Adjunctive local antibiotic therapy in the treatment of peri-implantitis II: clinical and radiographic outcomes

Detoxification of Implant Surfaces Affected by Peri-Implant Disease: An Overview of Non-surgical Methods

Objective:

The aim of this review is to summarize the findings of studies that have evaluated non-surgical approaches for detoxification of implant body surfaces in vitro and in vivo, and to evaluate clinical trials on the use of these methodologies for treating peri-implant disease.

Materials and methods:

A literature search was conducted using MEDLINE (Pubmed) from 1966 to 2013. In vitro and in vivo studies as well as clinical trials on non-surgical therapy were evaluated. The outcome variables were the ability of the therapeutic method to eliminate the biofilm and endotoxins from the implant surface, the changes in clinical parameters including probing depth, clinical attachment levels, bleeding on probing; radiographic bone fill and histological re-osseointegration.

Results:

From 134 articles found 35 were analyzed. The findings, advantages and disadvantages of using lasers as well as mechanical and chemical methods are discussed. Most of the in vivo and human studies used combination therapies which makes determining the efficacy of one specific method difficult. Most human studies are case series with short term longitudinal analysis without survival or failure reports.

Conclusion:

Complete elimination of the biofilms is difficult to achieve using these approaches. All therapies induce changes of the chemical and physical properties of the implant surface. Re-osseointegration may be difficult to achieve if not impossible without surgical access to ensure thorough debridement of the defect and detoxification of the implant surface. Combination protocols for non-surgical treatment of peri-implantitis in humans have shown some positive clinical results but long-term evaluation to evaluate the validity and reliability of the techniques is needed.

Treatment Alternatives to Negotiate Peri-Implantitis

Peri-implant diseases are becoming a major health issue in dentistry. Despite the magnitude of this problem and the potential grave consequences, commonly acceptable treatment protocols are missing. Hence, the present paper reviews the literature treatment of peri-implantitis in order to explore their benefits and limitations. Treatment of peri-implantitis may include surgical and nonsurgical approaches, either individually or combined. Nonsurgical therapy is aimed at removing local irritants from the implants' surface with or without surface decontamination and possibly some additional adjunctive therapies agents or devices. Systemic antibiotics may also be incorporated. Surgical therapy is aimed at removing any residual subgingival deposits and additionally reducing the peri-implant pockets depth. This can be done alone or in conjunction with either osseous respective approach or regenerative approach. Finally, if all fails, explantation might be the best alternative in order to arrest the destruction of the osseous structure around the implant, thus preserving whatever is left in this site for future reconstruction. The available literature is still lacking with large heterogeneity in the clinical response thus suggesting possible underlying predisposing conditions that are not all clear to us. Therefore, at present time treatment of peri-implantitis should be considered possible but not necessarily predictable.

Decontamination of dental implant surface in peri-implantitis treatment: a literature review

Etiological treatment of peri-implantitis aims to reduce the bacterial load within the peri-implant pocket and decontaminate the implant surface in order to promote osseointegration. The aim of this literature review was to evaluate the efficacy of different methods of implant surface decontamination. A search was conducted using the PubMed (Medline) database, which identified 36 articles including in vivo and in vitro studies, and reviews of different decontamination systems (chemical, mechanical, laser and photodynamic therapies). There is sufficient consensus that, for the treatment of peri-implant infections, the mechanical removal of biofilm from the implant surface should be supplemented by chemical decontamination with surgical access. However, more long-term research is needed to confirm this and to establish treatment protocols responding to different implant characterics.

Clinical efficacy of antibiotics in the treatment of peri-implantitis

OBJECTIVES

The aim of the present study was to review the pertinent literature with reference to the clinical efficacy of antibiotics in the treatment of peri-implantitis.

METHODS

To address the focused question 'Are locally and systemically delivered antibiotics useful in the treatment of peri-implantitis?' PubMed/Medline and Google-scholar databases were explored from 1992 until February 2013 using a combination of the following keywords: 'antibiotic,' 'dental implant,' 'inflammation,', 'peri-implantitis' and 'treatment'. Letters to the editor, case-reports and unpublished data were excluded.

