What is the Prevalence of Peri-Implantitis? A Systematic Review and Meta-Analysis

doi:10.21203/rs.3.rs-954156/v1

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What is the Prevalence of Peri-Implantitis? A Systematic Review and Meta-Analysis

https://doi.org/10.21203/rs.3.rs-954156/v1

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Background: Peri-implantitis is a usual finding but estimates of its prevalence fluctuate very much. This may be due to the wide variety of disease definitions. This systematic review aims to estimate the overall prevalence of peri-implantitis and the effect of different study designs, function times, and use of probing depth on prevalence rate.

Methods: Following electronic and manual searches of the literature published from January 2005 to December 2020, data were extracted from the studies fitting the study criteria. Fifty-seven articles were included in this study.

Results: Prevalence of peri-implantitis was 19.6% (95% CI, 15.25-24.75) at the patient-level, and 12.39% (95% CI, 9.46-15.43) at the implant-level and it remains highly variable even following restriction to the clinical case definition. The use of probing depth like diagnostic criteria affected the prevalence data.

Conclusion: The results indicate that it remains essential the identification of the diagnostic markers for more accurate disease classification.

Dentistry

Head & Neck Surgery

Dental implants

biological complications

peri-implant epidemiology.

Dental implants are currently one of the safest alternatives for the replacement of missing teeth, regardless of their cause. This treatment has shown a high degree of predictability, with a survival rate in the range of 90–95% for more than five years [1].

It is important to discriminate between survival and success rates of treatment. An implant with enough insertion and no mobility (positive survival) can be a failure (negative success) if it exhibits any coil or constant inflammation of the peri-implant soft tissue. The incidence of technical and biological complications appears to be common [2–4], and these complications can have substantial economic implications and effects on the perception of treatment of the patient [5–8]. As the number of patients receiving dental implants is continually growing, the prevention and treatment of associated complications represents a serious and relevant challenge.

Within the biological complications, peri-implant diseases are considered the most relevant. They have an infectious cause and two entities have been described: mucositis and peri-implantitis [9]. Peri-implantitis is characterized by a destructive inflammatory lesion of polymicrobian etiology that affects both soft and hard tissues leading to progressive peri-implant bone loss, along with the formation of a pocket and inflammation in peri-implant tissues [10, 11]. Thus, the pathognomonic clinical sign of peri-implantitis will be the increase in pocket depth accompanied by bleeding and sometimes suppuration [12].

In order to better understand peri-implant diseases and to implement preventive strategies effectively and efficiently, it is mandatory to understand their epidemiology. It has therefore been suggested that epidemiological studies with a cross-sectional design, adequate sample sizes, and clinical and radiographic records are necessary to study the prevalence and risk indicators of peri-implant diseases [13]. Previous study reported that the prevalence of peri-implantitis ranged from 14.38–24.27% [14]. The reported variability may depend on different factors, including the follow-up period or disease definition. The definition is quite controversial and many different definitions have been proposed [15], such as the one that comes from the new classification of periodontal and peri-implant diseases, [16] where, in the absence of a previous examination, the diagnosis of peri-implantitis may be based on the combination of bleeding on probing (BOP) and/or suppuration, probing depth ≥ 6 mm, and loss of supporting bone ≥ 3 mm. Another relevant factor is the use of convenience samples instead of randomized samples, which ultimately results in a potential selection bias [17].

The variability in the prevalence of peri-implantitis can be also explained by the different clinical parameters used to define the disease in the different studies, especially in terms of the magnitude of loss of supporting bone and the probing depth, the heterogeneity of the groups evaluated, or the individual risk factors of each population. Individual risk factors significantly increase the prevalence of peri-implantitis and may include the patient's previous history of periodontal disease, smoking habit, poor oral hygiene, diabetes and genetic factors [18].

Due to the great heterogeneity in peri-implantitis prevalence and epidemiology data, it is necessary to evaluate the currently data to approach the knowledge of its epidemiology and provide the clinicians relevant information to develop strategies to prevent it and to establish early diagnosis and treatment. Therefore, the aim of this systematic review is to estimate the prevalence of peri-implantitis and its variations according to the applied definition and the elapsed time.

The present systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and it also fulfilled the PRISMA 2009 Checklist [19]. The practice-oriented research question was: “What is the current state of knowledge regarding the prevalence of biological complications (peri-implantitis) in patients treated with titanium dental implants?”

