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www.elsevierhealth.com/journals/jhin
REVIEW
Glasgow Dental Hospital and School, Faculty of Medicine, Glasgow University, Glasgow, UK
Infection Research Group, Glasgow Dental Hospital and School,
Faculty of Medicine, Glasgow University, Glasgow, UK
b
KEYWORDS
Dental implants;
Failure; Infections;
Peri-implantitis
Introduction
* Corresponding author. Address: Infection Research Group,
Level 9, Glasgow Dental Hospital and School, 378 Sauchiehall
Street, Glasgow G2 3JZ, UK. Tel.: 44 0141 211 9747; fax:
44 0141 353 1593.
E-mail address: a.smith@dental.gla.ac.uk
0195-6701/$ - see front matter 2009 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2009.02.010
Osseointegration
After endosseous implant fixtures are surgically
inserted into bone, the process of osseointegration
begins. Osseointegration is considered a direct,
structural and functional connection between
organised vital bone and the surface of a titanium
implant, capable of bearing the functional load.10
This is possible as the titanium surface oxide layer
(mainly titanium dioxide) is biocompatible, reactive and spontaneously forms calcium-phosphateapatite.11
Furthermore, the titanium oxide surface of
implants achieves a union with the superficial
gingivae restricting the ingress of oral microorganisms. Consequently, the implant/soft tissue
interface is similar to the union between tooth and
gingivae.12
105
Classification of failures
Implants can be described as failing or failed. A
failing implant demonstrates a progressive loss of
supporting bone but is clinically immobile,
whereas a failed implant is clinically mobile.18
When an implant has failed, removal is recommended while a failing implant may be salvaged if it is
diagnosed early and treated appropriately.19,20
Implant failures may also be categorised as early
or late. Early failures occur before osseointegration
and prosthetic rehabilitation has taken place with
late failures occurring afterwards.13 Factors affecting early failure of dental implants may be broadly
classified as: implant-, patient- and surgical technique/environment-related (Table I). Late failures
106
Comment
Implant
Previous failure
Surface roughness
Surface purity and sterility
Fit discrepancies
Intra-oral exposure time
Premature loading
Mechanical
Traumatic occlusion due to inadequate
overloading restorations
Oral hygiene
Patient (local Gingivitis
factors)
Bone quantity/quality
Adjacent infection/inflammation
Presence of natural teeth
Periodontal status of natural teeth
Impaction of foreign bodies (including
debris from surgical procedure) in the
implant pocket
Soft tissue viability
Vascular integrity
Smoking
Patient
Alcoholism
(systemic
Predisposition to infection, e.g. age,
factors)
obesity, steroid therapy, malnutrition,
metabolic disease (diabetes)
Systemic illness
Chemotherapy/radiotherapy
Hypersensitivity to implant
components
Surgical trauma
Surgical
Overheating (use of handpiece)
technique/
environment Perioperative bacterial
contamination, e.g. via saliva, perioral
skin, instruments, gloves, operating
room air or air expired by patient
the osseointegration process. Some of the most frequent causes of soft tissue infection during the healing period involve residual suture material, poorly
seated cover screws, protruding implants and trauma
from inadequately relieved dentures or occlusal
trauma from opposing teeth.19
107
Type of implant
(no. of patients/implants)
Method of detection
Bra
nemark
(37/1e4 per patient)32
Culture
Not stated
(41/not stated)33
Culture/indirect
immunofluorescence
Culture/dark field
microscopy
Culture
Checkerboard DNAeDNA
hybridization technique
Culture
Various (10/12)39
PCR
9 Astra
16 Bra
nemark
5 ITI
Staumann (17/30)40
Culture
theatre conditions compared to a less environmentally controlled dental school clinic.48 This may imply
that the operative environment is not as critical to
the success of dental implants compared to implant
placement within other body sites. Several strategies
to reduce contamination from the oral flora during
surgery have been postulated.49,50 One such strategy
involves rinsing preoperatively with chlorhexidine as
this may reduce microbial complications following
implant placement.51 An in-vivo study showed that
chlorhexidine in suspension form is more effective
in inhibiting Porphyromonas gingivalis than the use
of antibiotics.52 Others, however, failed to reach
these conclusions.53
During the surgical procedure, the implant
should be stored in the manufacturers sterile
packaging and only used in conjunction with the
recommended instruments. Previously, the drills
used for bone preparation were not designated
single use and were decontaminated according to
108
Table III Suggested treatments for infected dental
implants20,29,57
Mechanical debridement
Pharmaceutical treatment e irrigation with
chlorhexidine, local antibiotics (e.g. tetracycline
fibre) and systemic antibiotics
Surgical procedures e open flap debridement (to
decontaminate and smooth the implant surface)
Correct anatomical conditions that impair plaque
control and encourage the formation of an anaerobic
environment (includes both resective procedures and
regenerative techniques such as guided tissue
regeneration)
Monitoring of success/failure
In the UK there are no surveillance programmes in
place providing epidemiological data on the microbiology, success and failure rates of dental implants.
Conversely, in Finland an Implant Register provides
comprehensive data on the number of implants
inserted and removed together with any complications related to the treatment.14 The programme
strives to ensure safe treatment for patients and
has been operational for nearly 20 years.
Conclusion
Dental implants are an increasingly common form of
prosthetic device implanted into patients. The
apparent high success rate for the placement of
endosseous dental implants under uncontrolled environmental conditions and through a heavily colonised oral environment appears counterintuitive. If
dental implants become infected the causative
micro-organisms are usually those implicated in
periodontal disease and include a range of Gramnegative anaerobes and spirochaetes. Since
S. aureus and coliforms are infrequently detected
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