Understanding and Preventing Peri-Implant Diseases

In recent years, evidence-based research such as systematic reviews, meta-analyses, and randomized controlled trials has increased and replaced anecdotal or successful personal experience by practitioners. As you’ll see in the research I’m going to discuss about peri-implant diseases, scientific evidence has become an important aspect of care compared with expert opinion and clinical experience. We now talk about “best practice” instead of “the art of medicine/dentistry.”¹

A clinical practice guideline presents an evaluation of the quality of the relevant scientific literature and benefit/potential harms of treatment. For example, the American Dental Association has published several clinical practice guidelines on a variety of topics, such as recommendations by the American Heart Association on the use of antibiotics to prevent infective endocarditis or fluoride toothpaste recommendations for children younger than 6 years. Guidelines assist clinicians in the decision-making process for best outcome and consider systematic appraisal of published evidence as well as clinical experience. These guidelines can also help clinicians defend themselves in a court of law.

Peri-Implant Diseases

When a reversible inflammatory lesion affects the soft tissues surrounding a dental implant in the absence of radiographic bone loss (with bleeding on probing [BOP] as a key tool to distinguish an unhealthy peri-implant mucosa), a clinician will diagnose peri-implant mucositis. Other factors associated with peri-implant mucositis onset include biofilm accumulation, smoking, and radiation therapy.^2,3

When a clinician observes an irreversible pathological condition affecting hard and soft tissues around a dental implant, the resulting bone loss is referred to as peri-implantitis.^2,3 Peri-implantitis sites exhibit BOP and/or suppuration besides inflammation and are also associated with increased probing depths and recession of the mucosal margin.³ Etiology includes peri-implant plaque biofilm, history of severe periodontitis, poor oral hygiene, and irregular or no supportive peri-implant care following surgery. Less conclusive evidence for peri-implantitis consists of the following factors: smoking, diabetes, submucosal cement following prosthetic restoration of the dental implant, and positioning of the implant in such a manner that limits access to oral hygiene including professional maintenance.³

General Framework Used in Clinical Practice Guideline Development

The clinical practice guideline (2023) for peri-implant diseases was developed by the European Federation of Periodontology and overseen by an expert workshop committee. The overall effort included 13 systematic reviews conducted in support of the guideline development process. After the 13 reviews were conducted on specific, focused questions (eg, the efficacy of adjunctive measures to treat peri-implant mucositis), evidence-based recommendations were debated, and a consensus was reached and voted on.³

The quality of evidence for each of 13 areas (focused questions pertaining to peri-implant disease) was included, which reflected the degree of certainty/uncertainty of the evidence and the robustness of study results. In addition, the recommendation was graded, which reflected the criteria used to form a judgment and strength of consensus. Risk of bias was also included in group discussions and clinical practice guidelines.

Clinical Practice Guideline Components

The clinical practice guideline for peri-implant diseases (prevention and treatment) includes the following components:

• Prevention, diagnosis, and treatment sequence
• Recommendations for the prevention of peri-implant diseases

• Recommendations for the management of peri-implant mucositis
• Recommendations for nonsurgical management of peri-implantitis
• Recommendations for the surgical management of peri-implantitis

In highlighting some of the clinical practice guideline recommendations below, keep in mind that recommendations by the workshop committee were based on strength of available evidence and/or expert consensus and was graded according to quality and certainty. The clinical practice guideline is considered valid until 2028 and is free to read in its entirety.

1. Prevention, Diagnosis, and Treatment Sequence

Patients who receive a dental implant should be considered at risk for some type of peri-implant disease.3 During the 2014 European Workshop in Periodontology, 2 systematic reviews demonstrated a patient-level prevalence estimate for peri-implant mucositis and peri-implant implantitis. In one systematic review, meta-analyses from 11 studies demonstrated a patient-level prevalence estimate of 43% (95% CI, 32%-54%) for peri-implant mucositis and 22% (95% CI, 14%-30%) for peri-implantitis. Another systematic review included 47 studies and reported a prevalence of 46.83% (95% CI, 38.30%-55.36%) for peri-implant mucositis and of 19.83% (95% CI, 15.38%-24.27%) for peri-implantitis.³

Interventions to prevent peri-implant disease should begin at the treatment planning stage and continue throughout the life of the dental implant in the oral cavity. Known risk factors associated with peri-implant diseases should be controlled, such as poor oral hygiene, smoking, diabetes, and untreated periodontitis.

