Peri implantitis

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Information about Peri implantitis
Health & Medicine

Published on February 17, 2014

Author: iarabii

Source: slideshare.net

Peri-Implantitis Dignostic, Preventive, and Therapeutic aspects. Iyad ABOU-RABII DDS PGD(OMFS) MRes PhD FADFE

2011 Course Director of MSc in Implant Dentistry (University of Warwick) 2005 PG Certificate (Implant Dentistry) 2004 PhD(Dental Pharmacology) 2001 PG Diploma (Pharmaceutical Engeneering) 1998 PG Certificate (General Pharmacology) 1998 MRes (Master of Research) in Medicine and Biology 1993 PG Diploma Oral and Max-Fac Surgery 1991 Doctor of Dental Surgery

What is Peri Implantitis? Peri-implantitis is an inflammatory process that affects the tissue around an osseointegrated dental implant and results in exaggerated marginal bone loss

Pathogenesis of peri-implant diseases At the First European Workshop on Periodontology in 1993, two disease patterns associated with oral implants were identified and defined. 1. Peri-implant mucositis is a term used to describe reversible inflammatory reactions in the mucosa adjacent to an implant. 2. Periimplantitis is defined as an inflammatory process that affects the tissues around an osseointegrated implant in function and results in loss of supporting bone

Prevalence of Peri-Mucositis and Peri-Implantitis Prevalence and risk variables for peri-implant disease S. D. Ferreira G. L. M Silva, Journal of Clinical Periodontology 2006 212 subjects (smokers were excluded) with a total of 578 implants were evaluated three and a half years later..... 73.5% of subjects presented with peri-implant BOP 64.6% with peri-implant mucositis 8.9% with peri-implantitis

Prevalence of Peri-Mucositis and Peri-Implantitis Extent of peri-implantitis-associated bone loss, Tord Berglundh, Journal of Clinical Periodontology 2009. 1070 implants examined at the ten year mark. (No note was made of the incidence of peri-mucositis) The study was to examine pathological bone loss 419 of the 1070 implants exhibited peri-implantitis- associated bone loss..........40%

Prevalence of Peri-Mucositis and Peri-Implantitis Peri-implant diseases : Consensus Report of the Sixth European Workshop on Periodontology, Jan Lindhe Joerg Meyle, Journal of Clinical Periodontology 2008. One study included a review of 3,413 implants assessed at the five year mark........ Peri-implant mucositis occurred in about 80% of subjects restored with implants. Peri-implantitis occurred in between 28% and 56%

Etiology Triggering factors for peri-implantitis are generally gathered under four categories: 1. Lesions of peri-implant attachment (poor oral hygiene) 2. Presence of aggressive bacteria (subgingival dental plaque) 3. Excessive mechanical stress (functional overloading) 4. Corrosion (early or late implant contamination) Peri-implantitis is a general term dependent on a synergy of several factors, irrespective of the precise reason for the first triggering of symptoms.‟‟ (Albrektsson 2009)

Etiology: microbiologic aspects O Oral implants represent hard, non-shedding surfaces in a fluid system, as do teeth. O A layer of glycoproteins will coat the implant surfaces after a few minutes to hours after implant installation.

Etiology: microbiologic aspects O Already after a few minutes to hours after implant installation, single bacterial colonies will adhere to the pellicle coat . O Following this, the colonies will divide and form larger and more expansive aggregates of oral bacteria. Scanning electron micrograph depicting an implant surface 2 hours after installation. (Courtesy of Dr S. Abati.)

Etiology: microbiologic aspects O Such early colonization is usually predominated by a Gram-positive coccoidal and rod microbiota. O As time passes, the biofilm development will result in a more complex microbiota, the composition of which is dependent on the microbiota of the entire oral ecosystem Scanning electron micrograph depicting an implant surface 7 days after implant installation. (Courtesy of Dr S. Abati.)

Etiology: Cement excess

Etiology: Cement excess

Etiology : occlusal trauma

Etiology : occlusal trauma

Etiology : occlusal trauma

Diagnostic Aspects of Peri-Implantitis Mobility O The bone loss encountered in association with the development Peri-implantitis is marginal O This, in turn, means that the implant still remains fully osseointegrated in the apical portion, O An increase in implant mobility cannot be expected.

