|Year : 2021 | Volume
| Issue : 2 | Page : 68-77
Clinical decision-making in diagnosis and treatment of peri-implant diseases and conditions with 2017 Classification System
Department of Periodontology, H.P. Government Dental College and Hospital, Shimla, Himachal Pradesh, India
|Date of Submission||19-Aug-2020|
|Date of Decision||15-Oct-2021|
|Date of Acceptance||05-Nov-2021|
|Date of Web Publication||14-Dec-2021|
Dr. Deepak Sharma
Department of Periodontology, H.P. Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
As the practice of dental implantology keeps growing exponentially worldwide, implantologists face an ever-increasing challenge to manage peri-implant diseases and complications. At present, the approaches to diagnose, classify, and treat peri-implant diseases are not uniform, standardized, or systematic. To address these limitations, a classification for peri-implant diseases and conditions was presented in the Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions in 2017 organized by the American Academy of Periodontology and European Federation of Periodontology. Since its inception in 2017, this comprehensive classification system has become the new standard of clinical practice around the world. The article provides an overview and description of peri-implant diseases, their classification criteria, diagnostic techniques, and management approaches based on the 2017 Classification System. The flowcharts and decision trees presented can guide implantologists on how to deal with implant complications, in particular peri-implant diseases, including peri-implant mucositis, peri-implantitis, and implant soft- and hard-tissue deficiencies. Future long-term studies in this area are definitely needed to establish the effectiveness of various treatment approaches.
Keywords: Anti-infective agents, decontamination, dental implants, guided tissue regeneration, peri-implantitis
|How to cite this article:|
Sharma D. Clinical decision-making in diagnosis and treatment of peri-implant diseases and conditions with 2017 Classification System. J Dent Implant 2021;11:68-77
|How to cite this URL:|
Sharma D. Clinical decision-making in diagnosis and treatment of peri-implant diseases and conditions with 2017 Classification System. J Dent Implant [serial online] 2021 [cited 2022 Jan 20];11:68-77. Available from: https://www.jdionline.org/text.asp?2021/11/2/68/332469
| Introduction|| |
The World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, jointly organized by the American Academy of Periodontology and the European Federation of Periodontology (EFP), introduced a new classification scheme for periodontal and peri-implant diseases [Figure 1]., The workshop updated the 1999 Classification of Periodontal Diseases and Conditions with key and significant changes. A classification for peri-implant health, peri-implant mucositis, and peri-implantitis was also introduced. All characteristics of peri-implant health, mucositis, peri-implantitis, and other relevant implant site conditions and deformities were reviewed to achieve a consensus for the classification and its global acceptance. The World Workshop also proposed case definitions and clinical and radiographic features for both periodontal and peri-implant diseases with an aim to establish a diagnostic framework for the treatment of periodontal and peri-implant diseases. The system also aims to establish uniform terminology, case definitions, and features to universally communicate the diagnosis and treatment of peri-implant diseases. However, the clinical application of the new classification may seem challenging to implant practitioners.
Peri-implant diseases, including peri-implant mucositis and peri-implantitis, were first described at the First European Workshop on Periodontology. Following this, there have been numerous workshops addressing the definition, prevalence, and treatment of these diseases. The histopathologic and clinical conditions leading to the conversion from peri-implant health to peri-implant mucositis and mucositis to peri-implantitis are not completely understood.,
The aim of this article is to provide a narrative review of current protocols used in decision-making for diagnosis and treatment of peri-implant diseases and conditions. Clinical algorithms and their background rationale are presented to help the implant practitioner make clinical decisions.
This article thus seeks to meet the following objectives:
- To summarize the diagnostic criteria, clinical, radiographic, histologic features, risk factors, case definitions, and etiology of peri-implant diseases and conditions as mentioned in the 2017 World Workshop
- To describe the different diagnostic aids used for detection and diagnosis of peri-implant diseases
- To design framework for evidence-based diagnosis and management of peri-implant diseases.
