Q&A with Lisa Heitz-Mayfield on the Oral Regeneration Topic Peri-Implantitis

On 8 April 2020, Lisa Heitz-Mayfield held her successful Oral Regeneration webinar focusing on “Peri-Implantitis” on THE BOX moderated by Jae Kook Cha. Due to the high volume of questions during the live webinar there was not time to answer them all, so Lisa took the time to answer the remaining ones afterwards. Find the questions about “Peri-Implantitis and the implant disease risk assessment (IDRA)” below and read Lisa’s expert answers.

You can find the recording of the whole webinar on THE BOX, and if you would like some reading material, the publication “Implant Disease Risk Assessment IDRA–a tool for preventing peri‐implant disease” by Lisa J. A. Heitz‐Mayfield, Fritz Heitz and Niklaus P. Lang is here (open access).

Lisa Heitz-Mayfield and Jae Kook Cha during the webinar from 8 April 2020

Q: Is there something like this IDRA for periodontal classifications or conditions? Do you have a link?
A: Yes, it is the periodontal risk assessment (PRA): www.perio-tools.com

Q: Can the number of teeth with periodontitis or mucositis affect the stage and grade in the new periodontal disease classification?
A: Please refer to the Tonetti et al. 2018 paper in Journal of Clinical Periodontology here. It is open access, so it is freely available. The extent and severity of the disease are part of this classification.

Q: Are a Guided Bone Regeneration (GBR) procedure and materials a risk factor for implant disease?
A: A recent systematic review concluded that GBR is not a risk factor for peri-implant disease. Refer to the publication “Long-term biological complications of dental implants placed either in pristine or in augmented sites: A systematic review and meta-analysis” by Salvi et al. 2018 here (open access) for further information.

Q: Is the probing depth (PD) really significative? Could it not be due to the level of insertion of implants and the height of the Keratinized Mucosa?
A: It is the PD of teeth and implants, not just implants. You can see the description in the IDRA publication at the following link.

Q: Is there an option to include smoking status and medical history in the IDRA diagram?
A: Smoking and medical conditions are both included in the grading in the periodontitis susceptibility vector.

Q: Dormant bacterial populations can be retained in bone and only recognized through skilled recognition within radiographs of sclerotic and lytic areas in the bone. These populations can remain dormant for several years before converting to planktonic forms, initiating the peri-implantitis pathology. Do you consider these dormant bacterial populations to be a pivotal risk factor?
A: The IDRA is open to adjustments. If there is sufficient scientific evidence to show a strong association between any factor and peri-implantitis then it can be added to the other parameters already in the IDRA.

Q: Are you taking into account the use of irrigation with antibiotics during the treatment of peri-implantitis?
A: Yes, our protocol includes use of systemic peri-operative antibiotics.

Q: IDRA for patient level or implant level?
A: Patient level

Q: Could you please tell us what kind of treatments or supportive periodontal therapy (SPT) are recommended based on the IDRA?
A: You can find details about this by watching the webinar “Peri-implantitis: Decision-making in clinical practice” by following the link – it also has details on treatment approaches and the protocols we use in our practice. I would also recommend the publication “Group 4 ITI Consensus Report: Risks and biologic complications associated with implant dentistry” by Heitz-Mayfield 2018 here (open access) for further information.

Q: Should we routinely increase keratinized tissue around implants?
A: There is not enough evidence to say we should do it routinely. If the patient has discomfort during cleaning or is unable to clean it would be indicated.

Q: Can you share your SPT protocol according to risk category?
A: If patient is at higher risk, I would see them more frequently (once every 3-4 months). I would see all implant patients at least every 5-6 months in line with evidence from Monje et al. 2016 (PubMed).

Q: Can we use the IDRA in edentulous patients?
A: Yes, it can still be used but with some modifications as you cannot evaluate bone loss/age. This is then set to moderate risk. On the online tool we will have an option for edentulous patients, which is coming soon.

Q: Can you summarize your feelings on the theory that the primary aetiology/pathology of the bone loss is a foreign body reaction and the infection is secondary?
A: My feelings are based on the scientific evidence. When sufficient evidence of sufficient quality is presented to support this idea, I will be open to it.

Q: How was the distance between restorative margin and bone defined? The baseline bone level (implant placement/crown delivery/loading after one year)? Or the cemento-enamel junction (CEJ) level of neighbouring teeth? How about the cases with multi-abutment?
A: Use the radiograph following delivery of restoration. Where there are multiple abutments, choose the one which presents the smallest distance to the bone crest from the restorative margin.

Q: In patients with multiple implants or edentulous patients with only implants in the mouth, how do you record and calculate bleeding on probing (BOP) and PD percentages, considering that implants bleeding and pocket depth may be interpreted differently from the natural teeth?
A: I would record it in the same way. 

Q: At the time of the final delivery of prosthesis, do you record all the indicators and warn the patient about the disease?
A: Yes, this is correct. It can be used to evaluate the risk and communicate with the patient.

Q: Can the distance of the restorative margin to the gingival crest be considered as another risk factor for peri-implantitis?
A: This is included in the prosthesis vector as the supramucosal margin.

Q: How frequently is monitoring required in high-risk patients?
A: There is no definitive answer. The frequency and protocol should be individualized, but in general I would recommend every 3-4 months.

Q: How can I prevent peri-implantitis?
A: Treat peri-implant mucositis and reduce the modifiable risk factors identified by the IDRA such as BOP percentage and PD > 5 mm.

Q: What is the best method for implant surface decontamination?
A: There is no one method that has been shown to be superior. You can use mechanical, chemical or a combination.

Q: Should we use antibiotics in the treatment of peri-implantitis?
A: Systemic antibiotics may be prescribed in combination with surgery. Many surgical protocols include preoperative antibiotics. However, the evidence for the use from randomized controlled trials is limited. According to Carcauc et al. 2017 (PubMed), there is more benefit when the implant has a moderately rough surface than when the implant surface is turned (smooth).

Q: How can we know the SPT situations from the very beginning? Does it mean the IDRA can only be used after a certain period?
A: You can ask the patient how often they have maintenance care. 

Q: In the IDRA, how is the threshold of restorative margin to bone defined?
A: It is defined according to the study by Derks et al. 2016 (PubMed), by taking a measure from the restorative margin to the bone crest on a radiograph. You can read more in the IDRA manuscript by following this link.

Q: Do you think that biofilm properties can affect the disease severity and treatment success? Some studies have shown that a biofilm matrix can promote biofilm virulence and growth of pathogens related to peri-implantitis.
A: Yes, this is plausible when dysbiosis occurs, but we need further research in this field. There is no unique microbial profile associated with peri-implantitis – it is diverse and complex.

Q: Wouldn’t having the vector for history of periodontitis in addition to the perio-susceptibility be redundant? Why are there are two factors related to periodontitis? Is perio-susceptibility not enough?
A: No, you need both parameters. A positive history of periodontitis cannot be deemed low risk. There is strong evidence for this risk factor. However not all periodontally compromised people are high risk, therefore there must be a range of additional risk factors. This is provided by the staging/grading vector.

For further information about treatment approaches and the protocols which are used in practice you can also watch the webinar with Lisa Heitz-Mayfield about “Peri-implantitis: Decision-making in clinical practice” here.