Diagnostic Aspects of Peri-Implantitis Bleeding on probing (BOP) O (BOP) represents a clinical parameter which is defined as the presence of bleeding noticed after the penetration of a periodontal probe into the periimplant sulcus or pocket using gentle force. O The size (point diameter) of the probe applied and the application force should be standardized.

Diagnostic Aspects of Peri-Implantitis Bleeding on probing (BOP) O For teeth, the probing pressure for this parameter has been determined. O In the healthy and normal periodontium, the probing force used is 0.25 N. O The same force is used in a healthy but periodontally reduced dentition. O Recently, the application of the same probing force for the determination of BOP around oral implants has been established (Gerber et al. 2009).

Diagnostic Aspects of Peri-Implantitis Bleeding on probing (BOP) O BOP has been studied for its value in predicting future attachment loss around teeth (Lang 1986). O The positive predictive value remained rather low for repeated BOP prevalence in one retrospective (Lang 1986) and two prospective (Lang et al. 1990, Joss et al. 1994) studies (30% or less). O The negative predictive value in the same studies reached almost 100%. O Similar data for oral implants have been gathered in a prospective cohort study (Luterbacher et al. 2000).

Diagnostic Aspects of Peri-Implantitis Bleeding on probing (BOP) O The diagnostic accuracy of BOP was significantly higher than that of teeth. Hence, from a clinical point of view, absence of BOP around implants would indicate healthy peri-implant tissues . Probing of a peri-implant sulcus applying light force (up to 0.25 N). Bleeding on probing indicating periimplant mucositis.

Diagnostic Aspects of Peri-Implantitis Bleeding on probing (BOP) O The diagnostic accuracy of BOP was significantly higher than that of teeth. Hence, from a clinical point of view, absence of BOP around implants would indicate healthy peri-implant tissues . Absence of bleeding on probing on light force application indicates peri-implant stability. Radiograph confirming absence of any peri- implant bone loss after 5 years of function

Diagnostic Aspects of Peri-Implantitis Modified gingival index O The gingival index (GI) system has been modified and adapted by Mombelli et al. . (1987) for application around oral implants. O Although the modified GI may be used to assess the status of health or inflammation in peri-implant mucosal tissues, and hence to indicate mucositis in clinical research, it may be preferable and simpler to use BOP for routine clinical documentation. O Calibration exercises to determine the accuracy and repeatability of examiners using BOP should be performed before initiating studies in the same manner as for the GI

Diagnostic Aspects of Peri-Implantitis Probing depth and loss of attachment O Periodontal probing to determine probing depth and the level of periodontal attachment in relation to the cementoenamel junction (CEJ) is the most widely used clinical parameter in periodontal practice. O It appears logical to apply these parameters to the peri-implant mucosal seal. O Instead of relating probing depth to the CEJ, clinicians may use the implant shoulder, which provides a landmark that is easy to localize in clinical practice.

Diagnostic Aspects of Peri-Implantitis Probing depth pros and cons O Opinions have been expressed that peri-implant probing may sever the soft- tissue seal and hence jeopardize the integrity of an implant. O There is no scientific evidence for such concern. O On the contrary, it may be assumed that after probing the peri-implant epithelial attachment to the titanium surface may be re-established within the course of 4– 5 days (Etter et al. 2002), as already established for teeth (Taylor et al. 1979)

Diagnostic Aspects of Peri-Implantitis Probing depth pros and cons Healing of the epithelial attachment following probing of the periimplant sulcus. Distance from the most apical cell of the junctional epithelium (aJE) to the most coronal cell of the junctional epithelium (cJE) increases linearly up to 5 days indicating complete healing of the epithelial attachment following probing. (Adapted from Etter et al. (2002).

Diagnostic Aspects of Peri-Implantitis Probing depth and loss of attachment O Christensen et al. (1997) found that clinical probing depth determined by three automatic probing devices yielded slightly higher values around oral implants (approximately 0.5 mm higher) than around healthy contralateral control teeth. O Also, the buccal and lingual aspects of oral implants generally scored 0.5– 1.0 mm less than the interproximal aspects.

