Peri-implant Health and Disease

Missing teeth and supporting structures lost to dental diseases and trauma have been replaced in myriad ways through fixed and/or removable dental prostheses. In 1977, Dr. P.I. Brånemark demonstrated that bone will integrate into the surface of endosseous titanium dental implants,³² and the modern era of root form endosseous dental implantology arose. It is estimated that up to 5 million dental implants are placed in the United States each year.² While longitudinal survival rates of osseointegrated dental implants range between 90-95%,^11,33 these numbers represent implants that are present and in function, but may not fully capture rates of peri-implant disease and or health. It is estimated that rates of peri-implantitis range from 10-47% and rates of peri-implant mucositis have been observed in up to 65% of subjects with dental implants.^34-38 Futhermore, it has also been demonstrated that these peri-implant diseases are increased in patients who smoke and have a history of periodontal disease, which may increase the difficulty in treating these implants.³⁹

Given the high prevalence of peri-implant diseases, surveillance, early identification of disease, and intervention is critical. A key factor in long-term success of implants is proper maintenance of their surrounding soft and hard tissues. It has been shown that bacterial accumulation induces inflammatory changes in the tissues surrounding implants.⁴⁰ Furthermore, it has been estimated that a monitoring program including regular examination and supportive implant therapy to identify and intercept peri-implant mucositis is highly cost-effective and the economic advantage is increased in high risk patients.⁴¹ In order to determine proper treatment steps to intervene for an implant with signs of peri-implant disease, it is essential to identify disease as early as possible to provide intervention. Clinicians must distinguish between “ailing” and “failing”/”failed” implants to select an appropriate intervention.

The primary etiology for both peri-implant and periodontal diseases is virulent bacterial plaque.^40,42 While the inflammatory process that occurs around implants is similar to that around natural teeth, progression of disease is quicker in the peri-implant environment and the histologic peri-implant inflammatory lesions are larger and may prove more difficult to resolve at implant sites.⁴³ This may relate to the peri-implant attachment apparatus and lack of a periodontal ligament as well as the unique implant-soft tissue interface.⁴³ Multiple systematic reviews and randomized controlled trials have evaluated the efficacy of various treatment strategies for peri-implant diseases and identification of one ideal treatment strategy has proven elusive.^11,44,45, Ideal therapy of peri-implantitis would result in active disease resolution (no suppuration, bleeding on probing, no further bone loss) and the establishment and maintenance of healthy hard and soft peri-implant tissues in a patient and clinical environment where plaque removal was feasible over time.¹¹ Studies have shown that many therapies may be used to achieve these goals including non-surgical and surgical interventions, alone or combined, including mechanical debridement, pharmaceutical therapy, laser therapy, and open flap debridement with either resective or regenerative procedures.¹¹ This discussion will focus on laser interventions as an adjunct to improve overall implant health. . Table 1 describes the clinical and histologic characteristics of peri-implant health, peri-implant mucositis, and peri-implantitis.

Table 1: Case definitions for peri-implant health, peri-implant mucositis, and peri-implantitis⁴⁶