The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference 9 - 10 September 2016, Kaunas, Lithuania
Introduction
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PREFACE. The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference 9 - 10 September 2016, Kaunas, Lithuania
Baltic Ossoeintegration Academy (BOA) together with the Lithuanian University of Health Sciences (LSMU) and Universities from Europe and USA organized their first Consensus Conference (CC) devoted to the topic of peri-implantitis. BOA - LSMU consensus development group (CDG) was seeking to review the dental literature on a topical area in implantology and to produce high-quality, unbiased evidence-based guidelines and consensus statement (CS). CDG as the responsible body formulated the task of developing CS devoted to the topic of peri-implantitis to Gintaras Juodzbalys (Lithuania). CS Panel members were invited by the chairman. They are representatives of Universities, experts in a field and made every effort to produce nonbiased, independent, evidence-based clinical practice guidelines. Panel members had no conflicts of interest and signed a Panel Member Agreement (PMA). Working groups were established and following clinically relevant topics suitable for consensus discussion were identified:
Objectives: To systematically examine influence of soft tissue condition and plaque accumulation around dental implants on peri-implantitis development.
Material and Methods: An electronic literature search was conducted of two databases - MEDLINE (Ovid) and EMBASE from 2011 to 2016. Sequential screenings at the title, abstract, and full-text levels were performed. Clinical human studies in the English language that had reported soft tissue condition or plaque accumulation influence on peri-implantitis development were included. The resulting articles were independently subjected to clear inclusion and exclusion criteria by two reviewers as follows.
Results: The search resulted in 8 articles meeting the inclusion criteria. These studies reported gingival index, plaque index, pocket depth, bleeding on probing/modified bleeding index for sites with “adequate” (≥ 2 mm) and “inadequate” (< 2 mm) width of keratinized mucosa. Results demonstrated that the amount of keratinized mucosa has little influence on soft-tissue inflammation in the presence of good oral hygiene. However, suboptimal oral hygiene due to difficulty in access for plaque control in the areas of minimal keratinized mucosa may lead to greater tissue damage.
Conclusions: In cases with insufficient keratinized gingiva in the vicinity of implants, the insufficiency does not necessarily mediate adverse effects on the hygiene management and soft tissue health condition. Nonetheless, the risk of the increase of gingival index, plaque index, pocket depth, bleeding on probing/modified bleeding index is present. Therefore, the presence of an appropriate amount of keratinized gingiva is required.
Objectives: The purpose of this review was to evaluate whether history of periodontitis and smoking habits could represent a risk factor for peri-implantitis and implant loss.
Material and Methods: This systematic review followed PRISMA guidelines and was registered at the PROSPERO database [registration numbers CRD42016034160 (effect of history of periodontitis) and CRD42016033676 (effect of smoking)]. Broad electronic (MEDLINE) and manual searches were conducted among articles published from January 1st 1990 up to December 31st 2015, resulting in 49332 records for history of periodontitis and 3199 for smoking habits. Selection criteria included prospective studies comparing two cohorts of patients, with and without the investigated risk factor, with a minimum follow-up period of three years, and reporting data on peri-implantitis and implant loss occurrence. Considering that only prospective studies were included, dichotomous data were expressed as risk ratios and 95% confidence intervals.
Results: Three studies evaluating history of periodontitis (on which quantitative analysis was performed) and one study on smoking effect were included. Both implant and patient-based meta-analyses revealed a significantly higher risk of developing peri-implantitis in patients with a history of periodontitis compared with periodontally healthy subjects, but not a statistically significant increased risk for implant loss.
Conclusions: The outcomes of this systematic review indicate history of periodontitis as a possible risk factor for peri-implantitis, while insufficient data are present in literature to evaluate the role of smoking. However, available evidence is still weak and immature, and sound epidemiological studies are needed to analyse the specific contribution of these potential risk factors.
Objectives: To systematically review risks of mechanical impact on peri-implant strain and prosthetic influence on stability across finite element studies.
Material and Methods: An online literature search was performed on MEDLINE and EMBASE databases published between 2011 and 2016. Following keywords tiered screening and selection of the title, abstract and full-text were performed. Studies of finite element analysis (FEA) were considered for inclusion that were written in English and revealed stress concentrations or strain at peri-implant bone level.
Results: There were included 20 FEA studies in total. Data were organized according to the following topics: bone layers, type of bone, osseointegration level, bone level, design of implant, diameter and length of implant, implant-abutment connection, type of supra-construction, loading axis, measurement units. The stress or strain at implant-bone contact was measured over all studies and numerical values estimated. Risks of overloading were accented as non-axial loading, misfits, cantilevers and the stability of peri-implant bone was related with the usage of platform switch connection of abutment.