Diagnostic Aspects of Peri-Implantitis Probing depth and loss of attachment O Different probing depth values may be considered as “normal” in different implant systems. O As an example, for the Straumann® dental implant system, normality associated with healthy peri-implant mucosal tissues averaged 3–3.5 mm (Christensen et al. 1997).

Diagnostic Aspects of Peri-Implantitis Probing depth and loss of attachment O The localization of the periodontal probe tip around implants has been studied in different mucosal tissue conditions such as health, mucositis, and peri-implantitis (Lang et al. 1994). O Results confirm the excellent sealing effect of the soft-tissue collar in health and mucositis and the relatively uninhibited penetration to the alveolar crest of the probe in peri-implantitis lesions.

Diagnostic Aspects of Peri-Implantitis Probing depth and loss of attachment Probing errors in relation to the tissue characteristics around implants. The histologic attachment level (HAL) and the histologic probing depth (HPD) at 0.2 N probing force differ up to 0.2 mm in periimplant health and mucositis While the difference between the two positions is up to 1.2 mm in peri-implantitis sites. This means that probing is a highly sensitive parameter for the diagnosis of peri-implantitis. Adapted from Lang et al. (1994).

Diagnostic Aspects of Peri-Implantitis Probing depth and loss of attachment O Since the soft-tissue seal inhibited probe tip penetration in healthy and only slightly inflamed peri-implant soft tissues, but did not do so in periimplantitis, probing around oral implants must be considered a sensitive and reliable clinical parameter for long-term clinical monitoring of periimplant mucosal tissues.

Diagnostic Aspects of Peri-Implantitis Pus formation O Pus formation is always a sign of infection with active tissue destructive processes taking place. O Periimplantitis lesions usually yield some pus formation upon provocation by pressing on the mucosal tissues, while mucositis lesions may not. Hence, pus formation represents a specific diagnostic sign for the presence of peri-implantitis.

Diagnostic Aspects of Peri-Implantitis Pus formation. (1) Pressure on the buccal mucosal aspect may result in a discharge of pus in sites of peri-implantitis. (2) A peri-implant probing depth of 9 mm documents the presence of peri-implantitis. (Courtesy of PD Dr N. Zitzmann.)

Diagnostic Aspects of Peri-Implantitis Radiographic interpretation O Conventional radiography is used to evaluate the bony structures adjacent to the implants over long periods. O However, it should be noted that minor changes in bone morphology in the crestal area may not be revealed until they reach a significant size and shape (Lang et al. 1977 ).

Diagnostic Aspects of Peri-Implantitis Radiographic interpretation O Nevertheless, the distance from the implant shoulder to the alveolar bone crest (DIB) represents a reliable radiographic parameter for long-term monitoring in clinical practice. O Conventional radiographs have a proportion of false-negative findings, and low proportion of false-positive findings which limits radiographs to being confirmatory rather than exploratory (Brägger et al. 1988).

Diagnostic Aspects of Peri-Implantitis Radiographic interpretation O In digitizing radiographs of identical exposure geometry, minute changes in the level and density of the alveolar bone may be revealed by subtracting subsequent images from a baseline radiograph (Brägger et al. 1988). O Hence, for clinical research, DSR is highly recommended and has been successfully applied in longitudinal studies (Brägger et al. 1996).

Preventive Aspects of Peri-Implantitis Instruction in oral hygiene and patient motivation O Oral infections such as existing periodontal disease have to be treated before implant therapy. O Plaque control forms the basis for the prevention future disease. O The patient, therefore, should be motivated to perform an adequate level of plaque control on a regular basis.

Preventive Aspects of Peri-Implantitis Cleanable reconstructions O Overcontoured reconstructions, prevent the patient from attaining optimal oral hygiene. O Subgingivally placed reconstructions with imprecise margins influence the composition of the subgingival microbiota with increased proportions of putative periodontal pathogens (Lang et al. 1983). O Interproximal contours adjacent to abutment teeth or implants have to be shaped to accommodate appropriate cleaning devices.

