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After reading this article, the reader should be able to: comprehend the importance of periodontal maintenance for the long-term success of periodontal and dental implant care. use an evidence-based approach to assign the type of maintenance and an appropriate posttreatment maintenance interval to a clinical case. identify during maintenance the signs of recurrent periodontal or peri-implant diseases, the appropriate therapy to deliver, and when/how to reevaluate results.
The goal of periodontal therapy is the maintenance of the dentition and/or its implant replacements in a state of health, comfort, function, and esthetics for the duration of a patients life. With the increasing number of patients receiving dental implants and the aging of existing dental implants in service, the prevalence of peri-implant inflammatory problems presenting to clinical practices is rising. 1 As well-stated by Newman et al: The periodontal care of the public is primarily the concern of the general dentist, who cannot disregard his or her responsibility to examine, treat, or refer all periodontal problems. The high incidence of periodontal problems and the close relationship between periodontal and restorative dental therapies make this an incontrovertible point. 2 The maintenance phase of treatment most often is conducted in the general practice and, therefore, it is critical for general dentists to understand the importance of monitoring and maintaining not only periodontal health but also peri-implant health. 3,4 A clear understanding of the signs of disease recurrence is crucial so that early and definitive action can be taken to prevent further clinical attachment and bone loss around teeth and/or implants, which might otherwise go unnoticed until advanced stages. This article provides a review of periodontal maintenance goals, procedures, and efficacy involving natural teeth and dental implants, as well as makes recommendations on when and how to address signs of recurrent disease activity during periodontal maintenance (PM).
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Figure 2a
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Figure 2b
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Figure 4b
It is also important that the etiology and chronology of bone loss around implants be identified. Peri-implant bone loss resulting from surgical trauma or technique, such as pressure necrosis from inadequate osteotomy preparation or coronal bony voids from excessive countersinking, must be differentiated from peri-implant bone loss resultant from bacterial plaque-mediated immunoinflammatory bone loss. Implants placed using a subcrestal platform position tend to have deeper baseline probing depths than those placed supracrestally; therefore, it is important to know the baseline probing depth after initial healing to allow monitoring for changes over time. The incidence and prevalence of peri-implantitis has been reported in the literature. Berglundh et al 1 found the incidence of peri-implantitis was up to 14.4% and appeared to be related to the number of years that the fixtures were in service. Additionally, Roos-Jansker et al 17 reported that of implant cases not enrolled in a regular posttreatment PM program, 16% demonstrated peri-implantitis by 7 to 9 years after implant placement.
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The incidence of peri-implantitis may be underestimated because few studies exist with follow-up longer than 10 years. Considering that chronic periodontitis often takes 30 years or more to develop, the current literature does not evaluate long-term peri-implantitis incidence sufficiently. While dental implants have been shown to be successful in patients with severe periodontitis, several researchers have demonstrated the bacterial profile around implants is similar to the patients natural teeth. 18,19 Dental implants may harbor a complex microbiota with a large proportion of known periodontal pathogens, such as Porphymonas gingivalis, Prevotella intermedia, and Fusobacterium nucleatum, which have been associated with the onset of peri-implant mucositis and peri-implantitis.20 -22 Additionally, studies examining long-term follow-up dental implants in patients with a history of periodontitis have suggested a higher incidence of soft-tissue inflammation (mucositis) and peri-implantitis, as well as a slightly higher failure rate. 23 These findings support the recommendation that patients with dental implants require regular and careful evaluation at selected PM intervals to detect any clinical signs and symptoms of peri-implant disease.
Preventive PM: Intended to prevent inception of disease in those who currently do not have periodontal pathology (eg, patients at high risk for development of periodontal or peri-implant problems because of systemic disease or dexterity problems that prevent practicing hygiene). Trial PM: Intended to maintain borderline periodontal conditions to assess over time any progression of disease and the need for further treatment (eg, borderline pocket depths or furcation defects, inadequate gingiva around teeth or implants, or gingival architectural defects). Compromise PM: Intended to slow disease progression in patients who would benefit from corrective treatment but are not surgical candidates because of health, economics, inadequate oral hygiene, or other considerations. This type also includes situations in which periodontal or peri-implant defects persist after corrective therapy attempts (eg, patients with moderate chronic periodontitis or peri-implantitis who cannot undergo treatment because of current gastric cancer treatment). Posttreatment PM: Designed to prevent recurrence of disease after successful corrective therapy. This type of PM is the most commonly prescribed (eg, patients with localized aggressive periodontitis or periimplantitis who have been treated successfully with regenerative surgical therapy).
