Implant Tribune Middle East & Africa No. 1, 2024
Ready for the future with Implantmed Plus / Peri-implantitis: Can it be treated without surgery?
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DTMEA_No.1. Vol.14_IT.indd
PUBLISHED IN DUBAI
www.dental-tribune.me
Vol. 14, No. 1
Large-scale study links periodontitis
and infl flammatory bowel disease
Researchers found evidence for connection between diseases
By Franziska Beier, Dental
Tribune International
Even though previous research
has suggested a link between periodontitis and inflammatory bowel
disease (IBD), the relationship and
its impacts have not been fully explored. In a large-scale study—the
first of its kind in a European population—researchers from Malmö
University, in collaboration with
other Europe-based researchers,
have found evidence for a strong
connection between the two diseases.
IBD is a group of inflammatory
disorders of the gastrointestinal
tract, principally Crohn’s disease
and ulcerative colitis. The incidence
of IBD is increasing worldwide, and
more than 1.3 million people in Europe suffer from it. Its cause remains unknown, but an inappropriate immune response is considered
to be involved.
Periodontitis and inflammatory bowel disease are chronic inflammatory diseases
with similarly complex pathogeneses. (Image: Emily eddows-animator/Freepik)
Periodontitis and IBD are
chronic inflammatory diseases with
similarly complex pathogeneses.
“Both diseases can be described as
a strong overreaction of the im-
mune system against a theoretically relatively mild bacterial trigger. You can say that the immune
system attacks one’s own body,”
explained co-author Prof. Andreas
Stavropoulos from the Faculty of
Odontology in a university press
release.
The study was conducted in
Denmark and the data collected via
an online questionnaire answered
by around 1,100 patients with IBD
(of whom approximately half had
Crohn’s disease and the rest ulcerative colitis) and around 3,400
matched controls without it.
The evaluation of the survey responses showed that patients with
IBD had a higher probability of perceiving the overall health of their
teeth and gingivae as worse and of
having severe periodontitis. Those
patients diagnosed with Crohn’s
disease reported worse oral health
than those diagnosed with ulcerative colitis and had higher odds of
having lost more teeth than the
control group.
“The study shows that patients
with IBD have more periodontitis
and fewer teeth compared to peo-
ple without IBD. We also see that
patients with IBD and periodontitis
have an aggravated intestinal disease with a higher activity than patients with IBD who have no oral
health issues,” commented Prof.
Stavropoulos.
Based on the study results, the
research team concluded that patients with IBD should be kept
under close surveillance in order to
prevent the development of periodontitis and/or to slow down its
progression. “Similarly important,
it may be that treatment of periodontitis has a positive impact on
the management of IBD,” emphasised Prof. Stavropoulos.
The study, titled “Periodontitis
prevalence in patients with ulcerative colitis and Crohn’s disease—
PPCC: A case–control study”, was
published in the December 2022
issue of the Journal of Clinical Periodontology.
Ready for the future with
Implantmed Plus
By W&H Dentalwerk
Digitally always up to date:
W&H is constantly rolling out software updates and new product features for the Implantmed Plus. This
gives users unique perspectives
when treating their patients and for
their individual implantology and
surgical workflows.
For more than 20 years, Implantmed from W&H has been
helping clinics and dental practices
ensure that their work processes
are safe and efficient. Now, Implantmed software updates are
opening up even more opportunities for users, whether they are
using a brand-new device, or one
that’s five years old. These updates
are available for all Implantmed
Plus devices, and users can con-
tinue to look forward to new features in the future.
W&H is a digital pioneer
W&H has been providing software updates for its Implantmed
products for many years now, an
approach that sets it apart from
other manufacturers. The medical
technology company also follows
sustainable business practices, and
takes into account key factors such
as repairability, durability and upgradeability when developing its
products. This helps to extend the
service life of these products and
conserve resources in the process.
Sustainable solutions
W&H stands for sustainable
product and service solutions. Implantmed software updates ensure
users always have a state-of-theart device at their disposal. The upgradeability helps to conserve resources and reduce costs for the
customer at the same time. This approach helps keep devices in service for longer and ensures safe
and effective treatment thanks to
new technical features and unrivalled reliability.
Piezo technology as a simple
add-on for Implantmed
The launch of the Piezomed
module – which can be combined
with the Implantmed Plus as a simple add-on solution – was a highlight for W&H last year. This, coupled with the implant stability measurement and documentation feature, now makes W&H the first
manufacturer to cover the entire
surgical workflow. “This way of
thinking is exactly what we need
moving forward, i.e. modular devices with a range of integrated
features. And it shows that W&H’s
thinking has extended way beyond
the drill itself,” explains Dr Dennis
Rohner. The Implantmed software
updates were a key component of
this innovative technology and
provided the optimal conditions
for easily combining the devices
with each other.
