comparison with ultrasonic instrumentation during maintenance therapy. J Clin Periodontol 2011;38:820-827.
- Ramseier CA, Suvan JE. Behaviour change counselling for tobacco use cessation and promotion of healthy lifestyles: a systematic review. Journal of Clinical Periodontology 2015;42:S47-S58.
- Jepsen S, Berglundh T, Genco R, Aass AM, Demirel K, Derks J, et al. Primary prevention of peri-implantitis: managing peri-implant mucositis. J Clin Periodontol 2015;42 Suppl 16:S152-157.
- Polak D, Maayan E, Chackartchi T. The Impact of Implant Design, Defect Size, and Type of Superstructure on the Accessibility of Nonsurgical and Surgical Approaches for the Treatment of Peri-implantitis. The International journal of oral & maxillofacial implants 2017;32:356-362.
- Morton D, Chen ST, Martin WC, Levine RA, Buser D. Consensus Statements and Recommended Clinical Procedures Regarding Optimizing Esthetic Outcomes in Implant Dentistry. The International journal of oral & maxillofacial implants 2014;29:216-220.
- Sanz-Sanchez I, Sanz-Martin I, Figuero E, Sanz M. Clinical efficacy of immediate implant loading protocols compared to conventional loading depending on the type of the restoration: a systematic review. Clin Oral Implants Res 2015;26:964-982.
- Trisi P, Berardini M, Falco A, Podaliri Vulpiani M, Perfetti G. Insufficient irrigation induces peri-implant bone resorption: an in vivo histologic analysis in sheep. Clin Oral Implants Res 2014;25:696-701.
- Vercellotti T. Essentials in Piezosurgery: Clinical Advantages in Dentistry: Quintessence Publishing, 2009.
- Pavlikova G, Foltan R, Horka M, Hanzelka T, Borunska H, Sedy J. Piezosurgery in oral and maxillofacial surgery. International journal of oral and maxillofacial surgery 2011;40:451-457.
- Rodrigo D, Aracil L, Martin C, Sanz M. Diagnosis of implant stability and its impact on implant survival: a prospective case series study. Clin Oral Implants Res 2010;21:255-261.
- Lages FS, Douglas-de Oliveira DW, Costa FO. Relationship between implant stability measurements obtained by insertion torque and resonance frequency analysis: A systematic review. Clin Implant Dent Relat Res 2018;20:26-33.
- Baltayan S, Pi-Anfruns J, Aghaloo T, Moy PK. The Predictive Value of Resonance Frequency Analysis Measurements in the Surgical Placement and Loading of Endosseous Implants. J Oral Maxillofac Surg 2016;74:1145-1152.
- Atieh MA, Tawse-Smith A, Alsabeeha NHM, Ma S, Duncan WJ. The One Abutment-One Time Protocol: A Systematic Review and Meta-Analysis. J Periodontol 2017;88:1173-1185.
- Blanco J, Pico A, Caneiro L, Novoa L, Batalla P, Martin-Lancharro P. Effect of abutment height on interproximal implant bone level in the early healing: A randomized clinical trial. Clin Oral Implants Res 2018;29:108-117.
- Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. Journal of Clinical Periodontology 2015;42:S158-S171.
- Tonetti MS, Chapple ILC, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-implant diseases. Journal of Clinical Periodontology 2015;42:S1-S4.
- Salvi GE, Ramseier CA. Efficacy of patient-administered mechanical and/or chemical plaque control protocols in the management of peri-implant mucositis. A systematic review. Journal of Clinical Periodontology 2015;42:S187-S201.
- Salvi GE, Zitzmann NU. The Effects of Anti-infective Preventive Measures on the Occurrence of Biologic Implant Complications and Implant Loss: A Systematic Review. The International journal of oral & maxillofacial implants 2014;29 Suppl:292-307.
- Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. J Clin Periodontol 2012;39:173-181.
- Schwarz F, Schmucker A, Becker J. Efficacy of alternative or adjunctive measures to conventional treatment of peri-implant mucositis and peri-implantitis: a systematic review and meta-analysis. Int J Impl Dent 2015;1.
- Ramanauskaite A, Becker K, Schwarz F. Clinical characteristics of peri‐implant mucositis and peri‐implantitis. Clinical Oral Implants Research;0.
- Schwarz F, Becker K, Sager M. Efficacy of professionally administered plaque removal with or without adjunctive measures for the treatment of peri-implant mucositis. A systematic review and meta-analysis. J Clin Periodontol 2015;42 Suppl 16:S202-213.
- Ramanauskaite A, Daugela P, Juodzbalys G. Treatment of peri-implantitis: Meta-analysis of findings in a systematic literature review and novel protocol proposal. Quintessence international (Berlin, Germany : 1985) 2016;47:379-393.