Conclusions: Peri-implant area could be affected by non-axial loading, cantilever prosthetic elements, crown/implant ratio, type of implant-abutment connection, misfits, properties of restoration materials and antagonistic tooth. The heterogeneity of finite element analysis studies limits systematization of data. Results of these studies are comparable with other findings of in vitro, in vivo, prospective and retrospective studies.
Objectives: To systematically review the influence of systemic diseases or medications used in their treatment on the dental implant therapy success.
Material and Methods: The search strategy was implemented on the National Library of Medicine database (MEDLINE) (Ovid) and EMBASE electronic databases between January 2006 and January 2016. Human studies with available English articles analysing the relationship between dental implant therapy success and systemic diseases, such as diabetes mellitus, AIDS/HIV, rheumatoid arthritis, osteoporosis, Crohn’s disease, cardiovascular diseases, scleroderma, Sjögren’s syndrome, lichen planus, ectodermal dysplasia, post-transplantation status, were included in present review according to the PRISMA guidelines. The review protocol was registered on PROSPERO system with the code CRD42016033662.
Results: Present review included forty one retrospective and prospective follow-up studies, case-control studies, case report series and cohort studies. Despite some limitations this study reveals positive results of implantation in most systemic conditions that should be interpreted with caution. Influence of cardiovascular diseases on the dental implantation success should be explored deeply, because of controversial results and likelihood of comorbidity expressed by a history of cardiovascular diseases and periodontitis. There is only a weak relationship with bone density in osteoporosis and implant failure. All the other diseases did not show significant effect on implantation success.
Conclusions: Recent studies with low strength of evidence and controversy show that systemic diseases may have potential effect on the success of implantation, but further detailed studies are needed to provide these findings.
Objectives: The present manuscript aims a detailed characterization of the bone cells dynamics during physiological bone remodelling and, subsequently, to address the cellular and molecular mechanisms that play a fundamental role in the immune-inflammatory-induced uncoupled bone remodelling observed in peri-implantitis.
Results: An intimate relationship between the immune system and bone is acknowledged to be determinant for bone tissue remodelling and integrity. Due to the close interaction of immune and bone cells, the two systems share a number of surface receptors, cytokines, signalling pathways and transcription factors that are involved in mutual regulatory mechanisms. This physiological equilibrium is disturbed in pathological conditions, as verified in peri-implantitis establishment and development. Activation of the innate and adaptive immune response, challenged by the local bacterial infection, induces the synthesis of high levels of a variety of pro- and anti-inflammatory cytokines that disturb the normal functioning of the bone cells, by uncoupling bone resorption and formation, ending up with a net alveolar bone loss and subsequent implant failure. Most data points to an immune-inflammatory induced osteoclast differentiation and function, as the major underlying mechanism to the uncoupled bone resorption to bone formation. Further, the disturbed functioning of osteoblasts, reflected by the possible expression of a fibro-osteoblastic phenotype, may also play a role.
Conclusions: Alveolar bone loss is a hallmark of peri-implantitis. A great deal of data is still needed on the cellular and humoral crosstalk in the context of an integrated view of the osteoimmunologic interplay occurring in the peri-implantitis environment subjacent to the bone loss outcome.
The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference 2016. Summary and Consensus Statements: Group I - Peri-Implantitis Aetiology, Risk Factors and Pathogenesis
Claudio Stacchi, Francesca Andolsek, Inesa Astramskaite, Federico Berton, Roberto Di Lenarda, Maria Helena Fernandes, Andrea Frassetto, Pedro de Sousa Gomes, Zygimantas Guobis, Ryo Jimbo, Gintaras Juodzbalys, Aiman Khoury, Ricardas Kubilius, Ritva Kuoppala, Teresa Lombardi, Julius Maminskas, Ingrida Pacauskiene, Giuseppe Perinetti, Lukas Poskevicius, Mindaugas Pranskunas, Algirdas Puisys, Aune Raustia
Introduction: The task of Group 1 was to review and update the existing data concerning aetiology, risk factors and pathogenesis of peri-implantitis. Previous history of periodontitis, poor oral hygiene, smoking and presence of general diseases have been considered among the aetiological risk factors for the onset of peri-implant pathologies, while late dental implant failures are commonly associated with peri-implantitis and/or with the application of incorrect biomechanical forces. Special interest was paid to the bone cells dynamics as part of the pathogenesis of peri-implantitis.
