The Use of the Dental Endoscope and Videoscope for Diagnosis and Treatment of Peri-Implant Diseases










Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition.
Edited by Stephen K. Harrel and Thomas G. Wilson Jr.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
Companion Website: www.wiley.com/go/harrel/minimallyinvasive
65
5
Overview
Inflammation is frequently found around failed or failing implants. Some feel
that these are infections engendered by some of the same bacteria associated with
periodontal diseases [1]. Others have suggested that this inflammation is caused
at least in part by a foreign body reaction [2]. An inflammatory response limited
to the soft tissues surrounding implants is referred to as peri-implant mucositis.
If the inflammation results in progressive bone loss, the condition is currently
termed “peri-implantitis.” These two inflammatory responses are categorized
under the super heading of peri-implant disease.
Chapter objectives
This chapter outlines treatments available for peri-implant diseases using mini-
mally invasive procedures. The use of the dental endoscope in diagnosis and the
endoscope and videoscope in the treatment of peri-implant disease will beempha-
sized. Clinical and scientific information currently available indicates thatif the
inflammation associated with peri-implant mucositis is diagnosed and treated at
an early stage, loss of bone may not occur. It should also be understood that our
The Use of the Dental
Endoscope and Videoscope
forDiagnosis and Treatment
ofPeri-Implant Diseases
Thomas G. Wilson Jr.

66 Minimally Invasive Periodontal Therapy
understanding of these inflammatory processes is at an early stage. It should also
be stated that appropriate treatment for periodontal diseases may not be totally
applicable to the inflammatory responses seen around dental implants.
However, current information suggests that appropriate treatment of peri-
implant disease may slow down or in some cases halt further bone loss,although
reintegration of the lost bone has not yet been demonstrated inhumans [3]. At
present, most peri-implantitis is treated in its early stages using flap surgery
and in its advanced form by implant removal. However, in some of these cases,
the disease can be halted or delayed in the early stages by theuse of the dental
endoscope alone. The videoscope is suggested for more advanced lesions.
Diagnosis and technique
The diagnosis and treatment of peri-implant diseases begins with gathering
appropriate clinical and radiographic information. The current data gathering
mimics that used for periodontal diseases. This means that probing depths
around implants need to be measured and recorded. Signs of inflammatory
changes (bleeding upon probing, suppuration, color changes associated with
inflammation, etc.) should be noted and recorded. Periodic right-angle radio-
graphs are also appropriate. Because of the relatively high incidence of peri-
implant disease, it is imperative that implants be followed on a regular
maintenance schedule. This will allow for the comparison of clinical and radio-
graphic findings over time and enhance the clinicians’ ability to determine
when treatment beyond routine maintenance therapy should be performed.
Treatment is currently based on the diagnosis and characterization of the
inflammatory lesion. Patients who present with clinical signs of inflammation
but whose probing depths have not increased and have no radiographic signs of
increased bone loss are diagnosed as having peri-implant mucositis. Patients so
diagnosed should have their oral hygiene reinforced, the peri-implant space
(sulcus) and the implant/restorative surfaces debrided using curettes or ultra-
sonic devices. Attempts should be made to remove surrounding “granulation”
tissue. They are usually placed on chlorhexidine rinse twice a day for 30 days.
Some clinicians will elect to place the patient on 7–10 days of broad-spectrum
antibiotics at this time; but in the absence of suppuration, this does not appear to
be routinely indicated. Evaluation and possible treatment of any occlusal dishar-
monies on the implant prosthesis is also strongly suggested. The patient should
be reevaluated after 30 days. If at that time continued signs of inflammation are
detected, further treatment is indicated. In these cases, the use of the dental endo-
scope will enhance the evaluation and treatment of the subgingival environment
and help elucidate the source of peri-implant inflammation.
