Peri-Implant Therapy for the Dental Hygienist. Susan S. Wingrove

to fatty plaques in the arteries and forming clots. These clots can cause obstructions that can lead to a heart attack. Infection and/or inflammation responses can also affect the buildup of biofilm on the inner lining of the blood vessels supplying the heart (coronary arteries) or brain (carotid arteries) that occurs in atherosclerosis (4, 5).

      A growing number of research studies also support the contribution of periodontal/peri‐implant infection to the inflammatory burden theorized to be both a direct action on blood vessel walls and by indirectly inducing the liver to produce cardiac reactive proteins (CRPs) through an acute‐phase response (13). CRPs are produced by the liver in response to infection and inflammation, and are a specific systemic marker of vascular inflammation that appears to have a strong association with adverse vascular events; see Figure 2.1 (14).

CRPs are also referred to as hepatic plasma proteins or C‐reactive proteins. They are found in trace amounts even in healthy people, however, if elevated levels of these proteins are found it can signify serious inflammation in the body. CRP levels can go as high as 400–500 mg/L in seriously ill patients (see Table 2.1). Many different diseases and conditions can elevate CRP levels such as; periodontal disease, cardiovascular disease (CVD), trauma, surgery, burns, advanced malignancy, Alzheimer’s disease, blood sugar disorders, smoking, and obesity.

Table 2.1 Levels of cardiac reactive proteins (CRPs).

Normal CRP	<1.0 mg/L
Intermediate CRP	1.0–2.9 mg/L
High CRP	>3.0 mg/L

      Alzheimer’s disease is being viewed as an inflammatory brain disorder due to studies that have shown that patients with high levels of CRPs were three times more likely to develop Alzheimer’s disease. Tobacco also raises CRP levels and has a residual effect that remains in the body for years. Smoking causes oxidants to form and might accelerate the oxidation of low‐density lipoproteins (LDLs) constituents, which causes arterial inflammation even in healthy individuals with normal LDL levels.

      To detect and monitor inflammation, the CRP blood test is becoming a leading marker for systemic inflammation in the body. Intermediate to high levels of CRPs found in this specific blood test indicate an increase in inflammation somewhere in the body, are cause for concern, and the inflammation needs to be identified.

      CRP testing is a significant tool for identification of patients at risk for CV/CV, CVD, and prevention of CVD (15). Dental professionals are currently using high‐sensitivity C‐reactive protein (hs‐CRP) testing in dental practices chair‐side. They are requesting the test from the patient’s physician to identify and monitor patients at risk for acute coronary syndromes or periodontal/peri‐implant disease.

      Severe periodontal/peri‐implant disease patients have more harmful bacteria in their bloodstreams than patients with moderate or no disease (Figure 2.1). The inflammatory process of periodontal/peri‐implant disease increases CRP levels and when periodontal disease or peri‐implant disease are treated, the CRP levels decrease and the hemoglobin A1c (HbA1c) levels improve (16, 17). HbA1c level is also an important marker in monitoring diabetes. Both CRP and LDL cholesterol level tests are minimally correlated, but CRP has been found in some studies to be a stronger predictor of future cardiovascular events than LDL cholesterol (14).

      The bottom line is that CRPs are going to be an important link for dentistry. Inflammation is turning out to be the missing link for diagnosing and treating many systemic diseases. The key for dentistry is that periodontal disease and now peri‐implant disease is one of the most prominent inflammatory diseases in the body. In medical journals, the recommendation is that the first stop for a patient with increased CRP levels is a screening by a dentist or specialist for periodontal/peri‐implant disease or other oral infections. If the CRP levels remain elevated over 3.0 mg/L, a referral to the primary care physician is recommended for evaluation for systemic diseases. Educate your patients about pre‐procedural health before treatment for optimal successful long‐lasting results.

Preterm birth/low birth weight

There is a direct link between oral infections and premature births and low birth weight infant outcomes (6). Chronic infections such as periodontitis and implantitis can lead to an increased inflammatory response in pregnant mothers which, in turn, causes the production of higher levels of prostaglandins prematurely. The prostaglandins are produced naturally by the placenta to stimulate the birth of the baby, the end result being a low weight, and a prematurely birthed infant. In recent studies, researchers have also found that periodontal pathogens may travel from the oral cavity to the placenta to directly cause premature birth (7).

      Periodontal therapy for pregnant mothers has few adverse side effects and is recommended during the second trimester to reduce the occurrence of preterm low birth weight infants. The AAP strongly recommends good dental care during pregnancy. Women may experience increased gingivitis or pregnancy gingivitis beginning in the second or third month of pregnancy that increases in severity up to the eighth month.

      It is recommended to have an oral checkup with a dental professional with two dental prophylaxis visits: one in the first trimester and one in the third trimester. Studies demonstrate that periodontal therapy before 28 weeks of gestation can reduce the risk of preterm low birth weight infants in women with periodontitis.

Diabetes

      Diabetes mellitus is a group of metabolic diseases recognized as a global epidemic by the World Health Organization (WHO) that affects over 8% of the adult population worldwide (18). Diabetes is defined by elevated levels of glucose in the bloodstream. Type 1 diabetes is absolute insulin deficiency and type 2 diabetes is a metabolic disorder with high blood glucose with insulin resistance and some insulin deficiency.

      According to the latest 2017 World Workshop, Peri‐implantitis Review, the evidence is; “inconclusive as to whether diabetes is a risk factor/indicator for peri‐implantitis” (19). Recent studies showed evidence that a diabetic patient who completes dental implant therapy can masticate food, which will lead to improved nutrition and metabolic control (8). Diabetic patients do have an increased inflammatory response, are at risk for other complications, such as retinopathy, nephropathy, neuropathy, macrovascular disease, and poor wound healing. If they have poor metabolic control, successful periodontal and peri‐implantitis therapy can greatly improve diabetics’ metabolic control and tissue inflammation (20–26).

      It is recommended prior to implant therapy, that the dentist request a HbA1c test/results of any diabetic patient and continue to monitor their diabetic implant patients. This test allows for the dentist to monitor the diabetic patient’s blood sugar level to confirm that the patient’s levels are staying within a controlled range. Dental professionals can now offer their diabetic patients HbA1c tests in‐office. This allows the dentist the ability to monitor diabetic patients, identify and treat any signs of peri‐implant inflammation early.

      Good news for diabetic patients that current studies indicate that controlled diabetes show the same dental implant survival rate as patients without diabetes and it is now considered a predictable dental rehabilitation procedure for diabetics (8).

Respiratory disease

      Respiratory disease or lung diseases, especially hospital‐acquired pneumonia, are linked to poor dental health (9, 10). To define this link, pulmonary pathogens in plaque are aspirated into the lungs increasing the risk of pneumonia and chronic obstructive pulmonary disease (COPD) (9–12).