Findings: A patient-centered, evidence-based approach to dental implant treatment can reduce risk for peri-implantitis. Early recognition of clinical signs and symptoms of peri-implant disease allows for more efficacious and cost-efficient methods of treatment for peri-implant mucositis and peri-implantitis.
Abstract
Peri-implantitis is a frequently occurring biologic complication of dental implant therapy that occurs in up to 47% of implants placed. Understanding the underlying pathophysiology and prevalence, as well as the risk factors for the development of peri-implantitis, is critical to stratifying patients regarding their risk for peri-implant disease. Such risk stratification is also important when considering dental implant maintenance intervals. Current findings suggest that dental implant maintenance reduces the risk of development of peri-implantitis in all patients and has the highest impact on the costs associated with treatment of peri-implantitis over the long term. Thus, implant maintenance must be considered a critical part of dental implant therapy, and maintenance intervals should be tailored to reflect patient and site-level risks for the development of peri-implant disease.
Introduction
The need for tooth replacement with dental implants in individuals with missing teeth due to many causes, including agenesis, trauma, caries, fracture, and periodontal disease, is a common problem. It is estimated that up to five million dental implants are placed each year.1 Additionally, longitudinal survival rates of osseointegrated dental implants range between 90% to 95%,2-4 which would indicate implant failure rates may include half a million fixtures annually.
While survival data are most often reported, this may not give a full picture of the rate of complications, including peri-implant bone loss. Complication rates reported in a systematic review indicate that, in implants assessed over a five-year period, cumulative prosthetic and biologic complication rates were 8.8% and 12.3%, respectively.5 Given the high prevalence of implant complications, it is imperative for dental professionals to identify dental implant-related factors that may lead to increased biologic and prosthetic/occlusal complications.6-8 Further, adequate patient-delivered oral hygiene and regular peri-implant examinations and maintenance have been shown to reduce rates of biologic complications8-10 and may potentially allow intervention to treat implant complications at earlier time points, resulting in less traumatic and costly interventions.
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Peri-implant diseases: Etiology and prevalence
Proper diagnosis of implant health and/or disease is critical to development of an adequate treatment plan, and to identify and prevent peri-implant disease progression that causes hard and soft tissue loss around the implant, potentially compromising implant survival (table 1).
Peri-implant mucositis: Peri-implant mucositis has been defined as an inflammatory lesion of the mucosa surrounding an implant without loss of supporting peri-implant bone.11,12 Peri-implant mucositis has been shown to develop when biofilm deposits accumulate within the mucosal sulci at osseointegrated dental implants.11-13 While these lesions have been characterized as analogous to gingivitis lesions around teeth, it has been noted that the histologic inflammatory lesions associated with peri-implant mucositis are larger and require a longer time of pristine oral hygiene to reverse than gingivitis lesions.14,15 The overall incidence of peri-implant mucositis has been reported to be observed in up to 65% of subjects with dental implants.16 Clinical signs associated with peri-implant mucositis include bleeding upon gentle probing, erythema, edema, and suppuration.14 Additionally, while peri-implant mucositis is reversible and may be present for long periods of time without progression to peri-implantitis, it is considered a precursor to peri-implantitis and may progress if left untreated.13,14,17
Peri-implantitis: Peri-implantitis is a pathological condition occurring in tissues around dental implants that are osseointegrated and in function, which is characterized by inflammation of the peri-implant mucosa and loss of supporting peri-implant bone.12,18 Clinically, these lesions are characterized by swelling, erythema, pain, bleeding upon probing, suppuration, increasing probing depths and radiographic bone loss.12 Peri-implantitis lesions have been demonstrated to commence early (within three years of function) in the postrestorative period and to progress more rapidly than is seen with periodontitis lesions.19,20 Peri-implantitis progression occurs in a nonlinear, accelerating pattern.19
Risk factors that have been associated with peri-implantitis include a history of periodontitis, smoking, hyperglycemia, retained cement, restorative design, implant-abutment interface, and previous implant failure at the implant site.18,21-25 Overall incidence of peri-implantitis varies in different reports and has been reported to range from 10% to 47%.16,26,27 Given the highly prevalent nature of peri-implantitis and the relative difficulty in treating peri-implant lesions, identification of high-risk patients is critical in clinical practice.
Predisposing factors for peri-implant diseases
Systemic diseases: Many common systemic diseases may also directly affect the rates of implant survival. In particular I will discuss diabetes mellitus, osteoporosis/osteopenia, and autoimmune disorders. But emerging evidence suggest that many other systemic conditions may influence implant health.
Dental implants placed in patients with diabetes have been shown to have higher failure rates than those placed in nondiabetic patients.28,29 In humans, hyperglycemia is known to impair wound healing, impair host defense against pathogens, prolong the inflammatory response to injury, and impair new bone formation and bone repair.29 Future studies are needed to identify distinct cut-off points and quantify the risks, if any, associated with diabetes and development of peri-implantitis.
