Peri-implantitis: What Have We Learned?

Aug 22 / Prof. Nikos Mattheos
Last month Prof. Nikos Mattheos hosted a panel discussion on Peri-implantitis with 3 world class experts during the ITI World
Symposium 202ONE. Drs Lisa Heitz Mayfield, Mario Rocuzzo and Daniel Thoma came together to discuss the case of Claire, a patient
recently diagnosed with Peri-implantitis. In a discussion naturally evolving about an actual patient, the host and guest speakers
reviewed the latest developments in all aspects of Peri-implantitis, debated and responded to questions from the host and the
audience. Did you miss it? Well, don’t worry, we were there for you and we saved the most important “take-home” messages!
Lisa Heitz Mayfield is a world class expert in Peri-implantitis from
Australia, currently in private practice and affiliated with Universities in
Western Australia and Sydney. She started the discussion with a
presentation focused on the patients’ experience with Peri-implantitis
and reviewed the current state of evidence in assessing risks for the
disease.

Although studies reported that only around 10% of patients diagnosed
with peri-implantitis will present with symptoms, the diagnosis has
significant implications for them. Abrahamsen and his associates in
Gothenburg conducted open-ended interviews with patients who
were referred to the periodontist for treatment of peri implantitis and
documented the surprise, concern and feelings of disappointment or
frustration they often experienced. Such patients were suddenly
confronted with major decisions their trust to the dentist was shaken
and were worried about the financial costs and the prognosis of the
treatment. She placed therefore the emphasis on two important
factors before implant placement: patient-centered communication
and patient-centered risk assessment.

She went on to identify 3 major risks for peri-implantitis, based on the
current evidence:

- History of severe periodontitis
- Lack of compliance with maintenance care
- Deficient plaque control

Surprisingly maybe, the evidence against smoking and diabetes is less
robust, although both have been traditionally considered as major
risks. The good news is then that 2 of the major risks are controllable
with proper interventions. Proper design to ensure cleanability of the
prosthesis and professional maintenance care delivered at least twice
a year together with patient administered oral hygiene could minimize
the risks for peri-implantitis. Finally, she presented a recently
published instrument (IDRA) (1) for the assessment of the patients’
peri-implantitis risk based on 8 parameters: a) prosthesis design, b)
supportive care frequency, c) bleeding on probing, d) number of deep
pockets, e) susceptibility and f) bone loss in relation to age.


Mario Rocuzzo, adjunct professor in the University of Turin, focused his presentation in the surgical treatment of Peri-implantitis. He started by emphasizing the importance of the optimal implant position, as the treatment
 of Peri-implantitis is 
much more predictable if the implant is placed and
restored
appropriately. Malpositioned implants with compromised or uncleanable restorations might pose a serious challenge for the
treatment of peri-implantitis. The treatment of peri-implantitis with reconstructive surgery today is predictable and can be successful, provided it is applied on highly motivated patients with a low plaque and bleeding scores. He identified the surface and the shape / design of the implant as important
parameters of success, but maybe surprisingly he reported that in his
results the morphology of the peri-implantitis defect was less important
than the patient related factors. His approach of choice is
reconstructive surgery, which involves decontamination of the implant
surface, augmentation of the intrabony components of the defects with
the use of xenograft without the use of barrier membrane and finally
the placement of a soft-tissue graft as a “cuff” around the implant neck
at the closure of the surgical wound. In their recently published study
following 75 implants after 5 years, the implant survival rate was 80%,
but interestingly there was a huge difference between people who
completely adhered to the SPT compared to people who did not.
Mario Rocuzzo, adjunct professor in the University of Turin, focused his presentation in the surgical treatment of Peri-implantitis. He started by emphasizing the importance of the optimal implant position, as the treatment
 of Peri-implantitis is 
much more predictable if the implant is placed and
restored
appropriately. Malpositioned implants with compromised or uncleanable restorations might pose a serious challenge for the
treatment of peri-implantitis. The treatment of peri-implantitis with reconstructive surgery today is predictable and can be successful, provided it is applied on highly motivated patients with a low plaque and bleeding scores. He identified the surface and the shape / design of the implant as important
parameters of success, but maybe surprisingly he reported that in his
results the morphology of the peri-implantitis defect was less important
than the patient related factors. His approach of choice is
reconstructive surgery, which involves decontamination of the implant
surface, augmentation of the intrabony components of the defects with
the use of xenograft without the use of barrier membrane and finally
the placement of a soft-tissue graft as a “cuff” around the implant neck
at the closure of the surgical wound. In their recently published study
following 75 implants after 5 years, the implant survival rate was 80%,
but interestingly there was a huge difference between people who
completely adhered to the SPT compared to people who did not.
Daniel Thoma is Professor in the department of Prosthodontics in
the University of Zurich. His part was to point out the interactions between the prosthetic design and material with the health of the peri-implant tissue and
development of peri-implantitis. His first realization was that although the latest consensus workshops have gone to great length in defining peri-implantitis
and the related risks, very little information is available with regards to the role of the reconstruction, it’s design and material. When it comes to material some recent reviews comparing metal ceramic restorations with Zirconia in single
crowns have identified biological complications of 8-9% for both,
pointing towards any difference. With regards to type of retention,
when summing up results from in-vitro and clinical studies for single,
multiple, and full arch restorations, he concluded that screw retained
restorations presented with less risk for peri-implantitis. At the same
time, the design of cement retained restorations is crucial, as the
emergence profile and the depth of the cementation shoulder under
the soft tissues could predispose to cement rests and inflammation if
not properly planned. He went on to indicate the contour of the
prosthesis as a major parameter of risk, with some recent studies
showing a contour wider than 30 to be associated with increased risk
for peri-implantitis. In some of his unpublished data the contour wider
than 40 was associated with peri-implantitis. Finally, he concluded that
the evidence is slowly accumulating to support prosthesis modification
as an important part of the treatment of peri-implant tissue
inflammation, when there is obvious over contouring of the prosthesis,
or other designs that limit the accessibility to oral hygiene.

