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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Does the number of implants have any relation with peri-implant
disease?</title><author><name sortKey="Passoni, Bernardo Born" sort="Passoni, Bernardo Born" uniqKey="Passoni B" first="Bernardo Born" last="Passoni">Bernardo Born Passoni</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Dalago, Haline Renata" sort="Dalago, Haline Renata" uniqKey="Dalago H" first="Haline Renata" last="Dalago">Haline Renata Dalago</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Schuldt Filho, Guenther" sort="Schuldt Filho, Guenther" uniqKey="Schuldt Filho G" first="Guenther" last="Schuldt Filho">Guenther Schuldt Filho</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Oliveira De Souza, Joao Gustavo" sort="Oliveira De Souza, Joao Gustavo" uniqKey="Oliveira De Souza J" first="João Gustavo" last="Oliveira De Souza">João Gustavo Oliveira De Souza</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Benfatti, Cesar Augusto Magalhaes" sort="Benfatti, Cesar Augusto Magalhaes" uniqKey="Benfatti C" first="César Augusto Magalhães" last="Benfatti">César Augusto Magalhães Benfatti</name><affiliation><nlm:aff id="aff02"> Department of Surgery, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Magini, Ricardo De Souza" sort="Magini, Ricardo De Souza" uniqKey="Magini R" first="Ricardo De Souza" last="Magini">Ricardo De Souza Magini</name><affiliation><nlm:aff id="aff03"> Department of Periodontics, Federal University of Santa Catarina, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Bianchini, Marco Aurelio" sort="Bianchini, Marco Aurelio" uniqKey="Bianchini M" first="Marco Aurélio" last="Bianchini">Marco Aurélio Bianchini</name><affiliation><nlm:aff id="aff03"> Department of Periodontics, Federal University of Santa Catarina, SC, Brazil.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25466474</idno><idno type="pmc">4245752</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245752</idno><idno type="RBID">PMC:4245752</idno><idno type="doi">10.1590/1678-775720140055</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">003024</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">003024</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Does the number of implants have any relation with peri-implant
disease?</title><author><name sortKey="Passoni, Bernardo Born" sort="Passoni, Bernardo Born" uniqKey="Passoni B" first="Bernardo Born" last="Passoni">Bernardo Born Passoni</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Dalago, Haline Renata" sort="Dalago, Haline Renata" uniqKey="Dalago H" first="Haline Renata" last="Dalago">Haline Renata Dalago</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Schuldt Filho, Guenther" sort="Schuldt Filho, Guenther" uniqKey="Schuldt Filho G" first="Guenther" last="Schuldt Filho">Guenther Schuldt Filho</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Oliveira De Souza, Joao Gustavo" sort="Oliveira De Souza, Joao Gustavo" uniqKey="Oliveira De Souza J" first="João Gustavo" last="Oliveira De Souza">João Gustavo Oliveira De Souza</name><affiliation><nlm:aff id="aff01"> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Benfatti, Cesar Augusto Magalhaes" sort="Benfatti, Cesar Augusto Magalhaes" uniqKey="Benfatti C" first="César Augusto Magalhães" last="Benfatti">César Augusto Magalhães Benfatti</name><affiliation><nlm:aff id="aff02"> Department of Surgery, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Magini, Ricardo De Souza" sort="Magini, Ricardo De Souza" uniqKey="Magini R" first="Ricardo De Souza" last="Magini">Ricardo De Souza Magini</name><affiliation><nlm:aff id="aff03"> Department of Periodontics, Federal University of Santa Catarina, SC, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Bianchini, Marco Aurelio" sort="Bianchini, Marco Aurelio" uniqKey="Bianchini M" first="Marco Aurélio" last="Bianchini">Marco Aurélio Bianchini</name><affiliation><nlm:aff id="aff03"> Department of Periodontics, Federal University of Santa Catarina, SC, Brazil.</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Applied Oral Science</title><idno type="ISSN">1678-7757</idno><idno type="eISSN">1678-7765</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>The aim of this study was to evaluate the relationship between the number of
pillar implants of implant-supported fixed prostheses and the prevalence of
periimplant disease.</p></sec><sec><title>Material and Methods</title><p>Clinical and radiographic data were obtained for the evaluation. The sample
consisted of 32 patients with implant-supported fixed prostheses in function for
at least one year. A total of 161 implants were evaluated. Two groups were formed
according to the number of implants: G1) ≤5 implants and G2) >5 implants. Data
collection included modified plaque index (MPi), bleeding on probing (BOP),
probing depth (PD), width of keratinized mucosa (KM) and radiographic bone loss
(BL). Clinical and radiographic data were grouped for each implant in order to
conduct the diagnosis of mucositis or peri-implantitis.</p></sec><sec><title>Results</title><p>Clinical parameters were compared between groups using Student's t test for
numeric variables (KM, PD and BL) and Mann-Whitney test for categorical variables
(MPi and BOP). KM and BL showed statistically significant differences between both
groups (p<0.001). Implants from G1 – 19 (20.43%) – compared with G2 – 26
(38.24%) – showed statistically significant differences regarding the prevalence
of peri-implantitis (p=0.0210).</p></sec><sec><title>Conclusion</title><p>It seems that more than 5 implants in total fixed rehabilitations increase bone
loss and consequently the prevalence of implants with periimplantitis.