Preventive Aspects of Peri-Implantitis Clinical implications O The submucosal placement of restorative margins is practiced in the aesthetic zone. O Precise marginal fit is a requisite. This may best be achieved through the use of screw-retained prefabricated copings,

Preventive Aspects of Peri-Implantitis Clinical implications O The implant be retrieved from the sterile vial and carried directly to the osteotomy site without touching the gloves, suction tip, saliva, or other tissues. O If sutures are to be used, fine monofilament materials are recommended to avoid entrapment by bacterial plaque as much as possible

Preventive Aspects of Peri-Implantitis Preoperative care (Infection Control) There is some evidence suggesting that 2 g of amoxicillin given orally 1 h preoperatively significantly reduce failures of dental implants placed in ordinary conditions. No significant adverse events were reported. It might be sensible to suggest the use of a single dose of 2 g prophylactic amoxicillin prior to dental implant placement. It is still unknown whether postoperative antibiotics are beneficial, and which is the most effective antibiotic. Esposito M, Eur J Oral Implantol. 2010 Summer;3(2):101-10.

Preventive Aspects of Peri-Implantitis Postoperative care (Infection Control) O Continued 5-7 days O Amoxicillin 500 mg three times daily O Cefaclor 500 mg three times daily O Clindamycin 150 mg three times daily

Preventive Aspects of Peri-Implantitis Preoperative care (pain Control) O Taking an NSAID within 2 h before the dental procedure seems to be helpful. O Pre-treatment with paracetamol has not shown to be effective as pre-treating with NSAID O NSAIDs administered between 30 to 60 min before the procedure O The reasoning is that having the nalgesics already in the blood prevents the synthesis of inflammatory prostaglandins (Huynh & Yagiela, 2003)

Preventive Aspects of Peri-Implantitis Postoperative care (pain Control) O With regard to postoperative pain control, the literature is ambiguous on the effect of cyclooxygenase-1 (COX-1)/COX-2 and COX-2–only inhibitors on delayed bone healing. O The argument revolves around increased levels of prostaglandin E2 and F2 during the early phases of bone healing. O Nonsteroidal anti-inflammatory drugs or COX-2 inhibitors have been reported to inhibit these two types of prostaglandins.

Preventive Aspects of Peri-Implantitis Postoperative care (pain control) O A systematic review done by Cottrel 2010 and published in J Pharm showed clearly that NSAIDs inhibit or delay bone healing. O NSAIDs are better to be avoided. O Paracetamol and Tramadol when needed are privileged.

Preventive Aspects of Peri-Implantitis Maintenance care O It is important to ensure recall at regular intervals. O This will provide optimal preventive services and facilitate the treatment o ongoing or emerging disease processes by providing appropriate supportive therapy.

Preventive Aspects of Peri-Implantitis Maintenance care O It is important to ensure recall at regular intervals. O This will provide optimal preventive services and facilitate the treatment o ongoing or emerging disease processes by providing appropriate supportive therapy.

Therapeutic Aspects of Peri-Implantitis How you deal with Peri-Implantitis?

Protocol for treating peri-implantitis • Systemic antibiotics (Metronidazole 400 mg TDS for 3 days) • 1 minute mouth wash preoperatively with chlorhexidine 0.2%

Protocol for treating peri-implantitis Mechanical curettage of implant surface and curettage down to fresh bone after full thickness flap elevation

Protocol for treating peri-implantitis • Packing gauze strips soaked in chlorhexidine 0.2% into defect and under the flap for 5 minutes

Protocol for treating peri-implantitis After gauze removing washing the defect with tetracycline solution 1 g in 20 ml of sterile saline

Protocol for treating peri-implantitis Apply graft material hydrated with the tetracycline solution

Protocol for treating peri-implantitis Rehydrate a collagen membrane with the same solution and overlay the graft.