Osteoporosis/osteopenia have common risk factors with periodontal and peri-implant diseases, including cigarette smoking, dietary factors, and medications, but periodontal disease has also been independently associated with bone density and osteoporosis diagnosis.30,31 It is important to note that individuals with osteoporosis have decreased alveolar bone density and mass and thinner cortical bone than healthy counterparts, which has the potential to affect primary implant stability.31 While current studies have not shown a definitive association of peri-implantitis with osteoporosis, dental implant placement and the subsequent application of forces to the alveolar bone and the use of bisphosphonate medications in osteoporotic patients may mitigate progressive alveolar bone loss.30-32
Autoimmune disorders, particularly scleroderma, rheumatoid arthritis, and Sjögren’s syndrome have been associated with an increase in bleeding index and marginal bone loss after placement of dental implants, but this does not seem to affect cumulative success rates, which remain high in these patients.33 In patients with systemic diseases that may increase risks of biologic implant complications, more frequent assessments and maintenance may be warranted.
Systemic medications: Some systemic medications have been associated with a decrease in implant success through a decrease in osseointegration. Both selective serotonin reuptake inhibitors (SSRIs) and proton pump inhibitors (PPIs) have been associated with increased implant failure rates.34-37 Patients taking SSRIs saw rates of implant failures that were three times higher than for individuals who were not taking SSRIs.34.35 Furthermore, individuals taking PPIs also demonstrated a two to three times increase in failure rates.36
Smoking status and/or tobacco cessation: Smoking is a known risk factor for periodontal disease and this effect is mediated by a variety of mechanisms, including reduction in neutrophil chemotactic response, local vasoconstriction, alterations in immune response, a shift to a more dysbiotic biofilm, and a decrease in fibroblast number and collagen production.6,18,37 These effects of smoking can lead to chronic inflammation at periodontal and peri-implant tissues. Smoking is an established predisposing factor for peri-implantitis, and patients who smoke have up to two times the failure rate of implants compared to nonsmokers.6,18 In patients who use tobacco, maintenance is increasingly critical as supportive implant therapy for smokers shows a greater benefit in reducing rates of peri-implantitis than in nonsmokers.38
Periodontal health: It is well established that a history of periodontitis is a risk factor for peri-implant diseases.11,18,19 Findings suggest that bacteria associated with periodontal disease and peri-implant diseases are similar.39 Colonization with these bacterial species occurs within the first 28 days after implant exposure to the oral environment and bacteria can be transferred from distant reservoirs, such as periodontal pockets in teeth elsewhere within a patient’s mouth.40 Since periodontitis is the most common reason for tooth loss in adult patients, treatment of active periodontal disease and continued maintenance therapy for patients with dental implants is critical in maintenance of both teeth and implants.39-43
Plaque control and adherence to regular supportive implant therapy: Plaque control delivered by patients and professionals can result in a reduction in clinical signs of peri-implant inflammation, which is important in controlling peri-implant mucositis and preventing the shift from peri-implant mucositis to peri-implantitis.44 Furthermore, a lack of adherence to supportive peri-implant therapy results in more sites with mucosal inflammation, increased levels of pathogenic bacteria, and peri-implant bone loss.15 High levels of oral bacteria have also been associated with disruptions to implant surface characteristics and titanium corrosion, which can alter the biocompatibility and potential osseointegration of some dental implant surfaces.6 Personalized oral hygiene instructions, regular implant examination and imaging, and professional implant cleaning must be ongoing components of all implant treatment plans.6,15,44
Peri-implant soft tissue quality/quantity: It has been proposed that the establishment of a circumferential seal of tightly packed collagen around the implant-oral cavity interface may improve long-term implant success and that this is better facilitated in the presence of keratinized mucosa.45 Given the anatomical differences between soft tissue attachments around teeth and implants, it should be noted that higher levels of gingival inflammation are associated with a lack of keratinized mucosa.46,47 Particularly in patients with other biologic risk factors, including increased plaque accumulation and previous history of periodontitis, increased keratinized mucosa may be protective to allow for personal and professional plaque removal.45-50
Dental implant maintenance procedures
Examination and diagnosis of peri-implant disease: Proper examination, diagnosis, and treatment planning are critical to maintaining health at dental implants. To assess the health of a dental implant, a careful clinical assessment and adequate radiographs are necessary to identify signs of both health and disease. Importantly, baseline radiographs with a clear delineation of the crestal bone levels taken at the time of implant placement and prosthetic restoration are important references that will allow clinicians to evaluate any changes to crestal bone height that may occur. Radiographs taken at regular intervals can allow for longitudinal assessment of crestal bone height over time.