Ready for the future
But it doesn’t stop there. W&H
is working on further upgrades, the
aim being to ensure that Implantmed Plus users are ready for
the future at all times. As well as the
option of combining the Implantmed with the Osstell Beacon
and implementing the Zygoma
handpiece, the number of drilling
steps that can be selected has also
been expanded. There is further information on the latest software
updates available at wh.com or
through authorised W&H service
partners, who support W&H customers with the Implantmed software updates.
For more information contact
W&H Dentalwerk
Web: www.wh.com
E-mail: office@wh.com
[2] =>
DTMEA_No.1. Vol.14_IT.indd
IMPLANT TRIBUNE
C2
Implant Tribune Middle East & Africa Edition | 01/2024
Peri-implantitis: Can it be
treated without surgery?
By Prof. Hady Haririan, Austria
With the introduction of a uniform classification of periodontal
and peri-implant disease in 2018,
definitions of health and disease
have now also been established for
implants.1 Comparable evidence on
peri-implantitis should therefore
be possible in the future. In recent
years, there have been enormous
developments in implantology
with regard to the digital workflow
and materials, but also new insights
into what can lead to failure or how
to counteract peri-implant mucositis and, subsequently, peri-implantitis. 2
The proportion of patients with
implants is increasing, due to an
ageing population. A study at the
University Clinic of Dentistry
Vienna in Austria showed that the
proportion of older patients with
implants is continuously increasing. 3 For example, the proportion
of patients between 70 and 75
years of age with implants in the
outpatient clinic was already 30% in
2017; in 2013, this was only around
20%. 3 Old age is linked to various
dimensions, usually accompanied
by various diseases, which in turn
can lead to polypharmacy and to
malnutrition. In order to maintain
stable occlusion in old age, people
increasingly rely on fixed prostheses, which, however, are sometimes
more difficult to clean than removable prostheses. The risk of complications also increases with age, and
peri-implantitis is almost inevitable
if prophylactic measures and the
reduction of risk factors are not undertaken promptly and closely
monitored.
Once bone resorption around
the implant has begun, there is no
predictable therapy that reliably
leads to cessation of the inflammation or to regeneration, as is the
case with periodontitis. The established treatment paradigm is that a
conservative approach is limited
and surgical intervention—resective or regenerative—is inevitable
once several threads of the implant
have become exposed. However,
the following patient cases are intended to demonstrate that even
initially hopeless situations can be
resolved by relatively simple therapeutic measures if peri-implantitis
has not yet progressed to the point
of complete mobility of the implant
(which was the situation in the first
case presented).
Peri-implantitis prevalence
and risk factors
On the one hand, implants as
replacements for lost teeth have a
relatively high success rate over
observation periods of more than
ten years.4 On the other hand, it has
been shown that 10–50% of implants showed signs of peri-implantitis after ten years. In general,
1
2
Fig. 1: The patient presented because of a broken denture tooth and loose restoration. Lifting of the upper lip revealed multiple fistula exits with pus discharge. Fig. 2: No further conservative therapy could be initiated for the maxillary implants.
3a
3b
Figs. 3a & b: Situation before conservative therapy (a) of peri-implantitis affecting implant #46 in the second case and six to
12 months thereafter (b).
4a
4b
Figs. 4a & b: Situation before conservative therapy (a) of peri-implantitis affecting implants #36 and 37 in the third case and
six to 12 months thereafter (b).
5a
5b
Figs. 5a & b: Situation before conservative therapy (a) of peri-implantitis affecting implant #36 in the fourth case and six to
12 months thereafter (b).
6a
6b
6c
Figs. 6a−c: Implant #36 in the fifth case was initially planned for explantation, but could ultimately be preserved only with
regenerative surgical measures (one-year follow-up).
the prevalence of peri-implant mucositis is as much as 80% and that
of peri-implantitis between 28 and
56%.5 Peri-implantitis cases are rising in daily practice, but their development can usually be linked to
known risk factors.6 These include:
•
smoking;
•
history of periodontitis;
•
poor oral hygiene;
•
irregular supportive periodontal therapy intervals; and
•
systemic disease (poorly controlled
diabetes,
cardiovascular disease, immunosuppression).