Individuals who present with increased probing depths or radiographic signs
of progressive bone loss are given a diagnosis of peri-implantitis. Aggressive
treatment of the underlying cause of these clinical findings is indicated when this
diagnosis is made. The endoscope is valuable in both the diagnosis and treatment

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Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition. Edited by Stephen K. Harrel and Thomas G. Wilson Jr. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.Companion Website: www.wiley.com/go/harrel/minimallyinvasive655OverviewInflammation is frequently found around failed or failing implants. Some feel that these are infections engendered by some of the same bacteria associated with periodontal diseases [1]. Others have suggested that this inflammation is caused at least in part by a foreign body reaction [2]. An inflammatory response limited to the soft tissues surrounding implants is referred to as peri-implant mucositis. If the inflammation results in progressive bone loss, the condition is currently termed “peri-implantitis.” These two inflammatory responses are categorized under the super heading of peri-implant disease.Chapter objectivesThis chapter outlines treatments available for peri-implant diseases using mini-mally invasive procedures. The use of the dental endoscope in diagnosis and the endoscope and videoscope in the treatment of peri-implant disease will beempha-sized. Clinical and scientific information currently available indicates thatif the inflammation associated with peri-implant mucositis is diagnosed and treated at an early stage, loss of bone may not occur. It should also be understood that our The Use of the Dental Endoscope and Videoscope forDiagnosis and Treatment ofPeri-Implant DiseasesThomas G. Wilson Jr. 66 Minimally Invasive Periodontal Therapyunderstanding of these inflammatory processes is at an early stage. It should also be stated that appropriate treatment for periodontal diseases may not be totally applicable to the inflammatory responses seen around dental implants. However, current information suggests that appropriate treatment of peri-implant disease may slow down or in some cases halt further bone loss,although reintegration of the lost bone has not yet been demonstrated inhumans [3]. At present, most peri-implantitis is treated in its early stages using flap surgery and in its advanced form by implant removal. However, in some of these cases, the disease can be halted or delayed in the early stages by theuse of the dental endoscope alone. The videoscope is suggested for more advanced lesions.Diagnosis and techniqueThe diagnosis and treatment of peri-implant diseases begins with gathering appropriate clinical and radiographic information. The current data gathering mimics that used for periodontal diseases. This means that probing depths around implants need to be measured and recorded. Signs of inflammatory changes (bleeding upon probing, suppuration, color changes associated with inflammation, etc.) should be noted and recorded. Periodic right-angle radio-graphs are also appropriate. Because of the relatively high incidence of peri-implant disease, it is imperative that implants be followed on a regular maintenance schedule. This will allow for the comparison of clinical and radio-graphic findings over time and enhance the clinicians’ ability to determine when treatment beyond routine maintenance therapy should be performed.Treatment is currently based on the diagnosis and characterization of the inflammatory lesion. Patients who present with clinical signs of inflammation but whose probing depths have not increased and have no radiographic signs of increased bone loss are diagnosed as having peri-implant mucositis. Patients so diagnosed should have their oral hygiene reinforced, the peri-implant space (sulcus) and the implant/restorative surfaces debrided using curettes or ultra-sonic devices. Attempts should be made to remove surrounding “granulation” tissue. They are usually placed on chlorhexidine rinse twice a day for 30 days. Some clinicians will elect to place the patient on 7–10 days of broad-spectrum antibiotics at this time; but in the absence of suppuration, this does not appear to be routinely indicated. Evaluation and possible treatment of any occlusal dishar-monies on the implant prosthesis is also strongly suggested. The patient should be reevaluated after 30 days. If at that time continued signs of inflammation are detected, further treatment is indicated. In these cases, the use of the dental endo-scope will enhance the evaluation and treatment of the subgingival environment and help elucidate the source of peri-implant inflammation.Individuals who present with increased probing depths or radiographic signs of progressive bone