Perioperative interventions for the prevention of peri-implant diseases must include placing the dental implant(s) in an optimal position while considering local factors that prevent ideal placement and designing/installing prostheses that allow access for oral hygiene. Avoid submucosal cement and select screw-retained restorations instead.³

Peri-implantitis is an irreversible condition. Even after successful peri-implantitis therapy, a diagnosis of “stable” is made.³ Upon diagnosis, refer to an appropriate specialist and decide whether the affected tooth can be treated. The following key aspects in the management of peri-implant diseases are important to remember³:

1. Arresting the inflammatory processes and controlling local/systemic factors within the peri-implant tissues are key. Disruption of locally accumulating biofilms must be a priority.
2. Treatment of peri-implant mucositis is a key strategy in preventing early onset of peri-implantitis.
3. Treatment of peri-implantitis is performed sequentially: nonsurgically and then surgically, depending on the outcome of nonsurgical treatment. Supportive periodontal care must be an important component of treatment management and long-term success.

2. Recommendations for Prevention of Peri-Implant Diseases

Risk assessment and controlling risk factors are necessary in preventing peri-implant diseases in individuals who are candidates for dental implants, who have received dental implants, and who currently have healthy peri-implant tissues. Workshop participants created prevention categories of primordial primary, secondary, and tertiary to interpret evidence and expert-based consensus.³

Primordial prevention refers to the concept of optimal oral and general health prior to implant placement, but there is no current definition of optimal health and no studies directly addressing primordial prevention of peri-implant diseases. Instead, recommendations are based on indirect evidence and expert opinion. Primary prevention refers to the prevention of disease onset following dental implant placement and loading. No studies existed to provide direct evidence for primary prevention.

Clinical guidelines should be based on a thorough evaluation of the evidence and generally include a rating of the quality of evidence and an assigned strength to recommendations. Grading of Recommendations Assessment, Development, and Evaluations guidance warns against making strong recommendations when the certainty of the evidence is low or very low.

In this section, recommendations are mostly expert-consensus based due to low certainty of available evidence, and I would strongly recommend reading each pico question addressed online. [Pico questions are a way to construct a well built question in research. More information on this is available in the clinical practice guideline document referenced below.] Clinical practice guidelines should be based on a thorough evaluation of the evidence and assigned a strength of recommendation. When the certainty of evidence is low or very low, strong statements are not usually made.

Please read the entire clinical practice guideline document in the Journal of Clinical Periodontology³ for components not covered in this article. What follows is a synopsis of the recommendations for the prevention component:

1. Assessment of patient’s risk profile should be completed to identify and manage modifiable risk factors for peri-implant diseases.
2. Treatment of gingivitis and periodontitis should achieve a stable end point, and adherence to regular supportive care should be considered prior to implant placement.
3. Adequate buccal/lingual bone thickness will allow the implant to be placed in a guided position with good primary stability and surrounded circumferentially by bone.
4. Adequate mesio-distal distance between an implant and adjacent tooth/implant must allow adequate space for prosthetic components and access for oral hygiene aids.
5. Good access for oral hygiene aids by the patient to remove plaque is recommended (moderate evidence in addition to expert opinion).
6. Good access for professional monitoring (peri-implant probing) and professional plaque removal is recommended (moderate evidence in addition to expert opinion).
7. A prosthesis contour with a favorable emergence angle and profile to facilitate optimal plaque removal is recommended (moderate evidence in addition to expert opinion).
8. Experts recommend peri-implant probing to assess presence of BOP and to monitor changes in probing depths and in mucosal margin level. Baseline probing should be done within 3 months of prosthesis delivery and at every clinical exam. Width of keratinized attached peri-implant mucosa should be assessed and recorded. BOP and probing depths should be recorded at 6 sites circumferentially.
9. A baseline intra-oral radiograph should be obtained at the completion of the physiological remodeling to document marginal bone levels. If there is an increase in probing depths at future visits in conjunction with BOP/suppuration, oral radiograph is recommended to evaluate marginal bone levels.
10. In patients with diabetes who have healthy peri-implant tissues, experts recommend glycemic control to maintain peri-implant health.
11. Supportive peri-implant care is recommended in patients who have healthy peri-implant tissues to reduce the risk of incident peri-implant diseases, emphasizing to the patient the importance of their adherence to supportive periodontal therapy and home care. (Quality of evidence was moderate and supported by expert consensus.)
12. In patients with healthy peri-implant tissues, validated smoking cessation interventions (by conformance with guidelines) are recommended to reduce risk of peri-implant diseases. (Quality of evidence is very low, but there is strong consensus among the experts.)
13. In patients who have dental implants with an absence or deficiency of keratinized/attached mucosa who experience discomfort when toothbrushing, increasing peri-implant keratinized/attached mucosal to maintain peri-implant health should be considered. (Quality of evidence is low, and expert consensus was rated 0% due to potential bias.)
14. There is a lack of evidence to support an association between increasing soft tissue thickness and peri-implant tissue health; therefore, undertaking procedures to augment soft tissue thickness to prevent the development of peri-implant diseases is supported by low-quality evidence.
15. In patients with dental implants, the experts recommend individually tailored oral hygiene instructions to reduce the risk of incident peri-implant diseases. (Quality of evidence is very low, but there was unanimous consensus by experts.)
16. In patients with healthy peri-implant mucosa, it is unknown whether controlling bruxism/parafunctional habits reduces the risk of incident peri-implant diseases. There are no studies investigating control of bruxing/parafunctional habits in patients with healthy peri-implant tissues.

