4 Things to Know About Peri-Implantitis by Dr. Giacomo Tarquini

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Categories: Implant Dentistry; Periodontics;

Understanding the causes, risks and latest treatment strategies for peri-implantitis

by Dr. Giacomo Tarquini

Biological complications affecting osseointegrated implants are a topic of major interest in contemporary dentistry. Such complications, conventionally termed peri-implant diseases, are inflammatory conditions that affect the peri-implant tissues and are induced by the presence of a peri-implant bacterial biofilm.

Many articles about peri-implant diseases have been published over the years, and it is not always easy to make a point and draw conclusions so they can be of some use in everyday clinical decision-making.

The aim of this article is to shed light on these sources by summarizing the topic of peri-implant diseases in four main points:

Differential diagnosis of peri-implantitis and peri-implant mucositis.
Risk factors analysis.
Comparison among various decontamination protocols.
The importance of supportive peri-implant treatment.

Also, a clinical case of peri-implantitis treated using a novel ultrasonic device is described to show the proposed surgical protocol.

1. Differential diagnosis of peri-implantitis and peri-implant mucositis
The first thing to know is that two clinical varieties of peri-implant disease may be distinguished: peri-implant mucositis and peri-implantitis.^1,2

Peri-implant mucositis is an inflammatory lesion of the peri-implant mucosa, in the absence of continuing marginal bone loss. It is characterized clinically by bleeding on gentle probing, erythema, swelling and/or suppuration.³

Also, an increase in probing depth (PD) is frequently observed in the presence of peri-implant mucositis because of oedema and decrease in probing resistance.

On the other hand, peri-implantitis has been defined as a peri-implant biofilm associated pathological condition, occurring in tissues around dental implants, and characterized by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone. Peri-implantitis is therefore characterized by inflammation, bleeding on probing (BOP) and/or suppuration, increased PDs and/or recession of the mucosal margin, in addition to radiographic bone loss compared with previous examinations, which is the main diagnostic criterion.⁴

However, in the absence of previous examination data, the diagnosis of peri-implantitis can be based on the combination of the presence of bleeding and/or suppuration on gentle probing, PDs of ≥6 mm and bone levels ≥3 mm apical to the most coronal portion of the intraosseous part of the implant.⁵

2. Risk factors
he second thing to know about is risk factors—defined as something that increases the chance of developing a disease—since they don’t have the same impact on peri-implant diseases occurrence. Focusing our attention on peri-implantitis, the primary etiological factor is represented by the accumulation of a peri-implant plaque biofilm.

Other important risk factors and indicators have been identified, including a history of severe periodontitis, poor plaque control skills and no regular maintenance care after implant therapy. Less conclusive evidence was found for smoking and diabetes as potential risk factors for peri-implantitis, or local factors such as the presence of submucosal cement following prosthetic restoration of the implant, or positioning of implants limiting access to oral hygiene and maintenance.

There is some limited evidence linking peri-implantitis to other factors, such as the post-restorative presence of submucosal cement, lack of peri-implant keratinized mucosa and positioning of implants that make it difficult to perform oral hygiene and maintenance.

Other factors, such as occlusal overload, presence of titanium particles within peri-implant tissues, bone compression necrosis, overheating, micromotion or biocorrosion have been proposed as risk factors for peri-implant diseases onset and/or progression, but their role has yet to be determined.⁶

3. Decontamination protocols
Regarding surgical therapy—which can be addressed through a resective or a regenerative approach, depending on the defect anatomy—the most debated issue is achieving a complete implant surface decontamination before performing bone regeneration surgery. It has been demonstrated that the chance to get a new osseointegration process (also known as re-osseointegration) of previously infected implants is extremely limited. This limitation is most evident around polished, physiochemically altered and incompletely detoxified surfaces. Conversely, re-osseointegration occurs far more predictably around properly decontaminated, micro-roughened surfaces.^7,8