Notwithstanding, the number of implants does not have any influence on the
prevalence of mucositis.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Adell, R" uniqKey="Adell R">R Adell</name></author><author><name sortKey="Eriksson, B" uniqKey="Eriksson B">B Eriksson</name></author><author><name sortKey="Lekholm, U" uniqKey="Lekholm U">U Lekholm</name></author><author><name sortKey="Branemark, P I" uniqKey="Branemark P">P-I Branemark</name></author><author><name sortKey="Jemt, T" uniqKey="Jemt T">T Jemt</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Albrektsson, T" uniqKey="Albrektsson T">T Albrektsson</name></author><author><name sortKey="Buser, D" uniqKey="Buser D">D Buser</name></author><author><name sortKey="Chen, St" uniqKey="Chen S">ST Chen</name></author><author><name sortKey="Cochran, D" uniqKey="Cochran D">D Cochran</name></author><author><name sortKey="Debruyn, H" uniqKey="Debruyn H">H DeBruyn</name></author><author><name sortKey="Jemt, T" uniqKey="Jemt 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Wallace</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Winkelhoff, Aj" uniqKey="Van Winkelhoff A">AJ Van Winkelhoff</name></author><author><name sortKey="Goene, Rj" uniqKey="Goene R">RJ Goené</name></author><author><name sortKey="Benschop, C" uniqKey="Benschop C">C Benschop</name></author><author><name sortKey="Folmer, T" uniqKey="Folmer T">T Folmer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wennstrom, J" uniqKey="Wennstrom J">J Wennstrom</name></author><author><name sortKey="Palmer, R" uniqKey="Palmer R">R Palmer</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Appl Oral Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Appl Oral Sci</journal-id><journal-title-group><journal-title>Journal of Applied Oral Science</journal-title></journal-title-group><issn pub-type="ppub">1678-7757</issn><issn pub-type="epub">1678-7765</issn><publisher><publisher-name>Faculdade de Odontologia de Bauru da Universidade de São
Paulo</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25466474</article-id><article-id pub-id-type="pmc">4245752</article-id><article-id pub-id-type="doi">10.1590/1678-775720140055</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject></subj-group></article-categories><title-group><article-title>Does the number of implants have any relation with peri-implant
disease?</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>PASSONI</surname><given-names>Bernardo Born</given-names></name><xref ref-type="aff" rid="aff01">1</xref><xref ref-type="corresp" rid="c01"></xref></contrib><contrib contrib-type="author"><name><surname>DALAGO</surname><given-names>Haline Renata</given-names></name><xref ref-type="aff" rid="aff01">1</xref></contrib><contrib contrib-type="author"><name><surname>SCHULDT FILHO</surname><given-names>Guenther</given-names></name><xref ref-type="aff" rid="aff01">1</xref></contrib><contrib contrib-type="author"><name><surname>OLIVEIRA DE SOUZA</surname><given-names>João Gustavo</given-names></name><xref ref-type="aff" rid="aff01">1</xref></contrib><contrib contrib-type="author"><name><surname>BENFATTI</surname><given-names>César Augusto Magalhães</given-names></name><xref ref-type="aff" rid="aff02">2</xref></contrib><contrib contrib-type="author"><name><surname>MAGINI</surname><given-names>Ricardo de Souza</given-names></name><xref ref-type="aff" rid="aff03">3</xref></contrib><contrib contrib-type="author"><name><surname>BIANCHINI</surname><given-names>Marco Aurélio</given-names></name><xref ref-type="aff" rid="aff03">3</xref></contrib></contrib-group><aff id="aff01"><label>1</label> Department of Implant Dentistry, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</aff><aff id="aff02"><label>2</label> Department of Surgery, Federal University of Santa Catarina, Florianópolis, SC, Brazil.</aff><aff id="aff03"><label>3</label> Department of Periodontics, Federal University of Santa Catarina, SC, Brazil.</aff><author-notes><corresp id="c01"><bold>Corresponding address:</bold> Bernardo Born Passoni - R. Esteves