loss are given a diagnosis of peri-implantitis. Aggressive treatment of the underlying cause of these clinical findings is indicated when this diagnosis is made. The endoscope is valuable in both the diagnosis and treatment The Use of the Dental Endoscope and Videoscope 67of early peri-implantitis and should be employed as soon as feasible on these individuals. However in cases with significant bone loss, the videoscope pro-vides better visibility for removal of “granulation tissue” and foreign bodies.Endoscopic or videoscopic examination of patients with peri-implant diseases often reveals foreign material attached to the implant surface or to the prosthetic superstructure. The most common finding is a blue-gray film (Figure5.1) attached to or surrounding the surface of the implant or its superstructure. This material is easily displaced by the tip of the endoscope explorer. It is assumed that this material is a biofilm similar to bacterial plaque found around teeth. White highly reflective material (Figure5.1) is often seen attached to the implant or its super-structure. This material is dental cement. Subgingival calculus similar to that seen around teeth has never been observed by the author.After inspection of the implant and the attached superstructure, the endo-scopic explorer is rotated 180° and the peri-implant soft tissue (sulcular tissue) isevaluated. Foreign material is often seen in these tissues. This material shows up as very small white dots apparently embedded in the soft tissues. This material represents flecks of cement. Evaluation of human biopsies of soft tissues around implants suffering from peri-implantitis has routinely found deposits of cement and titanium surrounded by inflammatory cells [2].The use of an endoscope greatly improves the clinicians’ ability to debride the area. Current clinical experience in the treatment of peri-implant mucositis indi-cates that when the endoscope is used to treat the peri-implant inflammation; ina vast majority of cases, this results in a long-term elimination of the clinical manifestations of inflammation.Individuals with a diagnosis of peri-implantitis present greater challenges. By definition, these individuals have lost bone that is assumed to have been originally attached to the implant surface. Since reattachment of this bone Figure 5.1 An endoscope view (a) and drawing of the field (b). Cement (C) shows up as a highly reflective white areas. Biofilm is usually blue-gray.# 3 DB 6 mm(a) (b) 68 Minimally Invasive Periodontal Therapy(re-osseointegration) has not been demonstrated in humans, the clinician must decide on the most appropriate treatment based on the circumstances found around each individual implant. Treating early bone loss (<25% of the implant rough surface exposed) with the endoscope can often result in elimination or reduction of the clinical and radiographic signs of inflammation. It should beunderstood that recession of the soft tissues is likely to occur and this may create esthetic problems. In general, implants with 75% or more of the implant exposed should be removed. The quandary exists for those individuals between these two extremes.Individuals who have greater than 25% bone loss and less than 75% bone loss can often have the progress of the disease halted (at least in the short term) byremoving any implant-borne accretions and surrounding effected soft tissue. The videoscope is suggested for these procedures. This result is apparently because removal of peri-implant soft tissues reduces or eliminates the number of foreign bodies found surrounding the implant. The author’s opinion is that most surgical interventions should involve reduction of one- and two-wall bony craters, removal of affected soft tissues, and judicious smoothing of any exposed roughened sur-face of the implant followed by apical positioning of the flaps [3]. This is because adequate methods for removing biofilm and its products such as lipopolysaccha-rides from the implant surface have not yet been shown to be predictable. Multiple studies are currently underway on the best way to clean these implant surfaces. Once the best approach (or approaches) has been defined, then the routine use ofappropriate hard tissue grafting materials in these cases may be apropos. Until that time, it is suggested that graft materials not be routinely used since their long-term efficacy has not been demonstrated. Again, it should be remembered that surgical procedures for this category of bone loss will result in significant softtissue recession and exposure of the implant surface.Description of the mechanics of the procedures to be performedAfter a diagnosis of peri-implant disease is made and informed consent obtained, treatment can be initiated.Treatment of peri-implant mucositisOnly topical anesthetic is usually needed