A thorough search for literature was conducted from 1 December 2005 to 31 December 2020, using the following electronic databases: MEDLINE/PubMed, Web of Science, Science Direct and the Cochrane Library. The main key search terms used, alone or in combination with Boolean operators, for different searches were: "dental implants", "biological complications", "peri-implantitis" and "prevalence". The first combination was “dental implants and biological complications” and the second option was “dental implants and peri-implantitis”. This search strategy was adapted for use in the various databases.

Eligibility Criteria

The inclusion criteria were as follow: studies describing the diagnosis of peri-implantitis (BOP, probing depth, loss of supporting bone), studies with peri-implantitis prevalence rate data, observational and experimental studies published over the past 15 years, studies published in peer review system journals, and articles published in English language. Studies were excluded if the number of subjects treated with implants were less than 10, or if the minimum time of function of implants was less than 5 years.

The titles and summaries identified in the initial search were evaluated by three authors (PD, LJG-V and EG) for eligibility after removing duplicate items. Studies that appeared to meet the inclusion criteria were recovered in their full-text version and evaluated. A manual search of additional relevant titles was also carried out in the references section of each article. Any disagreement among the reviewers was resolved by discussion with all authors until consensus was reached.

Data Extraction and Collection

Once the articles meeting the inclusion criteria were identified, the following data for each article was collected using a specific form: surname and first author's name, geographic scope, sample size type of study design, type of peri-implantitis diagnosis, year and type of publication, and data on peri-implantitis for the calculation of prevalence at both the patient and implant level. This information was felt in different sections. These tasks were performed by the same three authors (PD, LJG-V and EG).

This initial electronic search produced 1045 articles and 33 were identified in the manual search. After eliminating duplication, examining, and applying inclusion criteria, 78 articles were included for data extraction and full-text evaluation. However, 22 articles were excluded because they did not meet the objectives of the review or they did not have a clear methodology. Therefore, a total of 56 articles [20-75], were selected as relevant to the objectives of the review. The PRISMA flowchart in Figure 1 synthesizes the screening and selection processes. The study designs were as follow: 18 cross-sectional studies, 18 longitudinal studies, 1 case-control study, 16 cohort studies, and 3 randomized controlled trials.

In order to reduce the heterogeneity of the results and to facilitate their interpretation, the studies were grouped according to diagnostic criteria into four groups (Tables 1-4). One study [62] was included in groups 1 and 2.

The peri-implantitis mean prevalence obtained was 19.6% (95% CI, 15.25 to 24.75%) at the patient-level and 12.39% (9.46 to 15.43%) at the implant-level. By diagnostic criteria groups, for group 1 (BOP + loss of supporting bone ³ 3mm), 16.4% (0.9 to 31.89%) at the patient-level and 12.12% (2.96 to 21.29%) at the implant-level, while for group 2 (BOP + loss of supporting bone ³ 2mm), 20.67% (15.89 to 25.44%) at the patient-level and 12.65% (8.98 to 16.31%) at the implant-level. Table 5 shows all the results of the study. Given the high specific weight of group 2 compared to the other groups (54.39%), the totals were calculated by weighted average.

In addition, an analysis of the influence of the load time or time variable was carried out based on implants on the registered peri-implantitis prevalence at the patient level and at the implant level, that is displayed in Table 6. No significant differences were observed in prevalence among studies with follow-up period of 5 to 9 years and studies with greater longevity, both at patient-level (17.19% and 17.75% respectively) as at implant-level (11.11% versus 9.43%).

Considering the Consensus report of the 2017 World Workshop on the classification of periodontal and peri-implant diseases and conditions that recommended that probing depth should not be included as a diagnostic criterion, studies have been divided according to this variable to study its impact on peri-implantitis prevalence (Table 7). Prevalence in studies that used probing depth, as one more diagnostic criterion was higher than those that do not used it, both at patient-level (25.26% and 17.17% respectively) and at implant-level (15.66% and 11.07% respectively). However, no significant differences were observed (p = 0.24 and p= 0.26 respectively).