To the authors' best knowledge, this is the first article in literature which proposes clinical guidelines for the diagnosis, prevention, treatment, and maintenance of peri-implant diseases based on the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions.
| Material and Methods|| |
Available published English literature pertaining to peri-implant diseases was reviewed in May 2020. The literature including consensus report of World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions, consensus reports of European Workshop on Periodontology on Bone Regeneration, consensus reports of workshops of EFP, consensus reports from the FDI Workshop on Prevention, Diagnosis, and Treatment of Peri-implant diseases was analyzed. An electronic search with MeSH Terms((”peri-implantitis” [MeSH Terms] OR “peri-implantitis” [All Fields] OR “periimplantitis”[All Fields]) AND (”therapy” [Subheading] OR “therapy” [All Fields] OR “treatment” [All Fields] OR “therapeutics” [MeSH Terms] OR “therapeutics” [All Fields])) OR (periimplant [All Fields] AND (”disease” [MeSH Terms] OR “disease” [All Fields] OR “diseases” [All Fields])) was also performed through Medline and EMBASE databases, followed by a hand search through previous studies and reviews. Screening, study selection, and evaluation of publication bias were conducted by two independent examiners.
| Results|| |
The prevalence of peri-implant complication is expected to be on the rise with the increased number of implants being placed. Clinicians face difficulties in making treatment plan for peri-implant diseases, as the literature is overwhelming, ambiguous, and lack consensus on various treatment approaches.
Several decisions for the treatment of these may be considered: etiologic nonsurgical treatment, surgical treatment in nonresponding or severely affected peri-implant sites, explantation for strategic reasons or when the implant maintenance is impossible, and importantly professional peri-implant maintenance program. Patient's medical, periodontal conditions, peri-implant soft- and hard-tissue changes, defect configuration, esthetic outcome, and ability to perform oral hygiene are other crucial factors considered during treatment of peri-implant diseases. After an electronic and manual articles search, 29 studies were selected for the final analysis. Inconsistent definitions and treatment approaches of peri-implant diseases, peri-implant mucositis, and peri-implantitis were reported across the studies.
| Discussion|| |
The World Workshop categorized peri-implant health as characterized by features, namely absence of bleeding on probing, erythema, swelling, and suppuration. Peri-implant health can also exist around implants with reduced bone support. Various diagnostic aids can be used to assess peri-implant health, as shown in [Table 1].
|Table 1: Aids for diagnosis of peri-implant diseases at maintenance program|
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Peri-implant mucositis has been defined as an inflammatory lesion of the mucosa surrounding an endosseous implant without loss of supporting peri-implant bone. The main clinical characteristic is bleeding on gentle probing. Other features include erythema, swelling, and/or suppuration. The diagnosis should be based on clinical and radiographic methods. The major etiological factor is plaque accumulation. Smoking, diabetes mellitus, and radiation therapy may modify the condition. Mucositis is a reversible condition on the removal of etiological factors and if left untreated, can progress to peri-implantitis. Regular supportive peri-implant therapy with biofilm removal is an important preventive strategy against the conversion of health to peri-implant mucositis and also against the progression of peri-implant mucositis to peri-implantitis which may occur in the absence of adequate plaque control.
Peri-implantitis is defined as a pathological condition occurring in tissues around dental implants, characterized by inflammation in peri-implant connective tissue and progressive loss of supporting bone. The onset of peri-implantitis may occur early during follow-up, and the disease progresses in nonlinear and accelerating pattern. A meta-analysis estimated weighted mean prevalence of peri-implant mucositis and peri-implantitis of 43% (confidence interval [CI]: 32%–54%) and 22% (CI: 14%–30%), respectively. Peri-implantitis sites exhibit clinical signs of inflammation, bleeding on probing and/or suppuration, increased probing depths, and/or recession of the mucosal margin in addition to radiographic bone loss compared to previous examinations. At sites presenting with peri-implantitis, probing depth is correlated with bone loss and is, hence, an indicator for the severity of disease. It is important to recognize that the rate of progression of bone loss may vary between patients. The various risk factors are summarized in [Table 2]. The goal of peri-implantitis treatment is the resolution of soft-tissue inflammation and, subsequently, the prevention of further marginal bone loss. Nonsurgical treatment modalities are frequently insufficient to achieve this objective, while surgical procedures are considered more efficacious in the treatment of peri-implantitis [Figure 2].
|Figure 2: Clinical decision making flowchart for peri-implant disease management|
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Hard- and soft-tissue deficiency around the implant is another category of peri-implant diseases. Hard-tissue deficiencies encompass intra-alveolar, dehiscence, fenestration, horizontal ridge, and vertical ridge defects. Soft-tissue defects include volume and quality deficiencies, i.e., lack of keratinized tissue. These complications are difficult to treat and may threaten the survival of the implant. The causative factors for such deficiencies include natural resorption processes following tooth extraction, trauma, infectious diseases such as periodontitis, peri-implantitis, endodontic infections, growth and development, expansion of the sinus floor, anatomical preconditions, mechanical overload, thin soft tissues, lack of keratinized mucosa, malpositioning of implants, migration of teeth, lifelong growth, and systemic diseases. All these factors are not proven with a good level of evidence. These complications can be avoided with good implant surgical and prosthetic protocol and later treated with different surgical approaches as situations mandate. [Table 3] summarizes all features of categories put forward in the 2017 World Workshop.