Material and Methods: The main areas indagated by this group were as follows: influence of smoking, history of periodontitis and general diseases on peri-implantitis development, bio-mechanics of implant loading and its influence on peri-implant bone and cellular dynamics related to the pathogenesis of peri-implantitis. The systematic reviews and/or meta-analyses were registered in PROSPERO, an international prospective register of systematic reviews: http://www.crd.york.ac.uk/PROSPERO/. The literature in the corresponding areas of interest was screened and reported following the PRISMA (Preferred Reporting Item for Systematic Review and Meta-Analysis) Statement: http://www.prisma-statement.org/. Method of preparation of the systematic reviews, based on comprehensive search strategies, was discussed and standardized. The summary of the materials and methods employed by the authors in preparing the systematic reviews and/or meta-analyses is presented in Preface chapter.
Results: The results and conclusions of the review process are presented in the respective papers. One systematic review with meta-analysis, three systematic reviews and one theoretical analysis were performed. The group′s general commentaries, consensus statements, clinical recommendations and implications for research are presented in this article.
Group II: Peri-Implantitis Diagnostics and Decision Tree
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Diagnostic Principles of Peri-Implantitis: a Systematic Review and Guidelines for Peri-Implantitis Diagnosis Proposal
Objectives: To review and summarize the literature concerning peri-implantitis diagnostic parameters and to propose guidelines for peri-implantitis diagnosis.
Material and Methods: An electronic literature search was conducted of the MEDLINE (Ovid) and EMBASE databases for articles published between 2011 and 2016. Sequential screening at the title/abstract and full-text levels was performed. Systematic reviews/guidelines of consensus conferences proposing classification or suggesting diagnostic parameters for peri-implantitis in the English language were included. The review was recorded on PROSPERO system with the code CRD42016033287.
Results: The search resulted in 10 articles that met the inclusion criteria. Four were papers from consensus conferences, two recommended diagnostic guidelines, three proposed classification of peri-implantitis, and one suggested an index for implant success. The following parameters were suggested to be used for peri-implantitis diagnosis: pain, mobility, bleeding on probing, probing depth, suppuration/exudate, and radiographic bone loss. In all of the papers, different definitions of peri-implantitis or implant success, as well as different thresholds for the above mentioned clinical and radiographical parameters, were used. Current evidence rationale for the diagnosis of peri-implantitis and classification based on consecutive evaluation of soft-tissue conditions and the amount of bone loss were suggested.
Conclusions: Currently there is no single uniform definition of peri-implantitis or the parameters that should be used. Rationale for diagnosis and prognosis of peri-implantitis as well as classification of the disease is proposed.
Objectives: To review the current understanding of the biomarkers and enzymes associated with different forms peri-implant diseases and how their level changes influence the pathogenesis of the inflammatory diseases around dental implants.
Material and Methods: An electronic search in two different databases was performed including MEDLINE (PubMed) and EMBASE between 1996 to 2016. Human studies analyse peri-implant crevicular fluid (PICF) biomarker and enzyme levels of implants having peri-implant mucositis and peri-implantitis published in English language, were evaluated. A systematic review was performed to assess which biomarkers and enzymes in PICF were used to identify the inflammatory conditions around dental implants.
Results: Fifty-one articles were identified of which 41 were further evaluated and included in the analysis. Due to significant heterogeneity between included studies, a meta-analysis could not be performed. Instead, a systematic descriptive review was performed.
Conclusions: Biomarkers and enzymes in peri-implant crevicular fluid have shown promising results in differentiating from peri-implant disease condition to health. However, due to inconsistent results and acquiring much evidence from cross-sectional studies, additional evidence supported by randomized-controlled trials is needed to validate the links reported.
Objectives: To describe the microbial profiles of peri-implant diseases and the main detection methods.
Material and Methods: A literature search was performed in MEDLINE via PubMed database to identify studies on microbial composition of peri-implant surfaces in humans published in the last 5 years. Studies had to have clear implant status definition for health, peri-implant mucositis and/or peri-implantitis and specifically study microbial composition of the peri-implant sulcus.
Results: A total of 194 studies were screened and 47 included. Peri-implant sites are reported to be different microbial ecosystems compared to periodontal sites. However, differences between periodontal and peri-implant health and disease are not consistent across all studies, possibly due to the bias introduced by the microbial detection technique. New methods non species-oriented are being used to find ‘unexpected’ microbiota not previously described in these scenarios.
