|Year : 2020 | Volume
| Issue : 1 | Page : 16-21
A comparative evaluation of changes in microbial flora in delayed and immediate placed implants: An in vivo study
Keerthi G Hiremath, Viraj N Patil, Zarir Ruttonji, Preethi Kusugal, KM Sushma, Preeti Astagi
Department of Prosthodontics and Crown and Bridge, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belagavi, Karnataka, India
|Date of Submission||03-Sep-2019|
|Date of Acceptance||11-Nov-2019|
|Date of Web Publication||08-Jul-2020|
Dr. Keerthi G Hiremath
Department of Prosthodontics and Crown and Bridge, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Dental implants provide a unique opportunity for the observation of initial bacterial colonization and also for the estimation of time needed for the establishment of complex microflora. While many factors are important in determining the long-term success or failure of dental implants, very little is known about the relative importance of the subgingival bacterial populations around implants.
Aim: The aim of the study was to estimate peri-implant microbial colonization in patients with immediate and delayed implants and the differences in peri-implant microflora between immediate and delayed implants.
Materials and Methods: In the current study, the organisms found in the oral cavity prior to placing the implants and during the various stages of implant treatment in both the categories were assessed.
Results: In the current study, organisms such as Streptococci are consistently seen. The presence of organisms such as Porphyromonas gingivalis and Fusobacterium, which have pathogenic potential, is of importance.
Conclusion: In this study, the following conclusions were made; the mode of implant placement either immediate or delayed does not alter the peri-implant microflora. Organisms present preoperatively were consistently present during the entire phase of the treatment. This study suggests that regular microbial evaluation along with clinical and radiographic monitoring could help in recognizing the potential for peri-implantitis and in the prevention of the same for better prognosis.
Keywords: Aggregatibacter actinomycetemcomitans, Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, Streptococci
|How to cite this article:|
Hiremath KG, Patil VN, Ruttonji Z, Kusugal P, Sushma K M, Astagi P. A comparative evaluation of changes in microbial flora in delayed and immediate placed implants: An in vivo study. J Dent Implant 2020;10:16-21
|How to cite this URL:|
Hiremath KG, Patil VN, Ruttonji Z, Kusugal P, Sushma K M, Astagi P. A comparative evaluation of changes in microbial flora in delayed and immediate placed implants: An in vivo study. J Dent Implant [serial online] 2020 [cited 2020 Oct 22];10:16-21. Available from: https://www.jdionline.org/text.asp?2020/10/1/16/289233
| Introduction|| |
Over the decades, oral rehabilitation of missing teeth by means of endosseous implants has proven to be the most predictable and successful treatment modality. The dental implants are unique as they consist of abutments that emerge and support one or more prosthetic component that extrudes through the lamina propria and stratified squamous epithelium in the oral cavity. This transmucosal network is a weak junction between the prosthetic component and the underlying bone that surrounds the dental implant. It is in this region peri-implant lesions origin with subsequent osteoclastic activity and resorption of the supporting bone. After implant surgery, mucoadhesion (pierced mucoadhesion) occurs to the implant body protecting the connective tissues and bone tissues from intraoral substances such as bacteria. The soft tissues surrounding titanium implant abutments have been examined by conducting clinical studies in human and animal experiments. The research by Berglundh et al. in 1991 conducted on dogs, which has become the basis for the series of experiments that followed, to compare the biological difference between the gingivae of natural teeth and the surrounding tissues of the implant, there were histological similarities between the two. The epithelium of natural tooth gingivae is highly keratinized and stretches to the junctional epithelium, the main fiber within the subepithelial connective tissues spread in a fan-shaped form toward the soft and hard tissues surrounding the periodontal membrane through the cementum of the tooth root. The mucous membrane around the implant is also covered by highly keratinized epithelium, which is connected to the epithelial barrier facing the abutment. This epithelial barrier corresponds to the junctional epithelium of natural tooth. The length is roughly 2 mm long and is attached to the surface of implant through hemidesmosome. However, since implant material is fundamentally a foreign material, the epithelium around the implant is thought to be more prone to invasion by foreign substances. Peri-implantitis is defined as a loss of the supporting bone caused by inflammation of the tissues surrounding the osseointegrated implant. A study by Cortelli et al. tested the hypotheses that there is: (1) higher bacterial frequency in peri-implantitis/periodontitis, followed by mucositis/gingivitis and peri-implant/periodontal health and (2) similar bacterial frequency between comparable peri-implant and periodontal clinical statuses. The result of the study was bacterial frequency increased from peri-implant/periodontal health to peri-implantitis/periodontitis but not from mucositis/gingivitis to peri-implantitis/periodontitis. There was a trend toward a higher bacterial frequency in teeth than implants. However, limited literature is available on the microbial colonization of the peri-implant sulcus area without clinical periodontal disease. Therefore, the aim of this study was to compare the changes in microflora in immediate and delayed placed implants during various stages of implant treatment which included monitoring the prevalence of pathogens preoperatively during the operative phase and maintenance phase.
