Peri-implantitis, peri-implant mucositis, and peri-implant gingivitis

treating peri-implantitis

What is peri-implantitis?

Peri-implantitis is similar to periodontal disease in that it has 2 phases; peri-implantitis which is similar to periodontitis and peri-implant mucositis which is similar to gingivitis.
Periimplantitis is an inflammatory process with suppuration (pus) and/or bleeding with progressing bone loss after the adaptive phase. In other words after the implant has healed it starts losing bone.  It starts with peri-implant mucositis, an inflammatory process of the soft tissue surrounding an implant but no progressing bone loss. Peri-implantitis is associated with loss of supporting bone, bleeding on probing/flossing, redness, and suppuration.
Table with classifications of peri-implantitis

Another term one might run across in the literature is peri-implant gingivitis. The difference between peri-implant mucositis and peri-implant gingivitis is the later has keratinized gingiva.

Prevalence of periimplant diseases

The stats on this have wide ranges in the literature. Mucositis is at 43% with a 19-65% range and periimplantitis is 22% with ranges of 2-44%. Salvi Implant Dent April 2019

Causes of  peri-implantitis is complex and related to a variety of factors:

  1. Patient-related factors including systemic diseases (e.g. diabetes, osteoporosis), dry mouth, and prior dental history. Patients with periodotnal disease have a 14 times greater risk Swierkot 2012.
  2. Social factors such as inadequate oral hygiene (18% for those that have maintenance program and 44% for those that do not Costa 2012), smoking, and drug abuse
  3. Parafunctional habits (bruxism and malocclusion) and occlusal over-load.
  4. Excess cement and loose, over-contoured, or poor fitting crowns.  Incomplete crown or abutment seating.
  5. Lack of keratinized tissue (especially less than 2mm)
  6. Poorly positioned implants

Risk factors for peri-implantitis are similar to the causes but there is a nice risk assessment survey on FOR

Risk assessment for peri-implantitis on FOR and from playing around with it a little the biggest impacts are previous periodontal disease and and plaque.

Treatment of peri-implantitis

Although implants have demonstrated a very high survival rate, a recent systemic review shows one-fourth of patients and one-fifth of implants will develop peri-implantitis after 5-10 years.  Many methods of treating peri-implantitis have been documented in the literature and most focus on removal of the contaminating agent from the implant surface. These treatments include:
  1. Mechanical debridement with or without systemic antibiotic treatment (Metronidazole 250mg 2 tabs qid for 7 days) Liñares JOMI 2019
  2. Debridement with or without localized drug delivery and chlorhexidine oral rinses
  3. Mechanical debridement combined and CO2, LASER decontamination, or LAPIP protocol
  4. Surgical debridement with or without guided bone regeneration (GBR) for reparation of bony and soft-tissue defects.

To date, studies suggest that nonsurgical treatment of peri-implantitis is unpredictable, and the use of chemical agents such as chlorhexidine has only limited effects on clinical and microbiological parameters. Adjunctive local or systemic antibiotics have shown to reduce bleeding on probing and probing depths in combination with mechanical debridement. Beneficial effects of laser therapy on peri-implantitis have also been shown. Left untreated chronic peri-imlpantitis results in epithelial down-growth, bone resorption, soft tissue encapsulation and a hopeless implant.

Our treatment protocol for peri-implantitis

  1. Double check bite to ensure tooth is not taking excessive biting force (malocclusion).
  2. Cemented crowns – access screw and removal; if find cement removal piezo if not add #3 Excellent thread on a case like this.
  3. Kavo Prophyflex with sodium bicarbonate or glycine. EDTA and citric acid then CHX then sterile saline rinse, localized dual drug delivery with Arestin antibiotic, and prescription for chlorhexidine rinse for 10 days. Only do this an an adjunct or pre-treatment to step 4. Can also use the Labrida BioClean brush with chitosan fibers as Samuelsson JOMI 2022 shows.
  4. Open flap surgery and air powder abrasive (has tons of great studies), EDTA and citric acid treatment, CHX and Piezoclean tip, and saline flush. (hydrogen peroxide irrigation daily, then saline, then minocycline for 3 days) or
  5. In complete vertical loss areas flap and smooth exposed threads, protocol below.*
This example appears to use diode laser?  Believe better to use CO2 or Er:YAG.

Unknown what laser best CO2, Er:YAG, and maybe diode can decontaminate as well as sandblast. Natto JOMI 2015

If you have any questions about wheaton implant care or service please feel free to email me or contact my office.  If you live in the Wheaton/Glen Ellyn area we would be happy to see you for a complimentary evaluation to see if you are an implant candidate.

Chemical disinfection of dental implant threads

There is no evidence of any chemical method being superior to another. Common agents that are in use include; hydrogen peroxide, chlorhexidine, citric acid, HCl, tetracycline, chloramines, NaOCl. Ntrouka 2011 COIR

How smooth dental implant threads

*Smooth threads by

  1. Course diamond
  2. 12 flute
  3. 30 flute
  4. brown point
  5. green point
  6. advance flap 1-2mm
** Ab protocol and flap, piezo, Er:Cr:YSGG 6W 30% H2O/30% air or scrub EDTA or citric acid, CHX, saline, bone, PRP membrane, suture Petrungaro
*** Sodium bicarbonate (baking soda) Profi II Ceramic at 70lb for 1 minute 10mm away Vieira ID ID 12 Perioflow with glycine doesn’t leave anything behind. Fine bicarbonate powder for 60 seconds using Prophy-Jet, Dentsply with a contra-angled tip to reach all areas of the exposed implant followed by 60-second irrigation sterile saline delivered by Infinity Irrigator, Ace Surgical. Froum 2012

Peri-implantitis research articles of interest

Cochrane = no answers yet

Apical peri-implantitis

An apicoectomy of the implant can be done as shown in JOI 2018 Manfro

Dental code for treatment of peri-implantitis.