Introduction: Among the considerable changes in dentistry is the introduction of implant science. Combined with the development of applications, implant research practitioners will face an unavoidable concern which is how to deal with such problems. Recent conducted researches are more focused on operative and prosthetic techniques, as the treatment for peri-implant diseases continues to be incomplete. Therefore, the aim of this review research is to give a extensive and descriptive analysis on peri-implant diseases and suggest the related treatments.
Materials and Methods: Scientific articles were gathered by electronic digital searching through EMBASE and Medline and since managed clinical trials were limited in this field, no limitation was enforced on the evaluated articles. Moreover, review articles and meta-analysis were used.
Results: For implants that bone resorption has influenced less than 50% of the implant size, the analysis is thoroughly suggested. Regarding conditions with a variety of significantly less than 2mm, the treatment plan will be more inclined towards non-surgical methods and really should be cared for by Peri-implant mucositis. In case the bone resorption is more than 2mm, operative methods are became more effective and in the conditions which has extended more than 50% of the implant length, it is better to eliminate the implant.
Conclusion: By increasing the number of annual dental implant, peri-implant diseases have grown to be a serious task in this field. The proposed treatment plan will be a manual for dentists regarding about how to cope with implant problems; although further researches are required to approve the suggested protocols.
Keywords: dental implant, disease, peri-implant inflammation.
The success of the implant treatment is approved through various studies (1-4); however, further evaluation is needed on how to treat peri-implant diseases.
One of the confirmed causes of dental implant failing is bacterial plaque along with extensive launching (5). Peri-implant diseases include non-specific inflammatory reactions that arise in host cells (6-9); while the cases of irritation in soft cells are known as peri-implant mucositis, which is often considered a reversible effect.
Clinical characteristics of peri-implant mucositis include bleeding when being probed, peri-implant colitis, upsurge in probe depth (often as wrong pocket), or erythema and inflammation of the implant that surrounds tissues (10). It must be observed that symptoms are not necessarily limited by these cases. In addition, when the inflammatory lesion attacks the bone, it is called peri-implant (11). Peri-implant can be an irreversible process and bone resorption in radiography, bleeding, pus release during probe, increased pocket depth, ache, or fistula are among its characteristics (12).
A loose implant is considered as a "failed implant" (12); while a "failing implant" is generally a progressive bone resorption without looseness. It really is a subject of the most importance to pay attention to practical differences of these two expressions. Tooth implants may are unsuccessful in various stages:
- Early declining: Occurs when the absence of initial osseointegeration is due to the shortcoming of reaching the primary bone to implant contact. Factors that can be suggested in this case include early loading, surgical trauma, or imperfect/inappropriate recovering response (such as patients with immune system suppression, Supports) (13, 14).
- Late failure: Happens following the first integration of physiologic remodeling and loading. Infection and excessive loading are among the main factors in later failure (15). Inability due to the first 12 months of launching is not widespread (16).
Ailing implant, also thought as peri-implant natural problems, is described the limited diseases of peri-implant's very soft tissue that do not impact the encouraging bone tissues. On the other hand, loosing non-progressive cable connections and no looseness are its characteristics (17, 18).
Peri-implant inflammatory procedures are around similar from what happens across the tooth, except in the instances that peri-implant attacks are at first less repellent to destruction due to the life of periodontal ligament (19, 20). In other words, unlike the existence of fibers that are vertically located around the teeth, peri-implant materials are mostly parallel due to absence of cementum. In addition, the blood supply in peri-implant has been low in comparison with tooth (20). The purpose of today's review article is to judge the sources of peri-implant diseases and its related treatment approaches.
Materials and Methods:
By electronic digital searching through EMBASE and Medline, the methodical articles were collected and since manipulated clinical tests were limited in this field, no restriction has been enforced on the evaluated articles. Moreover, review articles and meta-analysis were used. Words like Mucositis peri-implant, treatment, peri-implantitis, and implant complications were used while looking for articles.
The prevalence of peri-implant diseases was often advised by retrospective studies (21-23). Frasson et al. (24) suggested that more than 90 percent of peri-implant tissue involve some inflammatory response. They also have reported 28% prevalence regarding the mentioned diseases.
Roos-Jonsaker et al. (21) stated the prevalence of peri-implant mucositis as 48%, whereas 6. 6% of implants experienced the peri-implant. Generally, determining the prevalence of peri-implant diseases is marginally difficult because of the application of varied protocols, different follow-up periods, various implant systems, designs, and useful diameters. On the other hand, related information on implant placement area in conditions of bone width and elevation or its position in mouth cavity is not set in various studies.
