Jan Lindhe. Clinical Periodontology

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MAINTENANCE OF THE IMPLANT PATIENT •

1027

Fig.

45-4.

Clinically stable implant with VMK crown

(

region 21) characterized by absence of bleeding on

probing, suppuration, and a peri-implant probing

depth not exceeding 3 mm.

Fig.

45-5.

Peri-implant mucositis characterized by pres

ence of bleeding on probing, absence of suppuration

and a peri-implant probing depth of

mm.

Fig.

45-6.

Calculus deposits may be chipped off using

carbon fiber curettes with the aim of not scratching the

implant surface.

Fig.

45-7.

Mechanical and antiseptic cleansing. Applica

tion of chlorhexidine gel (Plakout®, 0.2%) to a site with

peri-implant mucositis.

dures with increasing anti-infective potential depend-

ing on the severity and extent of the lesion. Diagnosis,

therefore, represents a key feature of this supportive

therapy program.

The major clinical parameters to be used have been

discussed above and include:

Presence of a biofilm

Presence or absence of BoP

Presence or absence of suppuration

Increased peri-implant probing depth

Evidence and extent of radiographic alveolar bone

loss.

Oral implants without plaque and calculus and sur-

rounded by healthy peri-implant tissues, as evidenced

by (1) absence of BoP, (2) absence of suppuration, and

(3) probing depth usually not exceeding 3 mm, should

be considered clinically stable. Such sites should not

be exposed to therapeutic measures (Fig. 45-4).

Mechanical debridement; CIST protocol A

Implants with plaque and calculus deposits and sur-

rounded by a mucosa that is BoP positive but suppu-

ration negative and with a PPD 4 mm are to be

subjected to mechanical debridement (Fig. 45-5).

While calculus may be chipped off using carbon fiber

(

Fig. 45-6) or plastic curettes, plaque is removed by

polishing the implant surface with rubber cups and a

polishing paste. Carbon fiber curettes do not sever the

implant surface. They may be sharpened and are

strong enough to remove most accumulations of cal-

culus. Conventional steel curettes or ultrasonic instru-

ments with metal tips should not be used because they

may cause severe damage to the implant surface

(

Matarasso et al. 1996).

Antiseptic therapy; CIST protocol A+B

At implant sites, which are BoP positive, exhibit an

increased probing depth (4-5 mm) and may or may

not

demonstrate suppuration, antiseptic therapy is

delivered in addition to mechanical debridement.

Thus,

a 0.2% solution of chlorhexidine digluconate is

prescribed for daily rinsing, or a 0.2% gel of the same

antiseptic is recommended for application in the af-

fected site (Fig. 45-7).

Generally, 3-4 weeks of antiseptic therapy are nec-

essary to achieve positive treatment results.

1028 •

CHAPTER 45

Fig. 45-8. Treatment of peri-implantitis according to the protocol of CIST (cumulative interceptive supportive

therapy): (a) Clinical diagnosis of peri-implantitis: presence of bleeding on probing, suppuration, development of a

fis

tula, loss of alveolar bone. Peri-implant probing depth 7 mm. (b) Clinical resolution of the peri-implant

infection

one year following the mechanical and antiseptic cleansing and followed by the systemic application of

antibiotics

(500 mg Tiberal® b.i.d for 10 days). Some recession is visible. (c) Documentation of the healed peri-

implant infec

tion by contrast-enhanced subtraction radiography. The intrabony crater has been completely filled

1 year after

therapy. (d) Absence of mucositis, reduced peri-implant probing depth to 3 mm and bone-fill of the

lesion.

Antibiotic

therapy; CIST protocol A+B+C

At BoP positive implant sites with deep pockets (PPD

6 mm) (suppuration may or may not be present),

there are frequently also signs of radiographic bone

loss. Such pockets represent an ecological habitat,

which is conducive for the colonization of Gram-nega-

tive and anaerobic putative periodontal pathogens

(

Mombelli et al. 1987). The anti-infective treatment

must

include the use of antibiotics to eliminate or

reduce the

pathogens in this habitat. This, in turn, will

allow soft

tissue healing as demonstrated in a clinical

study by

Mombelli & Lang (1992). Prior to adminis

tering

antibiotics the mechanical (CIST A) and the

antiseptic (

CIST B) protocols have to be applied.

During the last 10 days of the antiseptic treatment

regimen, an antibiotic directed against the anaerobic

bacteria (e.g. metronidazole or ornidazole) is used.

