Missing the link

It was suggested to me that I write an article on peri-mucositis and peri-implantitis. This is a challenge for me because I do not know very much about it. Strange, you may think, an article coming from somebody who performs dental implant treatments and yet is so dumb about the subject.

One of my difficulties is that I have never clinically encountered peri-implantitis in my own practice and yet the disease apparently exists. I have only occasionally come across mild inflammation in the mucosa surrounding some implant abutments (due to plaque build up and on one occasion a loose abutment screw), but this has generally been easily resolved with improved oral hygiene practices or screw tightening. And in no case has it progressed to cause bone loss around the implant.

Dental implants are simply artificial tooth roots with artificial teeth on top. Although rare, like teeth and gums, they can fail. For the purpose of this article, I will be dealing with the potential ongoing loss of bone (the dental implant equivalent to periodontitis) around the implant as opposed to prosthetic failure.

Dental implant failures can be early or late. In my experience early failures, certainly in uncomplicated cases, are rare and, in my opinion, preferable to later failures and likely to be due to either surgical complications or something to do with the patient’s ability to heal.

Later failures, due to ongoing bone loss, I think are a bit more complex. Maybe in days gone by it was something to do with the implant surface designs and configurations combined with a patient’s susceptibility to bone loss around the implant (somewhat as in inflammatory periodontal diseases). Nowadays, if you are using one of a number of well established, quality dental implant systems, the question must arise as to what causes late failure, if it does actually occur.

Going back a few years, ongoing bone loss around a dental implant was considered normal, being defined as so many fractions of a millimetre per year after the first year. I think we have moved on from this concept and in my experience bone levels do remain stable, even up to the neck of the implant with some systems. So does peri-implantitis exist? And if it does exist, what is the cause?

One of the difficulties is that periodontal concepts are perhaps, somewhat erroneously, being applied to dental implants, possibly because it is the best starting point we have. Peri-mucositis equals gingivitis and peri-implantitis equals periodontitis.

The two disease processes are the same and the organisms causing the two diseases are the same (simply because periodontal pathogenic organisms have been isolated around failing implants). But is this true? Implants do not have a periodontal ligament, having direct bone to implant contact instead.

In cases where ongoing bone loss has occurred, the best treatments we have to offer are periodontal in nature involving elimination of the organisms causing the disease by cleaning and disinfection of the implant surface.

There is a lot we do not know. My experiences may be different to other implant operators. My knowledge tells me that maybe peri-implantitis does not exist, certainly in the same way as periodontitis. And if it does exist, is it the same disease process? Am I missing something?

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