The Importance of Histopathological Diagnosis in the Management of Lesions Presenting as Peri-Implantitis

Detecting lymphadenopathy affected by peri-implantitis using diffusion-weighted magnetic resonance imaging

PURPOSE

This study aimed to assess peri-implantitis-induced lymphadenopathy on diffusion-weighted imaging (DWI).

METHODS

This retrospective study was conducted from October 2017 to March 2020 in patients with and without peri-implantitis who underwent magnetic resonance imaging (MRI). Patients in the peri-implantitis group had radiographically confirmed loss of alveolar bone > 2.0 mm and clinical findings such as bleeding on probing, suppuration of tissues surrounding the teeth, probing-pocket depth of > 4 mm, pain on implant function, and clinical implant mobility, whereas those without peri-implantitis had none of the abovementioned clinical findings. The Mann-Whitney U test was used to compare groups, using lymph node (LN) short-axis diameters and apparent diffusion coefficients (ADCs) as the criterion variables and presence or absence of peri-implantitis as the explanatory variable. Receiver operating characteristic (ROC) analysis was done to investigate the effectiveness of LN size and ADC use in detecting peri-implantitis-induced lymphadenopathy. Statistical significance was established at P < 0.05.

RESULTS

There were 66 lymph nodes from 12 patients analyzed. The mean LN size and ADC were significantly higher in patients with peri-implantitis than in those without (P < 0.01). ROC curve analysis showed cut-off LN sizes of 4.78 and 4.84 mm and cut-off ADCs of 1.12 and 1.09 for lymphadenopathy affected by peri-implantitis corresponding to levels IB and II, respectively.

CONCLUSIONS

Cervical lymphadenopathy may be an inflammatory finding associated with peri-implantitis.

Peripheral giant cell granuloma associated with dental implants: Case-series

PURPOSE

The objectives were to characterize clinico-pathologically a large series of peri-implant peripheral giant cell granuloma (PGCG), and investigate the role of foreign material as a possible etiological factor.

MATERIAL AND METHODS

The study was retrospective, conducted on peri-implant specimens submitted for histology between 2005 and 2021.

RESULTS

Three hundred and thirty-five peri-implant biopsies were retrieved, of which 52 (15.5%) were PGCG. The study population included 28 females and 24 males, age 35-92 years, mean 61. 51.2% reported bone involvement. The lesion involved the margins of the specimen in 65.3%, recurrence was reported in 46.1%. In 58.8% the implant was removed at the same time the specimen was submitted for histopathological analysis. Small foci of black granular foreign material were observed in 53.8% of cases of which 67.8% were birefringent under polarized light. The foreign material granules were not ingested inside multinucleated giant cells, but were scattered in the stromal compartment.

CONCLUSIONS

Peri-implant PGCG is locally aggressive, with frequent bone involvement and high recurrence rate, resulting in implant loss in the majority of cases. The high recurrence rate may be related to conservative or inadequate surgery. Foreign material although common does not seem to have a role in its development.

Retrospective Clinicopathological Analysis of 65 Peri-Implant Lesions

Background and Objectives: Peri-implantitis is a common finding among patients with dental implants. There is no consensus regarding the treatment of this disease, but in many cases, surgical treatment is common practice. A histopathological analysis is not an integral part of suggested protocols. The present study investigated the clinical and histopathological parameters of lesions mimicking peri-implantitis and correlated them with the outcome and follow-up data. Materials and Methods: The study included 65 consecutive biopsies taken from peri-implantitis patients between 2008-2019. Results: The three common diagnoses were fibro-epithelial hyperplasia 20 (30.7%), pyogenic granuloma 16 (24.6%), and peripheral giant cell granuloma 15 (23%). There were 18 cases of recurrent lesions in the study group (27.7%). The recurrence rate was the highest in peripheral giant cell granuloma (8, 12.3%), versus 6% in pyogenic granuloma and fibro-epithelial hyperplasia. These differences in the recurrence rate were statistically significant (p = 0.014). Conclusions: This study emphasizes the necessity of submitting tissue of peri-implantitis cases for histopathological analysis since the more locally aggressive lesions (peripheral giant cell granuloma and pyogenic granuloma), which comprise nearly half of the cases in this study, do not differ in clinical or radiographic characteristics from other peri-implant lesions.

An Unusual Case of Early Dental Implant Failure in an Otherwise-Healthy Patient due to Actinomycosis

Actinomyces spp. are members of normal oral flora that may give rise to a rare disease- oral actinomycosis . Here we present a case of early implant failure associated with actinomycosis in an otherwise -healthy 43-year-old female and the treatment adopted following explantation. Clinically, one month after the implant placement, the peri-implant soft tissues were hyperplastic and associated with an excessive tissue reaction, bleeding, suppuration, deep probing depth , and implant mobility at #19 and #20 implants. Both implants were removed and all granulomatous tissues were thoroughly debrided. Histopathological examination revealed signs of acute ulcerative inflammatory reaction and Actinomyces colonies. The patient was prescribed short-term oral penicillins. After six months following explantation, the deficient bone was augmented with using a combination of absorbable collagen membrane, autogenous block and xenograft. The patient was followed up for one year ; and subsequently, two implants were reinserted at the same positions. The patient was followed up and no recurrences were observed. Implant failure due to actinomycosis is an extremely rare condition , and a definitive diagnosis is therefore essential for successful treatment.

