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JADA Specialty Scan - Radiology
Radiology - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Prevalence of peri-implantitis in medically compromised patients and smokers

Existing study data suggest that smoking and diabetes are systemically associated factors for peri-implantitis, according to a study published in the January/February 2016 issue of International Journal of Oral and Maxillofacial Implants.

The authors designed the systematic review to measure different systemic conditions and smoking as risk factors for peri-implantitis. The question they posed was “In patients with osseointegrated dental implants, does the presence of smoking habits or a compromised medical status influence the occurrence of peri-implantitis compared with the presence of good general health?”

The review included prospective and retrospective cohort studies, case-control studies, cross-sectional surveys, case series that include cases and controls, and split-mouth design studies. The authors screened the studies for smoking and systemic conditions such as type 2 diabetes mellitus, cardiovascular diseases, rheumatoid arthritis, Epstein-Barr virus, lung diseases, obesity, cancer, deep depression, and osteoporosis. Selection criteria included at least 10 patients per condition, 1 year of follow-up after implant loading, and strict cutoff levels to define peri-implantitis such as probing pocket depth, bleeding on probing or pus, and marginal bone loss.

The authors reported their findings on study design, systemic conditions, smoking habits, number of patients and implants, disease dentition, and outcomes for peri-implantitis.

The authors first retrieved 1,136 records, then selected 57 after they analyzed titles and abstracts. Six from that group were chosen for qualitative analysis because they presented soft probing pocket depth, bleeding on probing, suppuration, and hard marginal implant bone loss, as well-defined parameters for peri-implantitis. No randomized controlled clinical trial was found.

All 6 studies were published from 2006 through 2014. Follow-up periods after implant loading ranged from 1 through 14 years. Investigated patient populations were in Belgium, Italy, Norway, Spain, and mostly in Sweden. Except for patients recruited from local private centers, all patients received implant and prosthodontic treatments performed at university clinics or hospitals.

The authors identified smoking as the most prevalent condition in their systematic review. One study found that poorly controlled type 2 diabetes accentuated probing pocket depth and radiographic marginal bone level prevalence rates in peri-implant patients. One of 2 studies considered cardiovascular disease to be a risk. One study found that 23 patients with peri-implantitis were 3 times more likely to have the Epstein-Barr virus. The authors found no associations for rheumatoid arthritis.

The authors noted that implant development changes could be a confounding factor. Two different forms of cutoff values represented another source of bias. Patients’ records also did not show whether the implants were inserted more to the labial/buccal or the lingual/palatal aspects, a factor for peri-implantitis.

“The body of evidence is still immature, and the specific contribution of general health problems to peri-implantitis requires additional robust epidemiologic and clinical investigations,” concluded the authors.

Read the original article.


Consulting Editor: Clark M. Stanford, DDS, PhD
Distinguished Professor and Dean
University of Illinois at Chicago College of Dentistry
Treasurer, Academy of Osseointegration Board of Directors

How chronic smoking affects the osteo-immunoinflammatory mediators in the peri-implant fluid of clinically healthy dental implants

Smoking habits modulate the peri-implant cytokine profile, reducing levels of interleukin-4 and interleukin-8, the tumor necrosis factor-a, and osteoprotegerin (OPG). They also increase telopeptide of type 1 collagen (ITCP) and a produce a higher type 1 helper/type 2 helper (TH1/TH2) ratio in peri-implant crevicular fluid.

Those findings are from a study published in 2016 in Archives of Oral Biology.

Researchers designed their cross-sectional study to measure the influence of chronic cigarette smoking on the profile of osteo-immunoinflammatory markers in the peri-implant crevicular fluid from clinically healthy implants. For the study, they included 25 smokers and 23 nonsmokers with a unitary screwed implant-supported crown in the molar or premolar region. Patients were classified as smokers if they smoked more than 10 cigarettes a day regularly for at least 2 years. Nonsmokers were participants who had never smoked.

Implants were functioning for at least 1 year and the peri-implant tissue was clinically healthy; that is, with a probing depth of less than 4 millimeters, no bleeding on probing, and no signs of radiographic bone loss beyond remodeling.

All patients were enrolled in a periodontal maintenance regimen, and patients underwent supragingival scaling and root planing when necessary before clinical and peri-implant fluid assessment. A single examiner assessed plaque index, gingival index, bleeding on probing, and peri-implant probing depth at 4 sites of the dental implants. To assess differences between smokers and nonsmokers more effectively, researchers divided cytokines into groups according to their biological characteristics.

Researchers found that anti-inflammatory interleukin-4 levels were statistically lower (P < .05) in smokers compared with nonsmokers. They noted lower levels of interleukin-8 and tumor necrosis factor-a in the peri-implant fluid of the smoker group compared with the samples from nonsmokers. They also observed lower levels of OPG in smokers compared with nonsmokers, and higher ICTP levels in the peri-implant samples of smokers compared with nonsmokers. Researchers further noted a higher TH1/TH2 ratio in smokers compared with nonsmokers. No significant difference between smokers and nonsmokers was observed with regard to bone-related markers.

