Assessment of marginal tissues is a good indicator to evaluate the health of an implant and is done as discussed below:
Mucosal Conditions
In addition to the redness and swelling of the marginal tissues, bleeding on probing (BOP), pocket formation, and suppuration have been reported to result from periimplant infections. Assessment of these clinical signs has been considered important in the diagnosis of periodontal diseases. Therefore, the definition of periimplant parameters based on the Gingival index system is indicated. The Gingival Index has been modified to be applied around dental implants and periimplant marginal tissue can be assessed by passing a periodontal probe along the mucosal margin adjacent to the implant. The severity of response varies from no bleeding, isolated bleeding spots to heavy/profuse bleeding. Evaluation of tissue on the basis of appearance of redness of tissue, oedema and ulceration is also done. However,around implants the soft tissue texture and colour depends on the normal appearance of the recipient tissues before implant placement and maybe influenced by the material characteristics of the implant surface. Therefore, only a weak correlation between the Gingival Index type scores and periimplant crestal bone levels have been reported.
Bleeding on Probing (BOP)
BOP when elicited (notated in patient record as BOP +) after the insertion of a probe into the sulcus with light pressure i.e. 25 N has been shown to detect the presence of an inflammatory lesion in the gingiva around teeth with a normal and healthy but a reduced periodontium. On the other hand an absence of BOP (BOP-) has been reported to represent periodontal health with a negative predictive value of 98.5 per cent that means the absence of bleeding on probing is a very sound indicator for periimplant health.Criteria of Success of
Mucosal Conditions
In addition to the redness and swelling of the marginal tissues, bleeding on probing (BOP), pocket formation, and suppuration have been reported to result from periimplant infections. Assessment of these clinical signs has been considered important in the diagnosis of periodontal diseases. Therefore, the definition of periimplant parameters based on the Gingival index system is indicated. The Gingival Index has been modified to be applied around dental implants and periimplant marginal tissue can be assessed by passing a periodontal probe along the mucosal margin adjacent to the implant. The severity of response varies from no bleeding, isolated bleeding spots to heavy/profuse bleeding. Evaluation of tissue on the basis of appearance of redness of tissue, oedema and ulceration is also done. However,around implants the soft tissue texture and colour depends on the normal appearance of the recipient tissues before implant placement and maybe influenced by the material characteristics of the implant surface. Therefore, only a weak correlation between the Gingival Index type scores and periimplant crestal bone levels have been reported.
Bleeding on Probing (BOP)
BOP when elicited (notated in patient record as BOP +) after the insertion of a probe into the sulcus with light pressure i.e. 25 N has been shown to detect the presence of an inflammatory lesion in the gingiva around teeth with a normal and healthy but a reduced periodontium. On the other hand an absence of BOP (BOP-) has been reported to represent periodontal health with a negative predictive value of 98.5 per cent that means the absence of bleeding on probing is a very sound indicator for periimplant health.Criteria of Success of
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| Plastic autoclavable perio- probe with marking at 3-6-9-12 mm. |
This probing around implants has been controversial as some groups refute it stating that bleeding could have been caused by inappropriate force transmission by the periodontal probe tip to the periimplant soft tissue. Conversely other studies have conclusively proved the efficacy of BOP in periimplant conditions with the negative BOP status serving as a predictor for stable periimplant condition whereas both perimucositis and periimplantitis show substantially increased BOP (67 percent and 91 percent respectively).
Periimplant Probing Depth
In contrast to natural teeth, for which the average periodontal probing depth (PD) has been reported, the physiologic depth of the periimplant sulcus of successfully osseointegrated implants has been a matter of debate. There is widespread acceptance however that increasing periodontal PD and loss of clinical attachment are pathognomic for periodontal diseases. Pocket probing is therefore an important diagnostic process for the assessment of periodontal status for the evaluation of periodontal therapy. The extent of the probe penetration is influenced by factors such as probing force and angulation, probe tip diameter, roughness of the implant or root surface, inflammatory state of the periodontium and firmness of the marginal tissues.
Periimplant Probing Depth
In contrast to natural teeth, for which the average periodontal probing depth (PD) has been reported, the physiologic depth of the periimplant sulcus of successfully osseointegrated implants has been a matter of debate. There is widespread acceptance however that increasing periodontal PD and loss of clinical attachment are pathognomic for periodontal diseases. Pocket probing is therefore an important diagnostic process for the assessment of periodontal status for the evaluation of periodontal therapy. The extent of the probe penetration is influenced by factors such as probing force and angulation, probe tip diameter, roughness of the implant or root surface, inflammatory state of the periodontium and firmness of the marginal tissues.
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| The use of plastic perio probe around a healed implant. The visibility of green band (i.e.PD < 3mm) indicates healthy sulcus. |
The differences with respect to soft tissue composition, organization and attachment between the gingiva and root surface on one hand and between the periimplant mucosa and the implant surface on the other, make the conditions for PD measurement around teeth and implants not fully comparable. One potential explanation for the differences in probe penetration is that most collagen fibres in the supracrestal connective tissue compartment have been demonstrated to run mostly in a direction parallel to the implant axis and not perpendicular as seen in teeth.
