Peri-implant Disease - Research Paper Example

Literature Review One of the rapidly growing problems in the implant dentistry in spite of refinement in the implant design and the surface features is the peri-implant disease. According to an estimate, the number of people in the US who have dentin hypersensitivity exceeds 40 millions (DePaola 8). From this number, the importance of this issue of healthcare can be estimated. One of the therapeutic techniques that have gained increased importance lately are the implant-based methods of dental rehabilitation. This technique is prescribed for patients who are partially or totally edentulous. Nevertheless, certain complications have been identified with such treatments. One of the most important of these complications is the loss of alveolar bone that surrounds the implant. The disease peri-implant derives its name from the pathological inflammatory alterations which happen in the tissue which encapsulates the load-bearing implant. Peri-implant diseases are by nature, infectious. There are two entities that are conventionally explained through peri-implant diseases; peri-implantitis and mucositis. Peri-implantitis is the name of a condition in which the bony support of the implant is lost radiologically as well as clinically. This causes the peri-implant mucosa to swell. Peri-implantitis is an inflammatory reaction that happens as the supporting bone contained in the tissues that encapsulate a functioning implant starts deteriorating. Peri-implantitis is also referred to as an infection that is site-specific and generates numerous features that are commonly found in the chronic adult periodontitis. A number of researchers have found microorganisms a fundamental cause of the development of this condition. The deterioration of the peri-implant results in the establishment of a complex for of microbiota which is similar to the one that occurs in the adult periodontitis. In their research, (Rosenberg et al.) identified two categories for the patients that failed the implants. The first category was of suspected infection and the second category was of trauma. In the patients belonging to the category of suspected infection, microbiota colonized the implants that resembled the ones that occur in periodontitis. On the other hand, patients belonging to the second category felt no pain and the failed implants showed a microbiological profile that resembled the one that occurs at the healthy implant sites. On the other hand, in mucositis, there occur certain changes pertaining to the peri-implant mucosa which are reversible if treated appropriately. “Osseointegration is defined as the direct connection between live bone and a functioning endosseous implant, the term “functioning” implying that the contact between live bone and the surface of the implant is sustained while active or load-bearing” (Bobia and Pop). Local iatrogenic factors are some of the most significant contributors towards the commencement and maintenance of peri-implantitis. These local iatrogenic factors include but are not limited to poorly fitting crowns, excess of cement, poor positioning of implants and over-contouring of the restorations. The risk of acquiring the peri-implant disease is also enhanced by poor control of the chronic periodontitis. While a lot of studies have found greater loss of bone during the first year of the function of implant and the process of healing as compared to the years that follow, different researchers have proposed different reasons for the same. The etiologies identified include but are not limited to the surgical trauma, peri-implantitis, and occlusal overload. Many researchers have consented upon the surgical trauma as the prime etiology for the early failure of implant. A lot of heat is generated while drilling. This combined with the rise of the periosteal flap and pressure development during the placement of implant at the crestal region cause loss of implant bone in the healing period. Eriksson and Albrektsson (cited in Oh et al. 323) said that the implant site when prepared gets as hot as to reach the temperature of 47C for a minute. Overheating of the bone causes a tremendous increase in the risk of failure of the implant. The force that is applied is also a significant causal factor of the increase in temperature in addition to the speed with which drilling takes place. Nevertheless, a general increase of the applied force as well as the speed of drilling does not raise the temperature because of the consequential efficient cutting. Occlusal overload causes a loss in the marginal bone. Bacteria are the cause of some of the most common scratches which occur in the peri-implant disease; the peri-implantitis and the peri-implant mucositis. Peri-implantitis makes an impact upon the supporting bone whereas the peri-implant mucositis’s scratch is found inside the soft tissues. 