Sometimes it is a combination
of several risk factors that drastically increase the risk of complications. Zitzmann et al. have already
noted in a review that the incidence
of peri-implantitis is almost six
times higher in patients with periodontitis compared with non-periodontitis patients.7
Patient cases
Implant loss due to poor oral
hygiene and lifestyle habits
In the following patient case,
several factors led to failure. Despite the patient smoking more
than 40 cigarettes daily, implants
were placed in such a way that a
fixed restoration was possible. The
patient stated that she could not
tolerate any palatal coverage and
wanted a fixed option. Since her
smoking, abundant alcohol consumption and poor brushing habits
were not improved, peri-implantitis was not a surprise diagnosis.
This usually occurs around seven
years after implantation if—like in
the following case—periodontitis
treatment for the remaining dentition is ignored and the patient’s
lifestyle aggravating to the periodontium. The patient presented
because of aesthetic problems, but
also because the implants were already very loose (Fig. 1). Conservative periodontal therapy with instruction on the correct use of interdental brushes could not prevent the loss of the implants (Fig. 2).
Implant preservation with
the aid of subgingival cleaning
by air-scaler and concomitant
administration of systemic antibiotics
Is conservative peri-implantitis
therapy ever enough to resolve advanced peri-implantitis cases? The
following cases show that a single
subgingival cleaning with airscaler and adjunctive systemic antibiotics helped to regenerate the
bone around the implants. A single
-blind randomised clinical trial concluded that systemic adjunctive antibiotic administration does not
necessarily provide a clinically relevant benefit when, for example,
► Page C3
[3] =>
DTMEA_No.1. Vol.14_IT.indd
IMPLANT TRIBUNE
C3
Implant Tribune Middle East & Africa Edition | 01/2024
◄ Page C2
amoxicillin and metronidazole are
administered systemically in combination.8 Would the same effect
have occurred in the cases shown
here even without adjunctive metronidazole administration for seven
days after subgingival cleaning?
According to a more recent randomised clinical trial, the administration of metronidazole as an adjunct to non-surgical peri-implantitis therapy resulted in significant
improvements in clinical, radiographic and microbiological parameters after 12 months of follow-up.9
In the second, third and fourth
patient cases (Figs. 3–5), subgingival debridement was performed
once by air-scaler and then metronidazole was taken at a dosage of
500mg three times daily for seven
days.
Implant retention through
interdisciplinary treatment
Not all cases develop as promisingly as the second, third and
fourth cases did. The conservative
approach should always be attempted first, and if this does not
lead to the desired clinical success,
further surgical measures can be
considered, including the use of
methods for which there is not yet
a strong evidence base.10 The fifth
case involved an implant that was
inititally thought to be lost,
but could have been finally saved
after periodontitis/peri-implantitis
treatment and subsequent augmentation and use of a membrane
as well as use of the GalvoSurge implant cleaning system (Fig. 6). Such
interventions are relatively costly
and the corresponding costs for
augmentation material and the application of the electrode in that
•
•
•
•
7a
•
7b
Figs. 7a & b: Situation of a removable prosthesis in the upper jaw and a screw-retained prosthesis in the lower jaw in a patient.
procedure are ultimately borne by
the patients, who have an additional financial outlay in order to
save the implant. Surgical interventions can only take place in an operating theater or clinic—a challenge that older people are usually
no longer able to cope with, as they
are largely no longer able to attend
an appointment on their own.11
Ultimately, the best periimplantitis therapy is prevention
and control of risk factors, ideally
before implant placement begins.
In my view, the most common mistake is inadequate peri-implantitis
prevention and inadequate therapy, which usually consists only of
oral hygiene by the prophylaxis assistant. Sometimes patients are
also instructed to attend oral hygiene sessions every few weeks—
but this will not stop already existing peri-implantitis, and further
bone loss will occur.
The following scheme can help
to prevent complications with implants:
•
regular checks using a conventional periodontal probe (a
special plastic implant probe is
not necessary, but can make
access for probing a little easier);
annual close-up check of implants to detect incipient bone
loss as soon as possible;
screw-retained implants to
make it easier to deal with
complications;
a backup strategy for older
people so that initially fixed
restorations can be converted
into removable ones—supported on the same implants;
cleanable design of the superstructure—no artificial gingivae up to the alveolar ridge;
conscientious training on
using interdental brushes—
often people are still instructed on the use of dental
floss, which is usually insufficient when cleaning the implant superstructure to remove plaque from the often
wide interdental spaces.
Ageing population
According to the United
Nations, the global proportion of
people over the age of 65 will rise
to over 1.5 billion by 2050, and this
population group will account for
25–40% of the total population in
the EU. As the population ages, so
does the proportion in need of
care. According to the Austrian
Federal Statistical Office, for example, 70% of women older than 90
and around 50% men in this age
group require care, most of which
is provided at home by relatives.