|Table 3: Features of various categories of peri-implant condition and diseases recommended by 2017 World Workshop,,,,|
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The practice of dental implantology is witnessing an exponential rise worldwide and is providing patients with unparalleled levels of efficient, predictable, convenient, and affordable options of oral rehabilitation. This is also leading to a corresponding increase in prevalence of peri-implant disease cases. It is important for dental professionals to understand that peri-implant diseases may arise from failure to identify and manage risk factors, improper treatment planning, suboptimal surgical or prosthetic execution, and improper maintenance care. Clinical, radiographic assessment and risk factors evaluation should be done to diagnose peri-implant diseases.,,,,,
It is necessary to establish the standard treatment approaches for these diseases to reduce the disease recurrence and improve the longevity and success of implant therapy. Meticulous plaque control, treatment and control of preexisting periodontal disease, risk factor identification and management, and regular comprehensive supportive peri-implant therapy (SPT) are highly crucial to preserve and maintain peri-implant health.,,,, Peri-implant mucositis is usually treated by nonsurgical therapy. It is aimed at the removal of biofilm removal by mechanical debridement with or without surface decontamination and followed by strict SPT program.,,
For peri-implantitis, a more comprehensive management approach is needed. After eliminating the infection and reducing inflammation of the soft tissues with nonsurgical therapy, surgical intervention may be required. If bone loss is at an incipient stage, treatment will be identical to that prescribed for peri-implant mucositis; with the addition of decontamination of the prosthetic abutments and anti-infective therapy, prosthetic design may also be modified if necessary.,,,,, If bone loss is advanced or persists despite the initial treatment, it will be necessary to perform intensive surgical treatment, namely resection techniques,,,,, and regenerative techniques or their combination.,,,, The morphology of bone defects and the number of preserved bone walls determine the choice of the method of treatment and allow evaluation of the possibilities of bone repair., In cases of severe peri-implant bone loss, implant mobility, recurrent peri-implantitis, and nonresponsiveness to peri-implant therapy, explantation remains a strategic option.
A systematic surgical and prosthetic treatment planning should be done before implant placement and loading. The precise execution of the plan and additional augmentative surgery, if required, should be performed to prevent peri-implant hard- and soft-tissue deficiencies., The deficiencies developing later during implant functioning should be managed by appropriate regenerative and periodontal plastic surgical techniques.,,,,,
There is a lack of standardization in management approaches of peri-implant diseases, which leads to difficulty in drawing valid conclusions. [Table 4] describes the various management and preventive approaches for peri-implant health, mucositis, peri-implantitis, and hard- and soft-tissue deficiencies. The concise presentation in tabulated form is done to assist readers in summarizing the different protocols used worldwide for the management of peri-implant conditions and diseases. For a detailed understanding, it is advised to read the proceedings of international workshops, meetings, and the research publications cited in the article text at appropriate places. The detailed review of these approaches and their consensus positions is beyond the scope of the present article. The review is narrative in nature; as a result, some studies might not have been included. A comprehensive systematic review following appropriate international guidelines should be done to overcome present limitations and achieve evidence-based conclusions on the treatment of peri-implant diseases and conditions.
|Table 4: Clinical decision-making algorithm for management of peri-implant conditions and diseases|
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| Conclusion|| |
A classification for peri-implant diseases and conditions was presented in the 2017 World Workshop. Categories of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies were introduced, and their characteristics were described. This article attempts to enhance the current understanding of various aspects of peri-implant diseases according to the World Workshop on Periodontal and Peri-implant diseases. The decision-making chart provided may serve as a reference guide for dentists when making the decision to diagnose, prevent, and treat peri-implant diseases.
The implant practitioner must be aware of the importance of pretreatment planning, should consider appropriate case selection and execution of sound surgical and prosthetic protocols. Patient's symptoms should be evaluated. Early diagnosis of peri-implant diseases is imperative, and initiating the correct treatment protocol depends on proper diagnosis.