80 per cent of the patients that are restored with implants are affected by peri-implant mucositis whereas peri-implantitis happens in anywhere from 28 per cent to 56 per cent of the patients (Lindha and Meyle). Factors that cause the risk of infection include but are not limited to a patient’s record of periodontitis, poor oral hygiene, smoking and diabetes. “People who smoke are at a greater risk of infection following surgery, and may heal more slowly. When an implant is placed in a smoker, it is more likely to fail. This means a patient’s smile may be negatively affected, and the potential for more bone loss in the areas surrounding the gums and teeth” (Perez cited in “Smoking can cause”). Smoking has an adverse effect on the supply of blood to the tissues which surround the gums and the bones i.e. teeth. This has a retarding impact on the bone healing. In a vast majority of cases, the failure of implants occurs because of a failed integration with the bone tissues. The impact of smoking on the tendency of success of a dental implant was investigated by a team of researchers from the University of Murcia in Spain. The research identified smoking as a threat both because it causes tooth loss and a failure of dental implant. The researchers included 66 patients in the study and observed them for more than 5 years. The patients had received a total of 165 implants. The researchers found the percentage of implants failed in the non-smokers was 1.4 as compared to a 15.8 per cent of failure of implants among the smokers (“Smoking can cause”). This suggests that smoking is a potential retarder in the healing process as well as a risk factor in the dental implants. Signs of the peri-implant mucositis include swelling and redness in the soft tissue. A very important sign is the bleeding on probing. Peri-implantitis is diagnosed by identification of the deepened pockets and suppuration, but deterioration of the supporting bone is compulsory. Not much is known about the prevalence of the peri-implant disease. Most of the resources refer to the problem of implant loss without indicating the peri-implant disease. “Recording what triggers the onset of the pain, whether the pain is dull or sharp, and how long the pain lasts, as well as whether the patient is in the process of whitening their teeth, provides information necessary for directing treatment” (DePaola 8). Conventionally in the dentistry, diagnosis of a problem happens to be the first step towards the resolution of the problem. In order to diagnose the condition, it is advisable for the doctors to take baseline radiographs while inserting the final prosthesis so that the baseline alveolar bone levels can be determined. These radiographs can be compared to the ones taken in future so that any loss of bone that differs from normal trend can be determined. Prudent supervision of implants should identify deviations in such clinical parameters as suppuration on probing, bleeding on probing and increase in the depth of probing. Radiographs help the clinician determine bone loss. Before any treatment can be given to the patient, it is advisable for the clinician to make the patient aware of the response of the peri-implant tissues to the plaque accumulation. Peri-implant disease is often caused by a poor oral hygiene which causes the accumulation of plaque. The clinician should know that peri-implantitis can be recognized by suppuration in the implant site. To monitor the conditions of peri-implant, the clinician should perform probing so that the peri-implant disease can be diagnosed. “At least, annual monitoring of the peri-implant probing depths and the presence of bleeding on probing and suppuration must be performed to allow comparisons with the baseline recordings and to allow early diagnosis of peri-implant disease” (Lindhe and Meyle 285). If the outcome of the treatment is successful, it is imperative that it is inclusive of the parameters which lay description of the resolution of inflammation as well as perpetuation of the bone which provides support (Lindhe and Meyle 284). It is possible to reverse the condition of peri-implant mucositis with minimal intervention. The problem usually gets adequately resolved with careful mechanical debridement of the region together with the prescription of anti-microbials to the patient. Anti-microbials commonly prescribed include Dentomycin and Chlorhexidine irrigation. The area should be examined thoroughly to make sire that all local iatrogenic factors which are known to cause the infection have been eradicated. Sometimes, the diseases progresses far too much to cause a loss of bone. In such cases, the phase of initial treatment is usually the same i.e. prescription of anti-microbials to the patient along with strict oral protocols of hygiene