Peri implantitis is becoming a major issue for dental implants and it is important to be aware of this when embarking on implant treatment to replace missing teeth. The term relates to a number of factors around implants but the main issues are:

1. Inflammation of the surrounding mucosa ( gum )

2. Increased pocket depths around the dental implant

3. Bleeding on probing

4. Suppuration ( pus oozing from the tissues)

5. Loss of bone around the implant either in a horizontal , vertical or both directions. 

This differs from peri implant mucositis where there is bleeding on probing, possible swelling and inflammation and increase in pocket depths BUT there is NO loss of bone around the implants. Peri implant mucositis is reversible but peri implantitis is irreversible. Diagnosis is essential and the earlier the treatment, the better the diagnosis. Often, the disease may go un noticed, very much like gum disease, but once symptoms develop it is often too late to prevent bone loss. It is essential that regular dental and hygiene visits are maintained after dental implant treatments so that any problems can be spotted at an early stage. In general, we would advise twice yearly appointments or quarterly hygiene appointments if there has been past gum disease present.
 

Article written by Beata Knysak for dentists, dental hygienists and therapists.

Periodontal disease is a major public health concern due to its high prevalence. According to the data severe periodontitis is the sixth-most prevalent condition in the world [1]. In the United Kingdom, 62% of adults under 40 years of age are affected by moderate periodontal disease [2] and throughout the Covid-19 pandemic we have seen an immense increase in the number of patients with periodontal tissue breakdown and tooth loss.

While there is an increase in life expectancy and a significant decrease in tooth loss, periodontal disease puts a burden on the national healthcare systems across the globe.

Although bacteria arising from plaque is the main aetiological factor of periodontal disease, the host’s immune inflammatory response is accountable for the majority of the destructive changes seen in periodontal tissues. Even in healthy periodontium, host immune cells are continuously present, supporting the balance between microbial plaque and the host [6]. Any interactions between the host and oral microbiota will either support the homeostasis or results in dysbiosis within the community of pathogenic microorganisms [7].

Periodontal health-associated commensals are vital in protecting this equilibrium by for example inhibiting the growth of periopathogenic microorganisms. However, quantitative and qualitative changes within subgingival plaque biofilm may lead to disturbed homeostasis, which subsequently leads to the onset of the periodontal disease with various degrees of periodontal tissue breakdown.

This is not a continuous process but alternates between a period of inactivity and aggravation and it can be affected by local and systemic factors [3&4]:

• Microbial plaque-biofilm burden
• Patient’s age, ethnicity, genetic predisposition and patient’s immune response
• Systemic diseases i.e., Diabetes Mellitus, Osteoporosis
• Tooth morphological factor: i.e., defective restoration, malocclusion, bulbous crowns and dental bridge that unbales the patient to perform an adequate oral hygiene routine
• Patient’s socio-economic factors i.e., education and access to dental care
• Life-style choices i.e., smoking, obesity, poor diet, stress, sleeping pattern,
• Deficiencies in patient’s oral hygiene routine.

If not treated, periodontal disease leads to connective tissue destruction and alveolar bone resorption that eventually results in tooth loss [5]. It negatively affects patient’s chewing function and aesthetics, it is a source of social inequality, and significantly impairs their quality of life.

The main objectives of non-surgical periodontal therapy (NSPT) are to provide the least invasive treatment that gives the patient the best and most predictable outcomes through the promotion of periodontal tissue regeneration and restoration of tooth function. After successful treatment, periodontal ligament (PDL) cells (fibroblasts) migrate and attach to the microorganism free root surface. They proliferate, differentiate and synthesise extracellular matrix proteins to form collagen fibres. It is crucial to obtain newly formed PDL to prevent apical migration of junctional epithelium and to allow regeneration of PDL, cementum and alveolar bone; therefore, the application of laser irradiation has been proposed to allow for the compatibility of root surfaces with regenerative processes.

An increasing number of studies have demonstrated the benefits of adjunctive laser therapy in conventional NSPT due to its reported ability to significantly reduce pathogens, promote healing and to suppress the inflammatory cytokine cascade through to surgical ablation of diseased tissues [8]. As a result of its deeper penetration, diode laser has not only had bactericidal effects but also bio-stimulatory effects on periodontal ligament stem cells, osteoblasts and fibroblasts [9]. The Erbium Chromium: Yttrium Scandium Gallium Garnet (Er,Cr:YSGG) laser, however, allows selective subgingival biofilm and calculus ablation without causing any thermal side effects (carbonisation) or morphologic changes to the root surface to allow the attachment of these cells [10]. Also, when compared with conventional hand instrumentation, Er,Cr:YSGG laser therapy was not only found to promote PDL fibroblast cell migration and attachment, but it also increased the number of cells that differentiate in periodontal regeneration [11,12,13].

Although in the treatment of periodontal disease, surgical interventions (with the use of osseous graft material, barrier membranes or application of a biologically active material) deem to have more predictable outcomes than conventional NSPT, they may however, possess multiple shortfalls including high cost, painful healing and post-operative complications. Also, with regard to the application of local or systemic antibiotic there are multiple side-effects including antibiotic resistance, gastrointestinal complications or drug interactions.
 

Our case of the month for July 2021 is quite a complex one involving multiple ceramic crowns after an accident during the first lockdown. Our patient, Xavier, had a cycling accident where he cracked 3 of his front teeth. Now with any trauma case, there is a certain way to handle the situation and it is important not to rush into a specific treatment. The reason being is that once the teeth and gums have been damaged, the consequences may not be apparent for several weeks or months. Hence the use of provisional materials such as composite and temporary crowns are vital during this healing phase.

Periodontal or gum health is paramount also and we needed to spend some time stabilising the gum health with conventional and laser treatments. Beata Kynsak did a wonderful job using Waterlase i Plus and the Epic 10 diode laser with a complete transformation from inflamed , swollen gums to a pink, firm attached gum line. Laser dentistry, although not new, is still a rarity across our profession but we are firm believers in the technology and have many years of experience highlighting great results. 

Once the gums were stable, provisional crowns were made using a diagnostic wax up. This is where our laboratory, Ceramic Studios, re create the teeth using digital means to provide us with a prototype of the final teeth. We can use this guide to define our preparations of the teeth, make the temporary teeth and allow our patients to see what the final crowns can look like. Our temporary crown material of choice is Luxatemp; the gold standard. 

After some time in the temporary crowns, we were ready to proceed with the final crowns which were E Max all ceramic crowns, again the gold standard when it comes to aesthetics. There is no better. Ceramic Studios did a great job and just take a look at the before and after results:
 

Our case of the month for July is an unusual one in the sense that we are not highlighting a wonderful new smile , straighter teeth, whiter teeth or a fantastic new technology. This month, our focus is on peri-implantitis. Now you may wonder what on earth is peri-implantitis. Well, we can report that peri-implantitis is becoming a major issue in relation to dental implants and the prevalence will only increase as more and more dental implants are placed.