RESULTS

Ten studies were included. In six studies, peri-implantitis was treated using a non-surgical approach (scaling and root planing), whereas in four studies, a surgical approach was adopted for treating peri-implantitis. In three studies systemic antibiotics were administered and in six studies locally delivered antibiotics were used for treatment. One study used the oral route for antibiotic delivery. In three studies, minocycline hydrochloride was locally delivered as an adjunctive therapy to non-surgical mechanical debridement of infected sites. Nine studies reported that traditional peri-implantitis treatment with adjunct antibiotic therapy reduces gingival bleeding, suppuration and peri-implant pocket depth. In one study, despite surgical debridement of infected sites and systemic antibiotic cover, nearly 40% of the implants failed to regain stability. There was no placebo or control group in eight out of the nine studies included.

CONCLUSION

The significance of adjunctive antibiotic therapy in the treatment of peri-implantitis remains debatable.

Biofilm and dental implant: The microbial link

Mouth provides a congenial environment for the growth of the microorganisms as compared to any other part of the human body by exhibiting an ideal nonshedding surface. Dental plaque happens to be a diverse community of the microorganisms found on the tooth surface. Periodontal disease and the peri-implant disease are specific infections that are originating from these resident microbial species when the balance between the host and the microbial pathogenicity gets disrupted. This review discusses the biofilms in relation to the peri-implant region, factors affecting its presence, and the associated treatment to manage this complex microbial colony. Search Methodology: Electronic search of the medline was done with the search words: Implants and biofilms/dental biofilm formation/microbiology at implant abutment interface/surface free energy/roughness and implant, periimplantitis/local drug delivery and dental implant. Hand search across the journals - clinical oral implant research, implant dentistry, journal of dental research, international journal of oral implantology, journal of prosthetic dentistry, perioodntology 2000, journal of periodontology were performed. The articles included in the review comprised of in vivo studies, in vivo (animal and human) studies, abstracts, review articles.

Decontamination of dental implant surfaces by means of photodynamic therapy

Several implant surface debridement methods have been reported for the treatment of peri-implantitis, however, some of them can damage the implant surface or promote bacterial resistance. Photodynamic therapy (PDT) is a new treatment option for peri-implantitis. The aim of this in vitro study was to analyze implant surface decontamination by means of PDT. Sixty implants were equally distributed (n = 10) into four groups and two subgroups. In group G1 there was no decontamination, while in G2 decontamination was performed with chlorhexidine. G3 (PDT − laser + dye) and G4 (laser, without dye) were divided into two subgroups each; with PDT performed for 3 min in G3a and G4a, and for 5 min in G3b and G4b. After 5 min in contact with methylene blue dye (G3), the implants were irradiated (G3 and G4) with a low-level laser (GaAlAs, 660 nm, 30 mW) for 3 or 5 min (7.2 and 12 J). After the dilutions, culture media were kept in an anaerobic atmosphere for 1 week, and then colony forming units were counted. There was a significant difference (p < 0.001) between G1 and the other groups, and between G4 in comparison with G2 and G3. Better decontamination was obtained in G2 and G3, with no statistically significant difference between them. The results of this study suggest that photodynamic therapy can be considered an efficient method for reducing bacteria on implant surfaces, whereas laser irradiation without dye was less efficient than PDT.

Microbiologic results after non-surgical erbium-doped:yttrium, aluminum, and garnet laser or air-abrasive treatment of peri-implantitis: a randomized clinical trial

BACKGROUND

The purpose of this study is to assess clinical and microbiologic effects of the non-surgical treatment of peri-implantitis lesions using either an erbium-doped:yttrium, aluminum, and garnet (Er:YAG) laser or an air-abrasive subgingival polishing method.

METHODS

In a 6-month clinical trial, 42 patients with peri-implantitis were treated at one time with an Er:YAG laser or an air-abrasive device. Routine clinical methods were used to monitor clinical conditions. Baseline and 6-month intraoral radiographs were assessed with a software program. The checkerboard DNA-DNA hybridization method was used to assess 74 bacterial species from the site with the deepest probing depth (PD) at the implant. Non-parametric tests were applied to microbiology data.

RESULTS

PD reductions (mean ± SD) were 0.9 ± 0.8 mm and 0.8 ± 0.5 mm in the laser and air-abrasive groups, respectively (not significant). No baseline differences in bacterial counts between groups were found. In the air-abrasive group, Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus anaerobius were found at lower counts at 1 month after therapy (P <0.001) and with lower counts in the laser group for Fusobacterium nucleatum naviforme (P = 0.002), and Fusobacterium nucleatum nucleatum (P = 0.002). Both treatments failed to reduce bacterial counts at 6 months. Porphyromonas gingivalis counts were higher in cases with progressive peri-implantitis (P <0.001).