Conclusions: Microbial profile of peri-implant diseases usually includes classic periodontopathogens. However, correlation between studies is difficult, particularly because of the use of different detection methods. New metagenomic techniques should be promoted for future studies to avoid detection bias.
The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference 2016. Summary and Consensus Statements: Group II - Peri-Implantitis Diagnostics and Decision Tree
Tolga Fikret Tözüm, Erhan Dursun, Pablo Galindo-Moreno, Gintaras Juodzbalys, Jesús López-Martínez, Francisco O'Valle, Miguel Padial-Molina, Ausra Ramanauskaite
Introduction: The task of Group 2 was to review and update the existing data concerning clinical and genetic methods of diagnostics of peri-implantitis. Special interest was paid to the peri-implant crevicular fluid (PICF) overview including analysis of enzymes and biomarkers and microbial profiles from implants.
Material and Methods: The main areas of interest were as follows: effect of smoking and history of periodontitis, prosthetic treatment mistakes, excess cement, overloading, general diseases influence on peri-implantitis development. The systematic review and/or meta-analysis were registered in PROSPERO, an international prospective register of systematic reviews: http://www.crd.york.ac.uk/PROSPERO/. The literature in the corresponding areas of interest was searched and reported using the PRISMA (Preferred Reporting Item for Systematic Review and Meta-Analysis) Statement: http://www.prisma-statement.org/. The method of preparation of systematic reviews of the literature based on comprehensive search strategies was discussed and standardized. The summary of the materials and methods employed by the authors in preparing the systematic review and/or meta-analysis is presented in Preface chapter.
Results: The results and conclusions of the review process are presented in the respective papers. The group′s general commentaries, consensus statements, clinical recommendations and implications for research are presented in this article.
Group III: Peri-Implantitis Treatment
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The Efficacy of Supportive Peri-Implant Therapies in Preventing Peri-Implantitis and Implant Loss: a Systematic Review of the Literature
Objectives: To study the efficacy of supportive peri-implant therapies in preventing clinical and radiological signs of peri-implantitis and implant loss.
Material and Methods: Longitudinal human studies, published between January 1, 2006, and February 1, 2016, were included based on an electronic search using MEDLINE and EMBASE databases and complemented by a manual search. Articles were included only if 1) they comprised a group of patients involved in/adhering to regular supportive peri-implant therapies (SPTs) and a control group without such therapies or with poor adherence to them, 2) the protocol of the SPTs was clearly described and 3) the outcome was indicated by means of clinical/radiological changes or implant loss.
Results: After initially identifying a total of 710 titles and abstracts, 12 full text articles were selected for eligibility assessment. Seven studies, three prospective and four retrospective, fulfilled the inclusion criteria for this review.
The frequency of recall visits varied between the studies from a minimum of one visit every three months to an individually tailored regimen. In all the studies a lack of SPTs or poor adherence to them resulted in significantly higher frequencies of sites with mucosal bleeding, deepened peri-implant pockets or alveolar bone loss. In line with the above, a lack of/poor adherence to SPTs was associated with higher implant loss.
Conclusions: To prevent peri-implantitis, an individually tailored supportive programme based on patient motivation and re-instruction in oral hygiene measures combined with professional implant cleaning seem to be crucial.
Objectives: The purpose of this paper was to systematically evaluate the effectiveness of non-surgical therapy for the treatment of peri-implant diseases including both, mucositis and peri-implantitis lesions.
Material and Methods: An electronic search in two different databases was performed including MEDLINE (PubMed) and EMBASE from 2011 to 2016. Human studies reporting non-surgical treatment of peri-implant mucositis and peri-implantitis with more than 10 implants and at least 6 months follow up published in English language were evaluated. A systematic review was performed to evaluate the effectiveness of the different methods of decontamination employed in the included investigations. Risk of bias assessment was elaborated for included investigations.
Results: Twenty-five articles were identified of which 14 were further evaluated and included in the analysis. Due to significant heterogeneity in between included studies, a meta-analysis could not be performed. Instead, a systematic descriptive review was performed. Included investigations reported the used of different methods for implant decontamination, including self-performed cleaning techniques, and professionally delivered treatment such as laser, photodynamic therapy, supra-/sub-mucosal mechanical debridement, and air-abrasive devices. Follow-up periods ranged from 6 to 60 months.
Conclusions: Non-surgical treatment for peri-implant mucositis seems to be effective while modest and not-predictable outcomes are expected for peri-implantitis lesions. Limitations include different peri-implant diseases definitions, treatment approaches, as well as different implant designs/surfaces and defect characteristics.