Patient interview to determine if there are signs of either biologic or prosthetic complications, including pain, occlusal dysfunction, or prosthesis mobility, is a critical component to the implant examination. During the clinical exam, it is important to note that it has been proposed that the soft tissue mucosal seal exhibits less resistance to probing, and gentle probing pressure (<25 N) is required.51 In addition, clinical evaluation including assessment of implant mobility, soft tissue color and contour, probing depth measurements, quantification of dental plaque accumulation, and assessment of bleeding or suppuration on probing are all required.12 Dental implants should be visually evaluated and probed routinely and periodically as part of comprehensive oral examinations, much like natural teeth. Using a systematic approach to diagnosis is critical to properly identify early stages of peri-implant disease, stratify risk of disease development, and formulate appropriate treatment strategies.Dental implant maintenance procedures: After examination of dental implants, instrumentation to remove biofilm and calculus with appropriate instruments should be performed. The utilization of implant-specific powered and manual scalers is critical to avoid scratching the surface of the dental implants.52 Use of air-polishing and/or other biofilm removal devices with specially designed implant tips can also be considered.52 Additionally, removal of fixed hybrid restorations annually to facilitate access to the underlying implant fixtures can aid in implant debridement, but care should be taken to avoid fatigue for implant abutment screws.52
Critical importance of implant maintenance: Clinical and economic impacts
Multiple studies have demonstrated the importance of supportive maintenance procedures in risk for development of implant complications, particularly peri-implantitis.53-55 Patients who were noncompliant with maintenance therapy demonstrated higher probing depths, plaque indices, gingival inflammation, and bleeding upon probing than those who attended maintenance visits.53,54 Further, a recent study demonstrated in patients who were compliant with supportive implant therapy over a six-year period, regular maintenance was associated with a significant decrease in peri-implant diseases, and those patients without regular maintenance were 4.25 times more likely to develop peri-implantitis than compliant patients.53
Noncompliance rates have been shown to increase over time after implant placement, but with reminders and discussion of the importance of implant maintenance, 60% compliance with three-month implant maintenance is achievable.54 Erratic or noncompliance with implant maintenance has been associated with a history of periodontitis, smoking, prosthesis type, and previous noncompliance with maintenance intervals.54,55 Given these findings, dental implant maintenance must be considered a critical component of implant therapy and the importance of compliance with such therapy should be repeatedly communicated with patients to reinforce their understanding of its importance. Current data suggest that for patients with lower risk of peri-implant complications, maintenance intervals of five to six months have been suggested, whereas patients with more significant risk profiles are suggested to receive maintenance therapy every three to four months.6,55,56
In an evaluation of the costs of various therapies to address peri-implantitis during a 20-year period, the cost-effectiveness of all treatments for peri-implantitis was predominantly determined by the ongoing provision of implant maintenance over the life of the implant.10 When analyzing the costs per 1% fewer implants lost, the most cost-effective strategy was to provide ongoing implant maintenance to all implants and to treat those with peri-implantitis with surgical debridement.10 Further, while nonsurgical treatment of peri-implant diseases was the least costly, it was also the least effective, particularly in high-risk patients and those who did not undergo implant maintenance.10
It was found that in individuals who received supportive implant therapy and did develop peri-implantitis, implant maintenance slowed disease progression and delayed the need for surgical intervention.10 This finding was particularly pronounced in patients with significant risk factors for the development of peri-implantitis, such as a history of periodontitis or smoking.10 These data suggest that critically evaluating individual patient risk profiles for developing peri-implant complications and establishing a maintenance interval based upon patient-centered risk analysis, as well as reinforcing ideal home care and the importance of dental implant maintenance, are critical to the long-term success of implant therapy.
Conclusions
Given the high prevalence of peri-implant diseases and the preponderance of data to suggest that peri-implant disease incidence is significantly increased in those patients who do not receive dental implant maintenance, dental implant maintenance should be a critical component of all dental implant treatment plans. Furthermore, identification of individuals with additional risk factors for the development of peri-implant diseases and modification of such risk factors, if feasible, are critical in reducing the incidence of peri-implant complications. Such high-risk patients may also require more frequent maintenance intervals and implant surveillance to allow for the earliest possible diagnosis of peri-implantitis and the most cost-effective and clinically impactful interventions.
Editor's note: This article appeared in the November 2021 print edition of Dental Economics.
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Maria L. Geisinger, DDS, MS, is a professor and director of advanced education in periodontology in the Department of Periodontology in the University of Alabama at Birmingham (UAB) School of Dentistry. Dr. Geisinger is a diplomate in the American Board of Periodontology. She currently serves as chair of the American Dental Association’s Council on Scientific Affairs and as a member of the American Academy of Periodontology’s Board of Trustees. She has authored more than 45 peer-reviewed publications, and her research interests include periodontal and systemic disease interaction, implant dentistry in the periodontally compromised dentition, and novel treatment strategies for oral soft- and hard-tissue growth