| Materials and Methods|| |
The present study was conducted on patients visiting the Department of Prosthodontics and Crown and Bridge of Maratha Mandals Nathajirao G Halgekar Institute of Dental Sciences and Research Centre, Belgaum, for the prosthetic replacement of teeth with dental implants. Microbiological analysis was carried out at the Department of Microbiology Maratha Mandals Nathajirao G Halgekar Institute of Dental Sciences and Research Centre, Belgaum.
The sample size comprised 40 implants; of these, 20 cases had immediate implants and 20 cases had delayed implants.
Informed consent of all the patients was obtained before the procedure. All materials and media used were presterilized. Scaling and polishing of the dentulous areas was done 1 day prior to sample collection. Sites to be sampled were isolated with sterile cotton rolls. A supragingival plaque was registered and removed with sterile cotton pellets. The area was carefully dried, and the bacterial samples were collected by gently inserting fine sterilized paper points at the following regions for 10 s.
- Gingival sulcus of teeth mesial and distal to the site of implant placement
- The alveolar ridge of edentulous site.
In case of edentulous ridge, paper points were placed in the vestibule and on the alveolar ridge.
Paper points soaked with GCF were placed in sterile transport vials filled with 1 ml anaerobic medium and were sent to the laboratory. Bacterial culture media used in the study include blood agar, Kanamycin blood agar, and Kanamycin-vancomycin blood agar.
The schedules for the collection of sample during the study were (1) preoperative (before antibiotic regimen) (S1), (2) 1 day postoperative 1st stage surgery (S2), (3) suture removal (7–10 days postoperative) (S3), (4) 2 weeks (S4), (5) 2nd stage surgery, (6) 2 days after abutment connection, (7) on the day of prosthesis placement, (8) 2 days after prosthesis placement, (9) 1-month recall (follow-up), and (10) 2-month recall. The collected samples were tested to estimate the growth of the following pathogenic microorganisms: Streptococcus, Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, and Fusobacterium nucleatum.
| Results|| |
The present study comprised two groups with a sample size of 20 each. One group comprised delayed placed implants and the other group comprised immediate placed implants. In each of these groups, the samples were collected and microbiological analysis was done. The samples were collected at the following intervals: preoperative (before antibiotic regimen) (S1), 1 day postoperative 1st stage surgery (S2), suture removal (7–10 days postoperative) (S3), 2 weeks after suture removal (S4), 2nd stage surgery (S5), 2 days after abutment connection (S6), on the day of prosthesis placement (S7), 2 days after prosthesis placement (S8), 1-month recall (follow-up) (S9), and 2-month recall (S10). The samples were tested to estimate the growth of the following pathogenic microorganisms: Streptococcus, A. actinomycetemcomitans, P. gingivalis, P. intermedia, and F. nucleatum. The values of the microbiological analysis of both the groups (immediate and delayed) are tabulated in [Table 1] and [Table 2].
|Table 1: Concentration of microorganisms found during various stages of delayed implant|
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|Table 2: Concentration of microorganisms found during various stages of immediate implant|
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Specific statistical tests were used for analyzing the data and for obtaining the results.