and mechanical debridement. It is also advisable for the patient to use chlorhexidine mouthwash. The clinician should also consider administering the systemic antibiotics in order to minimize the number of pathogens. The plaque-contaminated implant surface can be debrided with different methods which include the use of ultrasonic, mechanical or sonic scalers, air-powder abrasion and lasers. There are certain chemical solutions that also help debride the implant surface like citric acid, chlorhexidine digluconate and saline. Nevertheless, the required treatment differs from one case to another and one method of treatment cannot be generalized for all. After the initial treatment has been given, the next step for the clinician to take is to see if it is appropriate to recreate the bone to surround the implant. Various factors govern this decision of the clinician including the extent of bone deterioration, patient’s response and defect morphology. Little is known about the benefits of using systemic antibiotics to treat the peri-implantitis surgically. However, certain regenerative techniques including the bone graft techniques have conventionally yielded favorable results. While using such techniques, care must be exercised to make sure that rather than addressing the resolution of disease, the techniques just try to fill the osseous defect. “The high survival rate of osseointegrated dental implants is well documented, but it is becoming increasingly clear that successfully integrated implants are susceptible to disease conditions that may lead to the loss of the implant” (Chen and Darby 212). For the dental implants to be successful, one factor that plays a prime role is the implant’s integration with the tissue. Initially, in the endosteal implants that are successfully osseointegrated, the interface between the tissue and the implant distorts at the crestal region irrespective of the submergence of the surgical approaches. The loss of crestal bone begins to show up soon after the completion of the first year of function. From that point onwards, up to 0.2 mm of the bone is lost every year. A number of plausible etiological factors cause this, which include the trauma experienced during the surgery, occlusal overload, micrograp, implant crest module, peri-implantitis, and biologic width. The literature to date suggests that “the reformation of biologic width around dental implants, microgap if placed at or below the bone crest, occlusal overload, and implant crest module may be the most likely causes of early implant bone loss” (Oh et al. 322). Owing to the limited knowledge in the literature regarding the prevalence of the peri-implant disease, past researchers (Lindhe and Meyle 285) have recommended an epidemiological approach to the future researchers to explore knowledge about the prevalence of peri-implant disease. It is recommendable for the future researchers to collect the radiographic and clinical data by making use of a cross-sectional design upon an appropriate sample size. The best approach would be to include the participants in the research from the public or private dental clinics instead of the university clinics that have been the focus of most researchers to date. This would enable the researchers to “provide information on the “effectiveness” rather than “efficacy” in implant therapy” (Lindhe and Meyle 285). After-care of the dental implants Patients should take a lot of precautionary measures in order to heal up quickly and to maintain oral hygiene after the treatment has been given. Local anaesthesia is commonly given during the dental surgeries. It takes from three to four hours for the effects of the local anaesthesia to recede. The patient should be careful to protect the tongue, lips and inner sides of the cheeks by avoiding chewing till complete wearing off of the numbness. The patient should also keep distant from hot foods or drinks in the numbness. During the first and the second week post-surgery, the patient should avoid eating anything that exerts excessive pressure on the teeth. It is recommendable to eat only soft items of food. The diet should not only be soft, but also very nutritious and rich in proteins. The patient should not push the tongue to the area where the dental implant was made. Pain relieving medicines and antibiotics should be taken regularly until the course is finished. Painkillers should be taken when required. Area where the dental implant was made should not be brushed at least for the first two weeks after the surgery. However, the patient should use a good mouthwash twice a day to maintain oral hygiene. The patient should avoid physical exertion to minimize the risk of bleeding around the area where the implant was made. Any kind of drugs, alcohol and cigarettes should be abstained from for at least two weeks after the