Protocol for treating peri-implantitis Flap closed

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Depending on the clinical and the radiographic diagnosis, a protocol of therapeutic measures, called cumulative interceptive supportive therapy (CIST), has been designed by Lang. (Lang NP, Berglundh T, Heitz-Mayfield LJ, Pjetursson Salvi GE, Sanz M. Consensus statements and recommended clinical procedures regarding implant survival and complications. Int J Oral Maxillofac Implants 2004; 19: 150–4).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy O This protocol is cumulative in nature and includes four steps which should not be used as single procedures, but rather as a sequence of therapeutic procedures with increasing antibacterial potential, depending on the severity and extent of the lesion. O Diagnosis, therefore, represents a key characteristic of this maintenance care program.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy O The major clinical parameters include assessment of the following: 1. Presence or absence of dental plaque. 2. Presence or absence of bleeding on gentle probing (BOP). 3. Presence or absence of suppuration. 4. Peri-implant probing depth. 5. Radiographic evidence of bone loss.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy O Four Level of Interventions A. Mechanical débridement Polishing and scaling. B. Antiseptic cleansing 0.1% CHXgel 2 x daily for 3–4 weeks. C. Systemic or local antibiotic therapy D. Resective or regenerative surgery

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Mechanical débridement (supportive therapy protocol A) When ? Oral implants with evident plaque or calculus deposits adjacent to only slightly inflamed peri-implant tissues (BOP positive), but lacking suppuration and having a probing depth not exceeding 3–4 mm.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Mechanical débridement (supportive therapy protocol A) How ? Calculus may be chipped off using carbon-fiber curettes (Hawe Neos, Bioggio, Switzerland) Plaque is removed by means of polishing using rubber cups and polishing paste (e.g.Implaclinic® ; Hawe Neos, Bioggio, Switzerland).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Mechanical débridement (supportive therapy protocol A) Can I use conventional steel curettes or ultrasonic instruments ? Conventional steel curettes or ultrasonic instruments with metal tips leave marked damage on the implant surface (and render it conducive to future plaque accumulation. They should not be used (Matarasso et al. 1996). Removal of gross amounts of calculus, however, without touching the implant surface, is acceptable.

Therapeutic Aspects of Peri-Implantitis Scanning electron micrograph depicting the result of one stroke with a steel curette on a pristine titanium implant surface. Substantial damage is demonstrated. (Adapted from Matarasso et al. (1996).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antiseptic treatment (supportive therapy protocol B) When? Antiseptic treatment is performed in situations where, in addition to the presence of plaque and BOP, probing depth is increased to 4–6 mm. Suppuration may or may not be present.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antiseptic treatment (supportive therapy protocol B) How? Antiseptic treatment comprises the application of the most potent antiseptic available (Lang and Brecx 1986), i.e. chlorhexidine digluconate, either in the form of a daily rinse of 0.1%, 0.12%, or 0.2%, or as a gel applied to the site of desired action . In general, 3–4 weeks of regular administration are necessary to achieve positive treatment results.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antiseptic treatment (supportive therapy protocol B) How? Antiseptic rinses with chlorhexidine or applications of chlorhexidine gels may also be recommended for chemical plaque control on a preventive basis. This protocol has been validated both clinically and histologically in an animal experiment (Trejo et al. 2007) and in humans (Porras et al. 2002).

Therapeutic Aspects of Peri-Implantitis (1) Rinsing with chlorhexidine digluconate (0.12% twice a day) for 1 month. (2) Supplementing the rinses with the local application of chlorhexidine gel (0.2%) twice daily for 1 month

