Peri-implantitis: what have we learned!

Oct 12

  Last month Prof. Nikos Mattheos hosted a panel discussion on Peri-implantitis with 3 world class experts during the ITI World Symposium 2020one. Drs Lisa Heitz Mayfield, Mario Rocuzzo and Daniel Thoma came together to discuss the case of Claire, a patient recently diagnosed with Peri-implantitis. In a discussion naturally evolving about an actual patient, the host and guest speakers reviewed the latest developments in all aspects of Peri-implantitis, debated and responded to questions from the host and the audience.

Did you miss it? Well, don’t worry, we were there for you and we saved the most important “take-home” messages!

1. What is the longevity of implant therapy? Are implants for life?

All panelists agreed here that dental implants are not meant to last for life, despite being the most successful implantable materials in medicine. Studies have shown that approximately 90% of the patients maintain their implants at 10 years time point, but there is a very wide individual variation that makes it very difficult to give a reliable estimation for each patient. The panel suggested colleagues to conduct a thorough risk assessment of each patient and communicate the limitations to the patient, while emphasizing on the importance of attending a regular maintenance scheme. Mario Rocuzzo mentioned that he offers a free replacement if an implant is to be lost within 10 years, but only to patients who adhere to the recommended maintenance scheme, an idea however that was not adopted by the prosthodontist of the panel, Prof. Thoma. All authors stressed that it is important not to convey the message to patients that “implants last for life”, something that is actually not the case with any other medical device. Maybe not surprisingly however, the attitude that “implants last for life” was still very widespread among colleagues, as the audience poll showed..!

 

An online poll with the congress attendants showed that 36% of dentists believed that "implants are for life, but the prosthesis can be replaced", 28% believed the life expectancy to be 10-20 years and 22% admitted to "not have a good answer". 
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2. What can we expect from the surgical treatment of Peri-implantitis? What to do if our surgery fails to arrest disease progression?

Mario Rocuzzo the basis of  their 2021 study (reconstructive surgery) mentioned that he would expect around 2/3 of the patients to maintain success after 5 years, with success defined as the absence of deep pockets around the implants and absence of additional bone loss. At the same time around 17% of patients may lose an implant in the same period. Lisa Heitz Mayfield added that if one year after surgery after we maintain pretty shallow probing depths and a fairly good stability of the bone levels, we can anticipate a pretty good chance to still maintain success after 3 or 4 years. Recurrence of the disease can occur however at any stage. If deep pockets and marginal bone loss persist or reappear at some point in time, she will be not inclined to repeat the surgery, but rather consider explantation of the implant. Actually, removal of the implant is something that we should consider discussing with the patient, as one option or potential outcome to be aware of in any case of peri-implantitis.

 

3. What to do with implants which are placed in sub-optimal position?

Implants referred to the prosthodontist might be at times placed in more or less compromised position. Daniel Thoma acknowledged that this can be at times the case in particular in full arch restorations, therefore he always aims to discuss the treatment plan with the surgeon beforehand. In cases however where he ends up with a referral of  malpositioned implants, he will discuss the risks first with the referring colleagues as well as the patients. There were cases where he ended up choosing other restorative options than implant born restorations in such situations.

 

4. What about prosthesis modification in patients with Peri-implantitis?

This is a situation that is occurring often, especially in large and full arch reconstructions. When the prosthesis predisposes to plaque accumulation and peri-implantitis would discuss with the referring dentist and explain the need for modification. As however many patients are no longer followed by the dentist who placed the restoration or do not wish to return for further care, he often has to undertake such modifications himself or in collaboration with his lab, after a thorough explanation to the patient. In some cases prostheses cannot be easily modified and at times he had to remake them or resort to replace fixed with removable prostheses.

 

 

5. How do you decide between surgical treatment or explantation?

Here we have to use multiple levels. First of course the patient behavioural and systemic risk level. Obviously no surgery will be meaningful for a patient who is unable or unwilling to apply the proper oral hygiene. Then come several local parametres that can direct us to one or the other option. It is very important if the implant is properly positioned or in a compromised place. If there is an aesthetic involvement or not. Furthermore, added Mario Rocuzzo,  the surface and geometry of the implant, the familiarity of the operator to the implant and how easy it is to decontaminate it. The prosthesis type and accessibility to the defect, the amount of bone and tissue remaining, the presence and condition of neighbouring teeth, the overall rehabilitation plan and the strategic aspects of possible alternative solutions or not, all these might be important determinants in a case-by-case assessment.

 

6. Do systemic antibiotics help in the surgical treatment of peri-implantitis?

Maybe surprisingly to many, Lisa Heitz Mayfield acknowledged that the evidence in support of the use of systemic antibiotics as a supplement to peri-implantitis surgery is very weak. In very few randomized controlled trials a small benefit is shown in favour of systemic antibiotics which is limited in the first year. In the light of recent evidence about the potential harmful role of antibiotics, it is today debatable whether systemic antibiotoics should be used with peri-implantitis treatment. On the other hand she admitted that her studies with surgical treatment of peri-implantitis were conducted in conjunction with systemic antibiotics, mainly Amoxicillin and Metronidazole.

7. Which are the main risk factors for peri-implantitis?

Lisa Heitz Mayfiend identified 3 major risks  for peri-implantitis, based on the current evidence:

-       Deficient plaque control

-       History of severe periodontitis

-       Lack of compliance with maintenance care

Surprisingly maybe, the evidence against smoking and diabetes is less robust, although both have been traditionally considered as major risks. The good news is then that 2 of the major risks are controllable with proper interventions. Proper design to ensure cleanability of the prosthesis and professional maintenance care delivered at least twice a year together with patient administered oral hygiene could minimize the risks for peri-implantitis. Finally, she presented a recently published instrument (IDRA) for the assessment of the patients’ peri-implantitis risk based on 8 parametres: a) prosthesis design b) supportive care frequency, c) bleeding on probing d) number of deep pockets e) Perio susceptibility  and f) Bone Loss in relation to age.


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