#Preventive 23. Feb 2024

Managing peri-implantitis: a modern perspective

A scientific review by Dr. Marcin Maj

Growing insights, new disease definitions, and innovative treatment approaches have opened up new therapeutic venues for peri-implantitis - a subject of increasing relevance for contemporary implant dentistry. At the same time, a body of evidence on the factors influencing disease onset, prevention, and treatment is gradually emerging, providing clinicians with new venues to excel in implant treatment and its long-term maintenance.

NAVIGATING PERI-IMPLANTITIS – ESSENTIAL FACTS AND FIGURES

Peri-implantitis refers to a bacterial plaque-associated inflammatory condition of the peri-implant tissues. Patients and clinicians may face various challenges based on the disease stage and progression, ranging from compromised esthetics to complete prosthetic loss and associated financial and psychological burdens1–3. Generally, peri-implant pathology can be classified into two fundamental stages: peri-implant mucositis and peri-implantitis2. While the former is reversible and affects only the peri-implant soft tissues, it may, if left untreated, progress into peri-implantitis. The latter condition is associated with a progressive loss of peri-implant crestal bone4,5. Therefore, the progressive and deteriorating nature of the disease underlines the importance of regular recall programs to detect the condition as early as possible6–8.

The reported prevalence of peri-implant pathologies shows significant variation. Individual reported values for peri-implant mucositis range from 19% to 65%, while those for peri-implantitis range from 1% to 47%9. Consolidated average values from systematic reviews of 43-47% and 20-22% for peri-implant mucositis and peri-implantitis, respectively, may serve as a good approximation for the occurrence of these conditions9,10. Next to cohort-related differences, the relatively high variation has been partly associated with inconsistent disease criteria and case definitions applied throughout different studies. This shortfall was only recently rectified as part of the World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions held in 2017, where clear diagnostic and reporting classification criteria for peri-implant pathologies and their different stages were established2,11,12.

A vast and robust body of evidence supports the hypothesis that the primary etiology of peri-implant diseases is the accumulation of subgingival bacterial plaque1. Histological investigations have illustrated the detrimental effect of plaque-induced inflammatory reactions on peri-implant tissues. These studies indicated a limited capability of peri-implant tissues to prevent inflammatory cell infiltrates from progressing apically to underlying crestal bone structures compared to, e.g., periodontal tissues13,14. Despite this straightforward cause-effect relationship, the inflammatory response to subgingival plaque can vary significantly among patients12,15. These differences may at least partly be attributed to patient-individual risk profiles comprised of patient-behavioral, iatrogenic, local, and systemic factors and their aggregation14–17. Important risk factors/ indicators include a history of severe periodontitis, poor plaque control, and the failure to engage in regular supportive peri-implant care programs (SPIC)7,8,18. Further, an association between peri-implant disease and smoking, diabetes, and hyperglycemia appears commonly accepted, while attempts to prove this association by systematic reviews remain pending16– 19. Local factors include, e.g., the presence of submucosal cement, implant mal-positioning, or restorative designs limiting hygiene access16,18. There is a growing acknowledgment that patient-individual aggregated risk factor profiles are as crucial for peri-implantitis prevention and treatment as during implant placement itself17.

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