Mucositis and peri-implantitis: why it is important to distinguish
There are two possible conditions around the implant, and the difference between them is fundamental. Mucositis is an inflammation of only soft tissues: the gums become red, swollen, and bleed during cleaning and probing, but the bone around the implant is not touched. This is a reversible condition: with high-quality cleaning and good hygiene, the tissues return to normal completely, just as an inflamed gum heals around an ordinary tooth. Peri-implantitis is the next stage, in which the inflammation spreads to the bone and it begins to decrease. The difference is that the lost bone does not grow back: even successful treatment stops the process, but does not return what was lost.
Hence the logic of observation. The task of the doctor and the patient is not to miss the transition from the first state to the second. That is why it is not enough to evaluate an implant “by eye”: you need to carefully measure the depth of the gingival sulcus and a photograph that is compared with the original one taken immediately after prosthetics. Such a comparative image is the only way to see that the bone level has changed by a millimeter and a half, long before any complaints appear.
- Mucositis: redness, swelling, bleeding on probing, bone level unchanged - reversible
- Peri-implantitis: the same signs plus pocket deepening and bone loss in the image - irreversible loss of support
- There is usually no pain with either
- Implant mobility is not an early symptom, but a late one, meaning loss of integration
- Pus and fistula indicate a pronounced process, and not its beginning
- The analogy with teeth is direct: mucositis correlates with gingivitis, peri-implantitis - with periodontitis
Why inflammation starts
The trigger mechanism is always the same - a microbial biofilm on the surface facing the gum. But very different circumstances help it to gain a foothold, and some of them are related not to the patient, but to the design features and technique of its fixation. Knowing the causes is important because without eliminating the cause, any treatment will only give a temporary result.
- Remains of cement under the gum is one of the most common and most underestimated causes; excess cement invisible to the eye acts as a constant irritant and retains the biofilm
- Previous or current periodontitis: the same bacteria that destroyed the bone around the teeth readily colonize the surface of the implant
- Smoking is a proven factor that impairs gum blood supply and healing.
- Insufficient hygiene, especially in between, and lack of regular professional cleaning
- Poor implant position: too close to an adjacent tooth or another implant, too superficial or at an awkward angle - such an area is physically impossible to clean
- The absence of a strip of dense keratinized gum around the implant, due to which the brush injures the tissue and the person begins to spare this area
- Crown design with an overhanging edge, under which plaque is retained
- Overload due to teeth grinding and improper distribution of chewing pressure
- Uncompensated diabetes mellitus
It is worth saying more about cement, because this is a reason that the patient cannot notice or prevent. When fixing the crown with cement, its excess is squeezed out over the edge and, if this edge is located deep under the gum, it is almost impossible to completely remove the remains - they are not visible either to the eye or on a regular photograph. Months later, persistent inflammation develops around such a fragment. That is why in many situations they prefer screw fixation of the crown, in which cement is not used at all, and the crown itself, if necessary, is removed and reinstalled.
How is it discovered?
Diagnosis of peri-implantitis is based on three things: measurement, image and comparison. None of them alone provides an answer. Examination without probing misses the pocket, probing without an image does not distinguish mucositis from peri-implantitis, and an image without an initial one does not show the dynamics.
- Осмотр состояния десны: цвет, отёк, наличие отделяемого при надавливании.
- Зондирование десневой борозды вокруг импланта специальным зондом с малым усилием — оценивают глубину и появление крови. Кровоточивость при зондировании считается ключевым признаком воспаления.
- Проверка подвижности импланта и отдельно — подвижности коронки: раскрутившийся винт даёт подвижность конструкции при полностью интегрированном импланте, и это совсем другая ситуация.
- Прицельный рентгеновский снимок и сравнение уровня кости с исходным.
- КЛКТ — при подозрении на дефект с язычной или щёчной стороны, который на плоском снимке не виден, и при планировании операции.
- Поиск причины: остатки цемента, нависающий край коронки, нарушение смыкания, состояние соседних зубов и общее состояние здоровья.
Treatment: what really works
Treatment always consists of two parts: eliminate the cause and clean the surface. This is the order. If there is cement left under the gum, if the crown has an overhanging edge, or if hygiene in this area is physically impossible, no treatment will give a lasting result. Therefore, treatment often begins with the removal of the crown - this is not a loss of investment, but a condition for success.
- Устранение причины: удаление остатков цемента, коррекция или переделка коронки, восстановление доступа для чистки, коррекция смыкания.
- Механическая очистка поверхности импланта инструментами, не повреждающими титан, — специальными кюретами, ультразвуковыми насадками с мягким покрытием, воздушно-абразивной обработкой мелкодисперсным порошком.
- Антисептическая обработка кармана. Антибиотики применяют только по назначению врача и как дополнение — сами по себе они воспаление вокруг импланта не излечивают.
- Обучение гигиене с подбором конкретных ёршиков и техники — без этого этапа рецидив практически неизбежен.
- Хирургическое лечение при сохраняющемся кармане: откидывают лоскут, очищают поверхность импланта под контролем зрения, сглаживают или обеззараживают её.
- Восстановительная методика с подсадкой костнозамещающего материала — когда дефект имеет форму чаши и способен удержать материал.
- Резективная методика — когда дефект широкий: излишек воспалённой ткани убирают и формируют такой контур, который пациент сможет чистить.
- Удаление импланта — при выраженной подвижности и утрате большей части кости. После заживления нередко возможна повторная имплантация.
Separately, about the most tenacious expectation: that a course of antibiotics will solve the problem. An antibiotic can relieve an acute exacerbation - the swelling will go away, the discharge of pus will stop, and the person will decide that he has been cured. But the biofilm on the rough surface of the implant is resistant to systemic drugs, and the lost bone does not return from them. A few months later the process continues from the same place, only now there is less support. Antibiotics have their place in the treatment of peri-implantitis, but this place is next to mechanical cleaning, and not instead of it.
Prevention: What Really Reduces Risk
Peri-implantitis is much easier to prevent than to treat, and most prevention lies in the area of daily habits. The basic idea is simple: an implant requires as much care as your own tooth, and in some respects more, because it does not signal pain.
- Daily cleaning of gaps: brushes of the size selected by the doctor, superfloss, irrigator - a brush alone cannot cope with this task
- Professional hygiene at least once or twice a year, and in case of previous periodontitis - every three to four months
- Control image one year after prosthetics and further as prescribed by the doctor
- Complete treatment of periodontitis and caries before implantation and maintenance of results after
- Quitting smoking
- Protective mouthguard for teeth grinding
- Preferring a screw-retained crown where possible, or positioning the crown margin so that excess cement can be completely removed
- Monitoring blood glucose levels in diabetes