Junior, 463/701 - Centro - Florianópolis - SC - Brazil - 88015-130 - Phone: +55 48
37219077 - e-mail: <email>bpassoni@hotmail.com</email></corresp></author-notes><pub-date pub-type="epub-ppub"><season>Sep-Oct</season><year>2014</year></pub-date><pmc-comment>Fake ppub date generated by PMC from publisher
pub-date/@pub-type='epub-ppub' </pmc-comment>
<pub-date pub-type="ppub"><season>Sep-Oct</season><year>2014</year></pub-date><volume>22</volume><issue>5</issue><fpage>403</fpage><lpage>408</lpage><history><date date-type="received"><day>06</day><month>2</month><year>2014</year></date><date date-type="rev-recd"><day>15</day><month>6</month><year>2014</year></date><date date-type="accepted"><day>18</day><month>6</month><year>2014</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><license-p>This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.</license-p></license></permissions><abstract><sec><title>Objective</title><p>The aim of this study was to evaluate the relationship between the number of
pillar implants of implant-supported fixed prostheses and the prevalence of
periimplant disease.</p></sec><sec><title>Material and Methods</title><p>Clinical and radiographic data were obtained for the evaluation. The sample
consisted of 32 patients with implant-supported fixed prostheses in function for
at least one year. A total of 161 implants were evaluated. Two groups were formed
according to the number of implants: G1) ≤5 implants and G2) >5 implants. Data
collection included modified plaque index (MPi), bleeding on probing (BOP),
probing depth (PD), width of keratinized mucosa (KM) and radiographic bone loss
(BL). Clinical and radiographic data were grouped for each implant in order to
conduct the diagnosis of mucositis or peri-implantitis.</p></sec><sec><title>Results</title><p>Clinical parameters were compared between groups using Student's t test for
numeric variables (KM, PD and BL) and Mann-Whitney test for categorical variables
(MPi and BOP). KM and BL showed statistically significant differences between both
groups (p<0.001). Implants from G1 – 19 (20.43%) – compared with G2 – 26
(38.24%) – showed statistically significant differences regarding the prevalence
of peri-implantitis (p=0.0210).</p></sec><sec><title>Conclusion</title><p>It seems that more than 5 implants in total fixed rehabilitations increase bone
loss and consequently the prevalence of implants with periimplantitis.
Notwithstanding, the number of implants does not have any influence on the
prevalence of mucositis.</p></sec></abstract><kwd-group><kwd>Peri-implantitis</kwd><kwd>Mucositis</kwd><kwd>Dental implants</kwd></kwd-group></article-meta></front><body><sec sec-type="intro"><title>INTRODUCTION</title><p>Routine treatment of edentulism with fixed prostheses supported by osseointegrated
fixtures appears to be a highly efficient method, giving predictable long-term results
in edentulous patient populations<sup><xref rid="r01" ref-type="bibr">1</xref></sup>.</p><p>Peri-implant diseases are one of factors responsible for implant failures. These lesions
are commonly asymptomatic and frequently detected in follow-up visits. The presence of
increased probing depth (≥5 mm)<sup><xref rid="r20" ref-type="bibr">20</xref>,<xref rid="r28" ref-type="bibr">28</xref></sup> bleeding on probing and/or pus is a key
factor that may facilitate the diagnosis of peri-implantitis. Yet, peri-implantitis is
characterized mainly by the presence of progressive bone loss which occurs after the
biological response associated with the adaptation phase adjacent to the
implant<sup><xref rid="r02" ref-type="bibr">2</xref>,<xref rid="r22" ref-type="bibr">22</xref></sup>. The term mucositis is related to the infammatory lesion
induced by nonspecific biofilm<sup><xref rid="r18" ref-type="bibr">18</xref></sup>limited to peri-implant mucosa without involvement of bone tissue<sup><xref rid="r13" ref-type="bibr">13</xref></sup>.</p><p>Based on clinical findings, radiographs can be useful for the confirmation of the
presence or absence of the disease<sup><xref rid="r19" ref-type="bibr">19</xref></sup>.