Comparison of the mean concentration of different organisms in delayed implant placement shows a statistically significant result (Kruskal–Wallis = 40.744, P < 0.001). Streptococci which are normal commensals of the oral cavity are consistently seen at higher titers, whereas other organisms such as P. gingivalis, Fusobacterium, P. intermedia, and A. actinomycetemcomitans showed comparatively lesser titers [Graph 1].
Comparison of the mean concentration of different organisms in immediate implant shows a statistically significant result (Kruskal–Wallis = 40.264, P < 0.001). Streptococci which are normal commensals of the oral cavity are consistently seen at higher titers, whereas other organisms such as P. gingivalis, Fusobacterium, P. intermedia, and A. actinomycetemcomitans showed comparatively lesser titers [Graph 2].
In the current study, the following results were observed:
Organisms such as Streptococci which are normal commensals of the oral cavity are consistently seen. The presence of organisms such as P. gingivalis and Fusobacterium, which have pathogenic potential, is of importance.
Comparison of the mean rank of Streptococci, F. nucleatum, P. gingivalis, P. intermedia, and A. actinomycetemcometans in delayed and immediate implant showed a statistically insignificant result.
| Discussion|| |
Osseointegrated dental implants provide a unique opportunity for the observation of the initial bacterial colonization pattern and also for the estimation of time needed for the establishment of complex microbial flora since one is starting with bacteria-free surface. The composition of peri-implant microflora is similar to pocket around the natural teeth that seems to be an obligate ecological niche for some oral microbiota. Long-term success with immediate implants is comparable to that of delayed implants. While many factors are considered important in determining the long-term success or failure of dental implants (for example, occlusal loading forces, implant materials, surgical placement, and host acceptance), little is known about the relative importance of the subgingival bacterial colonies around the implants and their effects on peri-implant tissues.
The transmucosal abutment of osseointegrated dental implants serves as a surface for bacterial colonization of microbial biofilms. Like the gingival crevice around the natural tooth, the peri-implant mucosa, which covers the alveolar bone, is closely adapted to the implant. Microbial colonization and the inflammatory reactions in the peri-implant tissues might be analogous to key events in the pathogenesis of periodontitis. In partially edentulous subjects, the developing microbiota around the implants closely resemble the microflora of naturally remaining teeth.,
Quirynen and Listgarten used phase-contrast microscopy to evaluate the impact of periodontitis around the remaining teeth and probing depth around the implants on the composition of the peri-implant subgingival flora in partially edentulous subjects. The investigators found that the subgingival microflora around implants harbored increased spirochetes and motile rods compared with teeth present in the same jaw. Samples from deep peri-implant pockets (>4 mm) in the residual dentition of patients with chronic or refractory periodontitis showed a significantly higher proportion of spirochetes and motile rods than samples from periodontally healthy patients with comparable probing pocket depths.
Very scant longitudinal information is available on the subjugation of microbial flora around immediately placed dental implants. In the current study, the peri-implant microbial colonization and virulence in patients with immediate implant and delayed implant was studied. Papaioannou et al. also using phase-contrast microscopy and DNA probes determined the prevalence of putative periodontal pathogens in partially edentulous and completely edentulous patients with a history of periodontal disease. The microbiologic profiles were similar around the teeth and dental implants of equal pocket depth, which may indicate that pockets around the teeth can serve as a reservoir for putative periodontal pathogens. This finding was confirmed in several studies on partially edentulous patients.
As early as 1 month after implantation, putative periodontal pathogens were detected around the implants of partially edentulous patients. Implant failures due to the infection are characterized by a complex peri-implant microbiota, resembling that of adult periodontitis. In edentulous subjects, A. actinomycetemcomitans and P. gingivalis are not as frequently associated with peri-implant infection as in dentate subjects.
Danser et al. reported that after total extraction in patients with severe periodontitis, P. gingivalis could no longer be detected on the mucosal surface of edentulous patients. Furthermore, A. actinomycetemcomitans and P. gingivalis could not be isolated at the peri-implant pockets in these patients after the insertion of implants.
