FOCUS: EFP’s second Perio Master Clinic will offer in-depth accounts of developments in understanding and treatment of peri-implantitis

Peri-implantitis represents one of the biggest challenges in periodontology today: scientific understanding of its causes is still evolving and various forms of treatment are being used, although the “gold standard” has yet to emerge.

With cases of peri-implantitis in Europe expected to rise significantly over the next decade – reflecting the rapid growth of dental implants – the challenge thrown down by this disease has to be faced by periodontists and other oral-health professionals.

It is in this context that the EFP Perio Master Clinic 2017 takes place in March, devoted to the latest scientific findings about peri-implantitis and to current approaches to the clinical treatment of this disease. The two-day event, held in the Maltese capital of Valletta, will also focus on how peri-implantitis can be prevented.

One of the key findings of the EFP’s XI European Workshop on Periodontology (the “Prevention Workshop”) was that peri-implant diseases are highly prevalent and the situation is likely to get worse before it improves.

According to the EFP’s recent “Delphi study” on trends in periodontology and periodontics in Europe until 2025, the prevalence of periodontitis in Europe is expected to stabilise over the next decade, but implant-related diseases are expected to increase, despite anticipated improvements in surgical techniques and in the quality of implants.

“As implants are becoming a very popular treatment option to replace lost teeth and this has become very common in everyday practices, the number of peri-implantitis case will also increase,” says Stefan Renvert, scientific chair of Perio Master Clinic 2017.

“Even if implant therapy is a fantastic treatment option, we should not overlook that roughly 15 to 20 per cent of individuals have developed peri-implantitis within a time period of five to 10 years of receiving implants, which creates a big treatment need for all those patients.”

Turning to the causes of peri-implantitis, Prof Renvert notes that it is now widely accepted that micro-organisms play the major role in initiating an inflammatory process that may result in loss of bone adjacent to the implant. “Some individuals seem to be more prone to developing peri-implantitis than others,” he observes. “Individuals with a history of periodontal disease and smokers are at higher risk of disease.”

Comparing peri-implantitis with periodontitis, he points out that the inflammatory lesion at implants is larger and extends deeper, down to the bone, than the inflammation around teeth in periodontitis and it also seems to be more acute.

These current theories about the aetiology of peri-implantitis have been supported by several animal studies.

The challenge of treatment

“Although there is no consensus on treatment modalities, these diseases are preventable,” says Korkud Demirel, chair of the event’s organising committee. “Peri-implant diseases are not rare diseases and need to be treated in all clinical settings.”

In his view, the major challenge that peri-implantitis presents to periodontists is in decontaminating the previously contaminated implant surfaces.

Prof Renvert adds that the tools used for the treatment of periodontitis at teeth “are not ideal for the treatment of a roughened, threaded implant surface, which makes non-surgical therapy difficult.”

He notes that “there seems to be an advantage to get access to the implant surface through surgical techniques” and that, in cases where a regenerative approach is suitable, “it has been demonstrated that the result obtained may be stable over at least five years.”

The key to successful treatment is the elimination of inflammation and the removal of plaque-retention factors. Treatment may also include attempts to regenerate the lost tissues. In addition, patients need to be motivated to perform good oral hygiene and to return for regular supportive therapy.

Six sessions

Perio Master Clinic 2017 will address the various dimensions of this disease and the issues it raises in six sessions, organised around the core theme of “Peri-implantitis: from aetiology to treatment.”

• Peri-implantitis: aetiology, epidemiology, and diagnosis of the peri-implant diseases: The focus of this presentation by Niklaus Lang will be on early diagnosis, which makes cases of peri-implantitis much easier to handle.

• Can we reduce the risk of peri-implant diseases by improving soft tissues adjacent to implants? This session will focus on how to increase the width of keratinized tissue and soft-tissue thickness at implants in an attempt to avoid recessions.

• Soft-tissue recession at implants will consider the question of soft-tissue recessions in the aesthetic zone and whether it is possible to cover exposed metal that destroys the smile, together with a step-by-step approach to tackling dehiscence defects in combination with peri-implantitis.

• Resective surgical approaches – when are they an option? The focus here will be on pocket reduction in areas with fewer aesthetic demands and on surgery that increases cleanability, along with the question of whether the modification of implant surfaces is the therapy of choice.

• Regeneration of peri-implantitis defects – is it possible? Different techniques will be presented, including the use of membranes, various bone-augmentation procedures, and LPRF (leukocyte and platelet-rich fibrin) therapy.

• Treatment plan for advanced peri-implantitis cases will explore the questions of what happens if the “man-made bone” gets infected and when it is better to remove and replace an implant.

The meeting will end with a panel discussion involving the moderators of all six sessions and closing remarks from Stefan Renvert and Korkud Demirel.

Turning attendees into participants

One of the novelties of this second edition of the Perio Master Clinic is an innovative approach to scheduling through which attendees are able to influence the presentations given by the expert speakers.

When registering for the event, people are given a questionnaire which asks them to indicate the questions that are most important to them. For each session, five specific questions are listed and registered participants are invited to indicate their first and second choices from this list.

For example, the five questions on the session on the regeneration of peri-implant defects are:

1. In which clinical situations is a regenerative approach the preferred treatment option for peri-implantitis?

2. Is the selection of a regenerative procedure more important than the selection of an implant surface decontamination method?

3. If the peri-implant defect is favourable, what type of regenerative material should I use?

4. Which clinical situation would benefit from use of a membrane?

5. How would one assess if removal and replacement of the affected implant is preferable to attempting regeneration of the peri-implant defect? 

Attendees are asked to indicate the two questions that they consider most important. Through this feedback, speakers will be able to tailor their presentations to the specific interests of the audience.

“The main purpose was to get deeper involvement of attendees, making them part of the game, not only a spectator,” says Demirel, who adds that the questionnaire has been “very well accepted by the registrants, and the response rate is over 90%.”

Building on success of Paris

The aim of the EFP’s Perio Master Clinic meetings is to bring together clinicians who wish to improve their skills in clinical practice to the highest possible level. The idea is to offer a master clinic that take place between the triennial EuroPerio meetings and to keep it as a relatively small-scale event (a maximum of 600 participants) which enables all EFP member societies to be able to host the event now that there are few venues big enough to host EuroPerio.

The first Perio Master Clinic took place in Paris in February 2014, attended by 520 experts from 45 countries. Chaired by Jean-Louis Giovannoli, its topic was peri-implant plastic and reconstructive surgery.

Korkud Demirel says that the Paris event demonstrated the value of a focused meeting between the EuroPerio congresses and that it should be “a very clinically high-end meeting.”

Unlike the event in Paris, the Malta master clinic will also feature an exhibition (with 16 exhibitors confirmed and two pending). “This was requested by many of the attendees in 2014 and we want to offer them the chance to find, among other things, the surgical kits discussed by the speakers in an exhibition,” says Stefan Renvert.

Registrations for the event have been going well with 85% of places now booked with participants coming from 46 different countries.

The venue for the master clinic is certainly very attractive. The Mediterranean Conference Centre is located at the edge of historic city of Valletta, adjacent to Fort St. Elmo and overlooking the Grand Harbour. It is a sixteenth-century building formerly known as the “Sacra Infermeria” of the Order of St. John, the Knights of Malta.

There is still time to book a place at Perio Master Clinic 2017. Those who attend will come away with the latest insights on the aetiology and treatment of a disease which will continue to have a major impact on the work of periodontists for many years to come. These insights will be crucial to improving care for patients with implants, both in treating peri-implantitis and in preventing its occurrence in the first place.