for this procedure. Aided by endo-scope visualization, as much of the material adherent to the implant as possible should be removed. While a number of medicaments have been suggested to remove biofilm and its products, at present the author suggests the use of chlorhexidine [4]. It is currently assumed that some bacteria and/or their byprod-ucts will remain on the implant surface. Thus, the need for reinforcing of personal oral hygiene and frequent post-treatment evaluation arises. The most frequently found foreign body on the implant is cement. Once removal of material on the The Use of the Dental Endoscope and Videoscope 69implant surface is accomplished, the endoscope explorer is rotated 180° to view the peri-implant soft tissues. The soft tissue should be curetted with the goal of removing as much “granulation tissue” as possible. The patient is normally placed on chlorhexidine rinse to be used twice a day and an evaluation is scheduled for 30 days later. A broad-spectrum antibiotic such as amoxicillin is occasionally prescribed. At the reevaluation if any signs of inflammation arepresent, the endoscope should be used again, and this should be repeated until the signs of inflammation are gone. If this does not result in the elimination of the inflammatory process, appropriate evaluation for other local and systemic problems is appropriate.Treatment of peri-implantitisIn general, the endoscope should be used to diagnose peri-implantitis, and the videoscope should be used to treat it. After flap elevation (see Chapter7), any accretions on the implant or superstructure are removed. In these cases, aggres-sive removal of the inflamed peri-implant tissues is appropriate. Again it should be borne in mind that recession of the soft tissues is likely to occur. In these cases, the process of removing implant-borne materials often results in the fragmentation of these accretions and their embedding in the surrounding soft tissues. Since these particles often illicit an inflammatory response, this necessitates careful evaluation of the peri-implant soft tissues before flap closure. Chlorhexidine is usually prescribed and reevaluation is done at 30 days.It is suggested that clinicians new to minimally invasive procedures restrict their treatment to patients with peri-implant mucositis because of the inherent challenges of removal of foreign bodies both on the implant surface and in the soft tissues seen in cases of peri-implantitis.The cement problemThe vast majority of the implants receiving single- or multiple-unit fixed partial dentures are seated using dental cement. This approach has been shown to be less technologically challenging and less expensive than using a screw-retained restoration. This has resulted in the overwhelming use of the cemented approach for implant restorations [5]. Along with the ease and facility of this approach comes a very important problem—that of excess cement. This material has often been found on superstructures, implant surfaces, and in the peri-implant tissues and has been shown to be associated with peri-implant disease [6]. Early evi-dence has shown that it is virtually impossible at cementation to remove all of this luting material from around margins that are placed apical to the gingival marginal tissues [7].This retention of excess cement may act in a manner similar to calculus seen on natural teeth, in that it concentrates endotoxins that can result in an inflammatory 70 Minimally Invasive Periodontal Therapyresponse. Unfortunately, the clinical and radiographic manifestation of this problem often does not occur for years following cementation. This argues strongly for periodic maintenance visits for individuals with cemented dental implant restorations. This is especially true for mixed dentition, individuals who have both natural teeth and implants and whose teeth have periodontitis. These individuals have been shown to have more peri-implant disease than individuals with no remaining natural teeth [8].Prevention of peri-implant disease secondary to dental cement has four com-ponents: (i) proper surgical placement, (ii) proper abutment design, (iii) early removal of excess cement, and (iv) appropriate maintenance for patients.During surgery, the implant abutment interface should be placed slightly coronal to the gingival tissues to move the cement line to the level of the gingiva that allows for more predictable removal of excess cement. Flattening posterior bony ridges during surgery reduces the soft tissue accumulation seen on the facial/lingual plane of the bony housing that hinders cement removal.Minimal luting agent should be placed into the fixed partial denture, excess material can be extruded prior to final cementation using a stock abutment analog or a custom analog made from impression material after lining the