Dr. Sarmiento, how often do you see peri-implantitis in your daily practice?
Dr. Sarmiento: A lot of my referring doctors know that I specialize in this area. I would say that around 70 percent of my patients suffer from some sort of biologic complication resulting from an implant in need of repair.
That’s a rather high percentage…
Dr. Sarmiento: It is, but you have to remember that the number of those with peri-implantitis is quite high. About ten percent of all implants end up developing peri-implantitis after eight years. Peri-implantitis bone levels are influenced by not only pathological, but also non-pathological conditions. Our understanding of peri-implantitis has certainly evolved over the past decades. However, its classification is limited to descriptions of disease progression or to classification that involves soft and/ or hard tissues (peri-implant mucositis or peri-implantitis).
Is that why you have published a new classification system?
Dr. Sarmiento: We published the first classification system based on etiology.1 We wanted to identify various etiologies for peri-implantitis and to establish a classification system based on the pathogenesis.
What were your principal findings?
Dr. Sarmiento: Most of the bone loss was related to one of the following factors: 1) biofilm, including iatrogenic factors, 2) exogenous irritants, 3) the absence of keratinized tissue and 4) intrinsic pathology. This classification system allows for the clinician to properly diagnose peri-implantitis based on the etiology. (Fig. 1)
Does this mean adopting therapy based on etiology?
Dr. Sarmiento: Indeed. When a diagnosis is related to a bacterial component, the clinician can use nonsurgical or surgical therapies, or a combination of both, to prohibit the further progression of the disease. In addition to creating that targeted therapy, the clinician should have a better sense in predicting intervention and prognosis of the implant. I fully advocate that the determination of the underlying cause of peri-implantitis will strongly aid the clinician in the choice of a successful surgical procedure.
For example, if excess cement were to be found on the implant surface, removing the source should lead to the elimination of the causative factor; thus leading to a regenerative approach. If the implant were to break down from the lack of keratinized tissue, soft tissue enhancement in this case should be considered while decontaminating and repairing the implants. If you have an implant with bone loss that is related to an inflammatory response to biofilm, that implant may have a lower efficacy and a diminished long-term prognosis. On the other hand, if you have an implant that has bone loss related to residual cement, that might be easier to treat, hence leading to a predictable response to treatment and an effective prognosis.
Are targeted preventions based on etiology also possible?
Dr. Sarmiento: They absolutely are! The main cause usually involves bacteria, which is why patients need to be on strict hygiene regimens. As noted in our study,1 78.8% of the cases involving peri-implantitis were related to biofilm or bacteria-induced inflammation with bone loss.
Would a better understanding of microbiology help?
Dr. Sarmiento: As we continue to conduct more research on peri-implantitis, we must focus on the initiation of the disease progression and its impact on its severity. I believe that understanding the microbiology of peri-implant mucositis has to be the main focus of the prevention of peri-implantitis.
In addition to the classification you have also published a basic treatment protocol followed by different surgical alternatives.2
Dr. Sarmiento: We published the treatment option to have a basic protocol for how to treat peri-implantitis in a predictable manner, especially when it comes to the regenerative approach.2 The levels of debridement and decontamination are key. (Fig. 2) After proper mechanical debridement and surface detoxification using a combination of chemical solutions and lasers, a bone graft should be chosen based on characteristics that the literature have shown us to be superior. When it comes to peri-implantitis, we routinely elect a xenogenic bone substitute. All GBR fundamentals should be taken into consideration, including stabilization of a collagen membrane and tension free repositioning of the soft tissues.
However, none of the surgical approaches proved to be better in terms of probing depth and bleeding on probing…
Dr. Sarmiento: Having gathered all our results, we concluded from our investigation that the three different surgical approaches can all be effective in treating peri-implantitis. Nonetheless, an assessment involving risks and benefits that consider both functional and esthetic outcomes of each approach should be carried out.
Risk/ benefit assessment?
Dr. Sarmiento: This would entail a detailed clinical and radiographic examination of each patient as well as the use of nonsurgical treatment prior to surgery. After the assessment is done, the elimination of etiology is of extreme importance, followed by the restoration of the health of the implants’ surrounding soft and hard tissue. Lastly, to ensure the most effective longterm outcomes, patients undergoing surgical therapies for peri-implantitis should have three-month maintenance recalls.
Using your regenerative approach, how many implants are you able to maintain over a period of about five years?
Dr. Sarmiento: We have been able, and it is proven, to be quite successful in saving many implants. As studies have shown, the success rate is high. We too have had a high degree of success, in the over 500 peri-implantitis cases we treated using a regenerative approach with Geistlich Bio-Oss®.
What conclusions can we draw from the etiologic factors?
Dr. Sarmiento: According to the classification system, it was evident that many breakdowns occurred due to excess cement. We broadly recommend using a screw retained restoration, however, if that is not possible, the clinician must take all and every precaution when cementing crowns. The clinician also should make sure to follow up periodically with patients by having proper maintenance visits so that the absence of gingival inflammation is ensured. When considering soft tissue, the main priority here is to ensure, not only, that keratinized tissue is present, but attached gingiva is present as well. There are several surgical solutions including new soft tissue graft substitute materials such as 3D collagen matrices that have so far proven to be very successful; providing positive outcomes. Lastly, the clinician can always consider the gold standard in soft tissue augmentation with the utilization of the connective tissue graft and free gingival graft, when appropriate, harvesting the graft from the patient’s own palate.
You have used Geistlich Fibro-Gide® as well…
Dr. Sarmiento: Right, I have actually been incorporating soft tissue enhancement into my treatments for the past four years. It has been pretty challenging to get the patients to agree to a second soft tissue graft harvest procedure, considering they have already had an invasive surgical procedure to save their implants. For a while, I was searching for a biomaterial to replace the harvest grafts. Using Geistlich Fibro-Gide® in the last 13 months has led to significant improvements, facilitating my approach. It has also been a great asset in getting patients to move forward with their treatment plans. In my practice, patients have been more willing to accept the peri-implantitis treatments, once Geistlich Fibro-Gide® was introduced.
Is there a real clinical need for a soft tissue substitute such as Geistlich Fibro-Gide® in the context of peri-implantitis treatment?
Dr. Sarmiento: Of course; I think that because we had been so focused on treating peri-implantitis with just enhancement of hard tissue, we did not realize the deficiencies brought up by soft tissue enhancement. It is absolutely crucial to be treating peri-implantitis as a whole unit involving both soft and hard tissue, which is exactly why we want to move forward with incorporating soft tissue management in treating peri-implantitis.
What are your opinions on the new peri-implantitis classification from the World Workshop?3
Dr. Sarmiento: I was delighted to see the American Academy of Periodontology working to build more awareness for peri-implantitis. The breakdown when a clinician doesn’t have radiographic history of an implant being treated is so important, and I am glad they highlighted that.
Evidence is still rare in this field. How do you communicate this to your patients?
Dr. Sarmiento: There is an abundance of published surgical techniques. If the etiological factors of the disease are understood, you will be able to know whether a treatment is predictable or not. A patient has to understand that even when grafting a case that is not so predictable, your goal is still to save the implant. The patient must be informed of every technique being used and the fact that it might not work for ten years. Understanding that placing implants will not necessarily be a long-term solution is an immensely important idea that has to be shared with the general population.