Sigrun Eick Christoph A. Ramseier Kathrin Rothenberger €gger Urs Bra Daniel Buser Giovanni E. Salvi
Authors’ affiliations: Sigrun Eick, Christoph A. Ramseier, Kathrin Rothenberger, Giovanni E. Salvi, Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland Urs Br€ agger, Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland Daniel Buser, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland
Microbiota at teeth and implants in partially edentulous patients. A 10-year retrospective study
Key words: dental implants, long-term follow-up, microbiota, mucositis, peri-implantitis Abstract Objective: To determine the microbiota at implants and adjacent teeth 10 years after placement of implants with a sandblasted and acid-etched surface. Material and methods: Plaque samples obtained from the deepest sites of 504 implants and of 493 adjacent teeth were analyzed for certain bacterial species associated with periodontitis, for staphylococci, for aerobic gram-negative rods, and for yeasts using nucleic acid-based methods. Results: Species known to be associated with periodontitis were detectable at 6.2–78.4% of the
Corresponding author: Sigrun Eick Department of Periodontology, Laboratory of Oral Microbiology, School of Dental Medicine University of Bern, Freiburgstrasse 7 CH-3010 Bern, Switzerland Tel.: + 41 31 632 25 42 Fax: + 41 31 632 8608 e-mail: [email protected]
implants. Significantly higher counts at implants in comparison with teeth were assessed for Tannerella forsythia, Parvimonas micra, Fusobacterium nucleatum/necrophorum, and Campylobacter rectus. Higher counts of periodontopathogenic species were detectable at implants of current smokers than at those of non-smokers. In addition, those species were found in higher quantities at implants of subjects with periodontitis. The prevalence of Prevotella intermedia, Treponema denticola, C. rectus, and moreover of Staphylococcus warneri might be associated with peri-implant inflammation. Selected staphylococcal species (not Staphylococcus aureus), aerobic gram-negative rods, and yeasts were frequently detected, but with the exception of S. warneri, they did not show any association with periodontal or peri-implant diseases. Conclusions: Smoking and periodontal disease are risk factors for colonization of periodontopathic bacteria at implants. Those bacterial species may play a potential role in periimplant inflammation. The role of S. warneri needs further validation.
SE and CAR contributed equally to the manuscript and therefore share first authorship. Date: Accepted 4 March 2015 To cite this article: Eick S, Ramseier CA, Rothenberger K, Br€ agger U, Buser D, Salvi GE. Microbiota at teeth and implants in partially edentulous patients. A 10-year retrospective study. Clin. Oral Impl. Res. 00, 2015, 1–8 doi: 10.1111/clr.12588
Over the past 20 years, dental implants have been widely used. Although this treatment has continually become more predictable and successful, a certain number of implant failures still occur. Long-term retrospective analyses are conducted to evaluate dental implant systems and to find risk factors for failures and peri-implant diseases, which are infectious diseases. Peri-implant mucositis is defined as an inflammatory lesion in the mucosa surrounding an implant, while periimplantitis is accompanied by loss of the supporting bone (Lindhe & Meyle 2008). The prevalence of inflammatory periimplant diseases is high. In Brazil, in an examination of 212 patients with 578 implants, 64.6% of the subjects and 62.6% of the implants had peri-implant mucositis, and in 8.9% of the patients and 7.44% of the implants, peri-implantitis was diagnosed (Ferreira et al. 2006). In Sweden, Roos-Jansaker et al. (Roos-Jansaker et al. 2006) analyzed
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
218 subjects with 994 implants, with 48% of the implants and 76.6% of the patients demonstrating probing depths ≥4 mm and bleeding on probing. Smoking, periodontitis, diabetes, and poor oral hygiene have been found to be associated with development of peri-implantitis (Ferreira et al. 2006), indicating the presence of microbes and diminished host response as risk factors. Peri-implant microbiomes differ from those of periodontitis (Kumar et al. 2012). Recently, one study group reported less diversity in comparison with periodontitis (Kumar et al. 2012), whereas another study group reported more diversity (Koyanagi et al. 2013). Bacteria associated with peri-implant lesions are at least partially the same as in periodontitis. Black-pigmented Prevotella species, Aggregatibacter actinomycetemcomitans, and Porphyromonas gingivalis are cultured in higher quantities from peri-implantitis lesions than from healthy controls; furthermore,
1
Eick et al Microbiota at teeth and implants
superinfecting species, for example, enterobacteria and staphylococci, may play a role in pathogenesis of peri-implant diseases (George et al. 1994; Leonhardt et al. 1999; Hultin et al. 2002; Botero et al. 2005; Shibli et al. 2008). Early after placement of implants, periodontopathogens are detectable on implants (Mombelli et al. 1995; Takanashi et al. 2004; F€ urst et al. 2007). In patients having a history of treated gingivitis or periodontitis, already 1 week after placement, abutments are colonized by P. gingivalis, Tannerella forsythia, Treponema denticola, Fusobacterium nucleatum, and Prevotella intermedia (De Boever & De Boever 2006; Quirynen et al. 2006). A long-term retrospective evaluation of survival and complication rates of implants with a sandblasted and acid-etched surface (SLA) (Straumannâ Dental Implant System; Institute Straumann AG, Basel, Switzerland) was performed 10 years after placement in partially edentulous patients. Data about survival and success rates as well as complication and failure rates have been published
recently (Buser et al. 2012; Wittneben et al. 2014). Another part of that evaluation, reported here, focused on the microbiota at implants. The aims were (i) to compare microbiota at implants with those at adjacent teeth, (ii) to find associations between periodontal disease and the loads of certain microbes associated with periodontal and peri-implant diseases, (iii) to detect differences in bacterial loads of those species in connection with peri-implant inflammation, and (iv) to determine the influence of smoking on microbial counts.