CONCLUSIONS

At 1 month, P. aeruginosa, S. aureus, and S. anaerobius were reduced in the air-abrasive group, and Fusobacterium spp. were reduced in the laser group. Six-month data demonstrated that both methods failed to reduce bacterial counts. Clinical improvements were limited.

Comparative biology of chronic and aggressive periodontitis vs. peri-implantitis

This review was undertaken to address the similarities and dissimilarities between the two disease entities of periodontitis and peri-implantitis. The overall analysis of the literature on the etiology and pathogenesis of periodontitis and peri-implantitis provided an impression that these two diseases have more similarities than differences. First, the initiation of the two diseases is dependent on the presence of a biofilm containing pathogens. While the microbiota associated with periodontitis is rich in gram-negative bacteria, a similar composition has been identified in peri-implant diseases. However, increasing evidence suggests that S. aureus may be an important pathogen in the initiation of some cases of peri-implantitis. Further research into the role of this gram-positive facultative coccus, and other putative pathogens, in the development of peri-implantitis is indicated. While the initial host response to the bacterial challenge in peri-implant mucositis appears to be identical to that encountered in gingivitis, persistent biofilm accumulation may elicit a more pronounced inflammatory response in peri-implant mucosal tissues than in the dentogingival unit. This may be a result of structural differences (such as vascularity and fibroblast-to-collagen ratios). When periodontitis and peri-implantitis were produced experimentally by applying plaque-retaining ligatures, the progression of mucositis to peri-implantitis followed a very similar sequence of events as the development of gingivitis to periodontitis. However, some of the peri-implantitis lesions appeared to have periods of rapid progression, in which the infective lesion reached the alveolar bone marrow. It is therefore reasonable to assume that peri-implantitis in humans may also display periods of accelerated destruction that are more pronounced than that observed in cases of chronic periodontitis. From a clinical point of view the identified and confirmed risk factors for periodontitis may be considered as identical to those for peri-implantitis. In addition, patients susceptible to periodontitis appear to be more susceptible to peri-implantitis than patients without a history of periodontitis. As both periodontitis and peri-implantitis are opportunistic infections, their therapy must be antiinfective in nature. The same clinical principles apply to debridement of the lesions and the maintenance of an infection-free oral cavity. However, in daily practice, such principles may occasionally be difficult to apply in peri-implantitis treatment. Owing to implant surface characteristics and limited access to the microbial habitats, surgical access may be required more frequently, and at an earlier stage, in periimplantitis treatment than in periodontal therapy. In conclusion, it is evident that periodontitis and peri-implantitis are not fundamentally different from the perspectives of etiology, pathogenesis, risk assessment, diagnosis and therapy. Nevertheless, some difference in the host response to these two infections may explain the occasional rapid progression of peri-implantitis lesions. Consequently, a diagnosed peri-implantitis should be treated without delay.

Dental implants in the periodontal patient

The principal reason for providing periodontal therapy is to achieve periodontal health and retain the dentition. Patients with a history of periodontitis represent a unique group of individuals who previously succumbed to a bacterial challenge. Therefore, it is important to address the management and survival rate of implants in these patients. Systematic reviews often are cited in this article, because they provide a high level of evidence and facilitate reviewing a vast amount of information in a succinct manner.

Comparison of the effects of treatment of peri-implant infection in animal and human studies: systematic review and meta-analysis

OBJECTIVE

The main objective of this systematic review is to compare the effects of treatment of peri-implant infection between animal and human studies.

MATERIAL AND METHODS

A literature search was conducted using the Medline, Cochrane Central Register of Controlled Trials, and Latin American and Caribbean Health Sciences Literature databases up to and including May 2008. In addition, bibliographies of systematic reviews on peri-implant diseases were searched manually. Non-surgical and surgical treatments of peri-implantitis/mucositis in animal models or human studies were compared. Meta-analysis was conducted to investigate the difference between the reported treatment effects in animal and human studies. Changes in probing pocket depth (PPD) and probing attachment level (PAL) from baseline measurements were used as measures of outcome. Single-level and multilevel meta-regression analysis was performed by taking into account the different follow-up times of the studies included.