SOME PANEL QUESTIONS TO TAKE HOME

1. What is the longevity of implant therapy?
Are implants for life?

All panelists agreed here that dental implants are not meant
to last for life, despite being the most successful implantable
materials. Studies have shown that approximately 90% of
the patients maintain their implants at 10 years’ time point,
but there is a very wide individual variation that makes it
very difficult to give a reliable estimation for each patient.
The panel suggested colleagues to conduct a thorough risk
assessment of each patient and communicate the limitations
to the patient, while emphasizing on the importance of
attending a regular maintenance scheme. Mario Rocuzzo
mentioned that he offers a free replacement if an implant is
to be lost within 10 years, but only to patients who adhere to
the recommended maintenance scheme, an idea however
that was not adopted by the prosthodontist of the panel,
Prof. Thoma. All authors stressed that it is important not to
convey the message to patients that “implants last for life”,
something that is not the case with any other medical
device. Maybe not surprisingly however, the attitude that
“implants last for life” was still very widespread among
colleagues, as the audience poll showed...!

2. What can we expect from the surgical
treatment of Peri-implantitis? What to do if our
surgery fails to arrest disease progression?

Mario Rocuzzo the basis of their study (reconstructive
surgery) (2) mentioned that he would expect around 2/3 of
the patients to maintain success after 5 years, with success
defined as the absence of deep pockets around the
implants and absence of additional bone loss. At the same
time around 17% of patients may lose an implant in the same
period. Lisa Heitz Mayfield added that if one year after
surgery after we maintain pretty shallow probing depths
and a fairly good stability of the bone levels, we can
anticipate a pretty good chance to still maintain success
after 3 or 4 years. Recurrence of the disease can occur
however at any stage. If deep pockets and marginal bone
loss persist or reappear at some point in time, she will be not
inclined to repeat the surgery, but rather consider
explantation of the implant. Actually, removal of the implant
is something that we should consider discussing with the
patient, as one option or potential outcome to be aware of
in any case of peri-implantitis.

3. What to do with implants which are placed in
sub-optimal position?

Implants referred to the prosthodontist might be at times
placed in more or less compromised position. Daniel Thoma
acknowledged that this can be at times the case in particular
in full arch restorations, therefore he always aims to discuss
the treatment plan with the surgeon beforehand. In cases
however where he ends up with a referral of malpositioned
implants, he will discuss the risks first with the referring
colleagues as well as the patients. There were cases where
he ended up choosing other restorative options than implant
born restorations in such situations.

4. What about prosthesis modification in patients
with Peri-implantitis?

It is a need that is occurring often, especially in large and full
arch reconstructions. When the prosthesis predisposes to
plaque accumulation and peri-implantitis would discuss with
the referring dentist and explain the need for modification. As
however many patients are no longer followed by the dentist
who placed the restoration or do not wish to return for
further care, he often has to undertake such modifications
himself or in collaboration with his lab, after a thorough
explanation to the patient. In some cases prostheses cannot
be easily modified and at times he had to remake them or
resort to replace fixed with removable prostheses.

5. How do you decide between surgical treatment
or explantation?

Here we have to use multiple levels. First of course the patient
behavioral and systemic risk level. Obviously, no surgery will
be meaningful for a patient who is unable or unwilling to apply
the proper oral hygiene. Then come several local parameters
that can direct us to one or the other option. It is very
important if the implant is properly positioned or in a
compromised place. If there is an aesthetic involvement or not.
Furthermore, added Mario Rocuzzo, the surface and
geometry of the implant, the familiarity of the operator to the
implant and how easy it is to decontaminate it. The prosthesis
type and accessibility to the defect, the amount of bone and
tissue remaining, the presence and condition of neighboring
teeth, the overall rehabilitation plan and the strategic aspects
of possible alternative solutions or not, all these might be
important determinants in a case-by-case assessment.

6. Do systemic antibiotics help in the surgical
treatment of peri-implantitis?

Maybe surprisingly to many, Lisa Heitz Mayfield acknowledged
that the evidence in support of the use of systemic antibiotics
as a supplement to peri-implantitis surgery is very weak. In
very few randomized controlled trials a small benefit is shown
in favor of systemic antibiotics which is limited in the first year.
In the light of recent evidence about the potential harmful role
of antibiotics, it is today debatable whether systemic
antibiotics should be used with peri-implantitis treatment. On
the other hand, she admitted that her studies with surgical
treatment of peri-implantitis were conducted in conjunction
with systemic antibiotics, mainly amoxicillin and
metronidazole.

References
1. Reconstructive treatment of peri-implantitis infrabony
defects of various configurations: 5-year survival and success
Mario Roccuzzo et al Clin Oral Implants Res 2021
Oct;32(10):1209-1217.
2. Implant Disease Risk Assessment IDRA–a tool for
preventing peri-implant disease
Lisa J. A. Heitz-Mayfield et al Clin Oral Impl Res Volume31,
Issue4 April 2020