Material and methods Study design
The study design was published recently in detail (Buser et al. 2012). In short, out of the pool of patients from the Departments of Oral Surgery, Periodontology and Fixed Prosthodontics at the University of Bern, Switzerland, all patients having received at least one dental implant were recruited for a comprehensive evaluation 10 years after implant
installation. The patients had been treated according to a comprehensive treatment strategy prior to the installation of implants and incorporation of reconstructions. Thereafter, maintenance care at intervals between 3 and 6 months was offered to all of them. All the implants installed were solid screws with a diameter of 3.3, 4.1, or 4.8 mm, a length between 6 and 14 mm, and a sandblasted and acid-etched surface (SLA) (Straumannâ Dental Implant System, Institute Straumann AG). They were placed according to the manufacturer’s instructions (Buser et al. 2000). The reconstructions were either cemented or screw-retained and consisted of single-unit crowns or short-span fixed dental prostheses with or without cantilever extension(s). At reexamination, patients’ medical history and smoking history were assessed. Periodontitis was classified according to the American Academy of Periodontology (AAP) criteria (Page & Eke 2007). The implant and the mesial adjacent tooth (if missing the distal) were examined at 6 sites (i.e., buccal, mesio-buccal,
Table 1. Prevalence and numbers of samples with high (incl. very high) loads of selected species at implants and teeth. Difference of semiquantitative data was determined using the Wilcoxon test. The correlation was analyzed using Spearman correlation Implants (total n = 504)
Teeth (total n = 493)
Species
Positive n (%)
High load n (%)
Positive n (%)
High load n (%)
Difference implant – tooth P
Aggregatibacter actinomycetemcomitans Porphyromonas gingivalis Prevotella intermedia Tannerella forsythia Treponema denticola Parvimonas micra Fusobacterium nucleatum/necrophorum Campylobacter rectus Eikenella corrodens Eubacterium nodatum Capnocytophaga sp. Staphylococcus aureus Staphylococcus haemolyticus Staphylococcus epidermidis Staphylococcus hominis Staphylococcus warneri Staphylococcus simulans Staphylococcus lugdunensis Escherichia coli Proteus mirabilis Citrobacter freundii/koseri Klebsiella pneumoniae Klebsiella oxytoca Enterobacter agglomerans Enterobacter cloacae/aerogenes Enterobacter intermedium Serratia marcescens Pseudomonas aeruginosa Acinetobacter baumannii Stenotrophomonas maltophilia Candida albicans Candida glabrata Candida parapsilosis Candida tropicalis
31 85 64 176 119 280 395 217 197 85 303 11 29 36 131 185 0 74 3 2 221 21 311 4 2 391 0 0 1 9 124 194 17 4
14 48 16 61 29 83 151 98 22 3 98 0 0 0 1 3 0 0 0 0 1 0 67 2 0 68 0 0 0 0 30 66 9 3
33 73 50 135 90 205 356 189 198 80 307 17 33 42 127 202 1 61 3 0 232 16 314 4 3 389 0 0 1 8 130 191 16 3
23 40 16 48 34 58 143 67 28 0 99 0 0 0 3 4 0 0 0 0 1 0 186 3 0 51 0 0 0 0 21 67 5 3
0.104 0.326 0.379 0.005 0.051
Authors’ affiliations: Sigrun Eick, Christoph A. Ramseier, Kathrin Rothenberger, Giovanni E. Salvi, Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland Urs Br€ agger, Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern, Bern, Switzerland Daniel Buser, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern, Bern, Switzerland
Microbiota at teeth and implants in partially edentulous patients. A 10-year retrospective study
Key words: dental implants, long-term follow-up, microbiota, mucositis, peri-implantitis Abstract Objective: To determine the microbiota at implants and adjacent teeth 10 years after placement of implants with a sandblasted and acid-etched surface. Material and methods: Plaque samples obtained from the deepest sites of 504 implants and of 493 adjacent teeth were analyzed for certain bacterial species associated with periodontitis, for staphylococci, for aerobic gram-negative rods, and for yeasts using nucleic acid-based methods. Results: Species known to be associated with periodontitis were detectable at 6.2–78.4% of the
Corresponding author: Sigrun Eick Department of Periodontology, Laboratory of Oral Microbiology, School of Dental Medicine University of Bern, Freiburgstrasse 7 CH-3010 Bern, Switzerland Tel.: + 41 31 632 25 42 Fax: + 41 31 632 8608 e-mail: [email protected]