RESULTS

The single-level and multilevel random-effects meta-analysis showed that the difference in PPD reduction [0.31 mm, 95% confidence interval (CI): -0.27, 0.88] and in PAL gain (0.21 mm, 95% CI: -0.47, 0.88) between animal and human studies was not statistically significant. The random-effects meta-regression suggested that studies with longer follow-up times revealed greater PPD reduction (0.25 mm per month, 95% CI: 0.14, 0.35). However, when the different follow-up times were taken into account, these differences became greater. Substantial heterogeneity between studies was found in the meta-analyses (I(2)=97.6% for animal studies and 99.9% for human studies).

CONCLUSION

There was great heterogeneity between human and animal studies in terms of study designs and treatment procedures. Therefore, the results from this meta-analysis should be interpreted with caution. Heterogeneity between studies and its causes merit further investigations.

Short-term clinical and microbiological evaluations of peri-implant diseases before and after mechanical anti-infective therapies

OBJECTIVES

The aim of this study was to evaluate the clinical and microbiological effects of mechanical anti-infective therapies for mucositis and peri-implantitis.

MATERIAL AND METHODS

Subjects with at least one dental implant were assigned to healthy (n=10), mucositis (n=12) or peri-implantitis (n=13) groups. Implants with mucositis or peri-implantitis were decontaminated by means of teflon curettes and abrasive sodium carbonate air-powder, performed by an open flap for peri-implantitis and without surgery for mucositis. Visible plaque (PI), marginal bleeding (MB), bleeding on probing (BOP), suppuration (SUP), probing depth (PD) and relative clinical attachment level (rCAL) were assessed at baseline and at 3 months after therapies. At the same time points, submucosal plaque samples were collected from each implant and analyzed by Checkerboard DNA-DNA hybridization for 40 bacterial species.

RESULTS

All clinical parameters improved at 3 months post-therapy in mucositis and peri-implantitis groups (P<0.05). The mean reduction in rCAL (+/-SD) was 1.4+/-1.2 mm and 2.3+/-1.6 mm, and it was 1.3+/-1.2 mm and 3.1+/-1.7 mm in PD (+/-SD) for mucositis and peri-implantitis, respectively. Levels of Treponema denticola, Tanerella forsythia and Parvimonas micra, and of Fusobacterium nucleatum ss nucleatum, were significantly reduced after peri-implantitis therapy and after mucositis therapy, respectively (P<0.05). In addition, counts of Porphyromons gingivalis, Treponema socranskii and the proportions of red complex were reduced in both groups at 3 months after treatments (P<0.05).

CONCLUSION

Mechanical therapies alone were effective in treating mucositis and peri-implantitis over a period of 3 months. The open debridement procedure showed clinical and microbiological benefits on the treatment of peri-implantitis and could be safely used as a standard control group for future studies.

Non-surgical treatment of peri-implant mucositis and peri-implantitis: a literature review

OBJECTIVES

To review the literature on non-surgical treatment of peri-implant mucositis and peri-implantitis.

MATERIAL AND METHODS

A search of PubMed and The Cochrane Library of the Cochrane Collaboration (CENTRAL) as well as a hand search of articles were conducted. Publications and articles accepted for publication up to November 2007 were included.

RESULTS

Out of 437 studies retrieved a total of 24 studies were selected for the review. Thus the available evidence for non-surgical treatment of peri-implant mucositis and peri-implantitis is scarce.

CONCLUSIONS

It was observed that mechanical non-surgical therapy could be effective in the treatment of peri-implant mucositis lesions. Furthermore, the adjunctive use of antimicrobial mouth rinses enhanced the outcome of mechanical therapy of such mucositis lesions. In peri-implantitis lesions non-surgical therapy was not found to be effective. Adjunctive chlorhexidine application had only limited effects on clinical and microbiological parameters. However, adjunctive local or systemic antibiotics were shown to reduce bleeding on probing and probing depths. Minor beneficial effects of laser therapy on peri-implantitis have been shown; this approach needs to be further evaluated. There is a need for randomized-controlled studies evaluating treatment models of non-surgical therapy of peri-implant mucositis and peri-implantitis.