Peri-Implant Diseases and Collaborative Treatment

Traditional goals of the dental profession are to conserve the natural dentition for the life of the patient. In cases where dental disease presents, such as caries, periodontal disease, endodontic disease, etc, the goals are to restore the teeth and supporting structures to a state of health, function, and aesthetics. Periodontists, working in collaboration with restorative dentists, diagnose and treat gingivitis and the various forms of periodontitis—both chronic and aggressive—in an effort to help our patients keep their natural teeth. Clinical procedures such as the elimination of pathological pockets, crown lengthening, and rebuilding of the lost surrounding soft and hard tissues are some of the techniques periodontists use to control and reverse the disease process. If the natural tooth cannot be saved, periodontists are able to prepare the supporting tissues for any necessary restorative therapy.
With the advent of dental implants, new options have become available for the replacement of teeth that could not be preserved. Currently, teeth with hopeless prognoses can be extracted and successfully replaced by implantsupported restorations. For patients who present with poor bone quality or tissue deficiencies, periodontists are able to rebuild bone and soft tissue using ridge, sinus, and socket augmentation procedures along with autogenous and allogenic softtissue grafts. In fact, success rates of implants placed in regenerated bone have been reported to be equal to that of implants placed in native bone.¹
The key to achieving longterm success of dental implants goes beyond just ensuring that they are placed in an ideal environment. Dental implant success also requires professional monitoring and careful maintenance by both the periodontist and restorative dentist. However, as periodontists and restorative dentists collaborate in placing and restoring an increasing numbers of dental implants, they have become aware of a new threat to implant survival: periimplant diseases.

PeriImplant Disease
Periimplant diseases are typically categorized into one of 2 forms: periim­plant mucositis and periimplantitis. Periimplant mucositis is an inflammatory disease confined to the soft tissue with no sign of supporting bone loss. Moreover, periimplant mucositis may be successfully treated using nonsurgical efforts if detected early. Periimplantitis is defined as inflammation of the soft tissue surrounding an implant and is associated with progressive loss of supporting bone. Without proper treatment, periimplantitis can result in loss of the implant.² The reported prevalence of periimplantitis varies depending on the definition and threshold of bone loss. Studies of periim­plantitis prevalence report a range of 6.6% to 36.6% of implants placed.³ In a recent systematic review of the literature by Mombelli et al,4 the disease was found in 20% of patients (corresponding to 10% of implants placed) within 5 to 10 years following implant restoration and natural bone remodeling. Even using the most conservative thresholds to define periimplantitis in the various published studies, these numbers represent a significant number of implants developing periimplantitis following placement of the final implantsupported restorations.

Prevalence of Periimplantitis
To understand the significance of this disease, one has only to look at research from the Millennium Research Group (an independent research organization) which reported that in 2012, 2.15 million implants were sold in the United States alone.⁵ Assuming these im­plants were placed and restored, a 10% prevalence rate would mean 215,000 implants placed in one year only will suffer from periimplantitis. A 5to10year extrapolation, as­suming the same number of implants placed as in 2012 (despite the projection for these numbers to rise), would mean 1.275 million implants in 5 years and 2.55 million implants over a period of 10 years would be affected by periimplantitis. This again is the prevalence of implants placed in the United States only. Based on the number of implants placed in the US, Europe, and Asia Pacific area, this number would increase approximately 5 times.⁶
These data indicate a substantial number of implants that will require periimplant treatment to avoid implant loss. According to many researchers, periimplantitis resembles periodontitis in etiology, the pathogens involved, and progression. As a result, it is common for the periodontist to be confronted with the diagnosis and treatment of implants affected with periimplantitis. Perio­dontists should be considered key partners of the general and restorative dentist in helping to ensure that our patients keep their implants for life.
While it is universally accepted that not all patients with perimucositis will develop periimplantitis, it is recommended that periimplantitis should be treated as soon as possible. Diagnosis is oftentimes first made by the treating dentist or his/her hygienist based on bleeding on probing around an implant combined with progressive loss of bone support. Although treatment strategies may vary, it has been reported from several reviews of the literature that nonsurgical therapy is not effective for treating periimplantitis.⁷ The goal of treatment must include arresting the disease process, and where possible, reversing bone and softtissue loss.