What follows are recommendations for supportive periodontal therapy that are labeled as secondary and tertiary prevention³:

1. Supportive periodontal therapy is recommended to reduce risk of recurrence of peri-implantitis and consequent implant loss, emphasizing importance of adherence to these visits and home care. (Quality of evidence is low, but there was unanimous consensus.)
2. Following nonsurgical treatment of peri-implantitis and peri-implantitis surgery, supportive periodontal therapy should be provided 3 to 4 months for the first 12 months, commencing 3 months after treatment, and thereafter the frequency should be tailored according to patient, implant, and restoration-based risk factors. (Quality of evidence was low, but there was unanimous consensus.)
3. Experts recommend implantation of a patient-centered supportive periodontal therapy protocol with the following components: interview (medical, social, and oral history update; risk assessment; and patient feedback) and assessment of oral/peri-implant tissue health including prosthetic components, patient compliance, and competence with oral hygiene. Risk factors should be reinforced and controlled like smoking, xerostomia, and glycemic control. Professional intervention should include an individualized oral health care plan, oral hygiene coaching, and appropriate recall interval based on risk.
4. There are no studies comparing professional mechanical plaque removal to reduce risk of disease occurrence. Based on the periodontal literature and indirect evidence, the following approaches for dental implant biofilm removal can be used alone or in combination: titanium or stainless-steel area-specific curettes, ultrasonic/sonic instruments, rubber cup or brushes, air polishing devices with glycine powder or erythritol alone or in combination.
5. Experts do not know which specific oral hygiene method is most effective in reducing the risk of recurrent peri-implantitis. Based on the periodontal literature, indirect evidence, and expert opinion, individually tailored oral hygiene care is recommended, which includes twice-daily toothbrushing with either manual or powered toothbrushes and once-daily uses of interproximal brushes of an appropriate size. Oral hygiene methods should be demonstrated by the patient to the oral health care professional and periodically reinforced.
6. In an expert-based consensus recommendation, it is not suggested to use professional application of adjunctive antimicrobial agents in supportive periodontal therapy to reduce the risk of recurrent peri-implantitis. (No high-quality evidence was available to answer this question.)

Read Full Guideline Online

As noted earlier, you can read the clinical practice guideline in its entirety in the Journal of Clinical Periodontology.³ The guideline includes recommendations for peri-implant mucositis and peri-implant nonsurgical and surgical treatment management. Access is free.

Always keep in mind that clinical guidelines are only as good as the evidence and the judgment of the experts who are making them. However, the European Federation of Periodontology spent a lot of time evaluating studies and used a reliable system for grading quality of evidence and strength of recommendations.

References

1. Langweiler MJ. Evidence-based medicine and the potential for inclusion of non-biomedical health systems: the case for Taijiquan. Front Sociol. 2021;5:618167. doi:10.3389/fsoc.2020.618167

2. Barootchi S, Wang HL. Peri-implant diseases: current understanding and management. Int J Oral Implantol (Berl). 2021;14(3):263-282.

3. Herrera D, Berglundh T, Schwarz F, et al; EFP workshop participants and methodological consultant. Prevention and treatment of peri-implant diseases: the EFP S3 level clinical practice guideline. J Clin Periodonto. 2023;50(suppl 26):4-76.doi:10.1111/jcpe.13823