A meta-analysis of group 2 was performed due to its large specific weight (31 articles). Heterogeneity was evaluated using the Q and I² test [76]. The prevalence of peri-implantitis at patient level obtained was 19.6% (CI-95%, 18.4-20.8) for the fixed effects model and 20% (CI-95%, 16.6-23.7) for the random effects model. Heterogeneity analysis in both models was high (Q = 187.04; p < 0.05; I² = 87.169%). To prevent the presence of publication bias, those studies farther from the mean, one at a time, were eliminated, controlling with the Egger´s regression test its absence (p ³ 0.1) [77]. After performing this sensitivity analysis excluding studies of Gatti [36], Koldsland [42], Marrone [46], Romandini [64], and Tey [71], the prevalence at the patient level was 18.1% (CI-95%, 16.2-19.9%). Meta-analysis found heterogeneity (Q = 34.13; p = 0.018; I²= 44.3%). The Egger’s intercept test was 0.17 (CI-95%, 0.12-0.23; t = 6.70; df = 19; p = 0.846), indicating no small-study effects (Figure 2a, Figure 2b).

The prevalence of peri-implantitis at implant-level obtained was 12.3% (CI-95%, 11.7-12.9%) for the fixed effects model and 11.5% (CI-95%, 8-15.4%) for the random effects model. High heterogeneity in both models was also observed (Q =968.47; p < 0.05; I²= 97,21%). After performing the sensitivity analysis excluding studies of Fransson [33], Gatti [36], González-González [37], Koldsland [42], Lee [44], Marrone [46], Ravald [54], Rodrigo [62], Romandini [64] and Vandeweghe [73], the prevalence at the implant level was 9.1% (95% CI, 8.1-10.2%). Meta-analysis found heterogeneity among the studies (Q = 31.59; p = 0.017; I²= 46.2%). The Egger’s test was 0.06 (CI-95%, 0.00-0.39; t= 5.96; df= 17; p = 0.01) indicating the presence of small-study effects (Figure 3a, Figure 3b).

The present systematic review highlighted some limitations of the definition, severity and prevalence of peri-implantitis. Peri-implant health can exist around implants with reduced bone support. Peri-implantitis occurring in sites with clinical signs of inflammation, bleeding on probing and/or suppuration, increased probing depths and/or recession of the mucosal margin in addition to radiographic bone loss [16].

The case definition of peri-implantitis is affected by the different criteria used to define a “case” in studies investigating the prevalence of peri-implant diseases [78]. Discordance in disease definition among published studies makes the prevalence range highly variable and illustrates the lack of consensus in research, making difficult to globally estimate the real elementary epidemiological parameters such as prevalence [14, 79]. In fact, there is currently a difference in how the peri-implantitis is defined in daily clinical practice and in epidemiological studies. Zitzmann and Berglundh [11] suggested that epidemiological research on peri-implant diseases should report not only on the prevalence or incidence of such but also on extent and severity. To determine the prevalence and incidence of peri-implantitis correctly, more prospective studies with adequate sample size and sampling method would be needed. In addition, baseline radiographic and probing measurements before and after loading the implant supported prosthesis must be performed to establish a bone level reference of physiological remodeling. Currently not many studies of this type are available. Most of the studies included in this research provided data from convenience samples, and most data were cross-sectional or collected retrospectively, rather than using randomized samples, resulting in a potential selection bias.

In the present systematic review, because a direct comparison was not possible, the referent case definition of peri-implantitis was subdivided into 4 groups with various thresholds for bone loss or exposed implant threads, and values for included peri-implant pocket depths, due to the fact that only a few study protocols have applied the new classification of periodontal diseases of World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions [16]. The design was thoroughly done to review the published literature and to retrieve as much data as possible from the filtered papers.

Revised studies reported a mean prevalence for peri-implantitis of 19.6% at patient-level and 12.39% at implant-level. The global values reported at patient-level were similar to those previously reported by Ting et al. [80] (18.8%), Atieh et al. [81] (18.8%), and Lee et al. [82] (19.83%). However, the same authors reported lower prevalence values than in the present review at implant-level (9.25-9.6%). Derks and Tomasi [14] also showed similar results at patient-level (21.7%). Conversely, Salvi et al. [83] reported lower prevalence values both at patient-level (10.3%) and at implant-level (7.5%).

Follow-up time and the evaluation in a convenience population may have influenced the prevalence values since peri-implantitis represents rather a chronic form of disease implying time for the osseous destruction [84]. Analyzing the influence of the period of functional loading, the results showed no differences in prevalence among studies with a follow-up period of 5 to 9 years and studies over 9 years of function, both at patient-level (17.19 and 17.75% respectively) and at implant-level (11.11 and 9.43% respectively). Conversely, Derks and Tomasi [14] meta-regression showed a statistically significant positive relationship between the prevalence of peri-implantitis and mean function time, in a follow-up period of 3 to 9 years. Consistent with the present systematic review, Dreyer et al. [85] have reported that there is not an increase in the prevalence of peri-implantitis at patient-level due to longer functional loading period.

