peri-implantitis versus periodontitis – similarities and ... - Stomatologie

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PARODONTOLOGIE
PERI-IMPLANTITIS VERSUS PERIODONTITIS –
SIMILARITIES AND DIFFERENCES. LITERATURE
REVIEW
Cristina Alexandra Berechet M.D. 1 ; Ana-Maria Ionaşcu, M.D. 1 ; Valentin Sîrbu, M.D. 2 ;
Ioan Sîrbu, M.D., PhD 3
1 Faculty of Dentistry, University of Medicine and Pharmacy „Carol Davila“, Bucharest, PhD Oral
Implantology
2 Faculty of Dentistry, University of Medicine and Pharmacy „Carol Davila“, Bucharest, PhD
Clinical Anatomy and Topography, Universitary Assistant Department of Oral Rehabilitation
3 Head of Department of Oral Implantology, Faculty of Dentistry, University of Medicine and
Pharmacy „Carol Davila“, Bucharest
ABSTRACT
Novelty and motivation of this topic. Hard and soft tissues around an osseointegrated dental implant has
some similarities with the periodontium of natural teeth. The major difference occurs when collagen fi bers,
which are singles and are parallel to the dental implant surface, compared with insertion of the natural teeth,
which is perpendicular and functional, between bone and cement. As untreated periodontitis can ultimately
lead to loss of natural teeth, periimplantitis can result in loss dental implants. Recent studies show that the
main causative factor both of tooth loss from Periodontitis, as for the loss of dental implants due to
Periimplantitis is the microbial dental plaque.
The aim of the study. In this paper I have studied similarities and differences between periodontitis and periimplantitis
and the correlations that can be established between these disorders.
Methods. The study references: specialized primary literature: scientifi c articles, specialized undergraduate
theses; doctoral dissertations; specialized secondary literature: reference books, implantology papers;
specialized tertiary literature: journal literature, summarized articles.
Conclusions. Peri-implantitis is a general term to describe pathological changes that occur in hard and soft
tissues surrounding the implant and the clinical appearance is implant mobility. Another disease that
resembles peri-implantitis is mucositis. Mucositis is affecting only the soft tissue component, the occurrence
of infl ammation at this level, due to plaque accumulation. It can be considered analogous to the natural
teeth’s Gingivitis. Peri-implantitis requires, in addition to soft tissue damage also bone loss. It is caused by
bacterial factor, is frequently associated with other predisposing factors for onset of the disease. Periimplantitis
can be considered the analogous to natural teeth’s periodontitis.
ACKNOWLEDGEMENT
This paper is supported by the Sectoral Operational
Programme Human Resources Development
(SOP HRD) 2007-2013, fi nanced from the European
Social Fund and by the Romanian Government
under the contract number POSDRU/107/1.5/S/
82839.
Key word: periodontitis, gingivitis, mucositis, peri-implantitis
MOTIVATION OF THIS TOPIC
Soft and hard tissues surrounding a dental
implant have certain similarities with those in
natural dentition. The major difference appears in
collagen fi bers, which are unattached and parallel
to the dental implant surface, compared to the
insertion of the natural teeth, which is straight and
functional, between bone and cementum. (10)
Adresă de corespondenţă:
Cristina Berechet, M.D., Faculty of Dentistry, University of Medicine and Pharmacy „Carol Davila“, Bucharest
e-mail: dr.cristinaberechet@gmail.com
REVISTA ROMÂNÅ DE STOMATOLOGIE – VOLUMUL LIX, NR. 1, AN 2013

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOLUMUL LIX, NR. 1, AN 2013 33
The epithelial junction sealing achieved in the
gingival sulcus of natural teeth offers protection
against bacterial penetration or existing bacteria in
the mouth. If this seal is broken or gingival epithelial
apical fi bers are damaged or destroyed, the epithelium
migrates rapidly in apical direction, resulting
in periodontal pockets. (5)
Since there is no cementum or insertion of epithelial
fi bers in the case of a dental implant, mucosal
sealing is extremely important. If the seal is lost,
the bacteria infi ltration is rapidly expanding to bone
structures. (10)
The periodontal parameters’ values (depth appre
ciation of the space around the implant, clinical
gingival insertion levels, gingival bleeding on
examination with the probe, mobility) are important
indicators for detecting potential implant pathological
conditions. (6)
THE PURPOSE OF THE STUDY
In this paper I proposed to study similarities and
differences between periodontal disease and periimplantitis,
in order to reveal the correlations that
can be established between these disorders according
to the conclusions of the specialized literature.