In the absence of previous radiographic records, a threshold vertical distance of 2 mm
from the expected marginal bone level following remodelling post-implant placement is
recommended, provided peri-implant infammation is evident<sup><xref rid="r28" ref-type="bibr">28</xref></sup>. Thus, both the bone remodeling that occurs after
exposure of the implant to the oral environment (saucerization) and the late bone loss
characterized by gradual loss of marginal bone after osseointegration has been
consolidated<sup><xref rid="r31" ref-type="bibr">31</xref></sup> must be included
when evaluating the success of implants<sup><xref rid="r06" ref-type="bibr">6</xref></sup>. As seen in a particular study, gradual bone loss of 0.2 mm after the
first year of function can be considered successful. For this reason, a bone loss
<2.4 mm would be acceptable during the first five years of function<sup><xref rid="r03" ref-type="bibr">3</xref></sup>.</p><p>Moreover, peri-implant diseases (mucositis or peri-implantitis) are responsible for
several implant losses and, if not treated, may lead to failure of bone healing around
the titanium surface<sup><xref rid="r11" ref-type="bibr">11</xref></sup>.</p><p>Peri-implant diseases might be considered an imbalance of the action of specific
Gram-negative bacteria and spirochetes<sup><xref rid="r33" ref-type="bibr">33</xref></sup> against host organism, caused by a decrease in immunity. They can
affect only the mucosa (mucositis) and also the supporting bone, which characterizes
peri-implantitis<sup><xref rid="r18" ref-type="bibr">18</xref></sup>. These can be
developed after the implants are exposed to the oral environment and masticatory loads
for a period (at least 1 year in our research) and should be considered especially after
the formation phase of the biological distances. Our study considered that implants with
peri-implantitis had to present probing depth ≥5 mm, at least one point with
bleeding/suppuration on probing and radiographic bone loss >2 mm.</p><p>Based on clinical longitudinal studies, the time of prosthesis installation should be
chosen to establish baseline criteria. To establish a baseline, a radiograph should be
obtained to determine alveolar bone levels after physiologic remodeling, and
peri-implant probing assessments should be performed<sup><xref rid="r17" ref-type="bibr">17</xref></sup>.</p><p>Regarding patients' hygienic procedures, in order to maintain the implant healthy, it's
crucial to stimulate and orientate them. These procedures should be performed by the
patient under professional supervision<sup><xref rid="r19" ref-type="bibr">19</xref></sup>. Still, the understanding between the dentist and the technician may
facilitate prostheses production with less plaque accumulation potential<sup><xref rid="r30" ref-type="bibr">30</xref></sup>. In this context, it is suggested that
the lowest amount of implants in total rehabilitation can favor the homeostasis of
peri-implant tissues, mainly by the distribution/ position of the implants and their
relationship with the prosthetic piece.</p><p>What remains unclear in the literature is whether the number of implants has any
influence on the health status of the implants. Thus, the aim of this study was to
evaluate the relationship between the number of pillar implants (≤5 and >5) of
implant-supported fixed prostheses and the prevalence of peri-implant diseases
(mucositis and peri-implantitis).</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><sec><title>Sample selection</title><p>This study was approved by the ethics committee for clinical studies of Federal
University of Santa Catarina, Florianópolis-SC, Brazil (Protocol no. 128/2006). Each
patient read and signed an informed consent form before entering the study. The
patients included in the study were those who had received osseointegrated implants
with an external hex 4.1 mm connection and fixed metal with resin prostheses
supported by implants done at the Center of Teaching and Research in Dental Implants,
placed in the Center of Sciences and Health (CCS) of the Federal University of Santa
Catarina (UFSC) from 2004 to 2010. Participants were selected from a total of 35
patients that had implant-supported fixed prostheses and received the implants from
2004 to 2010. The individuals excluded from the study were the ones with radiographs
unable to be measured, patients with psychiatric disorders and those who participated
in any follow-up control for plaque removal. Thus, 32 patients were selected - 14 men
and 18 women - who had 161 implants in function for at least one year. However, at
first the implants were evaluated in groups according to quantity only, without
considering its location.</p></sec><sec><title>Data collection</title><p>Patient examination and collection of all data were blind, performed by an
independent and experienced clinician. All prostheses on implants were resin complete
dentures with metal substructures and were removed in order to facilitate data
collection. The cantilever evaluation was completed by considering the length of the
cantilever. For this evaluation, the study was divided into two groups: G1) ≤5
implants and G2) >5 implants as implant-supported fixed prostheses pillars.
Moreover, the following data were recorded for each implant after the prosthesis'
removal.</p><p>- Modified plaque index (MPi)<sup><xref rid="r24" ref-type="bibr">24</xref></sup> -
(0: no plaque, 1: detected with the point of the instrument, 2: visual plaque, 3:
excessive plaque accumulation).</p><p>- Modified bleeding on probing index (BOP)<sup><xref rid="r24" ref-type="bibr">24</xref></sup> - (0: no bleeding, 1: bleeding spots, 2: thin line of blood
around the implant, 3: excessive bleeding).</p><p>- Hygiene difficulty - ranked by the patient as high, medium or low.</p><p>- Probing depth (PD)<sup><xref rid="r20" ref-type="bibr">20</xref>,<xref rid="r28" ref-type="bibr">28</xref></sup>.</p><p>- Marginal recession - (0: absent, 1: :1 mm, >2 mm).</p><p>- Width of keratinized mucosa (KM) - (Differences in color, texture and mobility
served as markers for mucogingival junction detection)<sup><xref rid="r21" ref-type="bibr">21</xref></sup>.</p><p>- Distance between implants - classified as ≥3 mm or <3 mm.</p><p>- Radiographic bone loss (BL)<sup><xref rid="r30" ref-type="bibr">30</xref>,<xref rid="r34" ref-type="bibr">34</xref></sup> - measured by comparing the
periapical radiographs. Bone level was measured from the implant platform to the
first bone-implant contact (in mm).</p><p>- Dental arch positioning (in mm) - anterior (incisors and canines) or posterior (pre
molars and molars).</p><p>- Maxillary positioning - superior (maxilla) or inferior (mandible).</p><p>- Cantilever distal extension - (1: >10 mm and 2: ≤10 mm).</p></sec><sec><title>Radiographic analysis</title><p>The distance between implant platform and the first bone-implant visible contact was
measured in millimeters at the mesial and distal aspect of each implant using
periapical radiographs. Special care was taken to position the film parallel to the
fixture to provide an optimal and undistorted image<sup><xref rid="r09" ref-type="bibr">9</xref></sup>. The images were digitalized and the bone loss was
evaluated in the Digimizer image analysis software<sup>®</sup> (MedCalc Software,
Ostend, Belgium). For each implant, the highest value for bone loss found at the
mesial or distal aspect was used. Further care was taken to ensure that threads on
both the mesial and distal sides of the implants were clearly visible<sup><xref rid="r12" ref-type="bibr">12</xref></sup>. All the images were analyzed by the
same examiner.</p></sec><sec><title>Statistical analysis</title><p>Data were digitalized and organized for comparison between groups and analyses of the
results. Clinical parameters were compared between groups. Student's t test was
applied for numeric variables (KM, PD, BL). For KM and PD, a mean value (in
millimeters) related to all four examined areas was calculated. For BL, the analysis
considered the greatest value in millimeters. Categorical variables such as DP and
BOP were evaluated using Mann-Whitney test. Chi-square test was used for comparison
and statistical analysis for binary variables - prevalence of mucositis and
peri-implantitis. Furthermore, Yates correction was applied to adjust the value of
the chi-square test when the expected frequency by the law of averages was less than
5. For insufficient samples to perform the chi-square or Yates correction, Fisher's
test was applied. P value ≤0.05 was considered to indicate a statistically
significant difference between analyzes.</p></sec><sec><title>Diagnosis</title><p>The diagnosis of the implants was performed at the time of the follow-up visit. In
order to be considered with PI, implants had to present PD ≥5 mm, at least one point
of bleeding/suppuration on probing (BOP) and BL >2 mm. For PD, the highest value
was considered. Parameters for PD and BOP were obtained using a periodontal probe
(PCV12PT Hu-Friedy Inc., Chicago, IL, USA). Measurements were performed by a single
calibrated professional in order to reduce errors and establish reliability and
consistency. Also, all prostheses were removed prior to the examination to permit
data collection.</p></sec></sec><sec sec-type="results"><title>RESULTS</title><p>Implants were in function for at least one year. The mean time in function was 47.46
months for G1 and 67.56 months for G2. From the total implant fixed prosthesis, 14
(43.75%) were located in the maxilla and 18 (56.25%) in the mandible. Regarding the
number of implants, 75 (46.58%) and 86 (53.42%) were located in the maxilla and
mandible, respectively (<xref ref-type="table" rid="t01">Table 1</xref>). Patients' age
ranged from 45 to 80 years (mean age 63.43). For time in function, implants had an
average of 55.95 months with a standard deviation of 24.21 (12.48 to 64.79 months). The
average of implants per patients was 5.96.</p><table-wrap id="t01" orientation="portrait" position="float"><label>Table 1</label><caption><p>Frequency and distribution of data on the G1 implants (up to 5 implants) and G2