Treatment of Periimplantitis
Several reviews have discussed treatment op­tions for periimplantitis. Recently, research was published that looked at the regenerative treatment of 51 implants with a 3 to 7.5year followup period.⁸ The bone fill and pocket reduction reported in this study was even more significant in light of the fact that there was no increase in periimplant softtissue recession following treatment. In fact, there was a reported gain in softtissue levels ranging from zero to 4 mm and averaging more than one mm. This is encouraging for both the clinician and patient because it demonstrates that periimplantitis can be treated while improving the aesthetics of the surrounding soft tissue. More research is necessary to optimize these results, but the ability to return a diseased implant to a state of health when compared to the time, cost, and pain involved in removing an implant, re­building bone and soft tissue and replacing and restoring a new implant is well worth the effort.
A recent report published by the American Academy of Periodontology,³ “PeriImplant Mucositis and PeriImplantitis: A Current Un­derstanding of their Diagnoses and Clinical Implications,” re­viewed the diagnosis and prevention of periimplant mucositis and periimplantitis. This report3 provides a comprehensive review of the current knowledge of periimplant mucositis and periimplantitis, and is intended to guide dental professionals in their diagnoses and disease prevention.

Collaborative Maintenance of Implant Restorations
While any dental professional would prefer to help patients preserve the natural dentition, when that is not possible, dental implants provide an excellent replacement solution. During the past decade, research indicates that when properly placed, restored, and maintained, dental implants demonstrate survival rates of more than 95%.9 Similar to natural teeth, the longterm maintenance of dental implants depends on a collaborative effort among the patient, periodontist, restorative dentist, and hygienist. In addition to diligent home care by the patient, regular professional maintenance and effective communication between the periodontist and restorative dentist has been shown to be the difference between implant failure or recurrence of periimplant disease and successful longterm outcomes. Early diagnosis of disease or disease recurrence is most often in the purview of the general dentist who is monitoring and maintaining the health of the teeth and implants, and any findings or concerns should be efficiently communicated to the periodontist as needed. In this way, our profession is able to offer new and successful restorative options to our patients and ensure function and aesthetics for the lifetime of the patient.

References

1. Nevins M, Mellonig JT, Clem DS III, et al. Implants in regenerated bone: longterm survival. Int J Periodontics Restorative Dent. 1998;18:3545.
2. Lindhe J, Meyle J; Group D of European Workshop on Periodontology. Periimplant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(suppl 8):282285.
3. Periimplant mucositis and periimplantitis: a current understanding of their diagnoses and clinical implications. J Periodontol. 2013;84:436443.
4. Mombelli A, Müller N, Cionca N. The epidemiology of periimplantitis. Clin Oral Implants Res. 2012;23(suppl 6):6776.
5. Increase in Implant Placement from 20102014. US Dental Implant Market. London, UK: Millennium Research Group; 2012.
6. Dental Implants and Final Abutments Markets 2009 (US, European, and AsiaPacific markets). Vancouver, British Col­umbia, Canada: iData Research; 2010.
7. Renvert S, Samuelsson E, Lindahl C, et al. Mechanical nonsurgical treatment of periimplantitis: a doubleblind randomized longitudinal clinical study. I: clinical results. J Clin Periodontol. 2009;36:604609.
8. Froum SJ, Froum SH, Rosen PS. Successful management of periimplantitis with a regenerative approach: a consecutive series of 51 treated implants with 3 to 7.5year followup. Int J Periodontics Restorative Dent. 2012;32:1120.
9. Pjetursson BE, Helbling C, Weber HP, et al. Periimplantitis susceptibility as it relates to periodontal therapy and supportive care. Clin Oral Implants Res. 2012;23:888894.

Dr. Froum is a clinical professor and the director of clinical research in the department of periodontology and implant dentistry at New York University Krieser Dental Center. He is a Diplomate of the American Board of Periodontology and maintains a private practice limited to periodontics and implant dentistry in New York City. He is the presidentelect (2012 to 2013) on the Continuing Education Oversight Committee, and a past trustee for the American Academy of Periodontology. A past president of Northeast Society of Periodontics, he is also on the Research Committee for the Academy of Osseointegration. He is also a reviewer for Compendium of Continuing Education for Dentistry, International Journal of Periodontics and Restorative Dentistry, and Journal of Periodontology. He is the editor of the textbook Dental Implant Complications Etiology, Prevention and Treatment (WileyBlackwell). He received the Hirschfeld Award from Northeast Society of Periodontists and the William J. Gies Award. He can be reached at smile@drstuartfroum.com.

Disclosure: Dr. Froum reports no disclosures.