implants. Significantly higher counts at implants in comparison with teeth were assessed for Tannerella forsythia, Parvimonas micra, Fusobacterium nucleatum/necrophorum, and Campylobacter rectus. Higher counts of periodontopathogenic species were detectable at implants of current smokers than at those of non-smokers. In addition, those species were found in higher quantities at implants of subjects with periodontitis. The prevalence of Prevotella intermedia, Treponema denticola, C. rectus, and moreover of Staphylococcus warneri might be associated with peri-implant inflammation. Selected staphylococcal species (not Staphylococcus aureus), aerobic gram-negative rods, and yeasts were frequently detected, but with the exception of S. warneri, they did not show any association with periodontal or peri-implant diseases. Conclusions: Smoking and periodontal disease are risk factors for colonization of periodontopathic bacteria at implants. Those bacterial species may play a potential role in periimplant inflammation. The role of S. warneri needs further validation.
SE and CAR contributed equally to the manuscript and therefore share first authorship. Date: Accepted 4 March 2015 To cite this article: Eick S, Ramseier CA, Rothenberger K, Br€ agger U, Buser D, Salvi GE. Microbiota at teeth and implants in partially edentulous patients. A 10-year retrospective study. Clin. Oral Impl. Res. 00, 2015, 1–8 doi: 10.1111/clr.12588
Over the past 20 years, dental implants have been widely used. Although this treatment has continually become more predictable and successful, a certain number of implant failures still occur. Long-term retrospective analyses are conducted to evaluate dental implant systems and to find risk factors for failures and peri-implant diseases, which are infectious diseases. Peri-implant mucositis is defined as an inflammatory lesion in the mucosa surrounding an implant, while periimplantitis is accompanied by loss of the supporting bone (Lindhe & Meyle 2008). The prevalence of inflammatory periimplant diseases is high. In Brazil, in an examination of 212 patients with 578 implants, 64.6% of the subjects and 62.6% of the implants had peri-implant mucositis, and in 8.9% of the patients and 7.44% of the implants, peri-implantitis was diagnosed (Ferreira et al. 2006). In Sweden, Roos-Jansaker et al. (Roos-Jansaker et al. 2006) analyzed
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
218 subjects with 994 implants, with 48% of the implants and 76.6% of the patients demonstrating probing depths ≥4 mm and bleeding on probing. Smoking, periodontitis, diabetes, and poor oral hygiene have been found to be associated with development of peri-implantitis (Ferreira et al. 2006), indicating the presence of microbes and diminished host response as risk factors. Peri-implant microbiomes differ from those of periodontitis (Kumar et al. 2012). Recently, one study group reported less diversity in comparison with periodontitis (Kumar et al. 2012), whereas another study group reported more diversity (Koyanagi et al. 2013). Bacteria associated with peri-implant lesions are at least partially the same as in periodontitis. Black-pigmented Prevotella species, Aggregatibacter actinomycetemcomitans, and Porphyromonas gingivalis are cultured in higher quantities from peri-implantitis lesions than from healthy controls; furthermore,
1
Eick et al Microbiota at teeth and implants
superinfecting species, for example, enterobacteria and staphylococci, may play a role in pathogenesis of peri-implant diseases (George et al. 1994; Leonhardt et al. 1999; Hultin et al. 2002; Botero et al. 2005; Shibli et al. 2008). Early after placement of implants, periodontopathogens are detectable on implants (Mombelli et al. 1995; Takanashi et al. 2004; F€ urst et al. 2007). In patients having a history of treated gingivitis or periodontitis, already 1 week after placement, abutments are colonized by P. gingivalis, Tannerella forsythia, Treponema denticola, Fusobacterium nucleatum, and Prevotella intermedia (De Boever & De Boever 2006; Quirynen et al. 2006). A long-term retrospective evaluation of survival and complication rates of implants with a sandblasted and acid-etched surface (SLA) (Straumannâ Dental Implant System; Institute Straumann AG, Basel, Switzerland) was performed 10 years after placement in partially edentulous patients. Data about survival and success rates as well as complication and failure rates have been published
recently (Buser et al. 2012; Wittneben et al. 2014). Another part of that evaluation, reported here, focused on the microbiota at implants. The aims were (i) to compare microbiota at implants with those at adjacent teeth, (ii) to find associations between periodontal disease and the loads of certain microbes associated with periodontal and peri-implant diseases, (iii) to detect differences in bacterial loads of those species in connection with peri-implant inflammation, and (iv) to determine the influence of smoking on microbial counts.