STUDY METHODS
This study is a review of specialized literature
based on the following references:
• primary specialized literature, specialty
scien tifi c articles, theses, PhD papers;
• specialized secondary literature-books, treatises
of implant dentistry;
• tertiary specialized literature journals, abstracts.
DESCRIPTION
Periodontium is a morphological and functional
complex that provides the setting up of the tooth in
the jawbone and it consists of periodontal ligament,
alveolar bone, gum tissue and root cementum. (4)
Marginal periodontium has two components:
• Gums: periodontal surface consisting of:
gingival epithelium, chorion and ligaments;
•
Deep periodontal support, desmodontium,
consisting of: root cementum and alveolar
bone.
The dento-alveolar ligament device is composed
of fi bers with different directions, creating the
ligament that connects the internal cortex of the
root cementum socket and the gum. (5)
CONTENT OF THE PERIODONTAL SPACE (5)
Lateral surface of the root, covered by cementum
and alveolar cavity, separates a small space, hourglass
shape in vertical section called periodontal or
alveolo-dental space.Periodontal space is occupied
by beams of alveolo-dental ligament, forming the
periodontal ligament. The round or oval areas of
ligament fi bers are lax connective tissue that contains
numerous connective tissue cells, epithelial
cell debris and network rich blood, lymphatic
vessels and nerves, ligaments realize a connection
between the tooth root and the alveolar bone. The
fi ber network also connects synergists tooth and
marginal gum to their neighborhood.
THE PERIODONTAL LIGAMENT (4)
It consists of functionally oriented collagen
fi bers (primary), elastic fi bers orientated vaguely
anarchic (secondary) and arranged around vessels,
reticulin and oxitalan fi bers.
Main collagen fi bers consist of fi brils, grouped
in the form of bands that make the periodontal
ligament developed area whose section for a
maxillary central incisor is about 3 cm2 . (1,2)
Fiber orientation is oblique, between alveolar
bone and cementum, root to tip binding the tooth to
the bone. The fi bers are wavy, with one end caught
in the bone, the other end in the cementum. (4,5)
The periodontal ligament has the following
functions: (2)
•
•
•
•
•
•
turns occlusal forces in strong pressure on
alveolar bone traction and disperse them all
over the compact internal pockets;
maintains the tooth into the socket securely;
keeps tightly applied gum tissue around the
tooth package;
offers protection from occlusion pressure;
protects vessels and nerves from crushing
their periodontal alveolar walls by its suspension
and damping systems, while acting
as a soft protective coating;
in case of general conditions or in different
functional deviations in alveolar bone and
root cementum-atrophic degenerative processes
occur, these aspects must be taken into
account in restorative therapy.
The periodontal ligament’s fi bers are arranged
in six groups: (4)
1. Transseptal fi bers extend over the alveolar
bone crest and are embedded in the cementum of
adjacent teeth; they form an interdental ligament.
These fi bers keep all the teeth aligned. These fi bers

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may be considered as belonging to the gingiva
because they don’t have osseous attachment.
2. Alveolar crest fi bers extend obliquely from
the cementum just beneath the junctional epithelium
to the alveolar crest. These fi bers prevent the extrusion
of the tooth and resist lateral tooth movements.
3. Horizontal fi bers attach to the cementum and
to the alveolar bone and run perpendicularly from
the root of the tooth to the alveolar bone.
4. Oblique fi bers are the most numerous fi bers
in the periodontal ligament, running from cementum
in an oblique direction to insert into bone, coronally.