In light of this, a complete and predictable decontamination is a prerequisite for achieving re-osseointegration around previously diseased implants. Eliminating the bacterial load without altering the titanium surface composition creates an ideal environment for plasma protein adsorption onto implant surface. Specifically, this includes albumin and fibronectin. This process promotes osteoblast-like cell adhesion and proliferation, enabling potential new osseointegration. Achieving this outcome is the ultimate goal of regenerative therapy.^9,10

Despite several protocols being proposed in recent years—mostly based on antimicrobial agents, power-driven tools, air abrasives, lasers or manual instruments—no single method of surface decontamination has been found to be superior.¹¹

Biofilm removal from dental implants may be quite difficult, and decontamination protocols used so far have shown limited success. Treated implants often present a remaining contaminated area that may affect cell adhesion and proliferation. Moreover, some of these methods can irreversibly damage the micro-roughened surface.^12,13

Ultrasonic cavitation is the formation of vapor-phase bubbles within a liquid, usually because of rapid changes in localized pressure. It has proven to be highly effective in removing the bacterial biofilm from a substrate at the microscopic level with no damage to the underlying surface. Cavitation bubbles are capable of yielding microstreaming, shock waves, high-speed jets and liquid heating, which cause biofilm disruption from both polished and micro-roughened surfaces.¹⁴

Several authors have shown the potential for this technique as a new method of bone defect debridement as well as dental implant decontamination.^15–18

A more recent protocol involves the use of ultrasonic cavitation occurring in the cooling water around ultrasonic scaler tips according to a non-contact approach. Essentially, when the cooling liquid around the exposed part of the implant cavitates, every crevice of its surface—such as macro- and microscopic irregularities—as well as the connection screw space, can be reached, causing a complete biofilm disruption without modifying the implant surface, unlike other decontamination protocols.^19,20

The main problem with ultrasonic cavitation is creating a confined space around the exposed part of the implant where the cooling liquid can pool and change at low flow rates. During clinical use, the ultrasonic scaler operates with cooling water flowing around the tip, and it’s hard to imagine the establishment of a truly effective cavitation inside this water mist.

In this regard, the use of a novel ultrasonic cavitation device (Piezoclean by Dr. Giacomo Tarquini) turns out to be particularly useful. As already shown in previous articles,^21,22 this device is composed of two parts:

An ultrasonic tip (which must be connected to a piezoelectric handpiece) provided with three micro-holes to promote the circulation of cooling water (ES004E, Esacrom srl, Imola, Italy).
A medical-grade silicone cavitation chamber specifically designed to pool the cooling water and perfectly fit any shape of crestal bone (ES004EP, Esacrom srl, Imola, Italy).

The device is easily assembled by inserting the cavitation chamber onto the ultrasonic tip.

After removing all the prosthetic components, the cavitation chamber is placed around the exposed part of the implant and the piezoelectric device is then activated.

This enables the creation of a secluded space where the cooling liquid cavitates without being dispersed. Thanks to the presence of the medical-grade silicone cavitation chamber, the cooling liquid is locally concentrated around the exposed portion of the implant, allowing for a complete decontamination of those areas—such as implant threads, surface microgrooves and connecting screw housing—that would otherwise be inaccessible to the traditional tools, like Gracey’s curettes, power-driven brushes or glycine airflow.

The optimal running time for a complete biofilm disruption is about three minutes. It is recommended to take a short break every 60 seconds to prevent the cooling liquid from overheating, as the temperature has been found to increase by approximately 10°C after operating for three consecutive minutes.

4. The importance of supportive peri-implant treatment
The fourth—and perhaps the most important—consideration is the follow-up of implant-treated patients,²³ also known as supportive implant therapy (SIT). Supportive periodontal therapy (SPT) has been widely considered a continuation after successful treatment of periodontal diseases, aiming to prevent periodontal reinfection and, consequently, the recurrence of periodontitis.

Analogous to SPT, special oral hygiene measurements and treatment of implants are considered helpful for maintaining the permanent health of peri-implant soft and hard tissues. This is why SIT has been developed to monitor and improve plaque control.