Thus

for instance, 350 mg t.i.d. of Flagyl® (Rhone-

Poulenc)

or 500 mg b.i.d. of Tiberal® (Roche) is admin

istered

via the systemic route. A site treated according

to the

above protocol is depicted in Figs. 45-8a-d. A

fistula

can be seen in the buccal aspect of implant site

45 (

Fig. 45-8a). The site exhibited BoP+ and had a

probing

depth of 7 mm. After therapy the inflamma

tion is

resolved (Fig. 45-8b) and some recession of the

mucosal margin has occurred. In Fig. 45-8c the bone

fill that took place in the angular defect is illustrated

a subtraction radiography image using contrast

enhancing. Fig. 45-8d presents the site 8 years after

active therapy.

An alternative to the systemic administration is the

controlled, local delivery of antibiotics. It must be

realized, however, that only devices with proper re-

lease kinetics must be used to assure successful clini-

cal results. The antibiotic must thus remain at the site

of action for at least 7-10 days and in a concentration

high enough to penetrate the submucosal biofilm

(

Mombelli et al. 2001). An example of such a control-

led-release device is the tetracycline-containing peri-

odontal fiber (Actisite®; Alza). The therapeutic effect

this controlled-release device appears to be identi

cal to

the effect obtained by the systemic use of antibi

otics (

Mombelli et al. 2001).

Regenerative or resective therapy; CIST protocol

A+B+C+D

It is imperative to understand that regenerative or

resective therapy is not instituted until the peri-im-

plant infection is under control. Thus, before surgical

intervention is planned, the previously diseased site

MAINTENANCE OF THE IMPLANT PATIENT • 1029

Fig. 45-9. Decision tree for Cumulative Interceptive Supportive Therapy (CIST). Depending on the mucosal condi-

tion and probing depth, either regime A or regime A+B, regime A+B+C or regime A+B+C+D are performed. A: Me-

chanical debridement; B: Antiseptic cleansing; C: Antibiotic therapy; D: Resective or regenerative surgery.

should have become BoP negative, exhibit no suppu

ration

and disclose a reduced probing depth. Depend

ing on the

extent and severity of the local bone loss, a

decision is

made whether regenerative or resective

measures are to be

applied.

In this context it must be realized that the goal of

regenerative therapy, including the use of barrier

membranes is new bone formation in the crater-like

defect

around the implant, although

de novo

osseointegration

may occur to a limited extend (Persson et al.

1999, Wetzel

et al. 1999).

Conclusions

An implant patient must always be enrolled in a sup-

portive therapy program that involves recall visits at

regular intervals. Each recall visit must start with an

examination to assess whether the implant sites are

healthy or exhibit signs of inflammation.

Cumulative Interceptive Supportive Therapy

(CIST)

includes a series of four protocols to be used

when the

examination and the diagnostic process are

completed.

Fig. 45-9 outlines (1) the decision process to be used for

the peri-implant tissue diagnosis and (2) the differ

ent

therapeutic measures that are available to treat

and/or

prevent peri-implant infections.

REFERENCES

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(1986). The long term efficacy of currently used dental im

plants; a review and proposed criteria of success.

International

Journal of Oral

and

Maxillofacial Implants

11-25.

Ericsson, I. & Lindhe, J. (1993). Probing depth at implants and

teeth. An experimental study in the

dog.

Journal of Clinical

Periodontology

20, 623-627.

Etter, T.H., Hakanson, I., Lang, N.P., Trejo, P.M. & Caffesse, R.J.

(2002). Healing after standardized clinical probing of the

periimplant soft tissue seal — a histomorphometric study in

dogs.

Clinical Oral Implants Research

13, 573-582.

Lang, N.P., Adler, R., Joss, R.A. & Nyman, S. (1990). Absence of

bleeding on probing. An indicator of periodontal stability.

Journal of Clinical Periodontology 1,

714-721.

Lang, N.P., Joss, A., Orsanic, T., Gusberti, F.A. & Siegrist, B.E.

(1986). Bleeding on probing. A predictor for the progression

of periodontal disease?

Journal of Clinical Periodontology

13,

590-596.

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probing as it relates to probing pressure and gingival health.

Journal of Clinical Periodontology

18, 257-261.

Lang, N.E. Wetzel, A.C., Stich, H. & Caffesse, R.J. (1994). His

tologic probe penetration in healthy and inflamed periim

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Rockier, B., Lindwall, A-M & Yoneyama, T. (1986). Marginal

tissue reactions at osseointegrated titanium fixtures.