5. Apical fi bers radiating from cementum around
the apex of the root to the bone, forming base of the
socket
6. Interradicular fi bers are only found between
the roots of multi-rooted teeth. They also attach
from the cementum and insert to the nearby alveolar
bone. (5)
Periodontitis or periodontal disease is a general
term indicating pathological changes in perio dontium.
They can be:
• acute or chronic;
• infl ammatory;
• dystrophic;
• involutive;
• hyperplastic or proliferative. (2)
Periodontium comprises two topographic areas:
(4)
• Superfi cial periodontium or the coating formed
periodontium
•
Deep or functional periodontium which in-
cludes cementum, alveolar bone and alveolodental
ligament, whose illness is acute and
chronic
Sometimes, apical tissue pathology is related to
endodontic pathology.
Periodontal illness presents several clinical
forms: mostly infl ammatory and dystrophic, predominantly
proliferative. These events were generally
called by numerous experts periodontal disease or
periodontitis. (4)
Periodontal disease is considered a disease of
the periodontal structures concerned with infectious
chronic infl ammatory lesions, with or without dystrophic
or proliferative lesions, leading to destruction
of supporting tissues, and fi nally, to tooth
loss.
Etiology of periodontitis has long been unspecifi
ed, issuing numerous assumptions, which
were verifi ed in part. Etiological factors were classifi
ed in: predisposing and causative factors, drivers,
local and general factors. (5)
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Periodontal disease is a chronic disease of marginal
periodontium, characterized by progressive
des truction of periodontal structures, leading to
reduced implantation and fi nally, mobilization and
tooth loss. (10)
The lesion is usually infl ammatory, by infection
with bacteria, viruses and fungi. Evolution is chronic,
progressive, without tendency to spon ta neous
healing, eventually losing bone and ligament support
of the tooth. Infl ammatory lesions are often associated
with dystrophic or proliferative lesions.
So metimes, involution of these lesions may occur.
(2)
Periodontitis should be considered an infection
from periodontal disease. (4)
Gingivitis – chronic microbial infl ammation of
the gums (free gingiva and papilla).
Periodontitis – is characterized by epithelial
insertion loss (the attachment) from the cementum
and clinical signs of infl ammation. (5)
The classifi cation of periodontal disease according
to the Department of Periodontology Bucharest
(4):
I. Gingivitis
A. Specifi c plaque-induced gingivitis.
B. Specifi c plaque-induced gingivitis, infl uenced
by local and general factors: physiological (puberty,
pregnancy), systemic diseases, medication (calcium
antagonists, hydantoin, cyclosporine).
C. Gingivitis not caused by specifi c plaque: here
ditary hyperplasic gingivitis, desquamative gingivitis,
herpetic and fungal gingivitis and gingivostomatitis,
allergic gingivitis, gum lesions in
his to plasmosis and varicella-zoster infection.
II. Periodontitis:
A. Chronic marginal periodontitis: superfi cial
chro nic periodontitis, deep slowly progressive
chronic periodontitis, deep necrotic ucerative periodontitis,
distrophyc periodontitis (deep periodontitis
rebellious to treatment).
B. Aggressive periodontitis.
III. Gingival, periodontal and oral manifestations
in AIDS
IV. Manifestations of occlusal trauma and
lack of occlusal contact
V. Gingival-periodontal tumors, benign and
malignant
VI. Gingival retraction (4)
Peri-implantitis describes pathological changes
that occur in soft and hard tissues surrounding the
implant and mobility of the implant as clinical
signs. (6) A disease that resembles peri-implantitis
is mucositis. This is affecting only the soft tissue
component, infl ammation occurring at this level,

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOLUMUL LIX, NR. 1, AN 2013 35
due to plaque accumulation. (9) Peri-implantitis
implies bone damage, in addition to soft tissue damage
(8), and it is caused by bacterial factors, in
combination with other predisposing factors.