It’s worth recalling that both anatomical and physiological differences between a tooth and an implant make dental implants more susceptible to inflammation and bone loss in the presence of bacterial plaque accumulation. Bacterial biofilm is the primary causative factor of periodontal disease processes. If left undisturbed, mature plaque will form, and bacteria will migrate from teeth to implants and/or from implants to other implants.

A typical maintenance visit for patients with dental implants should include updating the patient’s medical and dental history, reviewing the patient’s oral hygiene and modifying, if necessary, clinical and radiographic examination of the implants and peri-implant tissues, evaluating implant stability, removing any implant retained plaque and calculus, and setting maintenance intervals.

This maintenance visit should last one hour and should be scheduled every three months.²⁴

Since implants are fundamentally different from natural teeth, dental indices are often modified for the purpose of dental implant evaluation during maintenance care.²⁵

Clinical case
A 60-year-old female with no medical history is referred for suspected peri-implantitis affecting the implant #19. Peri-implant probing and preoperative periapical x-ray examination confirm the diagnosis of peri-implantitis, showing the presence of a large bone defect on the buccal side (Figs. 1–3). Clinical parameters such as mBI, mPlI, PD and implant mobility (IM) are registered at baseline.

Fig. 1: Pre-op implant-supported crown.

Fig. 2: Pre-op xray showing the presence of a peri-implant bone defect.

Fig. 3: Pre-op peri-implant charting, a deep buccal bone defect is present.

To facilitate peri-implant probing other than to allow for a submerged surgical procedure,^26,27 both the implant-supported crown and prosthetic abutment are removed (Fig. 4), after which a healing screw is placed on the diseased implant (Fig. 5).

Fig.4: Implant-supported crown and prosthetic abutment are removed.

Fig.5: A healing screw is placed on the diseased implant.

Surgery is performed as follows:

Antibiotic prophylaxis with amoxicillin/clavulanic acid is initiated. (Augmentin, GlaxoSmithKline, Verona, Italy). 2 g one hour before surgery and then every 12 hours for six days.
The patient undergoes mouth rinses with 0.2% chlorhexidine, to be continued for two weeks after surgery (Corsodyl, GlaxoSmithKline, Verona, Italy).
In addition, 100 mg of nimesulide is administered one hour before the surgery, then twice a day for three days (Aulin, Roche, Milan, Italy).
The surgical area is anesthetized using 40 mg/mL of articaine hydrochloride with epinephrine 1:100,000 (Septanest, Septodont, Saint-Maur-des-Fossés, France).
Based on the local anatomy, accessing the peri-implant defect is achieved using a trapezoidal full-thickness flap defined by two slightly divergent vertical incisions. After the flap is elevated, a large buccal peri-implant defect is detected. Both the peri-implant width and the depth of the bone defect are measured with a periodontal probe (Fig. 6).
A dedicated ultrasonic cavitation device is placed onto the exposed part of the implant and is then activated (Figs. 7–8).
Cortical bone perforations are performed using a specialized ultrasonic tip (ES012CT, Esacrom srl, Imola, Italy) to improve angiogenesis in bone grafts and enhance new bone formation in grafted areas, particularly in the early bony healing phase. A sterile cover screw is placed onto the implant (Fig. 9).
Because the bone defect has a space-maintaining morphology, a resorbable pericardium barrier membrane (Heart, Bioteck SpA, Arcugnano, Italy) is positioned on the lingual side to exclude certain cell types, such as rapidly proliferating epithelium and connective tissue, promoting the growth of slower-growing, bone-forming cells (Fig. 10).
Collagen-preserved equine cancellous-cortical granules (Osteoxenon, Bioteck SpA, Arcugnano, Italy) are grafted into the defect^28,29 to support the membrane and promote blood clot stabilization (Fig. 11).
The pericardium membrane is folded over the buccal aspect and then stabilized with titanium pins (Automatic Bone Tac, Bioactiva, Vicenza, Italy) (Fig. 12).
Tension-free flap closure is achieved. The flap is sutured using 5-0 nonresorbable polyamide sutures (Assumid, Assut Europe, Italy) (Fig. 13).
Sutures are removed after 14 days, and the patient is followed up with every three months until healing has occurred with no complications or adverse events.
After six months of undisturbed healing (Fig. 14), an intraoral periapical X-ray is taken. After evaluating the outcome of bone regeneration, a surgical re-entry procedure is planned (Fig. 15).
At the moment of flap elevation, the peri-implant bone defect appears completely filled, and previously exposed implant threads are fully covered with newly formed tissue (Fig. 16).
After placing a new healing screw over the implant, a three-dimensional collagen matrix is grafted beneath the flap (Fig. 17) to increase keratinized tissue thickness. The flap is then apically positioned and sutured in place to widen the keratinized tissue (Fig. 18).
Sutures are removed after seven days, and the patient is evaluated weekly for a month to clean the area with 0.2% CHX swabs and to provide oral hygiene instructions and motivational reinforcement.
After the complete healing of peri-implant soft tissue (Fig. 19), a new prosthetic crown is placed (Fig. 20).
Clinical parameters such as mBI, mPlI, PD and IM are registered at the 12-month follow-up visit, confirming peri-implant health (Fig. 21).