surgery to keep the process of healing from getting retarded. “Tobacco use has been shown to be a risk factor for periodontal diseases, which is the main cause of tooth loss in adults… if you want your dental implant to last, you should not smoke. Also, the treating dentist should make sure their patients are aware of this before placing an implant, and emphasize the importance of quitting smoking” (Miller cited in “Smoking can cause?”). In order to be eligible for the job of a dental hygienist, an individual should have done graduation from a renowned program in dental hygiene, successfully attempted the National Board Examination, and also the Clinical Board Examinations that apply. Duties of the dental hygienists vary by state, with some states being more critical than the others. A general dental practitioner assumes a very important role in the whole process of the diagnosis, surgery, treatment and the after care. “The clinician is faced with the task of identifying and maintaining hard and soft tissues that permit a thick, stable peri-implant environment” (DePaola 1). It is the general dental practitioner’s responsibility to make the patients aware of the potential implications of smoking and such other habits upon their oral hygiene, so that the patients abstain from displaying such risky behaviors. Crowns and implants may be suggested to patients depending upon the condition of teeth. Patients who are partially edentulous should go for dental implants as this would improve the look and mastication of the teeth. On the other hand, crowns are placed once the root canal therapy has been completed. Crowns provide the weakened tooth after the root canal therapy with additional support. Crowns and implants differ in their biological complications. One of the most common complications of crowns is loss of abutment vitality. 196 abutment teeth out of 1227 that were thought to be vital while cementing showed up loss of the vitality of the pulp during the period of observation (Pjetursson et al. 106). The second most frequently noticed complication of crowns is the dental caries. (Karlsson) found a decay of 8.1 per cent of all surfaces in a course of just 10 years. The biological complications of implant include peri-implant mucosal lesions, peri-implantitis, and complications of soft tissue. Signs of inflammation including swelling and pain accompanied with redness are the potential complications of implants. (Pjetursson, Zwahlen, and Lang) conducted analysis of the quality of the clinical researches’ reporting regarding the comparison and evaluation of the implant-supported restorations. They found that the clinical studies deviated considerably from the recommended standards of reporting. There was noticed a lack of information about the design of research, the methodology adopted for the selection of participants and also, a lack of justification for the lost to follow-up participants. In addition, the studies analyzed hardly talked about any limitations or sources of bias. This suggests that there is a lack of quality in the reporting of clinical researches. Works Cited: Bobia, F. and Pop, R. V. “Periimplantitis. Aetiology, diagnosis, treatment. A review from the literature.” Current Health Sciences Journal. Vol. 36. No. 3. 2010. Web. 2 Apr. 2012. . Chen, S. and Darby, I. “Dental implants: Maintenance, care and treatment of peri-implant infection.” Australian Dental Journal. Vol. 48. No. 4. pp. 212-220. 2003. DePaola, Dominick P. “Dental Implants: Placement, After Care, and Patient Expectations.” The Colgate Oral Care Report. Vol. 21. No. 3. pp. 1-13. 2011. Karlsson, S. “A clinical evaluation of fixed bridges, 10 years following insertion.” Journal of Oral Rehabilitation. Vol. 13. pp. 423–432. 1986. Lindhe, Jan and Meyle, Joarg. “Peri-implant diseases: Consensus report of the sixth European workshop on periodontology.” Journal of Clinical Periodontology. Vol. 35. pp. 282-285. 2008. Oh, Tae-Ju; Yoon, Joongkyo; Misch, Carl; and Wang, Hom-Lay. “The causes of early implant bone loss: myth or science?” J Periodontol. Vol. 73. No. 3. pp. 322-333. 2002. Pjetursson, Bjarni E.; Bragger, Urs; Lang, Niklaus P., and Zwahlen, Marcel. “Comparison of survival and complication rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns (SCs).” Clin. Oral Impl. Res. Vol. 18. pp. 97-113. 2007. Pjetursson, Bjarni E.; Zwahlen, Marcel, and Lang, Niklaus P. “Quality of reporting of clinical studies to assess and compare performance of implant-supported restorations.” J Clin Periodontol. Vol. 39. Suppl. 12. pp. 139–159. 2012. Rosenberg, E. S., and Torosian, J. P., “Slots J. Microbial differences in 2 clinically distinct types of failures of osseointegrated implants.” Clin Oral Implants Res. Vol. 2. pp. 135-144. 1991. “Smoking can cause dental implants to fail.” 30 June 2010. Web. 3 Apr. 2012. . Read More