The main condition for the success of an implant
treatment is bone and soft tissue integration of the
implant. (1)
Tissue integration of oral implants consists of two
main components: (8)
A. Bone integration: The bone integration of a
den tal implant (osseointegration) is the direct connection
established between the implant and bone without
soft tissue interposition. (9)
B. Peri-implant soft tissue integration: Equally
important is the peri-implant soft tisue integration
for the success of the implant treatment. This is to
achieve a closure around the implant at the soft
tissue-implant interface. (1)
Criteria for successful dental implant treatment:
(6)
• Favorable underlying bone without acute
infl ammatory processes
• Primary stability of the implant after placement
• Osseointegration
• Obtaining a superior aesthetic result
•
Optimal morphological and functional inte-
gration of the implant
Main reasons of peri-implantitis occurrence are:
(9)
• the patient did not maintain a good oral
hygiene;
• some areas were not suffi ciently accessible
for the patient to achieve adequate cleaning;
• abutment was not installed correctly;
•
•
the area around the implant consist of excess
non-keratinized tissue, which transformed
into a periodontal pocket;
no rules have been complied with prosthesis
(unadapted prosthetic piece, in relationship
to the gum in the neck of the implant).
Implant failures due to infection are characterized
by a periimplant bacterial complex resembling that
of adult periodontitis. In edentulous subjects, Actino
bacillus actinomycetemcomitans and Porphyromonas
gingivalis are not as frequently associated
with peri-implant infection as in partial edentulous
cases. (7)
Although bone-implant interface can be seen,
most tissue consists of collagen fi bers. (10)
Peri-implant ligament has the same functions as the
periodontal ligament, but structurally it is different.
In the Peri-implant fi brous tissue, collagen fi bers
have a distinctive orientation and a specifi c
interaction with the bone surrounding the implant
in direct interrelation with the implant design and
loading. (8) These fi bers are oriented in the threedimensional
space between implant and bone,
follo wing the distribution of biomechanical forces.
(5)
Bundles of collagen fi bers in the peri-implant
ligament are longer than those of the periodontal
ligament, passing from the bone trabecula to the
implant surface, through a fenestration or tangential
to the surface, and then inserting on another bone
trabecula. The length of these collagen bundles is a
key point for the stability and longevity of the implant.
(6)
The bone around a dental implant has a higher
thickness and density than that which surrounds
natural teeth, therefore, the mobility of the implant
is diminished. Histological studies have shown that
fi ber orientation around the implant has the
appearance of slings. (5)
Peri-implant ligament functions: (10)
1. Piezoelectric effect. It is assumed that occlusal
forces are transmitted to the peri-implant ligament,
stimulating the bone where the fi bers are
inserted. Studies have shown that deformation of
the surface of the implant socket, immediately
around the implant causes compression, generating
a negative charge, while the distal part of the trabecula
tensions, causing a release that generates a
positive charge. This potential difference seems to
stimulate cell differentiation into osteoblasts, osteoclasts
and fi broblasts in proportion to the voltage.
These cells help post-traumatic scarring, removes
debris and form a protein network, which will
calcify later. (10)
2. The hydraulic effect. Peri-implant ligament
is bathed in fl uids in the implant socket. Axial
occlusal forces are transmitted to collagen fi bers,
which in turn act on the fl uid that is incompressible,
are pushed in the bone, to bone marrow. Blood
vessels crossing the peri-implant ligament are also
pushed out. This creates a hydraulic effect appearing
also in the natural tooth. When the action ceases,
the fl uid returns, then the process restarts. (10)
3. The buffer effect. Because collagen fi bers
can be deformed, a buffer effect appears between
implant and bone. (10)
PERI-IMPLANT MUCOSITIS AND
PERI-IMPLANTITIS
Peri-implant mucositis is a reversible infl
ammation of the soft tissue around implants.
Effects of persistent plaque „de novo“ on the gum

36
tissue and peri-implant soft tissue were compared in
laboratory animals studied. Berglundh et al. (1992)
showed that both tissues reacted after a period of 3
weeks to form a plaque infl ammatory lesion.