Histopathological analysis of biopsies of "peri-implant inflammatory lesions." Everything is not what it seems

BACKGROUND

Peri-implantitis is the inflammatory process, which most commonly affects the therapy with dental implants. However, there are other reactive and neoplastic entities, mainly benign but also malignant, which also take place in the peri-implant mucosa. There is little information about the histopathological analysis of these peri-implant inflammatory diseases.

PURPOSE

To analyze the histopathological diagnosis of biopsies located in the peri-implant mucosa that showed an inflammatory clinical appearance.

MATERIALS AND METHODS

We have made a retrospective study of 111 peri-implant biopsies analyzed in the Oral and Maxillofacial Pathology Unit of the Dental Clinic Service at the University of the Basque Country, from January 2001 to December 2018. These samples corresponded to 84 women and 27 men, whose mean age was 59 years. We performed a standard histological processing with paraffin embedding, and sections were stained with H&E and PAS. All cases were analyzed following a specific diagnostic histopathological protocol. A descriptive statistical analysis was carried out with the obtained data.

RESULTS

Lesions located in the mandible (64.8%) were more frequent and 34.2% of the biopsies arrived without a presumptive clinical diagnosis. "Inflammatory peri-implant lesion" or peri-implantitis was the most common clinical diagnosis. Histopathologically, the majority of the lesions were peri-implant nonspecific inflammatory hyperplasia (60.3%), followed by peripheral giant cell granuloma (18.1%), pyogenic granuloma (lobular capillary hemangioma) (14.4%), actinomicotic infection (3.6%), and squamous cell carcinoma (3.6%). Individually, peri-implant lesions were more common among women and in the mandible, except for actinomicotic infection and squamous cell carcinoma.

CONCLUSIONS

An important percentage of cases whose initial presumptive clinical diagnosis was "peri-implant inflammatory lesion" truly corresponded to other reactive and neoplastic processes. Thus, it is key to always submit all the tissue removed during the implant surgery, in order to perform a good histopathological study and achieve the correct final diagnosis.

KRAS mutations in implant-associated peripheral giant cell granuloma

OBJECTIVES

To investigate the molecular pathogenesis of implant-associated peripheral giant cell granuloma (IA-PGCG).

METHODS

A convenience sample of 15 IA-PGCG cases was selected. Hotspot mutations of KRAS, FGFR1, and TRPV4 genes, previously reported in conventional giant cell lesions of the jaws, were investigated by Sanger sequencing. As these mutations could activate MAPK/ERK pathway, the expression of phospho-ERK1/2 was also evaluated by immunohistochemistry.

RESULTS

KRAS mutations were detected in 8/15 (53.4%) samples. Similar to conventional peripheral giant cell granuloma, the KRAS mutations most frequently occurred in codon 146 (p.A146V, n = 3), followed by codon 12 (p.G12A and p.G12D, n = 1 each) and codon 14 (p.V14L, n = 1). Variants of unknown significance (VUS) were also detected in two cases, affecting codons 37 (p.E37K) and 127 (p.T127I). All samples showed wild-type (WT) sequences for FGFR1 and TRPV4 genes. Consistent with MAPK/ERK pathway activation, all mononuclear cells of the lesion showed strong staining for phospho-ERK1/2 protein in the immunohistochemical analysis.

CONCLUSIONS

KRAS mutations and activation of the MAPK-ERK signaling pathway occur in IA-PGCG. This is the first study to demonstrate cancer-associated gene mutations in a non-neoplastic reactive condition associated with dental implants.

Peri-implantitis

OBJECTIVES

This narrative review provides an evidence-based overview on peri-implantitis for the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

METHODS

A literature review was conducted addressing the following topics: 1) definition of peri-implantitis; 2) conversion from peri-implant mucositis to peri-implantitis, 3) onset and pattern of disease progression, 4) characteristics of peri-implantitis, 5) risk factors/indicators for peri-implantitis, and 6) progressive crestal bone loss in the absence of soft tissue inflammation.