(more than 5 implants) according the implant placement area</p></caption><table frame="hsides" rules="groups"><thead><tr style="background-color:#dcddde"><th align="center" rowspan="1" colspan="1">G1</th><th align="center" rowspan="1" colspan="1">Implants n (%)</th><th align="center" rowspan="1" colspan="1">Healthy</th><th align="center" rowspan="1" colspan="1">Mucositis</th><th align="center" rowspan="1" colspan="1">Peri-implantitis</th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">Post-sup</td><td align="center" rowspan="1" colspan="1">10 (6.21%)</td><td align="center" rowspan="1" colspan="1">1 (6.25%)</td><td align="center" rowspan="1" colspan="1">7 (7.00%)</td><td align="center" rowspan="1" colspan="1">2 (4.44%)</td></tr><tr style="background-color:#dcddde"><td align="center" rowspan="1" colspan="1">Ant-sup</td><td align="center" rowspan="1" colspan="1">16 (9.94%)</td><td align="center" rowspan="1" colspan="1">1 (6.25%)</td><td align="center" rowspan="1" colspan="1">11 (11.00%)</td><td align="center" rowspan="1" colspan="1">4 (8.89%)</td></tr><tr><td align="center" rowspan="1" colspan="1">Post-inf</td><td align="center" rowspan="1" colspan="1">25 (15.53%)</td><td align="center" rowspan="1" colspan="1">3 (18.75%)</td><td align="center" rowspan="1" colspan="1">17 (17.00%)</td><td align="center" rowspan="1" colspan="1">5 (11.11%)</td></tr><tr style="background-color:#dcddde"><td align="center" rowspan="1" colspan="1">Ant-inf</td><td align="center" rowspan="1" colspan="1">42 (26.09%)</td><td align="center" rowspan="1" colspan="1">4 (25.00%)</td><td align="center" rowspan="1" colspan="1">25 (25.00%)</td><td align="center" rowspan="1" colspan="1">13 (28.89%)</td></tr><tr><td align="center" rowspan="1" colspan="1"><bold>G2</bold></td><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1"> </td></tr><tr style="background-color:#dcddde"><td align="center" rowspan="1" colspan="1">Post-sup</td><td align="center" rowspan="1" colspan="1">25 (15.53%)</td><td align="center" rowspan="1" colspan="1">2 (12.50%)</td><td align="center" rowspan="1" colspan="1">17 (17.00%)</td><td align="center" rowspan="1" colspan="1">6 (13.33%)</td></tr><tr><td align="center" rowspan="1" colspan="1">Ant-sup</td><td align="center" rowspan="1" colspan="1">24 (14.91%)</td><td align="center" rowspan="1" colspan="1">2 (12.50%)</td><td align="center" rowspan="1" colspan="1">13 (13.00%)</td><td align="center" rowspan="1" colspan="1">9 (20.00%)</td></tr><tr style="background-color:#dcddde"><td align="center" rowspan="1" colspan="1">Post-inf</td><td align="center" rowspan="1" colspan="1">6 (3.73%)</td><td align="center" rowspan="1" colspan="1">1 (6.25%)</td><td align="center" rowspan="1" colspan="1">4 (4.00%)</td><td align="center" rowspan="1" colspan="1">1 (2.22%)</td></tr><tr><td align="center" rowspan="1" colspan="1">Ant-inf</td><td align="center" rowspan="1" colspan="1">13 (8.07%)</td><td align="center" rowspan="1" colspan="1">2 (12.50%)</td><td align="center" rowspan="1" colspan="1">6 (6.00%)</td><td align="center" rowspan="1" colspan="1">5 (11.11%)</td></tr><tr style="background-color:#dcddde"><td align="center" rowspan="1" colspan="1">Total</td><td align="center" rowspan="1" colspan="1">161 (100.00%)</td><td align="center" rowspan="1" colspan="1">16 (100.00%)</td><td align="center" rowspan="1" colspan="1">100 (100.00%)</td><td align="center" rowspan="1" colspan="1">45 (100.00%)</td></tr></tbody></table></table-wrap><p>Evaluating the amount of KM, G1 showed lower height compared to G2 (p<0.001). The
results were similar in assessing DP (p=0.31), PD (p=0.99) and BOP (p=0.46) between
groups, showing no statistically significant difference. In contrast, the results of BL
were higher for G2 (p<0.001). The frequency and distribution of data from implants in
G1 and G2 for MPi, BOP, PD, KM and BL are displayed in <xref ref-type="table" rid="t02">Table 2</xref>.</p><table-wrap id="t02" orientation="portrait" position="float"><label>Table 2</label><caption><p>Frequency and distribution of data in G1 (up to 5 implants) and G2 (more than 5
implants) according keratinized mucosa (KM), plaque (DP), probing depth (PD),
bleeding probing (BOP) and bone loss (BL). SD: standard deviation. * Statistically
significant</p></caption><table frame="hsides" rules="groups"><thead><tr align="center" style="background-color:#dcddde"><th rowspan="1" colspan="1"> </th><th colspan="2" rowspan="1">G1</th><th colspan="2" rowspan="1">G2</th><th rowspan="1" colspan="1"> </th></tr><tr align="center"><th rowspan="1" colspan="1">Clinical Parameters</th><th rowspan="1" colspan="1">Mean</th><th rowspan="1" colspan="1">DP</th><th rowspan="1" colspan="1">Mean</th><th rowspan="1" colspan="1">DP</th><th rowspan="1" colspan="1">P value</th></tr></thead><tbody><tr align="center" style="background-color:#dcddde"><td rowspan="1" colspan="1">KM</td><td rowspan="1" colspan="1">2.53</td><td rowspan="1" colspan="1">1.40</td><td rowspan="1" colspan="1">3.66</td><td rowspan="1" colspan="1">1.80</td><td rowspan="1" colspan="1"><0.001*</td></tr><tr align="center"><td rowspan="1" colspan="1">DP</td><td rowspan="1" colspan="1">1.76</td><td rowspan="1" colspan="1">1.11</td><td rowspan="1" colspan="1">1.62</td><td rowspan="1" colspan="1">1.05</td><td rowspan="1" colspan="1">0.3112</td></tr><tr align="center" style="background-color:#dcddde"><td rowspan="1" colspan="1">PD (mm)</td><td rowspan="1" colspan="1">2.81</td><td rowspan="1" colspan="1">0.92</td><td rowspan="1" colspan="1">2.81</td><td rowspan="1" colspan="1">0.93</td><td rowspan="1" colspan="1">0.9929</td></tr><tr align="center"><td rowspan="1" colspan="1">BOP</td><td rowspan="1" colspan="1">1.89</td><td rowspan="1" colspan="1">1.25</td><td rowspan="1" colspan="1">1.74</td><td rowspan="1" colspan="1">1.15</td><td rowspan="1" colspan="1">0.4600</td></tr><tr align="center" style="background-color:#dcddde"><td rowspan="1" colspan="1">BL (mm)</td><td rowspan="1" colspan="1">2.71</td><td rowspan="1" colspan="1">1.10</td><td rowspan="1" colspan="1">3.76</td><td rowspan="1" colspan="1">1.43</td><td rowspan="1" colspan="1"><0.001*</td></tr></tbody></table></table-wrap><p>Regarding the prevalence of peri-implant diseases, the study showed 3 (9.38%) healthy
patients, 9 (28.13%) patients with mucositis and 20 (62.50%) with peri-implantitis.
