With its series of educational webinars for oral care professionals, Sunstar connected each month this year with two experts from different dental specialties to explore home-based oral care from their perspective: the special demands from patients, the specific challenges and the strategies to overcome those.
On October 6th, 2022, the 6th episode was dedicated to implantology. Read below a summary of what Prof. Ann-Marie Roos Jansåker, PhD, DDS, and Ms. Susan Wingrove, BS, RDH, shared on the topic.
Mucositis and peri-implantitis: how to diagnose
The etiology of mucositis and peri-implantitis is the accumulation of biofilm. Prof. Roos Jansåker points out: “It is important to know that a healthy peri-implant pocket can be 4mm or deeper so you can’t compare the pocket depth around an implant to one around a tooth. This depends on how deep you inserted the implant and on the thickness of the mucosa”. But peri-implant pocket >5mm can be a risk for the development of a pathological microbiota. She refers to the World Workshop on classification of periodontal and peri-implant diseases (Berglundh and Armitage, 2018) to remind that peri-implant mucositis disease is defined as an inflammatory lesion of the soft tissues surrounding an endosseous implant in the absence of loss of supporting bone or continuing marginal bone loss. The case definition includes clinical signs of inflammation, bleeding and/or suppuration on gentle probing but no further bone loss after initial remodeling. Unlike peri-implantitis that also demonstrates the same clinical signs but with increased pocket depth and bone loss. Peri-implantitis can lead to the loss of the implant. In most cases, the onset of peri-implantitis starts early and have a nonlinear progression, with an aggressivity and extent of the inflammatory infiltrate more important than in periodontitis.
Ms. Wingrove uses a 5-step protocol to assess the implant: visual soft tissue assessment; probe and palpate for signs of infection; assess calculus and cement; assess mobility and occlusion at every maintenance visit; and assess bone level on X-ray. She also shared a pragmatic table based on the same World Workshop that helps to determine clinically the implant health/disease categories. For example, she describes one criterion: “25% or less bone loss in comparison to the length of the implant would be mild peri-implantitis, 25 to 50% bone loss would be moderate and over 50% would be severe.”
Peri-implant diseases: how to prevent
From the new ITI treatment guide, there are three different preventions: primary, secondary and tertiary. Primary prevention aims to achieve a peri-implant health and lies in the five P’s:
– Planning the insertion of the implant in the correct way. Bone volume and keratinized mucosa are assessed for the need for a regenerative surgery, occlusal and mesial-distal space for the need for orthodontic therapy.
– Preparation of the patient by informing of the risk factors and indicators (such as medications, diabetes, smoking) and of course, treating periodontitis beforehand to put the implant in a healthy mouth.
– Placement of the implant with a proper surgical approach
– Prosthesis must allow assessment, probing and daily cleaning by the patient. Screwed prosthetics may be recommended to avoid cement excess. Loose abutments and heavy occlusal forces need to be addressed.
– Prophylaxis: regular maintenance every 3 to 6 months and reinforcement of oral hygiene to bring to “zero plaque”. Even patients with good oral hygiene need regular coaching.
Secondary prevention is managing peri-implant mucositis and preventing onset of peri-implantitis. Tertiary prevention is managing peri-implantitis and preventing implant loss.
Prof. Roos Jansåker also sees prevention in all the steps of the implant therapy: “Prevention in pre-implant therapy may be to say to the patient that the best treatment option is not an implant but another prosthetic solution. Prevention at implant therapy would be to follow the ITI’s SAC index (Simple, Advanced, Complex cases), to allow optimal surgery and prosthesis. Finally, prevention in the post- mplant therapy relates to individual maintenance: not every patient needs a fixed prosthesis, an overdenture may be better for the one who is not able to perform oral hygiene himself.”
Hygienists play an important role in the post implant therapy as they are the first responders. They must detect any sign of inflammation around an implant. But their role is first to educate the patients that the biofilm is the major risk factor for peri-implant disease. They then do a thorough professional biofilm removal, as biofilm must be removed professionally as equally as the calculus. “Not all implants need to be debrided: a lot of them just need to have the biofilm removed. But there are safe and effective tools that can be used around implants”, Ms. Wingrove says and continues in detailing them, from polishers to ultrasonic instruments. But most important is the home care that hygienists can really customize for the patients for an effective removal of the biofilm, be it floss, water floss, mouthrinses, electric/manual toothbrush, interdental brushes or even the again-popular rubber tip stimulator for gums. In any case, Ms. Wingrove stresses: “an implant is placed with maintenance and home care in mind: it’s about team working with the dentist and coaching of the patient.”
Peri-implant mucositis and peri-implantitis: how to treat non-surgically
A mild peri-implantitis can be treated by a non-surgical approach, however a surgical approach may be needed for a moderate peri-implantitis. A removal of the implant can even be considered for the severe peri-implantitis.
After assessment of the peri-implant tissues and prosthesis (that may need to be removed) and reinforcement of the oral hygiene, the professional mechanical removal of calculus and biofilm requires instruments that cause minimal alteration of the implant surface: plastic, carbon fiber and titanium curettes, ultrasonic instruments, air polishing, rotating brushes and cups. There is no study that shows that an instrument is significantly better than another: the end goal remains to disrupt the biofilm and remove the calculus.
Some studies show that adjunctive antiseptics such as chlorhexidine solution, gels or chips can have some effect. “Although they do not present a greater benefit than mechanical debridement alone, some patients may need adjunctive antiseptics.”, says Prof. Roos Jansåker. There are alsoadjunctivelocal and systemic antibiotics. However, for the latter, the threat of resistance must restrict their use to when they are really needed. “The upcoming consensus in November 2022 about treatment of peri-implantitis and antibiotics should analyze the latest studies”, Dr Roos Jansåker specifies.
Once the non-surgical professional mechanical treatment is done, a re-evaluation one month after is recommended by the ITI. If inflammation is resolved, the patient goes into maintenance program with supportive therapy. If not, another non-surgical treatment may be needed. If the probing depth is ≥6mm with bleeding on probing, there is a risk of progression, and a surgical approach may then be considered.
Watch the full webinar here.