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Maintenance Visits
PM visits should include an update of the medical and dental history; thorough extraoral and intraoral examinations that include oral cancer screening; periodontal and implant reevaluation; radiographic review; check of occlusion; removal of supra- and subgingival bacterial plaque and calculus; selective root planing; implant debridement if indicated; polishing if necessary; and a review of the patients oral hygiene efficacy. 5,24 A typical appointment should take no more than 60 minutes, with at least 25% of this time devoted to mechanical debridement. 24 If signs of persistent disease activity are evident at the PM visit, such as persistent gingival or peri-implant inflammation, bleeding on probing, implant mobility, and/or increasing probing depths, steps should be taken to address these findings to maintain health. If active treatment is performed during maintenance, a subsequent reevaluation should be scheduled at a 4- to 6-week interval to ensure any intervention was successful in controlling periodontal or peri-implant diseases and whether further treatment is necessary. 30 This interval is recommended based on classic studies by Proye et al as well as Morrison et al, which have demonstrated posttreatment periodontal healing (around natural teeth) requires at least 4 weeks for reductions in pocket depth and gains in clinical attachment levels to fully occur.30,31 There appears to be a paucity of specific studies on similar posttreatment response around ailing dental implants. However, most current studies suggest peri-implant wound-healing processes are similar to natural teeth, and therefore a similar interval of 4 to 6 weeks is empirically suggested for reevaluation after treatment of inflammation around dental implants. 16,29
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Following implant restoration, patients should be reevaluated regularly (ie, every 3 to 4 months) during the first year. After the first year, the peri-implant-tissue response should be evaluated and then the required customized frequency of PM should be determined, as discussed earlier in this article. Initial bone loss during the first year can be expected to be near the level of the first thread or may be less in systems that include platform switching.43 Additional bone loss of approximately 0.1 mm per year for the first 5 years (up to a total of 1.5 mm) is considered normal. 44 Complete seating of the associated parts (abutment and/or restoration), occlusal overloading, absence of restorative overhangs, and the removal of all restorative cements also should be verified from the radiograph because these problems can predispose to long-term complications. 45 Conventional periodontal therapy should be instituted if inflammation develops around an implant. Therapy should include efforts to improve patient oral hygiene, using similar methods as around natural teeth (Figure 4A and Figure 4B). Lang et al suggested a novel, systematic stepwise approach for the prevention and treatment of peri-implant diseases referred to as the cumulative interceptive supportive therapy (CIST) protocol46 (Table 4). This system is based on periodic monitoring with implementation of treatment as thresholds for a particular condition are met. The first step is protocol A, then B and, if conditions continue to worsen, the case may
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require more advanced treatment, which may include comanagement with a specialist who has implant training to execute protocol C, and finally D.20 Protocol A is used to control inflammation in peri-implant mucositis, that is, implants with minimal increase in pocket depth, slight (+) bleeding on probing, marginal erythema, plaque, and/or calculus. The therapeutic endpoint is to resolve inflammation with cautious mechanical debridement (using plastic curettes and rubber cup prophylaxis), twice-daily swabbing with 0.12% chlorhexidine, and a review of home care and patient motivation. Protocol B is initiated for conditions that exhibit similar mucositis features but with deeper pocket depths (4 mm to 5 mm); however, there is still no loss of supporting bone. The treatment should include the therapies of protocol (A), plus locally delivered antibiotic (minocycline microspheres, doxycycline gel) at the infected implant site(s). Recent studies have shown the use of minocycline microspheres may be beneficial in treatment of peri-implant mucositis and peri-implantitis.46 Management of early peri-implantitis, protocol C, requires a more robust approach and is used in conditions with evidence of osseointegrated bone loss of < 2 mm and pocket depths > 5 mm. The strategy should comprise the modalities for protocols A and B with the addition of systemic antibiotic therapy (metronidazole 250 mg t.i.d. for 7 days or amoxicillin 500 mg t.i.d. for 10 days).
Furthermore, periodontal surgical access for surface decontamination (citric acid 1 to 2 minutes or tetracycline 250 mg, 5 mL for 5 minutes) should be considered. Protocol D is initiated in circumstances of frank periimplantitis that reveal probing depths (> 5 mm), (+) bleeding on probing, plaque/calculus, and peri-implant bone loss of > 2 mm. This strategy requires periodontal surgical intervention for chemical disinfection, osseous resection, and/or guided bone regeneration (GBR). GBR will attempt to salvage the implant through bone regeneration techniques with the use of resorbable or nonresorbable semipermeable membranes and a bone replacement graft (such as freeze-dried bone allograft or anorganic bovine bone). In clinical practice, CIST is aimed at early detection and methodical stepwise treatment, which may rescue and reverse the fate of the ailing or failing endosseous dental implant. 47
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control). Many of these diseases and conditions are chronic and develop as a result of constant circulation of low-grade inflammatory cytokines and acute-phase proteins, such as interleukin-1 beta, tumor necrosis factoralpha, and C-reactive protein, which have been shown to be increased by periodontal inflammation. 51 While at first glance, it may appear that short-term periodontal treatment may affect these disease relationships, in general, it is doubtful that a single session of scaling and root planing will reverse, for example, 30 years of atherosclerosis. Therefore, the role of the dental practitioner in periodontal medicine best fits into a PM model. Lifelong PM is important not only in achieving periodontal health but also in minimizing the circulation of inflammatory cytokines for many years to mitigate the periodontally derived inflammatory risk factors for systemic diseases.
Conclusion
Periodontal treatment success, including both nonsurgical and surgical therapy, is dependent on appropriate maintenance. PM therapy also applies to dental implants, as they have been shown to be susceptible to periimplant disease. In addition, long-term control of periodontal inflammation may reduce the risk of several systemic diseases and conditions. It is the general practitioners responsibility to evaluate each patients dental history and prescribe appropriate periodontal and peri-implant maintenance care, as well as to identify when conventional treatment is failing and to execute a prompt and appropriate solution, which includes use of adjunctive agents, surgery, or referral to a periodontist. The keys to success include consistent reminders sent to the patients on the importance of long-term maintenance in preventing periodontal or peri-implant disease progression, as well as early identification and treatment of inflammatory and biomechanical problems to minimize their impact. This will maximize the likelihood of maintenance of natural teeth and dental implants in health, comfort, function, and esthetics for the duration of the patients life.
Disclosure
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.
References
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