Peri-Implantitis
Peri-implantitis affects the area that surrounds dental implants, causing inflammation and destruction to the bone and soft tissue immediately adjacent to the implants. The gums and other soft tissues of the periodontium grow inflamed, and the alveolar bone that supports the implant and helps stabilize it deteriorates over time. This bone destruction differentiates peri-implantitis from peri-implant mucositis, which is an inflammatory condition that affects only the soft tissue and is reversible. Peri-implantitis leads to different symptoms for every patient and can best be diagnosed with regular dental checkups.
The gum tissue that surrounds dental implants should never appear swollen or reddened, nor should it bleed or exude pus. While these symptoms are not necessarily present when peri-implantitis occurs, if they do appear, it is likely that there is inflammation present. In its earlier stages, peri-implantitis can cause bleeding while brushing the teeth, and patients may notice swelling around the implant as well as a bad taste or bad smell in the mouth. Some patients notice that the affected implant wobbles or feels loose in the bone, though this is usually a symptom of the later stages of peri-implantitis and can be an indication that the implant has separated from the bone near its apex. While a loose or noticeably mobile implant is usually related to bone loss, bone loss can also be assessed with an x-ray or other type of radiographic image. Evidence of bone loss in these images, along with bleeding when adjacent soft tissues are probed, are the most common signs of peri-implantitis that appear during clinical examinations. These examinations can also differentiate peri-implantitis, which must involve bone, from peri-implant mucositis, which affects only the mouth’s soft tissues. In some cases of peri-implantitis, patients also report pain in the area of the affected implant, as well as an overgrowth of the gum tissue around the teeth, a condition known as gingival hyperplasia, though these symptoms are more rare and may indicate a more acute infection.
The primary cause of peri-implantitis is the proliferation of bacterial plaque that is allowed to accumulate in the tissues of the mouth. As bacterial plaque accumulates and hardens into dental calculus, the tissues in the mouth become inflamed, much like they do with periodontitis. Peri-implant disease includes peri-implantitis and peri-implant mucositis, and the relationship between these two conditions is similar to the relationship between periodontitis and gingivitis. This is to say that both gingivitis and peri-implant mucositis affect only the soft tissues of the periodontium and can be reversed with proper treatment, whereas periodontitis and peri-implantitis both affect both the soft tissue and the bone and cannot be reversed. When the bacteria found in plaque colonize around dental implants, they lead to an inflammatory response that manifests in redness, inflammation, and swelling and causes bleeding upon probing of the gum tissue, all symptoms that parallel the symptoms of gingivitis. The infection process of peri-implant mucositis is also similar to gingivitis: invasion of bacteria found in plaque biofilm triggers inflammation in the soft tissues of the mouth. If peri-implant mucositis goes untreated, it is likely to develop into peri-implantitis, just as untreated gingivitis, if allowed to progress, often develops into periodontitis. Peri-implant mucositis can be reversed with regular, effective oral hygiene that successfully removes the bacterial plaque that triggered the disease. When the inflammation of peri-implant mucositis goes untreated and leads to the resorption of the bone that surrounds the affected implant or implants, a symptom that can be identified on a radiographic image, the disease has become peri-implantitis. If peri-implantitis is allowed to progress, it is likely to lead to implant mobility as more and more of the bone surrounding and supporting the implant is resorbed into the body, though this is a symptom of significantly advanced peri-implantitis and is an indication that substantial bone loss has occurred.
Peri-implantitis is difficult to treat, and treatment protocols vary dramatically based on the severity and location of the disease. Some non-surgical treatments seek to control infection while disinfecting the surface of the implant, and some surgical treatments aim to encourage regrowth of the alveolar bone that has been resorbed. Mechanical debridement, which is the removal of bacterial microorganisms from below the gumline using specialized dental tools, is an effective treatment for periodontitis but is not considered the best option for peri-implantitis, due in large part to the intricate shape and design and the technical materials of dental implants. For this reason, dentists may supplement non-surgical treatments like mechanical debridement with antibiotic therapy, or they may combine mechanical debridement with bone-regeneration surgery. There are multiple possible combinations of treatment methods for peri-implantitis, and these combinations are determined based on the nature of the disease. A therapeutic protocol called cumulative interceptive supportive therapy is used to guide dental practitioners in choosing the proper treatment regimen; cumulative interceptive supportive therapy assesses the condition of the oral mucosa, the probing depth of the tissue surrounding the implant, and the radiographic images of the implant area.
Mechanical debridement methods call for specialized dental tools, usually made of resin or carbon fiber, that are designed to clean the surface of the implant fixture without damaging it. When antiseptic treatment is required, chlorhexidine digluconate is the preferred antimicrobial. Most treatment plans call for three to four weeks of chlorhexidine exposure, either used as a daily rinse or an oral gel, though extended treatment with chlorhexidine beyond four weeks is not recommended and can cause staining of the teeth or adverse affects to the taste buds. Antibiotic treatment is intended to reduce or eliminate the bacterial pathogens in the oral cavity and is added to antiseptic treatment toward the end of the three to four week treatment cycle; this is intended to maintain health of the newly disinfected surface as antiseptic and mechanical treatments taper off. When surgical treatment measures are needed, surgical flap management with resective and/or regenerative techniques may be considered, though this is usually only an option when infection has been successfully controlled. These surgical options focus on healthily regenerating the alveolar bone, or on reshaping the soft tissue around the implant, working in tandem with mechanical and chemical treatments to create a sanitized and healthy surface that will be less prone to future infection.