In addition to the dark-pigmented, Gram-negative anaerobic rods, other bacterial species are associated with peri-implant infections (e.g., Bacteroides forsythus, F. nucleatum, Campylobacter, Peptostreptococcus micros, and P. intermedia). Organisms that are less frequently associated with periodontitis, such as Staphylococcus species, enterics, and Candida species, have also been found in peri-implant infections. Lindhe et al. suggested that peri-implant tissues, in contrast to periodontal tissues, have a limited capacity to resolve progressive, plaque-associated lesions. Few reports exist on peri-implant tissues at failed implant sites in humans. Although some documentation reveals the presence of inflammatory lesions in the peri-implant mucosa, other reports claim that inflammatory cell infiltrates were virtually absent. In a recent study on the histopathologic features of human peri-implantitis, it was reported that harvested soft-tissue specimens harbored large inflammatory cell infiltrates that extended to a position apical of a pocket epithelium. Furthermore, about 60% of the lesions were occupied by inflammatory cells, among which plasma cells dominated. Silverstein et al. discussed the relationship between the microbial flora around the dental implants and peri-implantitis and presented recommendations to improve the efficacy of dental implants. According to them, the same anaerobic Gram-negative organisms are found in periodontitis and peri-implantitis. The periodontium must be in a healthy state before the placement of dental implants and constantly monitored while implants are in function for the early detection of potential periodontal and/or prosthodontic problems. A study conducted by Sumida et al. showed that the polymerase chain reaction detection rates of P. gingivalis, P. intermedia, A. actinomycetemcomitans, B. forsythus, and Treponema denticola were 80.0%, 53.3%, 46.7%, 60.0%, and 40.0%, respectively. Colonizations by P. gingivalis and A. actinomycetemcomitans statistically correlated with periodontal pockets and implant sulcus regions. The pulsed-field gel electrophoresis (PFGE) patterns of the P. gingivalis strains isolated from each patient were identical but differed from those from other patients. The PFGE patterns of P. intermedia strains were identical in 2 of 3 patients; in conclusion, the elimination of these periodontal pathogens from the patient's oral cavity before administering dental implant treatment may inhibit colonization by these pathogens and reduce the risk of peri-implantitis.
In the current study, the organisms found in the oral cavity prior to placing the implants and during the various stages of implant treatment in both the categories (delayed and immediate placement) were assessed. In each of these groups, the samples were collected and microbiological analysis was done. The samples were collected at the following intervals: preoperative (before antibiotic regimen), day postoperative 1st stage surgery, suture removal (7–10 days postoperative), 2 weeks after suture removal, 2nd stage surgery, 2 days after abutment connection, 2 days after prosthesis placement, and 1-month recall (follow up).
Organisms such as Streptococci which are normal commensals of the oral cavity are consistently seen. The presence of organisms such as P. gingivalis and Fusobacterium, which have pathogenic potential, is of importance. The count of these organisms was lesser under antibiotic therapy. However, antibiotic therapy could not eliminate these anaerobic organisms completely. Implant treatment delayed or immediate placement does not alter the flora of the oral cavity. It is a matter of maintenance to prevent the disease. However, it is essential to identify the organisms, to understand their pathogenicity, and monitor these patients for a successful outcome. However, it is essential to identify the organisms, to understand their pathogenicity, and monitor these patients for successful outcome. The periodontium must be in a healthy state before the placement of dental implants and constantly monitored while implants are in function for the early detection of potential periodontal and/or prosthodontic problems. Peri-implant lesions may develop after several years so constant monitoring by periodic follow-up with assessment of peri-implant microflora is important for better prognosis. Although several anti-infective treatment strategies have demonstrated beneficial clinical effects in humans (e.g., resolution of inflammation, decrease in probing depth, and gain of bone defects), there is still insufficient evidence to support a specific treatment protocol. Microbial monitoring is useful in evaluating the peri-implant health condition and the microbial composition of a peri-implantitis site. This information can then potentially be used to determine the etiology of the breakdown of peri-implant tissue and as well select a specific antiobiotic regimen.