The authors are unaware of previous studies analyzing the influence of probing depth measurement and how it affects the prevalence of peri-implantitis. In this systematic review it was observed that the prevalence of peri-implantitis was higher when probing depth was used as one of the diagnostic criteria, but without significant differences. Hence the controversy of changes in the definition of peri-implantitis.

The meta-analysis of the prevalence of peri-implantitis should be interpreted with caution, due to the medium-low heterogeneity found in the group 2. Muñoz Giraldo et al. [86] reported a prevalence of peri-implantitis of 18% at patient-level, similar to the results of the study. However, their I² index of 95,7% indicated high heterogeneity, while our I² index value of 44,3% indicated medium-low heterogeneity. At implant-level, the present study reported a prevalence of peri-implantitis of 9% with I² index of 46,2% that indicates medium-low heterogeneity. Muñoz Giraldo et al. [85] obtained a prevalence of 10% consistent with our results, but with a high heterogeneity (I² = 95.0%). The differences in heterogeneity observed between both systematic reviews and meta-analysis, may be due to the number of studies included for the group analyzed (probing depth ≥ 6 mm).

Within the limitations of this study, it can be concluded that prevalence of peri-implantitis defined as bleeding of probing and/or suppuration, pocket depth ≥ 6 mm, and peri-implant bone loss ≥ 2 mm was found to be approximately 18% at patient-level and 9% at implant-level. The variation in follow-up time, the heterogeneity of case definitions, and the selection of patients present in the currently available literature constitute a bias for incorrect estimation of the true prevalence value of peri-implantitis. Further studies should use more consistent periodontal diagnostic measures and disease definitions.

CI: Confidence Interval; BOP: Bleeding Of Probe.

Acknowledgements

The authors thank Dr. Carmen Bravo, Centre of Data Processing, Computing Service for Research Support, Complutense University of Madrid for her assistance with the statistical analysis and Prof. Ignacio Sanz-Sánchez, Complutense University of Madridfor his assistance with the methodology.

Author’s contributions

PD contributed to the conceptualization, literature search, data acquisition and interpretation, first drafted and critically revised the manuscript; EG contributed to the conceptualization, literature search, analysis interpretation, writing, editing and critical review of the article; LJGV contributed to the literature search, data acquisition, writing, editing and critical review of the article; BM contributed to data acquisition, and critical review of the article; MJS contributed to the conceptualization, supervision, project administration and critically revised the manuscript. All authors gave final approval and agreed to be accountable for all aspects of the manuscript.

Funding

None

Availability of data and materials

All data analyzed during this study are included in this manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Author details

¹Department of Conservative Dentistry and Bucofacial Prostheses, Faculty of Odontology, University Complutense of Madrid, Madrid, Spain.

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Table 5. Means of peri-implantitis prevalence (%), with confidence interval in parenthesis.

Group	Patient-level	Implant-level
1	16.4 (0.9-31.89)	12.12 (2.96-21.29)
2	20.67 (15.89-25.44)	12.65 (8.98-16.31)
3	14.62 (4.06-25.17)	11.08 (3.64-18.52)
4	23.94 (1.91-45.98)	13.21 (-0.48-26.91)
TOTAL	19.6 (15.25-24.75)	12.39 (9.46-15.43)

Table 6. Prevalence of peri-implantitis (%) at patient-level and implant-level, in function of load time.

Group	Patient-level		Implant-level
	5-9y	>9y	5-9y	>9y
1	14.18	17.13	21.3	8.45
2	20.57	21.2	12.32	8.78
3	12.11	9.68	3.53	14.51
4	13.54	15.34	7.42	6.8
TOTAL	17.19	17.75	11.11	9.43

Table 7. Peri-implantitis prevalence with/without probing depth inclusion.

Peri-implantitis with probing depth			Peri-implantitis without probing depth
Group	Patient-level	Implant-level	Group	Patient-level	Implant-level
1	17.13	12.25	1	14.18	11.39
2	19.89	12.78	2	22.05	13.07
3	18.53	12.74	3	9.68	13.29
4	57.53	31.05	4	14.35	7.12
TOTAL	25.26	15.66	TOTAL	17.7	11.07

No competing interests reported.

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What is the Prevalence of Peri-Implantitis? A Systematic Review and Meta-Analysis

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