Patient awareness of importance of plaque control and professional regular supportive therapy is crucial in preventing peri-implant diseases. Identification of local and systemic risk factors plays a significant role in framing a tailor-made treatment plan for peri-implant diseases. Nonsurgical treatment of peri-implant diseases includes mechanical debridement, implant surface decontamination, and adjunctive anti-infective therapy. Nonresponding lesions or associated with progressive bone loss are treated by augmentative, nonaugmentative therapy, or their combinations.
This article provides clinical practice guidelines for plaque control regime, nonsurgical and surgical peri-implant therapies, and SPT. The article should be treated as a baseline document which may be modified based on the recommendation of future prospective long-term randomized clinical studies. Due to the lack of sufficient prospective randomized long-term follow-up studies, many different treatment modalities of peri-implant diseases exist in literature, but no universal consensus exists regarding effective peri-implant therapy. Improvement in future clinical research will lead to improved management strategies and hence a better and more predictable clinical implant practice.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Caton JG, Armitage G, Berglundh T, Chapple IL, Jepsen S, Kornman KS, et al.
A new classification scheme for periodontal and peri-implant diseases and conditions – Introduction and key changes from the 1999 classification. J Periodontol 2018;89 Suppl 1:S1-8.
Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM, 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 Clin Periodontol 2018;45 Suppl 20:S286-91.
Heitz-Mayfield LJ, Salvi GE. Peri-implant mucositis. J Clin Periodontol 2018;45 Suppl 20:S237-45.
Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. J Clin Periodontol 2018;45 Suppl 20:S246-66.
Salvi GE, Lang NP. Diagnostic parameters for monitoring peri-implant conditions. Int J Oral Maxillofac Implants 2004;19 (Suppl):116-27.
Mombelli A, van Oosten MA, Schurch E Jr., Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145-51.
Lindquist LW, Rockler B, Carlsson GE. Bone resorption around fixtures in edentulous patients treated with mandibular fixed tissue-integrated prostheses. J Prosthet Dent 1988;59:59-63.
Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38:l610-6.
Khocht A, Zohn H, Deasy M, Chang KM. Screening for periodontal disease: Radiographs vs. PSR. J Am Dent Assoc 1996;127:749-56.
Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol 2015;42 Suppl 16:S158-71.
Prathapachandran J, Suresh N. Management of peri-implantitis. Dent Res J (Isfahan) 2012;9:516-21.
Hämmerle CH, Tarnow D. The etiology of hard- and soft-tissue deficiencies at dental implants: A narrative review. J Periodontol 2018;89 Suppl 1:S291-303.
Renvert S, Polyzois I. Risk indicators for peri-implant mucositis: A systematic literature review. J Clin Periodontol 2015;42 Suppl 16:S172-86.
Gaviria L, Salcido JP, Guda T, Ong JL. Current trends in dental implants. J Korean Assoc Oral Maxillofac Surg 2014;40:50-60.
Lee CT, Huang YW, Zhu L, Weltman R. Prevalences of peri-implantitis and peri-implant mucositis: Systematic review and meta-analysis. J Dent 2017;62:1-12.
Bidra AS, Daubert DM, Garcia LT, Gauthier MF, Kosinski TF, Nenn CA, et al.
A Systematic review of recall regimen and maintenance regimen of patients with dental restorations. Part 2: Implant-borne restorations. J Prosthodont 2016;25 Suppl 1:S16-31.
Roos-Jansåker AM, Renvert S, Egelberg J. Treatment of peri-implant infections: A literature review. J Clin Periodontol 2003;30:467-85.
Jepsen S, Berglundh T, Genco R, Aass AM, Demirel K, Derks J, et al.
Primary prevention of peri-implantitis: Managing peri-implant mucositis. J Clin Periodontol 2015;42 Suppl 16:S152-7.
Mombelli A. Maintenance therapy for teeth and implants. Periodontol 2000 2019;79:190-9.
de Araújo Nobre M, Salvado F, Nogueira P, Rocha E, Ilg P, Maló P. A peri-implant disease risk score for patients with dental implants: Validation and the influence of the interval between maintenance appointments. J Clin Med 2019;8:E252.
Renvert S, Polyzois IN. Clinical approaches to treat peri-implant mucositis and peri-implantitis. Periodontol 2000 2015;68:369-404.
Muthukuru M, Zainvi A, Esplugues EO, Flemmig TF. Non-surgical therapy for the management of peri-implantitis: A systematic review. Clin Oral Implants Res 2012;23 Suppl 6:77-83.
Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis – A review. Head Face Med 2014;10:34.