How do complex and possibly even
fixed implant restorations fit into
the care regime? Even with patients who are institutionalised, the
nursing staff seem to be incapacitated (for example, the sixth case is
that of a patient from a Viennese
nursing home; Fig. 7). It is there-
fore of crucial importance to also
offer regular recall to the older
generation, especially to those who
can no longer visit the dental office
on their own. Mobile units are used
for this purpose, which unfortunately currently only take place on
a project basis and have not yet become established for the general
public in Austria.12
Editorial note: This article was first published in implants international magazine of oral implantology, Vol. 24, Issue
1/2023.
Prof. Hady
Haririan
is head of the
Department of
Periodontology at the dental clinic of
the Sigmund Freud University in Vienna
in Austria. He studied dentistry at the
Medical University of Graz in Austria
and the René Descartes University in Paris in France. He completed
postgraduate training in periodontics
at the Medical University of Vienna,
graduating with an MSc in periodontology in 2012. In 2017, he finished his
doctoral studies in the regeneration
of bones and joints programme at the
same university. In 2019, he completed
his habilitation in the field of periodontology. He has been a board member
of the Österreichische Gesellschaft
für Parodontologie (Austrian Society
of Periodontology) since 2013 and its
secretary general since 2019.
UCLA researchers develop
technology to dramatically reduce
peri-implantitis
By Anisha Hall Hoppe, Dental
Tribune International
With reported cases as high as
19%, the battle against periimplantitis has left clinicians and
researchers constantly searching
for ways to ensure that dental implant procedures can be more effective and less prone to postoperative complications. In this pursuit,
researchers at the University of
California, Los Angeles (UCLA) have
announced a new technology that
significantly reduces the risk of
postoperative
peri-implantitis
through enhanced osseointegration and removal of organic materials from the implant surface in
less than a minute.
The study explored a novel approach to make titanium implants
more compatible with the human
body. Over time, the surface prop-
erties and bioactivity of titanium
implants degrade owing to the
build-up of organic molecules on
their surface, impeding osseointegration once placed. Conventionally, a method called UV photofunctionalisation is used to clean
the titanium surface and enhance
its ability to bond with bone. However, this method is slow and not
very practical in a clinical setting
because it takes anywhere from 12
minutes to 48 hours. The new technology investigated in this study
uses a special kind of ultraviolet
light called vacuum UV (VUV) with
a wavelength of 172 nm, which is
very effective in breaking down the
unwanted organic molecules on
the titanium surface.
The researchers used methylene blue to simulate these molecules and found that VUV light
could remove 57% of this dye in
just 1 minute. This rapid cleaning
process with VUV light has several
potential advantages, in addition
to speed. VUV-treated implants exhibited almost 100% osseointegration, which increased anchoring
twofold and knocked off a full 60%
on measures of bacterial susceptibility. All tests were compared
against untreated control implants.
Dr Takahiro Ogawa, leader of
the research team and a professor
at the UCLA School of Dentistry,
commented in a press release: “We
have entered a new era in dental
implantology. This UV technology
not only enhances the effectiveness of dental implants but also improves the quality of life for patients. The possibilities are limitless, and I am incredibly excited
about the potential impact on oral
and overall health. Our goal is to
eradicate peri-implantitis.”
VUV works well on different
types of titanium and was effective
at treating titanium in quartz ampoules, indicating the possibility of
treating implants in their packaging to preserve sterility. It also has
potential uses with other materials,
and because time and efficiency
are crucial in medical settings, the
VUV process appears to be more
suitable than existing methods.
This technology could also result in
prostheses requiring fewer implants for their support and a lessened need for implant crowns of
reduced size according to the press
release.
The initial chronicle of the decade of research on the technology
performed by Dr Ogawa is detailed
in an article published in Journal of
Functional Biomaterials. In the latest research on VUV from 2023, Dr
Ogawa further illustrated that the
new 1 minute UV treatment was
able to induce gingival cells to form
a soft-tissue seal around implants.
This new development reduces the
potential for bacterial contamination of the implant and associated
peri-implantitis.
The new VUV light technology
offers a faster and more effective
way to prepare titanium implants
for surgery, potentially improving
the success rates of implants by ensuring better osseointegration and
sealing. This could be a significant
advancement in medical procedures involving implants, making
them safer and more reliable.
The study, titled “Vacuum ultraviolet (VUV) light photofunctionalization to induce human oral fibroblast transmigration on zirconia”,
was published online on 29 October 2023 in Cells.
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