inside of thecrown with Teflon tape. The use of retraction cord or rubber dam material to allow access for excess cement removal is often appropriate. Immediate attempts should be made to evaluate the area around the newly cemented crown for any excess luting material.Example casesCase 1This 34-year-old post-orthodontic patient wanted an implant in the space previously occupied by his mandibular left deciduous molar. This molar had been removed several years before and not replaced. Clinical and radio-graphic examination revealed absence of this tooth as well as a high mental foramen position in relation to the existing alveolar ridge, thus necessitating the placement of a short implant. An osseointegrated implant was placed uneventfully into the site (Figure5.2a). This patient was monitored once a year for evidence of peri-implant disease. A clinical and radiographic exami-nation performed 5 years after placement reveals no clinical or radiographic signs of peri-implant disease (Figure 5.2b). Five months later, the patient reported to the office with a chief complaint of swelling around the implant (Figure5.2c). Probing depths had increased from 3 to 7 mm, and there was radiographic evidence of bone loss on the distal of the implant compared with a radiographic exposed 5 months earlier.An endoscopic examination was performed using local anesthesia. A small flapwas raised and excess cement was seen on the distal of the implant and was removed using ultrasonic devices aided by endoscopic visualization. The area has The Use of the Dental Endoscope and Videoscope 71remained stable5 years after an intervention, the distal probing depth is now 4 mm, and there are no clinical signs of peri-implant mucositis, but the bone loss seen radiographically and clinically has not returned to its previous level (Figure5.2d).Case 2This patient presented with a failing fixed partial denture from the mandibular left second molar through the mandibular left second bicuspid. Clinical and radiographic examination revealed an extensive carious lesion on the molar (Figure5.3a). The molar was removed and two implants placed. The implant in the second molar position was placed as an immediate, and the fixture in the first molar was placed into mature bone (Figure5.3b). The mesial surface of the sec-ond molar implant placed immediately was covered by natural bone, and the exposed distal surface was covered with a hard tissue graft. The implant in theposition of the first molar was completely surrounded by mature bone. The Figure 5.2 (a) This radiograph was exposed immediately after placement of the implant in the mandibular left deciduous molar site. (b) A single-unit cemented fixed partial denture was placed after the implant integrated. (c) The patient reported with a chief complaint of swelling on the distal of the implant. There was a 7-mm probing depth in the area. (d) The area seen radiographically 5½ years after cementation.(a)(b)(c)(d) 72 Minimally Invasive Periodontal Therapypatient was seen for yearly follow-ups. Four years after placement, the patient presented with suppuration and radiographic bone loss on the mesial of the implant replacing the second molar (Figure5.3c). The bone loss had occurred on the surface originally encased by mature bone. Relevant clinical history included that the prosthetic superstructure had loosened within the last few months and was re-cemented by his general dentist.Endoscopic evaluation of the area found a large amount of excess cement on the mesial of the second molar implant that was removed. As a result, theprobing depths that had been 7 mm reduced to 3, and the radiographic evidence of bone loss disappeared. This result has been stable for 5 years (Figure5.3d).Figure 5.3 (a) This mandibular second molar abutment for a three-unit fixed partial denturehad extensive caries and was slated to be removed. (b) The molar was extracted andan implant placed immediately. A second implant was placed into the first molar site. (c)The patient was seen every year to evaluate the implants. Approximately 4 years after implant placemen, the patient presented with radiographic signs of bone loss and clinical signs of inflammation and the mesial of the second molar implant. Relevant history included recent re-cementation of his fixed partial denture. Endoscopy revealed a large deposit of excess cement associated with the lesion. The cement was removed with the help of the endoscope. (d) Following removal of the excess cement, the area showed clinical and radiographic signs of repair.