It is said that, the primary cause of swelling in peri-implant tissue is the resultant disease of anaerobic bacteria (25, 26). Initial progression of periodontal pathogens in the biofilm of implant levels is reported in edentulous people (27) and it is similar from what has been recognized in teeth (28-31). Periodontal pathogens could be colonized in implant level 2 weeks after mouth cavity exposition and an elaborate sub-gingival microbial biomass will condition within 28 days and nights after the implant exposition (32). Sato et al. (33) has obviously shown the existence of all periodontal pathogens in bone resorption circumstances compared with peri-implant mucositis. Peri- implant inflammation could lead to bone resorption and if it is not managed properly, it might cause implant reduction. Furthermore, they illustrated in a number of circumstances that the existence of more than 5mm remnant storage compartments after the treatment of active periodontal disease can increase peri-implant and implant damage (34). This issue underlines the significance of accurate examination in the original phases of the disease and the necessity of appropriate and well-timed intervention.
Managing and treating peri-implant diseases
Controlling peri-implant diseases is a difficult and unpredictable process. Among the most important factors in their treatment is to evaluate implant looseness. The implant must be removed immediately if it comes loose during specialized medical check, after analyzing the likelihood of abutment screw or prosthesis looseness (15, 18).
This type of decision-making is in line with Pisa implant health test criterion, where three groupings are launched as implants position (compromised success, failing, and sufficient) (12). On this classification, failure is recognized as a loose implant. Generally, looseness of the implant is the sign of weakened BIC; therefore, a tooth doctor must consider the situation as a criterion and instructions for deciding to whether keep the implant or not.
Treating peri-implant mucositis
When the implant is not loose, the next step is to recognize the occurrence or range of bone resorption. If no resorption was diagnosed, the examination of peri-implant mucositis is highly possible, to create Ailing implant (18). Alternatively, if the bone resorption has occurred, we'd be facing a peri-implant, known as declining implant. Peri-implant diseases, including peri-implant mucositis, are infectious diseases caused by Gram-negative pathogens in periodontal (35-37).
Similar to the natural tooth, preventing the development of biofilm and getting rid of it from the implant should be the first stage in preserving the fitness of peri-implant soft structure. Hence, treatment methods for peri-implant mucositis has nonsurgical basis and in the beginning consist of mucosa and submucosa scaling. Fabricated treatments, including mechanised debridement and the application of non-microbial factors (such as chlorhexidineand essential oils), have been analyzed with caution to prevent damaging hemidesmosome joints at sulcus foundation and acceptable results were obtained (38-40). However, most studies have suggested the use of antiseptics, the consequences of topical antibiotic providers, and irrigation with antibiotics as supplementary treatments in mechanical debridement (41-43). The important point is that, studies have reported some significant advantages regarding the use of such brokers in lowering index plaque. Schar et al. (44) suggested that the effect of nonsurgical treatments by photodynamic remedy is similar to topical ointment antibiotic; however, eliminating the whole inflammation has not been seen in treatment options.
Various surgical and man-made methods were useful for surviving and treating ailing implant, such as debridement, decontamination of implant, and regenerative methods (45-52). Nevertheless, determining the best treatment method is not possible because of the variety of clinical conditions.
Peri-implant is recognized as one of the key concerns in implant treatment. This obstacle is approximately peri-implant bone resorption without looseness. For successful treatment of this problem, dentists must realize the number of bone resorption as their first rung on the ladder. Since the common two-dimensional radiographs have low level of sensitivity and cannot effectively identify the original lesions (53), implants prognostic assessments are limited through these diagnostic methods. Alternatively, the treatment of implants with bone resorption is unstable in any way, because the mechanical loading of these implants could endanger the long-lasting success (54). Inside the situations of bone resorption stretching to more than 50% of the distance, it is highly recommended to remove the implant and following the reconstruction of hard and gentle cells and obtaining satisfactory results, it could be replaced in the region. Although these conditions are treatable by Guided Bone Regeneration (GBR), concerning the conducted studies in this field to do this osseointegration is extremely difficult and unpredictable (55).
For implants with significantly less than 50% bone resorption, the case must be evaluated accurately. In case the resorption is less than 2 mm, design is implemented by nonsurgical methods, which is similar to peri-implant mucositis treatment. Nonsurgical treatments have been assessed by different strategies (56-64). Mechanical debridement, whatever the strategy type, is not singularly useful in eliminating the lesion and complete halting of peri-implant diseases (56). Quite simply, conducted studies on canines, where suture was the cause of disease, shows favorable results in the form of decrease in periodontal pathogens (57), as well as improvement in professional medical parameters such as probe depth decrease, adhesion improvement, bleeding on probe (58), and plaque index credited to mechanical treatment.