Scope for the study
The current microbial study has scope for standardising routine maintenance protocol, developing a more specific antibiotic regime and isolating more specific organisms. Longitudinal studies can be carried out with a larger sample size to arrive at more specific conclusion on the presence of particular organisms during implant therapy. Microbial flora can be assessed with different graft materials used during different modes of implant treatment.
The individual microorganism can be specifically studied for its pathogenicity which may help in deciding on standard antibiotic regime during various modes of implant treatment.
| Conclusion|| |
The current study concluded that the mode of implant placement, either immediate or delayed placement, does not alter the peri-implant microflora. Organisms present preoperatively were consistently present during the entire phase of the treatment. Organisms such as Streptococci which are normal commensals of the oral cavity are consistently seen. The presence of organisms such as P. gingivalis and Fusobacterium, which have pathogenic potential, is of importance. In patients who showed the incidence of pathogenic organisms such as Prevotella, P. gingivalis, Fusobacterium in the preoperative state, revealed the growth of same organisms during the entire treatment period. The count of these organisms was lesser under antibiotic therapy. However, antibiotic therapy could not eliminate these anaerobic organisms completely. This study suggests that regular microbial evaluation along with clinical and radiographic monitoring could help in recognizing the potential for peri-implantitis and in prevention of the same for a better prognosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft tissue barrier at implants and teeth. Clin Oral Implants Res 1991;2:81-90.
Gould TR, Westbury L, Brunette DM. Ultrastructural study of the attachment of human gingiva to titanium in vivo
. J Prosthet Dent 1984;52:418-20.
Cortelli SC, Cortelli JR, Romeiro RL, Costa FO, Aquino DR, Orzechowski PR, et al.
Frequency of periodontal pathogens in equivalent peri-implant and periodontal clinical statuses. Arch Oral Biol 2013;58:67-74.
Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100.
Leonhardt A, Adolfsson B, Lekholm U, Wikström M, Dahlén G. A longitudinal microbiological study on osseointegrated titanium implants in partially edentulous patients. Clin Oral Implants Res 1993;4:113-20.
Mombelli A, Marxer M, Gaberthüel T, Grunder U, Lang NP. The microbiota of osseointegrated implants in patients with a history of periodontal disease. J Clin Periodontol 1995;22:124-30.
Quiryen M, Listgarten MA. The distribution of bacterial morphotypes around natural teeth and titanium implants ad modum Brånemark. Clin Oral Implants Res 1990;1:8-12.
Papaioannou W, Quirynen M, Van Steenberghe D. The influence of periodontitis on the subgingival flora around implants in partially edentulous patients. Clin Oral Implants Res 1996;7:405-9.
Mombelli A, van Oosten MA, Schurch E Jr. Land NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2:145-51.
Danser MM, van Winkelhoff AJ, van der Velden U. Periodontal bacteria colonizing oral mucous membranes in edentulous patients wearing dental implants. J Periodontol 1997;68:209-16.
Slots J, Rams TE. New views on periodontal microbiota in special patient categories. J Clin Periodontol 1991;18:411-20.
Esposito M, Thomsen P, Ericson LE, Sennerby L, Lekholm U. Histopathologic observations on late oral implant failures. Clin Implant Dent Relat Res 2000;2:18-32.
Berglundh T, Gislason O, Lekholm U, Sennerby L, Lindhe J. Histopathological observations of human periimplantitis lesions. J Clin Periodontol 2004;31:341-7.
Silverstein LH, Kurtzman D, Garnick JJ, Schuster GS, Steflik DE, Moskowitz ME. The microbiota of the peri-implant region in health and disease. Implant Dent 1994;3:170-4.
Sumida S, Ishihara K, Kishi M, Okuda K. Transmission of periodontal disease-associated bacteria from teeth to osseointegrated implant regions. Int J Oral Maxillofac Implants 2002;17:696-702.
[Table 1], [Table 2]