FOR DENTISTS- Peri-implantitis: Etiology, Diagnosis and Treatment
Dental implants have become the treatment of choice for many patients with missing teeth. It is often the most predictable solution that offers superior aesthetics and function compared to other treatment alternatives. However, literature has shown that 20-40 percent of dental implants may require treatment due to ongoing peri-implantitis.
The etiology of peri-implantitis is often multifactorial. Peri-implantitis can be broadly categorized into early vs. late failures. Early failures occur within the first six months of implant insertion and could be due to host (patient) rejection of the dental implant, overheating and/or compression necrosis of bone during insertion, or infection post-placement. Late failures occur typically a year after function and the progression of bone loss is significantly slower compared to early failures. A few possible reasons for late failures may be residual cement, excessive occlusal loading or improper design of the implant restoration that may be plaque retentive.
Peri-implant diseases can be broadly categorized into peri-implant mucositis and peri-implantitis. The first is similar to gingivitis, where the inflammation is confined to the soft tissue component of the implant. The latter is similar to periodontitis, where the inflammation and infection has progressed into the bony compartment that supports the dental implant.
Another common way to diagnose peri-implant disease is based on the progression of the peri-implantitis: ailing, failing and failed implant. Ailing implants are implants that have suffered from peri-implant bone loss but the disease is not currently progressive, while failing implants are undergoing active disease. Failed implants, on the other hand, are implants that have lost complete osseointegration and should be treated with extraction of the dental implant.
Consider a screw-retained restoration if possible. Treatment of peri-implant disease often requires the practitioner to understand the etiology of peri-implantitis in the particular situation. If a cement-retained implant restoration was used, presence of residual cement should be thoroughly checked and removed. Consider the use of radio-opaque cement as well so excess cement can be readily detected through radiographs. An even better solution would be to use a screw-retained restoration to eliminate the cement factor. In addition, a screw-retained restoration offers the additional advantage of submerged healing should the implant need to be grafted.
Occlusion is another important factor with implant restorations. Implant restorations should be in slight hypo-occlusion since the implant does not have periodontal ligament compared to natural teeth. If a cantilever must be utilized, mesial cantilever has a much more favorable occlusal pattern instead of distal cantilever restorations.
Grafting around implants with previous bone loss is possible, assuming the configuration of the bony defect is self-containing. Again, submerged healing post-grafting offers the most predictable outcome. In non-aesthetic areas, open flap debridement with concurrent implantoplasty can be performed to produce a smooth, non-plaque retentive and biologically acceptable implant surface. However, only use this treatment approach judiciously since it can create significant recession.
LAPIP stands for laser assisted peri-implantitis procedure. It is a flapless, minimally invasive way to treat peri-implantitis. During the first pass, an Nd-YAG laser is utilized to disinfect and selectively remove the diseased peri-implant tissue. Next, ultrasonics and hand instrumentation are used to create a plaque-free environment prior to the second pass of the laser. Once the implant surface has been detoxified, the second pass of the laser then creates a fibrin seal between the tissue and implant to allow regeneration of previously lost supporting structures.