Sahrmann P, Ronay V, Sener B, Jung RE, Attin T, Schmidlin PR. Cleaning potential of glycine air-flow application in an in vitro
peri-implantitis model. Clin Oral Implants Res 2013;24:666-70.
Koo KT, Khoury F, Keeve PL, Schwarz F, Ramanauskaite A, Sculean A, et al.
Implant surface decontamination by surgical treatment of periimplantitis: A literature review. Implant Dent 2019;28:173-6.
Chambrone L, Wang HL, Romanos GE. Antimicrobial photodynamic therapy for the treatment of periodontitis and peri-implantitis: An American Academy of Periodontology best evidence review. J Periodontol 2018;89:783-803.
Romeo E, Ghisolfi M, Murgolo N, Chiapasco M, Lops D, Vogel G. Therapy of peri-implantitis with resective surgery. A 3-year clinical trial on rough screw-shaped oral implants. Part I: Clinical outcome. Clin Oral Implants Res 2005;16:9-18.
Khoury F, Keeve PL, Ramanauskaite A, Schwarz F, Koo KT, Sculean A, et al.
Surgical treatment of peri-implantitis – Consensus report of working group 4. Int Dent J 2019;69 Suppl 2:18-22.
Renvert S, Polyzois I, Claffey N. Surgical therapy for the control of peri-implantitis. Clin Oral Implants Res 2012;23 Suppl 6:84-94.
Schwarz F, Sahm N, Schwarz K, Becker J. Impact of defect configuration on the clinical outcome following surgical regenerative therapy of peri-implantitis. J Clin Periodontol 2010;37:449-55.
Guler B, Uraz A, Yalım M, Bozkaya S. The comparison of porous titanium granule and xenograft in the surgical treatment of peri-implantitis: A prospective clinical study. Clin Implant Dent Relat Res 2017;19:316-27.
Javed F, Alghamdi AS, Ahmed A, Mikami T, Ahmed HB, Tenenbaum HC. Clinical efficacy of antibiotics in the treatment of peri-implantitis. Int Dent J 2013;63:169-76.
Froum SJ, Froum SH, Rosen PS. A regenerative approach to the successful treatment of peri-implantitis: A consecutive series of 170 implants in 100 patients with 2- to 10-year follow-up. Int J Periodontics Restorative Dent 2015;35:857-63.
Jepsen S, Schwarz F, Cordaro L, Derks J, Hämmerle CH, Heitz-Mayfield LJ, et al.
Regeneration of alveolar ridge defects. Consensus report of group 4 of the 15th
European workshop on periodontology on bone regeneration. J Clin Periodontol 2019;46 Suppl 21:277-86.
Greenstein G, Cavallaro J. Failed dental implants: Diagnosis, removal and survival of reimplantations. J Am Dent Assoc 2014;145:835-42.
Bhatavadekar N. Clinical decisions and the quality of evidence available for dental implants. J Periodontol 2009;80:1559-61.
Manicone PF, Raffaelli L, Ghassemian M, D'Addona A. Soft and Hard Tissue Management in Implant Therapy-Part II: Prosthetic Concepts. Int J Biomater 2012;2012:356817.
Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge preservation interventions following tooth extraction: A systematic review and meta-analysis. J Clin Periodontol 2019;46 Suppl 21:195-223.
Naenni N, Lim HC, Papageorgiou SN, Hämmerle CH. Efficacy of lateral bone augmentation prior to implant placement: A systematic review and meta-analysis. J Clin Periodontol 2019;46 Suppl 21:287-306.
Urban IA, Montero E, Monje A, Sanz-Sánchez I. Effectiveness of vertical ridge augmentation interventions: A systematic review and meta-analysis. J Clin Periodontol 2019;46 Suppl 21:319-39.
Bouri A Jr., Bissada N, Al-Zahrani MS, Faddoul F, Nouneh I. Width of keratinized gingiva and the health status of the supporting tissues around dental implants. Int J Oral Maxillofac Implants 2008;23:323-6.
Thoma DS, Naenni N, Figuero E, Hämmerle CH, Schwarz F, Jung RE, et al.
Effects of soft tissue augmentation procedures on peri-implant health or disease: A systematic review and meta-analysis. Clin Oral Implants Res 2018;29 Suppl 15:32-49.
Bassetti RG, Stähli A, Bassetti MA, Sculean A. Soft tissue augmentation procedures at second-stage surgery: A systematic review. Clin Oral Investig 2016;20:1369-87.
Bhatavadekar N. Peri-implant soft tissue management: Where are we? J Indian Soc Periodontol 2012;16:623-7.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]