(a)(b)(c)(d) The Use of the Dental Endoscope and Videoscope 73Case 3This patient is a 55-year-old man. He presented with a failed endodontic treatment on the maxillary left central incisor (Figure5.4a). Because of the large root form of the tooth and the minimal amount of apical bone available for implant stabilization (Figure5.4b). Delayed implant placement was chosen as the preferable approach. The tooth was removed and guided bone regeneration (socket enhancement) was performed. Approximately 6 months later, an osseo-integrated dental implant was placed. Following integration, a single-unit fixed partial denture was seated using dental cement. A 6-month post-cementation clinical examination revealed no apparent problems (Figure5.4c). Two months later, the patient presented with an abscess on the facial of the implant (Figure5.4d). The abscess had fenestrated the gingival tissue approximately 2 mm apical to the free (a)(b)Figure 5.4 (a) This patient’s maxillary left central incisor had a failed endodontic lesion. Because of the lack of bony support for a potential implant, the tooth was removed and thesocket treated with hard and soft tissue grafting. Six months later, an implant was placed. (b)A preoperative radiograph of the incisor seen in (a). 74 Minimally Invasive Periodontal Therapygingival margin. Endoscopy was performed and a small piece (~1/3 mm × 1/3 mm) of cement was visualized and removed. While the signs of peri-implant disease were eliminated, the opening in the soft tissues remains and the peri-implant tissues have been stable for 3 years after treatment (available on the book companion website).ConclusionsPeri-implant disease is seen in a significant number of implant patients. These inflammatory responses are is in some ways similar to periodontal diseases. Therefore, diagnosis and maintenance procedures are very similar for these problems. It appears that intervention at the mucositis stage and appropriate removal of noxious materials along with adequate personal oral hygiene will often result in elimination of clinical signs of inflammation and prevention ofsubsequent bone loss in most cases. Peri-implantitis, the progressive loss of bone around the implant, presents a greater challenge for the clinician. Many cases of peri-implant disease are related to excess cement. The early stages of peri-implantitis usually respond well to removal of the noxious materials from the implant and superstructure surfaces and soft tissue debridement. Advanced bone loss around these fixtures is usually best treated by the removal of the implant. At present, individuals with greater than 25% and less than 75% bone loss around their implants present the biggest challenge. Current approaches do not allow us to routinely arrest the progression of bone loss. However, the dental endoscope and videoscope have proved to be invaluable tools in diag-nosing and treating these diseases, but it should be understood that the current level of our understanding of these problems and their treatment needs to be expanded.(c)(d)Figure 5.4 (Continued) (c) Two months later, the patient presented with an abscess on the facial of the implant. (d) The clinical presentation 8 months after the crown was cemented. The Use of the Dental Endoscope and Videoscope 75References1. Heitz-Mayfield, L.J., Salvi, G.E., Mombelli, A., Faddy, M. & Lang, N.P. (2012) Anti-infective surgical therapy of peri-implantitis. A 12-month prospective clinical study. Clinical Oral Implants Research, 23 (2), 205–210.2. Wilson, T.G. Jr., Valderrama, P., Burbano, M., Blansett, J., Levine, R., Kessler, H. & Rodrigues, D.C. 2014. Foreign bodies associated with peri-implantitis human biopsies. Journal of Periodontology (in press).3. Valderrama, P. & Wilson, T.G. Jr. (2013) Detoxification of implant surfaces affected by peri-implant disease: an overview of surgical methods. International Journal of Dentistry. Epub August 4, 2013.4. Valderrama, P., Blansett, J.A., Gonzalez, M.G., Cantu, M.G., & Wilson, T.G. Jr. (2014) Detoxification of implant surfaces affected by peri-implant disease: an overview of non-surgical methods. The Open Dentistry Journal, 8, 77–84.5. Jung, R.E., Pjetursson, B.E., Glauser, R., Zembic, A., Zwahlen, M. & Lang, N.P. (2008) A systematic review of the 5-year survival and complication rates of implant-sup-ported single crowns. Clinical Oral Implants Research, 19 (2), 119–130.6. Wilson, T.G. Jr. (2009) The positive relationship between excess cement and peri-implant disease: A prospective clinical endoscopic study. Journal of Periodontology, 80 (9), 1388–1392.7. Linkevicius, T., Vindasiute, E., Puisys, A. & Peciuliene, V. (2011) The influence of margin location on the amount of undetected cement excess after delivery of cement-retained implant restorations. Clinical Oral implants Research, 22 (12), 1379–1384.8. Sgolastra, F., Petrucci, A., Severino, M., Gatto, R. & Monaco, A. (2013) Periodontitis, implant loss and peri-implantitis. A meta-analysis. Clinical Oral Implants Research. doi: 10.1111/clr.12319 [Epub ahead of print].

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