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Professor Niklaus Lang
Peri-implantitis as an opportunistic infection – the challenge for the future in dental medicine

Report by Sunny Kaushal

Prof Lang
After a long journey from Hong Kong and as last speaker of the day, Prof. Lang took to the podium at 4pm. He was still bursting with enthusiasm for his subject and this came across clearly to the audience throughout his lecture.

He began by stating that there is overwhelming evidence in the literature that peri-implantitis is an opportunistic infection. He then went on to describe how classical and opportunistic infections arise and differ in their management and also the significance of the Biofilm.

Classical infections arise as a result of exogenous pathogens entering the host and eliciting a response, whereas opportunistic infections are borne out of a change in the environment which allows the normally present pathogens to proliferate. 

Biofilms will readily form on all surfaces of the oral cavity. So as soon as an implant is placed it will become colonised via the formation of a biofilm. Early microbial settlers are followed by colonisation, proliferation and the formation of micro-colonies. As the micro-colonies expand the demand for substrate increases.  Oxygen is steadily used up and the environment becomes more anaerobic, which in turn allows the anaerobes to proliferate and elicit the host response. The European workshop on periodontology 1993 declared that P. gingivalis, Aggregatibacter Actinomycetemcomitans and Tamarella forsythia are the most important pathogens identified in peri-implantitis.

The biofilm itself is a structured environment with the intake of nutrient supplies, cross feeding and waste elimination. The pathogens within the biofilm are in a so called “protected niche.” The biofilm offers some resistance to antibiotics so in order to be effective, high doses would be required. Low doses will only contribute to the resistance.

Treatment strategies:

We can affect biofilm growth by tooth brushing but we also have to be aware that as soon as the brushing stops a new biofilm will start to form immediately. We have to affect this environment in a more aggressive way and be more disturbing to the colonies. Send in the Tsunami Prof Lang said!

In the treatment of a classical infection, the removal of the exogenous pathogens should return the situation back to a normal homeostasis whereas in the opportunistic case the idea is to decimate the pathogens so that there can be a return to the normal micro-biota. This can only be achieved by addressing the conversion factor (environmental change) that triggered the opportunistic infection from homeostasis in the first place.

There is a need to maintain good periodontal health and to eliminate the reservoirs of pathogens……..the ecological approach.

Professor Lang Concluded that:

Opportunistic infections have to be treated by applying an environmental approach

In Peri-implant infection, antibiotic therapy needs to penetrate the biofilm so high concentrations are required for long enough

Combination therapy may be successful

It is important to identify and treat the mucositis to prevent the later complication of peri-implantitis

Questions and Answers

Q1. A patient comes in with widespread chronic periodontal disease and we understand that it needs treatment prior to implant therapy.  Is widespread extraction part of the ecological approach or to put it another way are placing implants in to patients where you try and maintain these niches more susceptible than if we remove these niches before placing the implants?

A1. There may be a limit to maintaining the hopeless teeth or teeth that are completely irrational to treat. Clean up the mouth before implant therapy otherwise we are more prone to complications. The question to ask is “can I treat the patient successfully ?” if yes, then keep the tooth if not then extract the tooth….its a simple as that.

Q2. Do you feel that the peri-implantitis early on, for example, in the first year subsequent to loading is different to that peri-implantitis that may be seen later? In other words like in periodontitis is there an aggressive peri-implantitis versus a chronic peri-implantitis?

A2. I don’t know but a good point is raised. If an implant fails in the first six months it is usually due to surgical failure. Peri-implantitis however, takes time to develop and starts as a mucositis as a result of biofilm on a smooth surface. I don’t know if rapidly progressive or aggressive forms exist as there is no data on this.

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