However Perimplant PD should be measured routinely during maintenance appointment with a less probing force (0.2 to 0.3 N) as the tissue is more sensitive.Even with this less force, it was found that the probe caused a separation between the surface of the implant and the junctional epithelium, but not within the connective tissue adaptation. The healing of this breach is complete within 5 days of probing.There are also concerns that the probing can also introduce pathogens into the periimplant tissue. The PD is affected by the density of the peri implant tissues.In the presence of periimplant inflammation the periodontal probes penetrate close to the alveolar bone exceeding the connective tissue level by an average of 0.52.mm.Even with the influence of variables such as the roughness of the implant surface,difficult access, and location of the microgap in submerged implants, the advantages of probing (Simplicity, immediate availability of results, ability to demonstrate the topographic disease pattern) makes probing an indispensable part of the maintenance assessment.
Probing depths can be influenced by the tissue type— shallow depths are associated with a keratinized collar, whereas deeper depths are associated with mobile alveolar mucosa surrounding the dental implant.Use of a fixed reference point on the abutment or prosthesis for a reliable measurement of the attachment levels is recommended.Successful implants have a PD of 3 mm, whereas pockets of 5 mm or more serve as a protective environment for bacteria and is a signs of peri-implantitis.It is important to note that the PD should not be measured during the first 3 months after abutment connection to avoid disturbing the healing and the establishment of the soft tissue seal.
Width of the Periimplant keratinized Mucosa
Clinical and experimental studies have failed to support the concept of an “adequate width” of keratinized tissue adjacent to natural teeth for the maintenance of periodontal health. Implant research has also focused on the necessity of the presence of keratinized mucosa around oral implants.The absence of the keratinized mucosa around implants seems to increase the susceptibility of plaque induced periimplant disease. However, in the presence of good oral hygiene, the nature of the mucosa may have little influence on the long term survival of the implants. But, it is important to note that in case of suboptimal oral hygiene there is greater tissue damage around implants within alveolar mucosa than around implants within keratinized tissue. Therefore it is an important parameter to take note of.
Periimplant Sulcus Fluid Analysis (PISF)
This is not a parameter for clinical use but for experimental situations. However, it is important for us to know about it. Several biochemical mediators in the gingival crevicular fluid around natural teeth have been identified as potential host markers for periodontal disease activity and progression. A few studies have been reported on the association between the signs of periimplant inflammation and the levels of inflammatory mediators in the PISF. IL-1 Beta, PGE2, PDGF, enzymes from PMN, lactoferrin and elastase have been found in higher levels around affected implants than the control healthy ones.
Suppuration
High number of PMN cells have been detected around implants that are associated with severe signs of mucosal inflammation. Several studies have shown the presence of inflammatory cell infiltrates in cases of periimplantitis. This may explain the presence of suppuration at the sites with active periimplant disease.
However Perimplant PD should be measured routinely during maintenance appointment with a less probing force (0.2 to 0.3 N) as the tissue is more sensitive.Even with this less force, it was found that the probe caused a separation between the surface of the implant and the junctional epithelium, but not within the connective tissue adaptation. The healing of this breach is complete within 5 days of probing.There are also concerns that the probing can also introduce pathogens into the periimplant tissue. The PD is affected by the density of the peri implant tissues.In the presence of periimplant inflammation the periodontal probes penetrate close to the alveolar bone exceeding the connective tissue level by an average of 0.52.mm.Even with the influence of variables such as the roughness of the implant surface,difficult access, and location of the microgap in submerged implants, the advantages of probing (Simplicity, immediate availability of results, ability to demonstrate the topographic disease pattern) makes probing an indispensable part of the maintenance assessment.
Probing depths can be influenced by the tissue type— shallow depths are associated with a keratinized collar, whereas deeper depths are associated with mobile alveolar mucosa surrounding the dental implant.Use of a fixed reference point on the abutment or prosthesis for a reliable measurement of the attachment levels is recommended.Successful implants have a PD of 3 mm, whereas pockets of 5 mm or more serve as a protective environment for bacteria and is a signs of peri-implantitis.It is important to note that the PD should not be measured during the first 3 months after abutment connection to avoid disturbing the healing and the establishment of the soft tissue seal.
Width of the Periimplant keratinized Mucosa
Clinical and experimental studies have failed to support the concept of an “adequate width” of keratinized tissue adjacent to natural teeth for the maintenance of periodontal health. Implant research has also focused on the necessity of the presence of keratinized mucosa around oral implants.The absence of the keratinized mucosa around implants seems to increase the susceptibility of plaque induced periimplant disease. However, in the presence of good oral hygiene, the nature of the mucosa may have little influence on the long term survival of the implants. But, it is important to note that in case of suboptimal oral hygiene there is greater tissue damage around implants within alveolar mucosa than around implants within keratinized tissue. Therefore it is an important parameter to take note of.
Periimplant Sulcus Fluid Analysis (PISF)
This is not a parameter for clinical use but for experimental situations. However, it is important for us to know about it. Several biochemical mediators in the gingival crevicular fluid around natural teeth have been identified as potential host markers for periodontal disease activity and progression. A few studies have been reported on the association between the signs of periimplant inflammation and the levels of inflammatory mediators in the PISF. IL-1 Beta, PGE2, PDGF, enzymes from PMN, lactoferrin and elastase have been found in higher levels around affected implants than the control healthy ones.
Suppuration
High number of PMN cells have been detected around implants that are associated with severe signs of mucosal inflammation. Several studies have shown the presence of inflammatory cell infiltrates in cases of periimplantitis. This may explain the presence of suppuration at the sites with active periimplant disease.
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