Inflammation, infection

Peri-implant Inflammation, infection

Inflammation around the implant can be limited to the soft tissue (mucositis) or involve the underlying bone tissue as well (peri-implantitis). Infection can be caused by various risk factors, such as inadequate hygiene and patient compliance, reduced host defense capability, inadequate restoration design to allow cleaning, biomechanical stress (overloading), subgingival cement remnants, surgical-related factors, aggressive oro-pharyngeal microflora, lack of fixed keratinized tissue.

Plan regular hygiene recalls to check any inflammation signs. They can be subtle with light swelling, increased redness and discrete bleeding on probing (BOP). They can also be obvious with pain, distinct swelling and intense BOP, probing depth > 5 mm, exudation or even secretion of pus, clearly visible marginal bone loss. In extreme situations implant mobility may occur.

Therapy is depending on degree of inflammation and on the identified triggering factors. Difference in peri-implant environment (soft and hard tissue conditions, tridimensional implant positioning, triggering factor of disease) could change prognosis and suggest different treatment plans. It is key to reduce/eliminate the microbial load, as well as other causes for inflammation.

Mucositis

Treatment consists of cleaning of prosthetic components (including the implant-abutment interface), supra and- subgingival implant surfaces, plaque and calculus removal, eventually removal of inflamed tissues.

Clean and disinfect peri-implant pocket with antimicrobial solution, such as 0.2 % chlorhexidine or 2 % hydrogen-peroxide.

Check design of restoration for cleansablity, occlusion and articulation. If needed eliminate premature contacts and implant overload. If necessary, consider design adaptation or even remake of prosthesis with more adequate cleansability.

Hygiene re-instruction of patient is a must.

Prescribe 0.2 % Chlorhexidine oral rinses, 3 times daily.

Recall and reevaluate after 2 weeks. Consider increasing recall frequency and hygiene instructions.

Even if hard data on use of local antibiotics are lacking, in case of recurrence of infection consider local application of concentrated antibiotic gels (Metronidazole, Minocycline, Tetracycline).

If arguments for candida or other yeast infection arise prescribe the appropriate anti yeast medication like miconazole.

It is suggested that the removal of the crown/abutment complex and the disinfection/sterilization of the connection units both at the implant and abutment aspects could be indicated to improve soft and hard tissues healing.

Peri-implantitis

Peri-implantitis is defined by the presence of peri-implant probing [consider to include use of plastic or titanium probe only ] depth ≥ 5 mm associated with bleeding on probing and/or suppuration, and radiographic images of bone loss ≥2 mm, compared to initial radiographs at delivery of the prosthetic restoration (Lindhe & Meyle 2008; Lang & Berglundh 2011).

Peri-implantitis represents the most frequent biologic complication of dental implants. From an etiologic point of view, peri-implantitis was described to be the result of an imbalance between host response and bacterial load. Since peri-implantitis corresponds to progressive asymptomatic inflammatory disease, its timely diagnosis and appropriate treatment planning represent a key factor for implant survival. 

Treatment consists of :

• Removal of restoration, hygiene and disinfection measures, evaluation/adaptation of prosthetic restoration evaluation as described above.
• Removal of microbial biofilms, cleaning of implant surfaces with suitable plastic or titanium scalers and curettes and removal of infected soft tissue, if necessary implantoplasty with suitable diamond burs and implantoplasty brushes. Irrigation and disinfection of periimplant site with 0.2 % Chlorhexidine.
• If needed peri-implant soft tissue management and creation of sufficient keratinized gingiva may be an option.
• If indicated, resective and regenerative treatment of bony defects.
• In some cases explantation of the implant and revision surgery need to be considered.

Antibiosis

Local application of concentrated antibiotic gels (Metronidazole, Tetracycline) has been tried out with variable success.

Gram-negative anaerobe microorganisms are frequently involved (Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, Prevotella intermedia, and Fusobacterium nucleatum). For periimplantitis the effects of a systemic antibiotics, as adjunct to mechanical/surgical treatment remain unknown. Microbial testing can help selecting a proper antibiotic by detecting resistant species.

Typical antibiotics used are Metronidazole (3x 400 mg/d), Clindamycine (4 x 300 mg/d), and Amoxicilline (3 x 500 mg/d) (in case of patient intolerance against Penicillin, use Ciprofloxacine). Combination of Amoxicilline (3 x 500/d) and Metronidazole (3 x 400/d) is also effective against A.actinomycetemcomitans (or Ciprofloxacine 2 x 250 mg/d and Metronidazole 2 x 500mg/d)

Other adjunctive antimicrobial treatment measures

Use of abrasive powder airpolishing devices should be done, if at all, with great prudence due to risk of leaving powder remnants in the tissues or provoking an emphysema.

Effectiveness and efficiency of Antimicrobial Photodynamic Therapy remains controversial.

Co2 and Er:YAG Laser: Lasers seem to have an antimicrobial effect in vitro. However there is no clinical evidence Laser decontamination would be effective or even more effective as as other protocols used.