Consensus

Therapy of Peri-Implantitis

Bern 2013

Consensus Statements

The focused question for the review by Heitz-Mayfield and Mombelli was: In patients with osseointegrated implants diagnosed with peri-implantitis, how successful is treatment aimed at resolution of the disease?

Currently, there is no standard of care for treating peri-implantitis. Various clinical protocols for treating peri-implantitis have been proposed, including mechanical debridement, the use of antiseptics and local and systemic antibiotics, as well as surgical and regenerative procedures.

In view of the lack of comparable randomized controlled trials (RCTs) this review has taken a broader approach to capture as many relevant studies as possible, including randomized and observational studies, but with consideration to the strengths and limitations of the included research.

The ideal goal of the treatment of peri-implantitis would be the resolution of disease, ie, no suppuration or bleeding on probing, no further bone loss, and the re-establishment and maintenance of healthy periimplant tissues.

A composite outcome to reflect this would include absence of peri-implant PD ≥ 5 mm with concomitant bleeding on probing and no suppuration, in addition to no further bone loss.

If these criteria are met, it can be assumed that no further intervention other than nonsurgical maintenance care would be required, and the treatment outcome would therefore be regarded as successful. Unfortunately these data were rarely reported in the literature and therefore a compromise composite criterion for successful treatment outcome was employed, ie, implant survival with mean PD < 5 mm and no further bone loss. Although there is no consensus in the literature on whether a 5-mm peri-implant PD alone represents health or disease, this threshold was adopted for the purposes of the review.

This review was based on 33 studies reported in 43 papers including case-series of at least 5 patients treated with the same protocol and comparative studies. No studies were found comparing surgical and nonsurgical protocols. Based on this literature, the following conclusions were drawn:


  • Interpretation of the results of studies is complicated by unclear or high risk of bias, heterogeneity of study design, and difficulty of generalizing outcomes to practice settings due to frequent exclusion of patients who smoke, those with poorly controlled diabetes, and other conditions that may affect clinical outcomes.
  • There are no data investigating patient-reported outcomes and economic analysis of therapy.
  • Peri-implantitis therapy was associated with softtissue recession, which was most evident following surgical treatment. Postsurgery complications including membrane exposure and infection were also reported.

Treatment Guidelines

As peri-implantitis is an infection associated with the presence of a submucosal bacterial biofilm around implants, the primary goal of therapy must be the resolution of the infection, which is achieved by the disruption of the biofilm, the removal of calculus and/or overhanging restoration margins, and the prevention of recurrence of the disease.

It is important to try to establish if iatrogenic or other factors have contributed to the infection, for example, ill-fitting or noncleansable overcontoured prostheses, malpositioned implants, or foreign bodies such as impression material or excess luting cement. Noniatrogenic factors may include impacted dental floss.

The following sequence of treatment of peri-implantitis is normally recommended:

  • Pretreatment phase including:
    • Thorough assessment and diagnosis
    • Reduction of risk factors for peri-implantitis; in particular poor oral hygiene, prostheses that prevent adequate access for plaque control, tobacco use, presence of periodontal diseases, and systemic diseases that may predispose to peri-implant disease
    • If required, prosthesis removal and adjustment/replacement
  • Nonsurgical debridement focused on maximal removal of biofilm, with or without antimicrobials
  • Early reassessment of peri-implant health; normally within 1 to 2 months
  • Surgical access if resolution of peri-implantitis has not been achieved. This should include:
    • Full-thickness mucoperiosteal flaps and removal of granulation tissue to allow thorough cleaning of the implant surface.
    • Thorough surface decontamination of the implant and restorative components. The following techniques have been proposed: locally applied chemicals, gauze soaked with saline or antiseptics, hand-powered instruments, air-powder abrasives, Er-YAG lasers, photodynamic therapy, and implant surface modification. There is no evidence for the superiority of any one approach.
    • Surgical therapy might also include regenerative or resective approaches:
    • Regenerative approaches include filling of the intraosseous peri-implant defect with a bone substitute/graft/bioactive substance with or without a resorbable barrier membrane. Defect morphology for regeneration would normally require a contained defect. Submerged healing might reduce the risk of membrane exposure. Re-establishment of osseointegration following treatment has not been demonstrated in humans.
    • Resective approaches include osseous recontouring with apical positioning of the flap.
    • Immediate postoperative anti-infective protocol should include daily chlorhexidine rinsing during the healing period until mechanical oral hygiene can be resumed. In the absence of evidence comparing surgical treatment with or without antibiotics, peri- or postoperative systemic antibiotics are recommended in view of the aggressive nature of disease. Professional support of healing and plaque control will be needed during this phase.
  • Clinical monitoring should be performed on a regular basis and supplemented by appropriate radiographic evaluation as required. Supportive maintenance therapy including reinforcement of effective oral hygiene and professional biofilm removal should be provided on a frequency determined by oral health and the risk profile, likely to be between every 3 to 6 months.
  • Surgical access is likely to be needed for the majority of deep lesions due to the difficulty of accessing the threads and surfaces of the implant.

    The patient should be advised that:

    • Recession of the peri-implant mucosa should be expected following peri-implantitis treatment, in particular after surgical therapy.
    • Progression or recurrence of disease might require additional therapy or implant removal.

    The clinician should consider implant removal as a treatment option. Factors influencing this decision may include the severity of the peri-implantitis lesion, the position of the implant, the surrounding tissues, or when the treatment outcomes are likely to be unsatisfactory.

    Referral to specialist care for non-responding peri-implantitis should be considered.

    Regular assessment of peri-implant health is recommended during SPT to identify disease at an early stage.

    Training of dental team professionals should include diagnosis and management of peri-implant disease.

    Treatment Guidelines

    References

    Publication date: Oct 13, 2014 Last review date: Oct 6, 2014 Next review date: Oct 6, 2017
    • 5th ITI Consensus Conference
    • Biological Complications
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    • Consensus Statement
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    • Peri-Implantitis
    • Treatment Outcomes & Continuing Care

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