The study’s limitations include a lack of a dose-dependent relationship between both the amount of cigarette smoking and length of the smoking habit with chronic diseases and that only a few studies provided a definition for smoking status. By-products originating from tobacco oxidation modify the clinical characteristics and progression of periodontal and peri-implant diseases, promoting local effects that include vasoconstriction.

“Although the implants of the smoker in the present study seemed to be clinically healthy,” they noted, “some subclinical inflammation could be present even though it was not clinically detectable.” Furthermore, most of the biomarkers in the study had not been evaluated previously in the peri-implant fluid of smokers, making comparisons of the results difficult.


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Factors affecting the prevalence of peri-implant diseases

Smoking habits and the width of peri-implant keratinized mucosa as independent variables are associated with the prevalence of peri-implant diseases. Prostheses in function for at least 5 years showed an association with the presence of peri-implant mucositis and peri-implantitis.

Those key findings are part of a study published in the December 2015 issue of European Journal of Prosthodontics and Restorative Dentistry.

Researchers designed the study to identify associations of peri-implant disease with patient variables of age, sex, smoking habits, time of implant-supported prosthesis in function, implant location, and quantity of peri-implant keratinized mucosa.

The authors conducted a cross-sectional study of 193 patients who had received 725 external-hexed cylindrical implants supporting functional prosthesis for 1 through 9 years. All the implants were placed with the platform leveled at the alveolar crest. The clinical examination included probing depths, the width of peri-implanted kertanized mucosa, and bleeding on probing or suppuration. Peri-implant bone levels were measured by means of a radiographic examination.

Peri-implant mucositis was considered when the probing depth was less than 4 millimeters with bleeding on probing around an implant of less than 2 mm of bone loss. Data were compiled from observation at the mesial, distal, mid-buccal, and palatal/lingual sites.

Peri-implantitis was defined when probing depth was 4 mm or more, with bleeding on probing or suppuration, and bone loss of at least 2 mm. Bone loss data were compiled from observations at the medial and distal sites. The mid-buccal and lingual/palatal sites could not be evaluated in a radiograph.

The patients ranged in age from 14 to 85 years, with an average age of about 52 years. A total of 137 patients had the prostheses for up to 5 years, and 55 patients had them for more than 5 years. Of the 724 dental implants, 248 were placed in the anterior sites and 476 in posterior sites.

Researchers found that the prevalence of peri-implant mucositis in the posterior implants was 41% higher than in the anterior implants. The prevalence of peri-implant mucositis in prostheses in use for 5 years or more was 29% higher than those in use for less than 5 years. Patients with prostheses for more than 5 years were nearly twice as likely to develop peri-implantitis compared with those with implants for less than 5 years.

Among the 131 patients with healthy dental implants, 46 had at least 1 implant with peri-implant mucositis and 8 had at least 1 implant with peri-implantitis.

When combined, the factors of sex and the time the prosthesis was in function were associated with peri-implantitis. Other factors that could play a more direct association with peri-implant diseases include correct position of the dental implant, correct seating of the prosthetic abutment, type of prostheses that allow ideal oral hygiene, the use of angled abutments, and the presence of residual excess cement in cement-retained prostheses.

Read the original article.


How to manage the growing prevalence of peri-implantitis

Long-term concerns about dental implant–supported restorations suggest the need for better training, a standard definition of peri-implantitis, and a clearer distinction between implant survival and success rates.

These observations are part of a perspective article published in the January 2016 issue of Journal of Dental Research.

The author cited research that found that implants restored by general practitioners had a much higher rate of peri-implantitis. “This means that we are not spending enough time teaching generalists how to construct restorations that are cleansable and easy to manage,” the author noted. “This may be important for our schools to pay more attention to the teaching of implant restorations.”

The author noted that the lack of a clear definition of peri-implantitis allows 2 researchers looking at the same group of patients to identify drastic differences in the prevalence of the disease. One study found that altering the amount of bone loss from 0.4 millimeters to 3 mm changed the prevalence of peri-implantitis from 47% to 11%.

Research cited by the author also found a design difference among the 3 brands of implants used. Tissue-level implants, for example, featured a 1.8- or 2.8-mm polished collar. The other 2 implant brands were bone-level. One of the 2 systems used platform-switched implants, which have been shown to help reduce bone loss compared with nonplatform–switched ones.

The author also called for a clearer distinction between implant survival and success rates. “An implant with 70% bone loss may still be able to take on occlusal load well and may be listed as a ‘surviving implant,’ ” he noted. “However, this is certainly not a ‘successful’ implant.”

The author cited research noting that conservative estimates indicate that roughly 10% of all implants will exhibit some form of peri-implantits within a decade. The average amount of bone loss for those implants with peri-implantitis was about 30% of their total length.

“We in dentistry must get out of the habit of implying that all implants will last the lifetime of the patient,” the author cautioned. “Although that may be true for most of them, many may have to be ‘revisited’ over the years.”

Read the original article.

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JADA+ Specialty Scans and JADA+ Scans

JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.

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