What Is Peri-Implantitis?

Whenever conventional 2 stage implants are inserted into the bone of the upper or lower jaw, the clock starts ticking for the development of peri-implantitis. The longer the implants are in the mouth the higher the chances are for this type of bone loss, which will ultimately affect the entire implant and lead to its removal. At this point at the latest the treatment with conventional implants has failed.

Peri-implantitis occurs after the successful osseo-integration of the implant. This is especially unfortunate, since the disease starts to attack just as everything looks fine and the patient starts using the implant.

Peri-implantitis starts at the oral cortical and leads to its increasing erosion. Implantitis is distinguished from the endosseous rest-ostitis, which typically stems from a reactivation of older, dormant root infections. (Fig. 1)


Fig. 1: This X-ray shows four separately diagnosable bone resorbing diseases:

  • Visible bone loss at the cuspid distal-cresta due to (infectious) perio-dontitis.
  • Over pressed edodontic filling material at the tip of the root has led to an apical ostitis and the bone surrounding the apex has dissolved.
  • At the crestal aspect of the mesial implant we can see the crater like bone loss which is typical for a peri-implantits.
  • An ostisis is visible around the lower endosseous part of the distal implant, probably stemming from the rest of the radiopaque filling material.

Mild Cases

In mild cases bone loss around the implant is 1-3mm with some weak signs of inflammation of the mucosa, which may cause mild pain. These cases are treated symptomatically with local disinfectant and pain medication. It is known today that antibiotic therapy is not successful in stopping the progression of peri-implantitis (regardless of the severity).

Medium Cases

In cases of medium severity around 50% of the vertical bone along the implant is lost. The main problems are the recurrent emergence of pus and bleeding, the unsightly aesthetic appearance and foul smell.

Severe Cases

In serious cases of peri-implantitis nearly all bone matter gets resorbed, and deep soft tissue pockets result. Constant infection, discharge and heavy bleeding are the results. When pockets are surgically removed, the teeth’s appearance strongly deteriorates and enormous amounts of food get stuck between the implants and bridges (Fig. 1, Fig. 2).


Fig. 2: Example: The bone surrounding all three implants in the upper right jaw is lost up to the apex of the implant (here: conventional full screw implants). Although the patient suffers persistent severe intra-oral infection, she does not agree to an implant removal since she is aware she will lose all her chewing ability. The implants placed in the back of both sides of the lower jaw are lost due to peri-implantitis. One highly atrophic mandible remains. Another treatment approach with conventional 2 stage implants is not possible.


Fig 3: Nearly the entire bone along these conventional 2 stage implants is lost due to infective peri-implantitis. Most patients will not accept the peri-implantitis becoming so severe. They will request a removal of the implants at a much earlier stage.

What Are The Causes of Peri-Implantitis and the Reasons for Its High Prevalence?

The oral cavity holds millions of bacteria which are typically washed away by drink, food and saliva. These bacteria settle on all hard surfaces inside the mouth and will multiply in favorable conditions. We know this from our own teeth.

The problem with almost all conventional 2 stage implants is that they are manufactured with a rough endosseous surface. This is done to achieve a strong grip between the implant and the bone, a strong osseo-integration.

We know today that bone will retract 1-3 mm along all such implants within the first months of usage. Rough implant surfaces will become exposed and quite likely colonized by bacteria.

The typical dental implant patient has lost their teeth due mainly to a persistent lack of sufficient oral hygiene (i.e. negligence). In other words: the «non-cleaners» within the population receive their implants earlier than others. However, conventional dental implants with rough surfaces and large diameters require an substantial amount of oral hygiene to stay infection free.

In conclusion, these 2 stage implants with rough «endosseous» surface are quite unsuitable from the start for a large group of patients within the population. Additionally most conventional 2-stage implants provide enormous amounts of endosseous implant surface, much more than necessary for load transmission purposes. Since a lot of bonte-to-implant-contact requires functional stimuli, vertical bone loss along the implant is expected anyway.

Another general problem with conventional 2 stage implants is their utilization of the crestal cortical and underlying spongeous bone. These bone areas are already prone to resorption. This again leads to exposed implant surfaces that quickly hold a reservoir of bacterial and cause chronic infection and progressive bone loss. In this light most 2-stage implants are in principle a faulty design and should be forbidden or their indications severely reduced.

Treatment of Peri-Implantitis

Even by now there is no effective (final) treatment for this disease. All attempts at cleaning the infected areas remain ineffective due to oral bacteria multiplying hourly and perpetually creating millions of new bacteria at every moment. Attempts at «polishing» the rough surfaces in the mouth do not work either, as such polishing is not possible close to the bone since remnants of the polisher remain on the implant and in the deep pocket, fostering new inflammation.

In some cases peri-implantitis stops on its own when the bone loss reaches resorption-resistant «basal» bone areas.

It is generally admitted today that reliable and successful treatments for peri-implantitis are missing. Science still hopes to find such treatments:
Review of the treatment protocols for peri-implantitis.

The only way to avoid this disease with 100% certainty is to remove the 2 stage implant.

Level of Awareness of Treatment Providers regarding Peri-Implantitis

The Swiss Monthly Journal for Dentistry (SMfZ; «SSO-Zeitung») published a survey among active swiss dentists regarding their knowledge on the topic of peri-implantits.

It is not surprising that almost all answers by the polled swiss dentists were wrong by today's standard. Here is an overview:


Suggested Reasons for Peri-Implantitis (%)
- periodontitis 79.7 0.194 72.0
- smoking 76.9 0.365 71.4
- bad compliance 53.2 0.247 60.9
- parafunction 20.3 0.618 23.1
- smooth implant surface 24.4 0.126 16.2
- rough implant surface 31.6 0.914 32.3
- short implants 17.7 0.012 7.1
- reduced diameter 16.5 0.008 6.0
- after Sinuslift 10.1 0.999 10.1
- after Augmentation 21.5 0.799 20.1
- after immediate loading 31.6 0.671 29.0
Knowledge of CIST (%) 61.5 0.001 39.8

Only 31.6% of the survey's participants were able to identify «rough implant surfaces» as the reason of peri-imlantitis. The other two main reasons,- multipart implants and a large mucosal penetration diameter - were not mentioned at all by active swiss dentists.
Résumé: The awareness of swiss dentists regarding this important topic was extremely poor at the time of questioning. The survey reveals that no factual data is taught in either university education nor post-graduate training. We assume that this is owed to the strong influence of major implant manufacturers on the teaching of universities.

We are convinced that polls in most western countries would achieve equally shocking results. Not not only is knowledge apparently lacking, but also common sense (which would lead to correct results on such a simple question).

Conclusion

The very questionable design of most 2-stage implants (2-piece-design, large diameters, rough endosseous surfaces) is the main cause of this wide spread problem that severely affects the patient's quality of life. The design of the conventional 2-stage implants is unsuitable for use in a constantly infected oral environment. This feature of the implants is predominantly reponsible for the fact that no effective treatment exists for peri-implantitis.

Our reccomendation is to avoid such implant designs. These days, after the development of «basal implants» (Strategic Implants), safe alternative treatment devices and techniques are available. They prevent this severe clinical problem without any similarly serious side effects.