Due to similarities in size and composition of
these lesions was found that the gums and soft
tissue around implants have similar capabilities to
defend against plaque formed „de novo“. (1)
Patients discontinued oral hygiene for 3 weeks,
the result appearing as gingivitis and peri-implant
mucositis. (10)
The results of this study were that the period
when oral hygiene has not been performed demonstrated
a cause and effect relationship between
plaque accumulation and peri-implant Mucositis,
appearance similar in reaction to the presence of
gingival plaque in gingivitis.
These studies led to the following conclusions:
(1) for natural teeth, plaque from 3 weeks to 3
months produced no infl ammatory lesion expansion;
(2) for implants, the same factors produced an
expansion of the infl ammatory lesion toward the
apex. The conclusion is that gum defense system is
more effective than that of the mucosa around the
im plant. (1,10)
Clinical signs and symptoms found in periodontitis:
(4,5)
• subjective signs:
feeling of gum tension,
gingival itching, gingival bleeding, halitosis,
esthetic complaints;
• objective signs: changes of gingiva’s color,
gingival epithelium surface modifi cation,
change in the shape and volume of the gum,
alteration in the depth of gingival sulcus, formation
of periodontal pockets due to bone
loss, the presence of irritant factors (bacterial
plaque, tartar, debris), pathological mobility,
presence of gingival abscesses, fi stulas,
scars.
As periodontitis, peri-implantitis’ most important
signs are described as follows: (6,7)
• gingival infl ammation;
• deep pockets around the implant, with progressive
loss of alveolar bone.
Treatment of periodontitis and peri-implantitis
The goal of periodontal treatment is to maintain
the health of the teeth and dental implants, to ensure
comfort, functionality and aesthetics. With the increasing
number of patients receiving dental implants
the prevalence of infl ammatory problems of
the implant receiving tissues is also increasing. (3)
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The treatment in both pathological conditions must
be: (3,4,11)
• Early, the chances of success are best.
• Supported by procedures designed to lead to
the improvement towards healing.
• Simple removal of local factors is not suffi
cient.
• Supported and complemented by surgical
and biostimulation procedures.
• Complex procedures – antibiotics and antiinfl
ammatory drugs.
• Surgical procedures.
• Restoration of teeth and arch morphology.
• Occlusion – balancing.
• The more diversifi ed the disease, the more it
shows an advanced degree in evolution.
•
•
Designed for each individual, is the main
con dition of success, to improve the condition,
to obtain healing.
Treatment of periodontal disease must take
into account the general condition of the
patient as periodontal treatment can be both
local and general. (4)
The main stages of periodontal disease treatment:
(5)
1. Treatment of acute complications of chronic
mar ginal periodontitis.
2. Cleaning performed by a doctor to remove
microbial natural factors:
• gingival debridement by removing plaque
biofi lm;
• supragingival scaling;
• professional subgingival scaling;
•
suppression of infl ammatory processes ca-
used by root debris.
3. Patient education for learning a sanitation
system mainly by brushing and by using secondary
hygiene aids.
4. Detection and removal of iatrogenic factors.
5. Antimicrobial medication therapy of chronic
gingivitis and periodontitis marginal superfi cial.
6. Reduction of infl ammatory exudate from periodontal
pockets by antibiotic treatment.
7. Surgical suppression of infl ammatory sites
other than periodontal pockets and gingival hyperplasia.
8. Suppression of the actual surgical periodontal
pockets and gingival hyperplasia.
9. Restoring dental morphology affected by caries.
10. Occlusal balancing.
11. Prosthetic restoration.

REVISTA ROMÂNÅ DE STOMATOLOGIE – VOLUMUL LIX, NR. 1, AN 2013 37
12. Immobilization of teeth with pathological
dental mobility.
13. Biostimulative treatment.
14. Maintenance of the results through preventive
measures and further curative procedures.