Fig.6: After flap elevation, a large buccal peri-implant defect is detected.

Fig.7: Components of ultrasonic cavitation device Piezoclean by Dr. Giacomo Tarquini.

Fig.8: Piezoclean by Dr. Giacomo Tarquini is placed onto the exposed part of the implant.

Fig.9: Cortical bone perforations are carried out in order to improve angiogenesis. A sterile cover screw is placed onto the implant.

Fig.10: Pericardium resorbable barrier membrane is positioned on lingual side.

Fig.11: Cancellous-cortical granules are grafted into the defect.

Fig. 12: Pericardium membrane is folded on the buccal aspect and then stabilized with titanium pins.

Fig.13: The flap is closed using 5-0 nonresorbable poliammide sutures.

Fig. 14: Intraoral periapical X-ray taken at 6 months follow-up.

Fig.15: Soft tissue condition at 6 months follow-up.

Fig. 16: Re-entry surgery: peri-implant bone defect is completely filled and previously exposed implant threads are fully covered with newly formed bone.

Fig.17: After placing a new healing screw, a threedimensional collagen matrix is grafted beneath the flap to increase keratinized tissue thickness.

Fig.18: The flap is apically positioned and sutured to increase keratinized tissue width.

Fig. 19: Peri-implant soft tissue complete healing.

Fig. 20: A new prosthetic crown is delivered.

Fig. 21: Peri-implant charting at 12 months follow-up visit confirms peri-implant health.

Conclusion
Bacterial biofilm accumulation around dental implants is a significant problem, leading to peri-implant diseases and implant failure. Diagnostic, therapeutic and maintenance protocols for peri-implantitis are often confusing, to the extent that they have been summarized into four main points.

The most critical issue in regenerative therapy for peri-implant bone defects is certainly related to the ability to achieve predictable implant surface decontamination. Although several methods have been described, the literature does not clearly indicate the superiority of any specific decontamination protocol.

Cavitation that occurs in the cooling water around a dedicated ultrasonic tip can be used as a novel solution to disrupt bacterial biofilm without risking damage to the implant surface. The present article has demonstrated that the use of this device in combination with a guided bone regeneration procedure for treating peri-implant bone defects has produced positive clinical outcomes, including reductions in mBI, mPlI, PD around the treated implant when compared to the baseline.

Additionally, it is important to recognize that dental implants require constant maintenance and monitoring, which further involves a careful assessment of the patient’s general and oral health. Professional implant maintenance and diligent patient home care are critical factors that will ensure the long-term success of implants as a predictable replacement for natural teeth.