There was no statistical difference between groups, and all healthy patients were in G1
(p=0.49). There were 7 patients diagnosed with mucositis (33.33%) in G1 and 2 (18.18%)
patients in G2 (p=0.62). For peri-implantitis, 11 (52.38%) patients in G1 and 9 (81.82%)
patients in G2 (p=0.21). The distribution of healthy patients, mucositis and
peri-implantitis between G1 and G2 can be seen in <xref ref-type="fig" rid="f01">Figure
1</xref>.</p><fig id="f01" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Distribution of healthy, mucositis and peri-implantitis patients between G1 (fixed
denture supported by up to 5 implants) and G2 (fixed denture supported by more
than 5 implants)</p></caption><graphic xlink:href="jaos-22-05-0403-g01"></graphic></fig><p>From all implants evaluated, 16 (9.93%) were healthy, 11 (11.82%) in G1 and 5 (7.35%) in
G2 (p=0.5). Regarding the prevalence of mucositis between the implants present in each
group, there was no statistical difference between G1 and G2, which presented 63
implants (67.74%) and 37 implants (54.41%) with this condition (p=0.11). As for
peri-implantitis, however, G1 showed lower prevalence of 19 implants (20.43%) while G2
had 26 implants (38.24%) with this condition (p=0.02).</p><p>When the regions of implant placement were compared separately, only the
anterior-inferior region had higher rates of peri-implantitis in G1 compared to G2;
however, it was not statistically significant (<xref ref-type="table" rid="t01">Table
1</xref>).</p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The survival of implant-supported fixed prostheses by a smaller number of implants shows
good results both in the mandible and in the maxilla<sup><xref rid="r23" ref-type="bibr">23</xref></sup>. In this context, it is suggested that the fewer implants in
total rehabilitation, the better. Yet, a smaller number of implants may enhance the
homeostasis of peri-implant tissues, mainly by the distribution/position of the implants
and their relationship with the prosthetic piece.</p><p>Peri-implant health can be maintained over the long term even in areas with absence of
KM, provided that suitable plaque control is performed<sup><xref rid="r05" ref-type="bibr">5</xref>,<xref rid="r15" ref-type="bibr">15</xref></sup>. Other authors
disagree and suggest that KM is related to a reduced accumulation of plaque and mucosal
infammation<sup><xref rid="r07" ref-type="bibr">7</xref></sup>. In our study,
although G2 presents a statistically greater range of KM compared to G1, a larger band
of KM was not enough to prevent periimplantitis, since G2 showed higher rates of BL.
Interestingly, the lack of KM seems to negatively influence mucositis. It is explained
by the fact that G1 showed higher rates this disease. This result corroborates with
another study that reports that areas with higher amount of keratinized mucosa show
higher incidence of mucositis<sup><xref rid="r27" ref-type="bibr">27</xref></sup>. This
may be related to hygiene difficulty in the absence of KM<sup><xref rid="r10" ref-type="bibr">10</xref></sup>, but the accumulation of bacteria is not always the
cause of peri-implantitis, a factor that might explain why a higher rate of mucositis
did not provide a higher rate of peri-implantitis in G1. However, there is no parameter
able to predict whether this range is necessary or not<sup><xref rid="r14" ref-type="bibr">14</xref></sup>.</p><p>Greater BL was observed in the implants of G2 patients in comparison to G1. This might
have been a result of the difficulties of hygiene because of the larger area for plaque
control. In a recent epidemiological study, it was stated that partial or full dentures
are respectively 1.83 and 2.44 times more likely to have bone loss bigger than 2 mm that
unitary prostheses. This may be due to the difficulty of hygiene in the junction of the
implants from partial or full dentures<sup><xref rid="r31" ref-type="bibr">31</xref></sup>. Moreover, another factor taken into consideration is the improper
positioning of the implants. Usually, when placed very close to each other, it might
hinder hygiene procedures and compromise peri-implant biological distances<sup><xref rid="r32" ref-type="bibr">32</xref></sup>.</p><p>Group 2 showed 100% of patients with mucositis. As for implants analyzed separately,
results showed prevalence of peri-implantitis similar to the one found in the literature
(12% to 40%)<sup><xref rid="r16" ref-type="bibr">16</xref></sup> - G1 and G2 with 20.43%
to 38.24%. Regarding patients, 50% had peri-implantitis in the G1 and 81.8% in the G2.
