Dentists made a mistake.
For roughly three decades we have been so focused on implant surgery and implant prosthetics that we almost completely ignored implant hygiene. We saw implant patients in our hygienists’ chairs and we didn’t have any parameters to measure the health of the implant. We would joke with ourselves, “Well an implant can’t get a cavity, so who cares?” The only time we would be concerned if the implant showed sings of failure. A mobile, pussing, painful implant that was falling out of someone’s head… that would catch our attention. But there is a whole spectrum of disease that occurs leading up to that which deserves our attention.
The terms “peri-implant mucositis” and “peri-implantitis” have been around since the early 1990’s yet they are still not well understood by our profession. Here’s a quick run down:
Definition: A reversible inflammation in the mucosa adjacent to an implant. AKA implant gingivitis.
Signs: Bleeding on probing, rolled gingival margins, supparation, tenderness, change in tissue character (texture/color/etc.)
Definition: Inflammation of the tissues surrounding an implant that results in bone loss. AKA implant periodontitis.
Signs: Same as peri-implant mucositis but with radiographic bone loss
Okay, let’s look at an example…
A patient presents with a chief complaint of mild pain and bleeding on his implant #9. He notes that the implant was restored about three years ago and he had a connective tissue graft last year to “cover up some exposed metal.” Probing of 5mm on the mesio-buccal and 6 mm on the disto-buccal both generate significant bleeding.
The cause of this inflammation was revealed upon radiographic examination. Cement was clearly visible on a periapical film and was the likely culprit. Due to the history of a connective tissue graft, the patient was referred to a periodontist for flap debridement of the implant sulcus. If you think I was going to flap this myself… nuh uh.
We were fortunate that the cement was evident on the radipgraph. But if the excess had been on the buccal or lingual, it may not have been seen. Therefore, we must always suspect excess cement as an etiology for cementable crowns presenting with symptoms.
Diagnosis? This was a peri-implant mucositis caused by excess cement. Some clinicians even refer to this as a separate disease using the terms “peri-cementitis” or “peri-implant cementitis.” That’s fine, but I don’t love those terms because they don’t tell you the extent of the disease. Calling this case peri-implant mucositis lets us know that the inflammation has not lead to the destruction of supporting bone.
By the way, yes, I realize that there is an ugly looking post on the other central incisor that may have perforated the root. As you may suspect, the patient is hesitant about extracting it and placing an implant due to the troubles he’s had with his other implant…