Objectives: The purposes of the present study were 1) to systematically review the literature on the surgical non-regenerative treatments of peri-implantitis and 2) to determine a predictable therapeutic option for the clinical management of peri-implantitis lesions.
Material and Methods: The study search was performed on primary database MEDLINE and EMBASE from 2005 until 2016. Sequential screenings at the title, abstract, and full-text levels were performed. Clinical human studies in the English language that had reported changes in probing depth (PD) and/or bleeding on probing (BOP) and/or radiologic marginal bone level changes after peri-implantitis surgical non-regenerative treatment at 6-month follow-up or longer were included accordingly PRISMA guidelines.
Results: The first electronic and hand search resulted in 765 citations. From 16 full-text articles reviewed, 6 were included in this systematic review. Surgical non-regenerative methods were found to be efficient in reducing clinical parameters. BOP and PD values were significantly decreased following implantoplasty and systematic administration of antibacterials, but not after local application of chemical compounds or diode laser. Similarly, significant improvement in clinical and radiographic parameters was found only after implantoplasty compared with resective surgery alone. We found significant heterogeneity in study designs and treatments provided among the pooled studies. All of the studies revealed an unclear or high risk of bias.
Conclusions: Surgical non-regenerative treatment of peri-implantitis was found to be effective to reduce the soft tissue inflammation and decrease probing depth. More randomized controlled clinical trials are needed to assess the efficacy of surgical non-regenerative therapy of peri-implantitis.
Objectives: The purpose of the present study was to systematically review the literature on the surgical regenerative treatment of the peri-implantitis and to determine an effective therapeutic predictable option for their clinical management.
Material and Methods: The study searched MEDLINE and EMBASE databases from 2006 to 2016. Clinical human studies that had reported changes in probing depth (PD) and/or bleeding on probing (BOP) and/or radiologic marginal bone level (RBL) changes after peri-implantitis surgical treatment at 12-month follow-up or longer were included accordingly to PRISMA guidelines.
Results: The initial search obtained 883 citations. After screening and determination of eligibility, 18 articles were included in the review. The meta-analysis of selected studies revealed that the weighted mean RBL fill was 1.97 mm (95% confidence interval [CI] = 1.58 to 2.35 mm), PD reduction was 2.78 mm (95% CI = 2.31 to 3.25 mm), and BOP reduced by 52.5% (95% CI = 41.6 to 63.1%). Defect fill in studies using and not using barrier membranes for graft coverage was 1.86 mm (95% CI = 1.36 to 2.36 mm) and 2.12 mm (95% CI = 1.46 to 2.78 mm) correspondingly. High heterogeneity among the studies regarding defects morphology, surgical protocols, and selection of biomaterials were found.
Conclusions: All included studies underlined an improvement of clinical conditions after the surgical regenerative treatment of peri-implantitis, however, there is a lack of scientific evidence in the literature regarding the superiority of the regenerative versus non-regenerative surgical treatment. The presence of a barrier membrane or submergence in the regenerative procedure does not seem to be fundamental in order to obtain clinical success of the surgery.
The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference 2016. Summary and Consensus Statements: Group III - Peri-Implantitis Treatment
Fernando Suárez-López del Amo, Ricardo Faria de Almeida, Marco Cicciù, Povilas Daugela, Ausra Ramanauskaite, Nikola Saulacic, Tellervo Tervonen, Hom-Lay Wang, Shan-Huey Yu
Introduction: The task of Group 3 was to review and update the existing data concerning non-surgical, surgical non-regenerative and surgical regenerative treatment of peri-implantitis. Special interest was paid to the preventive and supporting therapy in case of peri-implantitis.
Material and Methods: The main areas of interest were as follows: effect of smoking and history of periodontitis, prosthetic treatment mistakes, excess cement, overloading, general diseases influence on peri-implantitis development. The systematic review and/or meta-analysis were registered in PROSPERO, an international prospective register of systematic reviews: http://www.crd.york.ac.uk/PROSPERO/. The literature in the corresponding areas of interest was searched and reported using the PRISMA (Preferred Reporting Item for Systematic Review and Meta-Analysis) Statement: http://www.prisma-statement.org/. The method of preparation of systematic reviews of the literature based on comprehensive search strategies was discussed and standardized. The summary of the materials and methods employed by the authors in preparing the systematic review and/or meta-analysis is presented in Preface chapter.
Results: The results and conclusions of the review process are presented in the respective papers. The group′s general commentaries, consensus statements, clinical recommendations and implications for research are presented in this article.