The treatments proposed for peri-implant disease
are based on the evidence gained from the treatment
of periodontitis; the surface of the implants facilitates
adherence of the bacte rial biofi lm and complicates its
elimination. (3)
The treatment of periimplantitis has the following
goals: (11)
• regeneration of bone structures;
• complete elimination of infl ammatory processes
in the peri-implant tissues;
• reduction in the duration of the treatment;
• creation of aseptic conditions around the implant;
• securing the reliability of the implanted artifi
cial supports.
Treatment methods: (5,8,9)
Peri-implantitis of infectious failure:
1. Acute bacterial infection control to reduce tissue
infl ammation:
• mechanical debridement in areas of local action;
• irrigation in subgingival sulcus to reduce environmental
pathogens;
• administration
of topical and systemic antibiotics.
(11)
BIBLIOGRAPHY
1. Berglundh, T., Lindh, J., Marinello, C., Ericsson, I., Liljenberg, B. –
(1992) Soft tissue reaction to de novo plaque on implants and teeth. An
experimental study in the dog. Clinical Oral Implants Research 3:1-8.
2. Cawson R.A., Odell E.W. – Cawson’s essentials of oral pathology and
oral medicine, Edition: 8, illustrated, ed. Elsevier Health Sciences, 2008.
3. Claffey N., Clarke E., Polyzois I., Renvert S. – Surgical treatment of
peri-implantitis. J Clin Periodontol 2008; 35 (Suppl. 8): 316-332.
4. Dumitriu S., Dumitriu H.T. – Microbial etiology of marginal periodontitis
chronic. Antimicrobial prophylaxis and treatment. Ed Cermei, Bucharest
1996.
5. Dumitriu H.T. – Periodontology, Ed. Romanian Medical Life 2006.
6. Klinge B., Hultin M., Berglundh T. – Peri-implantitis, Dent Clin N I 49
(2005) 661-676.
7. Karoussis I.K., Muller S., Salvi G.E. – Association between periodontal
and peri-implant Conditions: a 10 year prospective study. The
implementation Oral Clin Res 2004, 15:1-7.
2. Regeneration of bone defects. (3)
Peri-implantitis of traumatic failure – the treatment
is surgical correction of the pockets and regeneration
of bone defects around the implant.
Revaluation intervals post-therapy for peri-implantitis:
once a patient has developed peri-implantitis,
there is an increased risk of recurrence and is considered
a high-risk patient especially if he has a periodontal
disease case history. (5)
• assessment
at 3-4 months;
• alternate assessments between the specialist
and generalist.
CONCLUSIONS
Mucositis can be considered analogous to natural
teeth gingivitis. Peri-implantitis can be considered
analogous to natural teeth periodontitis. (10) The
borderline between gingivitis to periodontitis and
mucositis to peri-implantitis is defi ned by the degradation
of connective tissue and it is followed by
epithelial migration and bone resorption. (2)
Microbial colonization and infl ammatory reactions
in the peri-implant tissues might be analogous
to key events in the pathogenesis of periodontitis.
(6) Peri-implantitis can result in the loss of dental
implants just as untreated Periodontitis can lead to
the loss of natural teeth. (7) A history of periodontitis
and the presence of putative periodontal pathogens
are factors that can infl uence the condition of periimplant
tissues in partially edentulous subjects. (9)
8. Karoussis I.K., Salvi G.E., Heitz-Mayfi eld L.J.A. – Long-term implant
prognosis in Patients with and without a history of chronic periodontitis: a
10 year prospective cohort study of the ITI dental implant system. The
implementation Oral Clin Res 2003, 14:129-39.
9. Malmstrom H.S., Fritz M.E., Timmis D.P. – Osseo-integrated implant.
Treatment of the patient with rapidly progressive periodontitis. A case
report. J Periodontol 1990; 61:300-4.
10. Sirbu I. – Practical Course of Oral Implantology, second edition, CTEA
Publishing House, Bucharest, 2006.
11. Renvert S., Roos-Jansaker A.M., Claffey N. – Non-surgical treatment
of peri-implant mucositis and peri-implantitis: a literature review. J Clin
Periodontol 2008; 35 (Suppl.8): 305-315.