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antibiotic treatment (supportive therapyprotocol C) When? Probing depth values of the peri-implant sulcus or pocket increase to 6 mm or more, plaque deposits and BOP are usually encountered. Suppuration may or may not be present. Such a peri-implant lesion is usually evident radiographically.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antibiotic treatment (supportive therapyprotocol C) Why? The pocket with increased depth represents an ecologic niche which is conducive to colonization with Gram-negative anaerobic, and periodontopathic microorganisms (Mombelli et al 1987). . The antibacterial treatment approach must then include antibiotics to eliminate or reduce the pathogens in this submucosal ecosystem. This will allow soft-tissue healing (Mombelli and Lang 1992).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antibiotic treatment (supportive therapyprotocol C) How? Before administering antibiotics, the mechanical (A) and the antiseptic (B) treatment protocols have to be applied. During the last 10 days of the antiseptic treatment, an antibiotic directed at the elimination of Gramnegative anaerobic bacteria, is administered. These therapeutic steps have been validated in a clinical study (Mombelli and Lang 1992).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antibiotic treatment (supportive therapyprotocol C) The application of local antibiotics is discussed as alternative to systemic administration. However, only release devices with adequate release kinetics may be used to ensure successful clinical outcomes. Tetracycline periodontal fibers (Actisite® ; Alza, Palo Alto, CA, USA) have successfully been applied in some case studies (Mombelli and Lang 1998).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antibiotic treatment (supportive therapyprotocol C) Microspheres containing minocycline hyclate Arestin® ; Johnson & Johnson) are applied to the peri-implant pocket using a syringe. Several clinical studies have documented the efficacy of the product on both the clinical (Salvi et al. 2007) and the microbiologic level (Persson et al. 2006)

Therapeutic Aspects of Peri-Implantitis (1) 6 mm peri-implant pocket with pus discharge. (2) Bleeding on probing and pus formation confirming the diagnosis of peri-implantitis.

Therapeutic Aspects of Peri-Implantitis (3) Application of a controlled release device after mechanical and antiseptic cleaning. (4) Minocycline hyclate (microspheres) are sticking to the site after discharge from the applicator.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Antibiotic treatment (supportive therapyprotocol C) several in vitro tests have been performed in order to investigate the suitability of bone scaffolds as drug carriers. (In vitro published studies on Gentamycin, Vancomycin, Ciprofloxacin).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Regenerative or resective therapy (supportive therapy protocol D) This treatment is approached only if infection is controlled successfully, as evidenced by an absence of suppuration and reduced edema. Is it reasonable to either to restore the bony support of the implant by means of regenerative techniques or to reshape the peri-implant soft tissues and/or bony architecture by means of resective surgical techniques.

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Regenerative or resective therapy (supportive therapy protocol D) Single case presentations (Hämmerle et al. 1995) and animal studies (Wetzel et al. 1999) have provided evidence that bone fill of peri-implant defects resulting from previous peri-implantitis may be achieved following anti-infective therapy .

Therapeutic Aspects of Peri-Implantitis (1) Baseline radiograph of a periimplantitis lesion extending to the apical 2 mm of a hollow screw implant. Red arrows indicate the extent of the lesion from the crown implant level (approximately 5–6 mm bone loss). (b) Subtraction radiographic image 1 year after treatment documenting approximately 3–4 mm of bone fill (blue: increase in radiographic density). (Adapted from Lehmann et al. (1992).

Therapeutic Aspects of Peri-Implantitis Cumulative interceptive supportive therapy Regenerative or resective therapy (supportive therapy protocol D) There is no conclusive evidence identifies local decontamination of the implant surface during surgical exposure approach as being effective. Some clinicians smooth and polish the supra alveolar portion of the implant, although no beneficial effects of such a procedure have been documented

Therapeutic Aspects of Peri-Implantitis Explantation O If a previously osseointegrated oral implant is clinically mobile, explantation is mandatory. O The peri-implant lesion involves the entire length and circumference of the implant. O Radiographically, this may be visible in a radiolucency surrounding the entire outline.

Therapeutic Aspects of Peri-Implantitis Explantation O Explantation may also be necessary if the peri-implant infection has advanced to a degree where it cannot be controlled by the therapeutic protocols proposed above. O Such a situation is clinically characterized by the presence of a suppurative exudate, overt BOP, and severely increased peri-implant probing depth (usually ≥ 8 mm), eventually reaching perforations or vents of hollow body implants, and may be associated with pain.