The G2 values were higher than previous reports (28% to 56%)<sup><xref rid="r16" ref-type="bibr">16</xref></sup>. Differences in prevalence between patients and implants
can be explained by the fact that only one implant disease can is enough to categorize
patients as sick or healthy.</p><p>Measurement of bone level throughout time is a valuable indicator for evaluating
clinical performance of dental implants. This is because the gradual and undiagnosed
bone loss leads to loss of the implant. Radiographic monitoring of bone changes should
be analyzed with caution, since the pattern of bone loss varies among
individuals<sup><xref rid="r13" ref-type="bibr">13</xref></sup>. Thus, both bone
remodeling - after exposure of the implant to the oral environment - and late bone loss
should be included in evaluating the success of implants<sup><xref rid="r04" ref-type="bibr">4</xref></sup>. Bone loss in the first year in function was considered
acceptable if up to 2 mm<sup><xref rid="r09" ref-type="bibr">9</xref></sup>; therefore,
this study established diagnosis of peri-implantitis if probing depth was higher or
equal to 5 mm, associated with radiographic bone loss higher than 2 mm. This bone loss
can be related to bacterial and iatrogenic factors such as bad positioning of implant
placement and noncompliance with the minimum distances between them to form biological
distances. According to clinical observations of large plaque accumulation, these data
lead to the empirical belief that the higher the amount of implants, the bigger the
hygiene difficulty and, consequently, the higher the bone loss. Also, smoking habits in
combination with poor compliance and poor oral hygiene appears to enhance the risk of
peri-implantitis<sup><xref rid="r26" ref-type="bibr">26</xref></sup>.</p><p>Although the results have been presented above, in the analysis of some peri-implant
disease, it should be considered that the patients in this study had only total
rehabilitations. Indeed, this might have influenced the appearance of the lesions, since
the prosthetic piece can limit or hinder the control of plaque, mainly in the
individuals with the higher number of implants.</p><p>Even if some studies indicate that more frequent follow-up visits are better for
prevention, more studies are necessary to confirm that statement. For this study, it was
opted not to undertake patients to a follow-up program because it is not the reality for
all patients using implant-supported fixed prostheses<sup><xref rid="r29" ref-type="bibr">29</xref></sup>.</p><p>Low motivation and difficulty of cleaning can be considered main factors in the
development of peri-implant disease, since they may cause the larger dental plaque
accumulation. This reduced motivation is justified by motor difficulty of the patient
and the design of the inner portion of the prosthesis. The presence of concave shapes in
the inner portion of the prosthesis and intimate contact with the mucosa provide a
larger plaque accumulation and hinder the use of interdental brush, because it
traumatizes the mucosa of the patient. Nevertheless, it must be considered that an
peri-implant injury may have started and/or be active by iatrogenic factors such as
excess cement, inappropriate emerging profile of the prosthesis, inadequate pillars,
incorrectly positioned implants and complications in laboratory stages<sup><xref rid="r20" ref-type="bibr">20</xref></sup>. And this might also have been the
result of overloading and/or difficulty of hygiene due to a larger area for bacterial
plaque control, or misplaced implants that may hamper hygiene procedures<sup><xref rid="r31" ref-type="bibr">31</xref></sup>.</p><p>Renvert, et al.<sup><xref rid="r25" ref-type="bibr">25</xref></sup> (2011) state that
the risk of periimplantitis increases with age, and this is probably related to the
motor difficulty of the patients. However, on the other hand, a novel study showed that
in those aged >60 years old (18.63%), the prevalence is lower if compared with those
being ≤60 years (44.07%)<sup><xref rid="r25" ref-type="bibr">25</xref></sup>.</p><p>Thus, the motivation of the patient to perform correct hygiene<sup><xref rid="r08" ref-type="bibr">8</xref></sup>, reduced number of implants, the correct positioning of
implants and integrated planning between dentist and prosthetic favor the manufacturing
of a suitable prosthesis and especially peri-implant health.</p><p>In conclusion, within the limitations of this study, total rehabilitations supported by
up to five implants seem to have lower bone loss and are associated with lower
prevalence of implants with peri-implantitis. However, it is observed that the number of
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