Synthetic treatments along with systemic antimicrobial (amoxicillin, metronidazole, tetracycline and clindamycin) (59) or topical ointment antimicrobials (61, 62) (tetracycline materials, minocycline microspheres and chlorhexidine gel) have shown a general reduction in quantity of pathogens and improvement of scientific parameters (index plaque, pocket depth, adhesion limit, and BOP). Laser is suggested as an alternative to mechanised debridement (64) and motivating results has been reported; however, there is limited information on functionality, useful dosage, and probable effects on the bone, which shows further research is needed. Consequently, it will probably be worth mentioning that the obtained advancements is limited to clinical variables and as shared in various amounts of researches, not a single case has received the treatment completely. Accordingly, we can not treat an advanced peri-implant through only nonsurgical method, wanting successful and predictable results. Exemption can be produced when bone resorption is bound and therapeutic is facilitated by nonsurgical methods. Operative methods are advised when the bone resorption is more than 2 mm but has afflicted not even half of the implant period. Serino and Tutti (65) has mentioned that the success of surgery in peri-implant diseases relates to the number of original resorption. The applied peri-implant medical methods is comparable to the applied methods in periodontitis and the essential principles, like the removal of pathogens, are being used in all the brought up issues (25). If the purpose of treatment is to maintain the bone, pushing the flap besides, similar to flap with apical position is performable (58). Regarding circumstances in which bone contour adjustment is known as, bone medical methods are advised. In operative methods, the basic treating principles are the decontamination of infected implants (25). Nonetheless, retaining the integrity of the implant is a considerable task for clinicians. Various methods have been presented for implants debridement. Favorable results were achieved in a study that chemical agencies, such as metronidazole gel have been used as a flap (58). Although the number of the obtained bone home improvement is lowest, evidences were shown to show the efficiency of abrasive pumices by electric toothbrushes with rotational motion for the purpose of decontamination (66). The assessment of varied debridement and decontamination methods, including Air-power abrasive, citric acid, normal saline, gas impregnated with chlorhexidine, or the combination of these methods, did not illustrate a significant difference in conditions of bone regeneration and reintegration (67). According to an instance survey, using flap surgery ( along with decontamination by hydrogen peroxide ) with systemic antibiotic have induced a noticable difference in specialized medical parameter (Bleeding on probing) in long term and also halted the condition (68). Regardless of implant decontamination methods (the common mechanical methods, chemical type agents, Air-abrasive, laser, saline, and ultrasonic), flap surgery with implant decontamination is cure which enhances and subsides inflammation, reconstructs the appropriate bone contour around implant, and halts the bone resorption. Bone individual surgeries around the polluted implant (such as changing implant levels, implantoplasty) can be performed along with respected surgeries for contour modification and bone anatomy. The obtained results suggested that, implantoplasty has the prospect of more improvement in comparison to debridement with prescribing antibiotics(49).
To provide remission and achieve health position in surrounding implant tissues, reintegration is essential and reach that in a failing implant, various generative methods have been used and various graft materials have been used to increase the range of BIC. Graft materials including xenografts, allografts, and alloplasts with/without membrane were used for this purpose (46, 47, 51, 69). These studies show the improvement of professional medical and radiographic parameters as the reduction of probe depth and filling of lesion. There is no strong proof in this field to support the utilization of membrane, while in situations that membrane can be used, its exposition is reported as a comparatively universal problem (66). Some studies proposed resorbable membranes to prevent exposure effects and reduce re-surgeries for getting rid of non-resorbable membranes (51, 52). Currently, despite the lack of consensus on the privilege of a certain membrane, this is strongly suggested. Dentists must carefully verify the scientific condition of patients and adopt the perfect treatment strategy based on the proposed methods.
There are various methods to avoid the outbreak of disease around a implant, especially in patients with periodontal records, very sensitive to peri-implant diseases, and even more susceptible to colonization of pathogens (70-74). However, as long as the patient is a good talk about of health insurance and attends the follow-up sessions regularly, the problem is not a definite prescription for oral implants (75, 76). It must be mentioned that peri-implant delicate tissue inflammation can be done, even in patients without periodontal record as well. Accurate elimination and the removal of remnant infection is a prerequisite treatment, since the remaining pearly whites can become a way to obtain periodontal and bacterial pathogens. Early on pathologic diagnosis is a key point in stopping disease improvement and long retention of dental care implant health. It really is worth mentioning that, the depth of peri-implant probing is not considered as a reliable solution to check the fitness of a peri-implant (77) and radiographic evaluations are important, as well. Therefore, peri-implant probing and probe depth enhancement are related to adhesion reduction and bone resorption (78, 79), that could be a suited method for evaluating the adhesion limit. It must be known that, the accuracy and reliability of analysis methods is a restriction and also, bitewing and peri-apical radiographs are helpful in this field (80).
Consequently, a decision tree has been defined to control peri-implant diseases to be utilized as a manual (81-83). To be able to treat and measure the peri-implant problems, long-term and periodical clinical and radiograph assessments, along with their contrast to the standards are needed. Since peri-implantitis and periodontitis are not curable diseases and relapse is probable, longtime retention durations in patients to regulate preventing is the problem of the most importance.
By the increase in number of annual implant substitutes, peri-implant diseases has become a challenge. The proposed treatment in this job will be a manual for dentists to confront the problem. To verify the provided protocols, further studies are needed in this field.
Conflict of interest: None declared.