Another treatment algorithm for determining prognosis and the appropriate treatment for dental implants musosal inflamation (PIMI). GBR= guided bone regeneration ISD= implant surfacr debridement OHI= oral hygiene instructions SIT= supportive implant therapy Getulio Nogueira-Filho, DDS, MDent,J Can Dent Assoc 2010;77:b8

Conclusion about use of Medications • Simple implant surgery (1-2 implants, no ridge splitting, no sinus work, no grafting) • Middle of the road‟ cases (3-4 implants or 2 implants with „extras‟ like sinus surgery/sinus „tap up‟/simple bone grafting/ridge expansion) • Complex cases (a whole upper jaw/lower jaw, 4-16 implants, „block‟ bone grafts, etc) •

Optimal pain control strategy with Dental Implant Surgery Paracetamol Paracetamol + Codeine Paracetamol + Oxycodone or Hydrocodone Mild Pain Short acting (2 hours) Mild to severe pain 30 min to 5 hours Simple Implant Surgery Middle Road Surgery Paracetamol + Tramadol More effective Rapid and long acting pain relief than did Tramadol or Paracetamol alone Complex Surgery

Optimal Infection control strategy with Dental Implant Surgery No prophylactic antibiotics A preoperative loading dose of antibiotics With medically compromised patiens (A recommended preoperative loading dose of antibiotics and a single postoperative dose. 0.12% Chlorhexidine rinse twice a day until suture removal Followed by 3 postoperative doses per day for 3 days. A 0.12% Chlorhexidine rinse twice a day until suture removal Simple Implant Surgery Middle Road Surgery Loading dose of antibiotics a day before the procedure Antibiotic continued for 5 days. Chlorhexidine rinse 0.12% twice a day is also recommended, until suture removal. Complex Surgery

Conclusion O Oral implants are reaching the highly contaminated environment of the oral cavity. O biofilms form on titanium implants as on teeth, and bacterial plaque will develop. O If plaque is allowed to accumulate over prolonged periods, peri-implant mucositis may develop. O If not solved, lesion will extend apically with associated loss of alveolar bone, and is termed “peri-implantitis”.

Conclusion O The peri-implant mucositis lesion is characterized by BOP and a peri-implant sulcus depth usually of 2–4 mm. O Peri-implantitis, however, yields increasing probing depth usually exceeding 5 mm, with occasional suppuration and radiographic loss of crestal bone. O clinical stability is not yet jeopardized, and osseointegration in the apical portion of the implant usually persists.

Conclusion O Owing to the infectious nature of peri-implant mucositis and peri-implantitis, preventive procedures have to be rendered in a well-organized recall program. O Depending on continuing diagnosis during maintenance, developing peri-implant lesions are better to be treated according to the CIST protocols.

Conclusion O CIST includes as a first sequence mechanical, antiseptic, and antibiotic treatment to control ongoing infection. O Following this, peri-implant bony lesions may be corrected by regenerative or resective surgical techniques. O It is evident that preventive measures have to be reinstituted after such therapy.

Take home hints O Ensure that the patient is informed in detail about the possibility of developing inflammation and infection around implants. O Diligently instruct the patient in oral hygiene practices with special emphasis on cleaning the implant sites. O Require and organize a maintenance care system to recall the patient on a regular basis.

Take home hints O Maintenance care should be provided at least once a year depending on the patient‟s past history and susceptibility for periodontitis. O Define patients who are at higher risk of developing periimplant diseases. Hence, their recall interval ought to be shortened to 3–4 months. O During maintenance or follow-up visits, use a periodontal probe to monitor probing depth, bleeding tendency, and possible suppuration.

Take home hints O Intervene with prophylactic measures when mucositis (bleeding) is noted around the implant. O View a pocket with a probing depth of 6 mm as an ecologic niche harboring anaerobic bacteria and, consequently, treat such lesions. O Obtain a radiograph whenever the probing depth around an implant is 6 mm or more.

Take home hints O Follow the recommendations for treatment according to the concept of cumulative interceptive supportive therapy (CIST). O Do not intervene surgically without prior conservative, antibacterial therapy. O Maintain optimal oral hygiene standards after peri-implantitis therapy.

Cumulative interceptive supportive therapy CIST O The, cumulative interceptive supportive therapy protocol of therapeutic measures (CIST), has for Per-Implantitis designed by Lang 2004.

Thank you for your attention!

Contact Details Dr. Iyad Abou Rabii +447412924020 https://www.facebook.com/iyadabourabii www.Twitter.com/iarabii www.Scribd.com/iyad abou rabii Email I.Abou-Rabii@warwick.ac.uk

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