Prof. Giovanni E. Salvi
Dep. Director, Clinic for Periodontology,
Dental Clinics of the University of Bern
In maintenance visits following implant placement, the peri-implant tissue should undergo careful clinical and radiological monitoring so that changes will be promptly noted.
Implant probing plays a key role in diagnosing peri-implant disease, as does a radiological assessment, in which bone level changes should be compared with baseline radiographs from the time of prosthetic restoration.
A peridontal probe made of plastic or metal should be used to measure pocket depth in four to six sites around the implant. No probing should be done while the soft tissues are healing following implant placement (6–8 weeks). The probing pocket depth should be compared with the baseline measurements following prosthetic restoration. The probing pressure should not exceed 0.2–0.25 N.
An increase in probing pocket depth could be an indication of bone loss which requires further investigation. In the case of implants that are placed deeply in the esthetic zone, 5–6 mm probing depths are possible in the approximal region, even in non-inflammed conditions.
Clinical changes in the peri-implant mucosa, such as reddening and swelling, should be examined regularly. The absence of bleeding in response to probing is an indication of peri-implant health. A two-year observation period has shown that peri-implantitis progresses if bleeding on probing occurs in more than half of the follow-up visits1.
The radiographic depiction of the implant should always be linked to the clinical diagnosis. Intraoral dental imaging, orthopantomography (OPT) and, for special indications, digital volume tomography have been shown to be successful in radiographic diagnosis. The distance should be measured from a fixed reference point, for example the implant shoulder, to the crestal bone. The bone level at the time of restoration serves as a radiological reference (baseline).
Implant mobility is an indication of a complete loss of osseointegration, and therefore cannot be used for early diagnosis of peri-implantitis. Implant mobility, when there are no signs of bleeding on probing, increased probing pocket depths, suppuration or crestal bone loss, can indicate improper loading2.
A purulent secretion with or without formation of fistulae is the consequence of advanced inflammation. Suppuration is therefore also not suitable for early diagnosis of peri-implantitis.
The survival and success rates of implants in patients with previously recorded periodontitis are lower than in patients without periodontal issues3.
Conclusion: a check for periodontal infection prior to implant placement is highly recommended. Leaving residual pockets greater than 5 mm with bleeding on probing jeopardizes implant success rate4,5.
Implants with a smooth or micro-rough surface show a comparable incidence of peri-implantitis over a 13-year observation period17.
Diagnosed and untreated mucositis is more likely to develop into peri-implantitis than treated mucositis16.
Conclusion: treat mucositis promptly.
Insufficiently wide (less than 2 mm) keratinized gingiva is linked with elevated plaque accumulation, inflammation and recession15.
Conclusion: care should be taken during implant placement and re-entry to ensure that there is sufficient keratinized gingiva (≥ 2 mm).
Despite animal experiments failing to detect implant load as a cause for osseointegration loss14, without evidence of infection, osseointegration loss cannot be ruled out in humans2.
The 10-year survival and success rates of implants in patients with treated periodontitis are reduced with irregular hygiene6.
Conclusion: a regular 3–6 month recall interval tailored to a patient’s risk profile is recommended7.
Smoking causes soft tissue complications and elevated peri-implant bone or implant loss8–9.
Conclusion: a smoking cessation program improves implant survival rate10.
Prosthetic restorations with poor access for cleaning exhibit increased peri-implantitis compared with those that are easily accessable11.
Conclusion: a well-integrated restoration should provide adequate cleaning access.
Poor oral hygiene raises the risk for peri-implantitis12.
Conclusion: optimum oral hygiene is key to maintaining inflammation-free, peri- implant health.
Iatrogenic cement residue is linked to mucositis and peri-implantitis13.
Conclusion: a great deal of attention should be paid to a cemented restoration; otherwise, a screw-retained restoration is preferable.
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1Luterbacher S, et al.: Clin Oral Implants Res 2000; 11: 521–29
2Sanz M, et al.: Clin Oral Implants Res 1991; 2: 128–134
3Karoussis IK, et al.: Clin Oral Implants Res 2003; 14: 329–39
4Lee C-YJ, et al.: Clin Oral Implants Res 2012; 23: 325–33
5Lee C-YJ, et al.: Clin Oral Implants Res 2012; 23: 325–33
6Roccuzzo M, et al.: Clin Oral Implants Res 2013 (Epub ahead of print).
7Heitz-Mayfield LJ, et al.: Int J Oral Maxillofac Implants 2014; 29 (Suppl): 346–50
8Heitz-Mayfield LJ, Huynh-Ba G: Int J Oral Maxillofac Implants 2009; 24 Suppl: 39–68
9Strietzel FP, et al.: J Clin Periodontol 2007; 34: 523–44
10Bain CA: Int J Oral Maxillofac Implants 1996; 11: 756–59
11Serino G, Ström C: Clin Oral Implants Res 2009; 20: 169–174
12Ferreira SD, et al.: J Clin Periodontol 2006; 33: 929–35
13Wilson TG Jr: J Periodontol 2009; 80: 1388–92
14Heitz-Mayfield LJ, et al.: Clin Oral Implants Res 2004; 15: 259–68
15Lin GH, et al.: J Periodontol 2013; 84: 1755–67
16Costa FO, et al.: J Clin Periodontol 2012; 39: 173–81
17Renvert S, et al.: J Clin Periodontol 2012; 39: 1191–97