Preventing Peri-Implantitis

The popularity of dental implants has skyrocketed over the past 20 years, and their use is only projected to increase. The expected prevalence of dental implants in 2026 ranges from 5.7% to 23%.¹ A desirable and advantageous method to replace missing teeth, dental implants provide function and esthetics without sacrificing tooth structure in residual dentition as well as eliminating the need for removable prostheses.² 

Despite the effectiveness of dental implants, however, a growing number of implant patients are presenting with peri-implant diseases.³ An inflammatory process around an implant, peri-implantitis includes both soft tissue inflammation and progressive bone loss following initial bone remodeling.^4,5 While the etiology of peri-implantitis is multifactorial, the primary etiology of peri-implantitis is bacterial with subsequent activation of the host immune response.^5-7 Preventing peri-implantitis is imperative to maintaining oral health as the negative effects of this disease are significant, including adverse impact on systemic health, patient dissatisfaction, patient discomfort, increased costs, and possible loss of the dental implant.⁵ As such, identifying risk indicators and emphasizing the importance of interdental cleaning are key to maintaining peri-implant tissue health.

Patient-Centered Risk Assessment

Conducting a patient-based risk assessment before implant therapy based on individual risk indicators is integral to estimating the aggregate risk for complications. Curtis et al⁸ developed a patient-centered implant risk assessment tool to determine a patient’s risk for late biologic complications. This tool was developed through a review of current literature on risk indicators, supplemented by the Delphi process, in which experts in prosthodontics and periodontics debated on inclusion of risk indicators into the tool. The output score of the risk assessment tool designates patients as low (less than 6 points), medium (6-10 points), or high risk (greater than 10 points). The tool is designed to provide clinicians with an understanding of a patient’s aggregate risk score so they can further screen and educate patients about their potential risk for developing peri-implantitis. Therefore, clinicians treating patients categorized as high risk should advise patients to reduce their risk factors noted in the patient history before implant placement, or seek alternative treatment options if certain risk indicators are difficult to modify. In addition, understanding the risk beforehand allows clinicians to practice in a more predictable manner and minimize the risk of peri-implantitis.

Significance of Plaque Control

Animal studies have shown that high plaque levels can trigger the development of peri-implantitis.^9,10 Human studies have also shown a strong correlation between plaque and peri-implantitis.^11–14 A recent cross-sectional study by Schwarz et al¹² reported an odds ratio of 9.25 for peri-implantitis in patients with large amounts of plaque. Another study by Renvert and Quirynen¹⁵ found that plaque accumulation around dental implants triggers the inflammatory response, leading to peri-implantitis. However, unlike periodontal diseases, a “self-limiting” protective process is not seen in peri-implantitis.¹⁶ Experimental peri-implantitis in animal models also showed spontaneous continuous progression of bone loss even after ligature removal.¹⁶ Therefore, a frequent and comprehensive periodontal maintenance protocol should be facilitated for patients with a history of periodontitis because evidence suggests implants placed in a periodontally susceptible patient with a regular supportive maintenance program performed equally well when compared to periodontally healthy patients.¹⁷

Implants placed in patients with a history of periodontitis are associated with higher incidence of biological problems and lower success and survival rates.^18–22 Karoussis et al¹⁹ first described this finding in a prospective study. The authors conjectured that periodontal pathogens in residual periodontal pockets of the remaining dentition might be sources of infection for the subsequent bacterial colonization of newly placed implants. Also, individual host susceptibility might be different when pathogenic bacteria are present. 

Access for Proper Oral Hygiene

Evidence suggests that the prosthesis design significantly influences peri-implant tissue stability.^23-26 Serino and Strom²³ found a high percentage of patients with peri-implantitis had either limited capability or reduced access to proper oral hygiene. In addition, Katafuchi et al²⁴ reported that an implant-supported restoration with an emergence angle > 30° and a convex emergence profile create a significant risk for future peri-implantitis. Therefore, clinicians should develop more idealized crown contours, which offer both esthetic and biologic advantages, in order for the patient to facilitate better plaque control.²⁷

If the peri-implant tissues are clinically healthy without signs of clinical inflammation, and there are no signs of peri-implant disease progression compared with baseline records, coronal polishing with a rubber cup and low-abrasive paste should be performed during the maintenance visit.²⁸ However, for patients with limited ability to perform adequate oral hygiene or those who have a difficult-to-maintain prosthesis, other oral hygiene aids such power toothbrushes,²⁹ water flossers,³⁰ and airflow systems³¹ have been proposed to provide better plaque control in addition to regular maintenance visits. Other devices and aids such as interdental brushes, end-tuft brushes, and stiffened-end dental floss threaders should be introduced to patients for improved at-home care.^32,33 Customized self-care instructions should be given to patients based on implant design, accessibility for cleaning, and patients’ dexterity.^28,33 For example, a small-diameter interdental brush may be used for difficult-to-access areas. For implant-supported restorations with extremely limited access for hygiene, the use of a stiffened-end dental floss threader in combination with the “criss-cross” technique around dental implants can be effective. Patients should be instructed chairside on how to correctly insert the floss threader through the embrasure space underneath the implant-supported restoration. Subsequently, the floss should be wrapped around the restorations and moved back and forth against the side of each implant.

Maintenance Program

A frequent maintenance program with appropriate in-office and at-home regimens is crucial for achieving favorable long-term implant treatment outcomes.^25,34–39 Costa et al⁴⁰ compared patients with and without regular maintenance, and found that the incidence of peri-implantitis was significantly lower in the group with maintenance (18%) than the group without maintenance (43.9%) over 5 years. In addition, the tooth loss rate of 0.36 teeth/year was found for irregular compliers, and a rate of 0.12 teeth/year was reported for regular compliers.⁴⁰ Similarly, Rokn et al³⁷ reported that 20% of patients experiencing peri-implantitis were not participating in a regular maintenance program. Monje et al⁴¹ also found that patients who had two or more peri-implant maintenance therapy appointments per year had better dental implant prognosis than those who were not compliant. In conclusion, patients are much more likely to remain stable periodontally when in a regular maintenance program than if they are not.^42,43A minimum maintenance recare of every 5 to 6 months is recommended.^35,44,45 

In addition to maintenance frequency, the American Academy of Periodontology suggests a list of procedures that should be completed at each periodontal maintenance visit.⁴⁶ These procedures include but are not limited to: radiographic review, removal of bacterial plaque and calculus from supragingival and subgingival regions, selective root planing or implant debridement, review of patient’s plaque removal efficacy, and oral hygiene instructions. Clinicians should also obtain baseline radiographic and probing measurements at the first maintenance visit post-completion of implant-supported prosthesis.⁴⁷ These records are extremely critical to determining future peri-implant health and disease activity. Paying close attention to the presence of post-restorative submucosal cement and restoration contours that do not facilitate proper oral hygiene is also imperative.^23,47 Whenever possible, the submucosal cement should be carefully removed, and the implant-supported crowns with poor contours should be modified to allow adequate oral hygiene and maintenance.²³

Conclusion

The majority of the patients tend to overestimate the benefits and underestimate the risk of treatments. The lack of understanding among patients who are ready to receive implant therapy reflects an ineffective communication between patients and clinicians. Therefore, a thorough pre-surgical risk assessment, effective plaque control program, adequate access for proper oral hygiene, and comprehensive maintenance protocol can help clinicians minimize the risk of peri-implantitis development. These factors should be discussed with the patients so that risks and responsibilities are understood. Our challenge is to remain aware of changing evidence in emerging risk indicators contributing to the development of peri-implantitis. 

References

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