Material and methods Study design
The study design was published recently in detail (Buser et al. 2012). In short, out of the pool of patients from the Departments of Oral Surgery, Periodontology and Fixed Prosthodontics at the University of Bern, Switzerland, all patients having received at least one dental implant were recruited for a comprehensive evaluation 10 years after implant
installation. The patients had been treated according to a comprehensive treatment strategy prior to the installation of implants and incorporation of reconstructions. Thereafter, maintenance care at intervals between 3 and 6 months was offered to all of them. All the implants installed were solid screws with a diameter of 3.3, 4.1, or 4.8 mm, a length between 6 and 14 mm, and a sandblasted and acid-etched surface (SLA) (Straumannâ Dental Implant System, Institute Straumann AG). They were placed according to the manufacturer’s instructions (Buser et al. 2000). The reconstructions were either cemented or screw-retained and consisted of single-unit crowns or short-span fixed dental prostheses with or without cantilever extension(s). At reexamination, patients’ medical history and smoking history were assessed. Periodontitis was classified according to the American Academy of Periodontology (AAP) criteria (Page & Eke 2007). The implant and the mesial adjacent tooth (if missing the distal) were examined at 6 sites (i.e., buccal, mesio-buccal,
Table 1. Prevalence and numbers of samples with high (incl. very high) loads of selected species at implants and teeth. Difference of semiquantitative data was determined using the Wilcoxon test. The correlation was analyzed using Spearman correlation Implants (total n = 504)
Teeth (total n = 493)
Species
Positive n (%)
High load n (%)
Positive n (%)
High load n (%)
Difference implant – tooth P
Aggregatibacter actinomycetemcomitans Porphyromonas gingivalis Prevotella intermedia Tannerella forsythia Treponema denticola Parvimonas micra Fusobacterium nucleatum/necrophorum Campylobacter rectus Eikenella corrodens Eubacterium nodatum Capnocytophaga sp. Staphylococcus aureus Staphylococcus haemolyticus Staphylococcus epidermidis Staphylococcus hominis Staphylococcus warneri Staphylococcus simulans Staphylococcus lugdunensis Escherichia coli Proteus mirabilis Citrobacter freundii/koseri Klebsiella pneumoniae Klebsiella oxytoca Enterobacter agglomerans Enterobacter cloacae/aerogenes Enterobacter intermedium Serratia marcescens Pseudomonas aeruginosa Acinetobacter baumannii Stenotrophomonas maltophilia Candida albicans Candida glabrata Candida parapsilosis Candida tropicalis
31 85 64 176 119 280 395 217 197 85 303 11 29 36 131 185 0 74 3 2 221 21 311 4 2 391 0 0 1 9 124 194 17 4
14 48 16 61 29 83 151 98 22 3 98 0 0 0 1 3 0 0 0 0 1 0 67 2 0 68 0 0 0 0 30 66 9 3
33 73 50 135 90 205 356 189 198 80 307 17 33 42 127 202 1 61 3 0 232 16 314 4 3 389 0 0 1 8 130 191 16 3
23 40 16 48 34 58 143 67 28 0 99 0 0 0 3 4 0 0 0 0 1 0 186 3 0 51 0 0 0 0 21 67 5 3
0.104 0.326 0.379 0.005 0.051