References

Lang, N. P., and T. Berglundh. “Peri-implant Diseases: Where Are We Now? Consensus of the Seventh European Workshop on Periodontology.” Journal of Clinical Periodontology, vol. 38, suppl. 11, 2011, pp. 178–181.
Jepsen, S., et al. “Primary Prevention of Peri-implantitis: Managing Peri-implant Mucositis.” Journal of Clinical Periodontology, vol. 42, suppl. 16, 2015, pp. S152–S157.
Heitz-Mayfield, L., et al. “Supportive Peri-implant Therapy Following Anti-infective Surgical Peri-implantitis Treatment: 5-year Survival and Success.” Clinical Oral Implants Research, vol. 29, no. 1, 2018, pp. 1–6.
Berglundh, T., 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.” Journal of Clinical Periodontology, vol. 45, suppl. 20, 2018, pp. S286–S291.
Herrera, D., et al. “Prevention and Treatment of Peri-implant Diseases—The EFP S3 Level Clinical Practice Guideline.” Journal of Clinical Periodontology, vol. 50, suppl. 26, 2023, pp. 4–76.
Schwarz, F., et al. “Peri-implantitis.” Journal of Clinical Periodontology, vol. 45, suppl. 20, 2018, pp. S246–S266.
Persson, L. G., et al. “Reosseointegration after Treatment of Peri-implantitis at Different Implant Surfaces: An Experimental Study in the Dog.” Clinical Oral Implants Research, vol. 12, 2001, pp. 595–603.
Mouhyi, J. “The Peri-implantitis: Implant Surfaces, Microstructure, and Physicochemical Aspects.” Clinical Implant Dentistry and Related Research, vol. 14, no. 2, 2012.
Blus, C., et al. “Bactericide Effect of Vibrating Ultrasonic (Piezosurgery) Tips: An In Vitro Study.” Clinical Oral Implants Research, vol. 20, 2009, p. 905.
Arrojo, S., Y. Benito, and A. M. Tarifa. “A Parametrical Study of Disinfection with Hydrodynamic Cavitation.” Ultrasonics Sonochemistry, vol. 15, 2008, pp. 903–908.
Romanos, G. E., and D. Weitz. “Therapy of Peri-implant Diseases: Where Is the Evidence?” The Journal of Evidence-Based Dental Practice, vol. 12, suppl. 3, 2012, pp. 204–208.
Tran, C. Novel Methods for Debridement of Dental Implant Surfaces Contaminated by Biofilm. PhD thesis, The University of Queensland, School of Dentistry, 2017.
Vyas, N. “Improved Biofilm Removal Using Cavitation from a Dental Ultrasonic Scaler Vibrating in Carbonated Water.” Ultrasonics Sonochemistry, vol. 70, 2021, 105338.
Tarquini, G. “Ultrasuoni in Chirurgia Parodontale: Effetti Clinici.” Tecniche di Chirurgia Parodontale: Dalla Diagnosi alla Terapia, edited by G. Tarquini, Edizioni EDRA, Sept. 2017, pp. 25–26.
Tarquini, G. “Il Ruolo degli Ultrasuoni in Terapia Chirurgica delle Periimplantiti: Presentazione di un Caso Clinico.” Implant Tribune, vol. VI, no. 4, Nov. 2017, pp. 1–7.
Gartenmann, Stefanie J., et al. “Influence of Ultrasonic Tip Distance and Orientation on Biofilm Removal.” Clinical Oral Investigations, vol. 21, no. 4, 2017, pp. 1029–1036.
Zhang, Siyuan. Biofilm Removal with Acoustic Cavitation and Lavage. 2013. Theses and Dissertations, no. 243.
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Author Bio

Dr. Giacomo Tarquini graduated with honors in dentistry and dental prosthetics from the Sapienza University of Rome in 1994, and has been practicing dentistry for 25 years. He practices in Rome with particular interest in the disciplines of periodontology and implantology. He is also a consultant, professor, tutor and lecturer for a variety of dental specialties. Along with various articles, Tarquini is the author of the textbook Techniques of Periodontal Surgery: From Diagnosis to Therapy. Tarquini is also a member of the Dentaltown editorial advisory board.

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4 Things to Know About Peri-Implantitis by Dr. Giacomo Tarquini

Understanding the causes, risks and latest treatment strategies for peri-implantitis

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