CONCLUSIONS

1)Peri-implantitis is a pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant connective tissue and progressive loss of supporting bone. 2)The histopathologic and clinical conditions leading to the conversion from peri-implant mucositis to peri-implantitis are not completely understood. 3)The onset of peri-implantitis may occur early during follow-up and the disease progresses in a non-linear and accelerating pattern. 4a)Peri-implantitis sites exhibit clinical signs of inflammation and increased probing depths compared to baseline measurements. 4b)At the histologic level, compared to periodontitis sites, peri-implantitis sites often have larger inflammatory lesions. 4c)Surgical entry at peri-implantitis sites often reveals a circumferential pattern of bone loss. 5a)There is strong evidence that there is an increased risk of developing peri-implantitis in patients who have a history of chronic periodontitis, poor plaque control skills, and no regular maintenance care after implant therapy. Data identifying "smoking" and "diabetes" as potential risk factors/indicators for peri-implantitis are inconclusive. 5b)There is some limited evidence linking peri-implantitis to other factors such as: post-restorative presence of submucosal cement, lack of peri-implant keratinized mucosa and positioning of implants that make it difficult to perform oral hygiene and maintenance. 6)Evidence suggests that progressive crestal bone loss around implants in the absence of clinical signs of soft tissue inflammation is a rare event.

Changes in oncogenic protein levels in peri-implant oral malignancy: a case report

Background

Oral squamous cell carcinoma (OSCC) constitutes a group of tumors that exhibit heterogeneous biology, histopathology, and clinical behaviors.

Case presentation

A 73-year-old male had a whitish leukoplakia-like lesion around inflamed peri-implant area (#42, #43, and #44), and this lesion had transformed to OSCC within 3 years. He underwent mass resection, selective neck dissection, and reconstructive surgery. To detect any carcinogenesis progression, we examined the removed tumor tissue as well as the patient’s preoperative and postoperative sera to identify causative oncogenic proteins using immunoprecipitation high-performance liquid chromatography (IP-HPLC).

Conclusions

The protein expression levels of p53, E-cadherin, β-catenin, MMP-10, HER2, NRAS, Met, HER2, and ERb were significantly lower in the serum collected on postoperative day 10 than in the preoperative serum, and if these proteins are consistently not elevated in the serum 3 months after surgery compared with the preoperative serum, these proteins can be potential oncogenic proteins. However, we also found that the serum extracted 3 months after the operation had elevated levels of oncogenic proteins compared with that of the preoperative and 10-day postoperative serum indicating the possibility of tumor recurrence. At postoperative follow-up period, ipsilateral neck metastasis and second primary lesion were found and additional surgery was performed to the patient. IP-HPLC using the patient’s serum shows the possibility of oncogenic protein detection. However, follow-up IP-HPLC data is needed to find out patient-specific prognostic factors.

Peri-implantitis

OBJECTIVES

This narrative review provides an evidence-based overview on peri-implantitis for the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

METHODS

A literature review was conducted addressing the following topics: 1) definition of peri-implantitis; 2) conversion from peri-implant mucositis to peri-implantitis, 3) onset and pattern of disease progression, 4) characteristics of peri-implantitis, 5) risk factors/indicators for peri-implantitis, and 6) progressive crestal bone loss in the absence of soft tissue inflammation.

CONCLUSIONS

1)Peri-implantitis is a pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant connective tissue and progressive loss of supporting bone. 2)The histopathologic and clinical conditions leading to the conversion from peri-implant mucositis to peri-implantitis are not completely understood. 3)The onset of peri-implantitis may occur early during follow-up and the disease progresses in a non-linear and accelerating pattern. 4a)Peri-implantitis sites exhibit clinical signs of inflammation and increased probing depths compared to baseline measurements. 4b)At the histologic level, compared to periodontitis sites, peri-implantitis sites often have larger inflammatory lesions. 4c)Surgical entry at peri-implantitis sites often reveals a circumferential pattern of bone loss. 5a)There is strong evidence that there is an increased risk of developing peri-implantitis in patients who have a history of chronic periodontitis, poor plaque control skills, and no regular maintenance care after implant therapy. Data identifying "smoking" and "diabetes" as potential risk factors/indicators for peri-implantitis are inconclusive. 5b)There is some limited evidence linking peri-implantitis to other factors such as: post-restorative presence of submucosal cement, lack of peri-implant keratinized mucosa and positioning of implants that make it difficult to perform oral hygiene and maintenance. 6)Evidence suggests that progressive crestal bone loss around implants in the absence of clinical signs of soft tissue inflammation is a rare event.

Reactive oral lesions associated with dental implants. A systematic review

Reactive lesion formation around dental implants a complication that has been given much consideration. These lesions can lead to marginal bone loss, and consequently, implant failure. In the present systematic review, all reported reactive lesions associated with dental implants in the literature were assessed. An electronic search was performed using PubMed Central, Scopus, Google Scholar, and Science Direct. The search strategy was limited to human studies (case reports and case series), full-text English language articles, published until May 2017. A total of 19 articles reporting 27 lesions in 25 cases were included. Peripheral giant cell granuloma and pyogenic granuloma were the most reactive lesions found around dental implants. The mean age of the patients was 51.28 ± 14.48 years, with a slight female predilection. Posterior mandibular gingiva was the most common location for these lesions. The recurrence rate of lesions was 33.33%, and the chance of implant removal was 29.62%. Due to the clinical significance of these lesions, early histopathologic examination is recommended to exclude the presence of such pathological lesions.