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and

Maxillofacial Surgery

15, 53-61.

Luterbacher, S., Mayfield, L., Bragger, U. & Lang, N.P.(2000).

Diagnostic characteristics of clinical and microbiological tests

for monitoring periodontal and periimplant mucosal tissue

conditions during supportive periodontal therapy (SPT).

Clinical Oral Implants Research

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Lang, N.P. (1996). Maintenance of implants: an in vitro study

of titanium implant surface modifications, subsequent to the

1030 • CHAPTER 45

application of different prophylaxis procedures.

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Clinical Oral Implants Research

3, 162-

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Oral Microbiology and Irn-

munolaq-rI 2,

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10, 195-203.

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Clinical Oral Implants

Research

10,111-119.

Index

abscesses, 240

periodontal, 240-66, 333

classification, 240-41

complications, 266

diagnosis, 262-4

microbiology, 262

pathogenesis and histopathology, 261-2

prevalence, 261

treatment, 264-5

abutment selection, 863

access therapy, 519-58

anesthesia, 538-40

comparison with non-surgical therapy, 552-8

contraindications for, 537-8

distal wedge

procedures, 531-4

dressings, 549-50

flap procedures, 522-31,

544 5

general

guidelines, 535-46

gingivectomy, 520-

22, 543-4, 550-51

healing after, 550-52

indications for, 535-7

instruments, 540-43

objectives, 535

osseous surgery, 534

outcome, 550-58

postoperative pain, 539, 550

postsurgical care, 550

regenerative procedures, 531

root surface conditioning/biomodification, 546-50

root surface instrumentation, 545-6

selection of technique, 543-5

suturing, 546-9

acidified sodium chlorites, 475

Actinobacillus

actinomycetemcornitans, 70, 71, 107, 113, 114

16, 120, 127, 129, 133, 134-5, 136, 137, 138, 172,

375, 389, 494, 497, 681

aggressive periodontitis, 169, 217, 225, 226-7, 228, 235,

238

antibiotics and, 499, 500, 501, 502-3

chronic periodontitis, 169

diabetes and, 182

effects of therapy on, 563, 568, 571

linear gingival erythema (LGE) and, 274

peri-implantitis and, 1020

periodontal abscesses, 262

virulence, 164

Actinomyces

spp., 84, 126-7, 262, 266, 568

A. naeslundii,

129, 133, 136

A. odontolyticus,

127, 565

viscosus,

111

acute necrotizing ulcerative gingivitis (ANUG), 108-9, 110,

111, 130, 189, 205-7, 243

additional (corrective) therapy, planning, 420-22

adrenal function, 538

adrenaline (epinephrine), 539

adult periodontitis, 54-7

advanced flap procedures, 597-601

aesthetics, see

esthetics

age

chronic periodontitis and, 211

implants and, 853-4

necrotizing periodontal disease and, 255

aggressive periodontitis, 54, 216-38 classification

and clinical syndromes, 217-18

diagnosis, 233-

epidemiology, 218-25

permanent dentition, 220-21

primary dentition, 219-20

screening, 221-5

etiology and pathogenesis, 225-32

generalized (GAP), 217, 227-8, 234, 235

genetic predisposition, 231-2, 237, 388

immune system and, 226, 228-30, 235-7

localized (LAP), 58, 60-61, 217-18, 234, 235, 502-3

pathogens, 225-32, 235, 238

radiography, 223-4

treatment, 237-8

antibiotic therapy, 238, 501-3

agranulocytosis, 538

AIDS,

see

HIV infection and AIDS

alcohol

amine alcohols, 475

necrotizing periodontal disease and, 255

allergic reactions, 286-7, 400

alveolar hone, 3, 27,

34 42

angular bone defects, 557-8, 731

infrabony pockets, 752-4

assessment of loss, 52

basic bone biology, 866-7

defect closure, 885

dehiscence, 36, 889

examination of patients, 409-10

fenestration, 36, 889

formation, 866-94

grafts, 654, 663-7, 876-7

guided tissue regeneration (GTR), 877-84

bone regeneration with GTR, 892-4

clinical applications, 885-92

healing,

867-77

osseous surgery, 534

radiography, 52, 409-10

regeneration adjacent to implants, 879

regenerative capacity of bone cells, 657

1032

• INDEX

alveolar bone

(contd)

ridge augmentation, 631—44, 767—8, 880—83, 885—9, 897

—

913

sequestrum formation in necrotizing periodontal dis

ease,

246