Christoph Hàmmerle

Though dental implants have a high level of success and impressive survival rates, biological complications can sometimes occur. Peri-implantitis is one such complication that, due to its unsolved nature, has often been a topic of discussion. In this article, we will shed some light on peri-implantitis and explain how the new GalvoSurge® dental implant cleaning system can help bring this condition under control.

What is the definition of peri-implantitis?

Defining peri-implantitis has been a contentious matter for many years, with debate over whether it should be considered a disease or a complication resulting from the placement of a dental implant in the mouth.
A 2017 consensus meeting conducted jointly by the European Federation of Periodontology (EFP) and the American Academy of Periodontology (AAP) sought to provide a classification for peri-implant diseases and conditions. In a report released afterwards, the working group defined peri-implantitis as:

“[A] plaque‐associated pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri‐implant mucosa and subsequent progressive loss of supporting bone.” 1

In addition, the group characterized a healthy peri-implant site as one that has an “absence of erythema, bleeding on probing, swelling and suppuration”.

Symptoms and diagnosis of peri-implantitis

Based on this definition, patients with peri-implantitis may demonstrate bleeding and/or suppuration on probing, inflammation, as well as greater probing depths when compared to previous examinations.1

These symptoms alone, however, are not enough to diagnose peri-implantitis in an implant patient. A series of radiographs conducted over several follow-up appointments are necessary to determine whether an implant site is displaying progressive marginal bone loss (MBL).2

What are the risk factors?

As outlined in the EFP and AAP’s consensus report, there is strong evidence that implant patients with a history of severe periodontitis, sub-optimal plaque control and a lack of regular follow-up maintenance appointments after active implant treatment are at an increased risk of developing peri-implantitis.1

Data also suggests that patients with peri-implant mucositis can go on to develop peri-implantitis – especially for patients who neglect follow-up maintenance. It remains unclear, though, what conditions are required for this progression to occur.1

How common is peri-implantitis?

Estimates regarding the prevalence of peri-implantitis vary. The European Academy of Osseointegration (EAO) released a consensus report in 2012 that estimated a prevalence of 10% at the implant level,3 while a 2019 retrospective study of 4,591 dental implants found a peri-implantitis rate of 4.7% after 6 to 7 years.4

A study in Sweden that examined a randomly selected sample of 588 patients who had received implant treatment at least nine years previously, diagnosed 14.5% of patients with moderate/severe peri-implantitis (bleeding on probing/suppuration and bone loss >2 mm). Based on the study’s case definition of peri-implantitis – bleeding on probing/suppuration and detectable bone loss >0.5 mm – 45% of patients presented with this condition.5

Whatever the prevalence of peri-implantitis may be, many implantology experts predict that this rate will increase. In the EAO’s Delphi Study – Horizon 2030,6 which sought to identify future trends in European implantology, a consensus was reached that peri-implantitis prevalence will likely increase over time as more dental implants are placed by general dentists without specialist training.

Predicted prevalence of peri-implantitis

Delphi Study – Horizon 2030: Identifying and predicting future trends in implant dentistry in Europe; EAO Online Library, 2019

 

What are the current options for treating peri-implantitis?

Traditionally, the first step in treating peri-implantitis involves a combination of non-surgical treatment, such as mechanical debridement, and strategies of disinfection such as the use of chlorhexidine mouthwashes. If symptoms continue to persist and potentially worsen even with non-surgical treatment, antibiotics may be delivered to help arrest the inflammation. Once this has been controlled, the dental specialist may consider surgical intervention including local mechanical and/or chemical disinfection as well as bone grafting.

In the Delphi Study – Horizon 2030, a high level of consensus was achieved on how peri-implantitis will be treated moving forward.6 The participating experts largely agreed that treatment would be a combination of surgical and non-surgical modalities.

The main challenge today in the treatment of periimplantitis is that no cleaning method can properly achieve detoxification of the implant surface, a required step for a successful therapy.

There is, however, a novel method available to efficiently clean dental implants in peri-implantitis. The GalvoSurge dental implant cleaning system lifts the bacterial biofilm away from the implant surface without causing undesired harm to healthy hard and soft tissue, creating an implant surface amenable to re-osseointegration.

This mode of action uses an electrolytic process that creates hydrogen bubbles to lift the biofilm and leaves the implant clean and ready for additional therapy like bone grafting.7 The efficacy of GalvoSurge has already been assessed and documented in multiple studies. In a randomized controlled clinical trial, all implant sites treated with GalvoSurge were inflammation-free, displayed significant clinical bone fill, and cleaning with this product made complete re-osseointegration for certain peri-implantitis cases possible.8

In addition, an in vitro study demonstrated that GalvoSurge removed oral biofilm and bacteria significantly better than other commercially available dental implant cleaning methods without negatively modifying the implant surface.6

GalvoSurge has been developed for the decontamination of titanium implant surfaces and can be used with most available implant systems.

Clinical case

Courtesy of Dr. Urs Brodbeck

Peri-implantitis diagnosis

1. Diagnosis: peri-implantitis with ongoing bone loss and puss discharge

2. Implant cleaning with GalvoSurge.

3. Implant after cleaning. Both implant outer surface and inner connection are cleaned.

4. Implant after cleaning. Both implant outer surface and inner connection are cleaned.

5. Bone augmentation with creos xenograft

6. Site covered with resorbable membrane

7. Soft tissue healing around healing abutment after 7 days

8. Final result after 4 months. Healthy peri-implant tissues free from inflammation.

9. Pre-op

10. Final result after 4 months.

 

References

  1. Berglundh T, Armitage G, Araujo MG, et al. Peri-implant diseases and conditions: Consensus report of workgroup 4 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol 2018;89 Suppl 1:S313-318. Read on PubMed
  2. Albrektsson T, Canullo L, Cochran D, et al. Peri-implantitis: a complication of a foreign body or a man-made disease. Facts and fiction. Clini Implant Dent Relat Res 2016;18(4):840-849. Read on PubMed
  3. Klinge B, Meyle J. Peri-implant tissue destruction. The third EAO Consensus Conference 2012. Clin Oral Implants Res.2012;23:108-110. Read online
  4. French D, Grandin HM, Ofec, R. Retrospective cohort study of 4,591 dental implants: Analysis of risk indicators for bone loss and prevalence of peri-implant mucositis and peri-implantitis. J Periodontol 2019;90(7):691-700. Read on PubMed
  5. Derks J, Schaller D, Håkansson J, et al. Effectiveness of Implant Therapy Analyzed in a Swedish Population: Prevalence of Peri-implantitis. J Dent Res. 2016 :43-9 Read on PubMed
  6. Sanz M; Noguerol B; Sanz-Sanchez, I; et al. European Association for Osseointegration Delphi study on the trends in implant dentistry in Europe for the year 2030. Clin. Oral Implant. Res. 2019, 30, 476–486.6.Read on PubMed
  7. Ratka C, Weigl P, Henrich D, et al. The effect of in vitro electrolytic cleaning on biofilm-contaminated implant surfaces. J Clin Med 2019;8(9):1397. Read on PubMed
  8. Schlee M, Rathe F, Brodbeck U, et al. Treatment of peri-implantitis – electrolytic cleaning versus mechanical and electrolytic cleaning – a randomized controlled clinical trial – six-month results. J Clin Med 2019;8(11):1909 Read on PubMed

Posted by Prof. Christoph Hammerle