Sustained release of doxycycline for the treatment of peri-implantitis: randomised controlled trial

The potential use of bacteriophages as antibacterial agents in dental infection

Dental infections, such as apical Periodontitis, periodontitis, and peri-implantitis (PI), are closely associated with specific bacterial species, including Streptococcus mutans (S. mutans), Porphyromonas gingivalis (P. gingivalis), and Fusobacterium nucleatum (F. nucleatum), among others. Antibiotics are extensively utilized for prophylactic and therapeutic purposes in the treatment of dental infections and other dental-related issues. Unfortunately, the rapid emergence of antimicrobial resistance has accompanied the increased use of antibiotics in recent years. Specific bacterial pathogens have reached a critical stage of antibiotic resistance, characterized by the proliferation of pan-resistant strains and the scarcity of viable therapeutic alternatives. Therapeutic use of particular bacteriophage (phage) particles that target bacterial pathogens is one potential alternative to antibiotics that are now being seriously considered for treating bacterial illnesses. A kind of virus known as a phage is capable of infecting and eliminating bacteria. Because they can't infect cells in plants and animals, phages might be a harmless substitute for antibiotics. To control oral disorders including periodontitis and dental caries, several research have been conducted in this area to study and identify phages from human saliva and dental plaque. The capacity of these agents to disturb biofilms expands their effectiveness against dental plaque biofilms and oral pathogens in cases of periodontitis, PI, and apical periodontitis. This review summarizes the current antibacterial properties of phages used to treat a variety of dental infections, such as periodontitis, peri-implantitis, infected dentin, and apical periodontitis.

Rational design of multifunctional hydrogels targeting the microenvironment of diabetic periodontitis

Periodontitis is a chronic inflammatory disease and is the primary contributor to adult tooth loss. Diabetes exacerbates periodontitis, accelerates periodontal bone resorption. Thus, effectively managing periodontitis in individuals with diabetes is a long-standing challenge. This review introduces the etiology and pathogenesis of periodontitis, and analyzes the bidirectional relationship between diabetes and periodontitis. In this review, we comprehensively summarize the four pathological microenvironments influenced by diabetic periodontitis: high glucose microenvironment, bacterial infection microenvironment, inflammatory microenvironment, and bone loss microenvironment. The hydrogel design strategies and latest research development tailored to the four microenvironments of diabetic periodontitis are mainly focused on. Finally, the challenges and potential solutions in the treatment of diabetic periodontitis are discussed. We believe this review will be helpful for researchers seeking novel avenues in the treatment of diabetic periodontitis.

The Role of Autologous Platelet Concentrates as a Local Antibiotic Delivery System: A Systematic Scoping Review

OBJECTIVES

Ongoing research has begun to develop innovative approaches to deliver local antibiotics while minimizing systemic side effects, antimicrobial resistance, and limited tissue penetration. Autologous platelet concentrates (APCs) offer promise in delivering antibiotics directly to infection sites. Despite the interest, a comprehensive evaluation of their effectiveness is lacking. Therefore, this systematic scoping review aims to collect and appraise studies regarding the efficacy of APCs in delivering antibiotics.

METHODS

A systematic electronic search of PubMed, Scopus, and Web of Science, using a combination of keywords, was conducted up to February 2024. Articles addressing the use of APCs as a local antibiotic delivery system were included.

RESULTS

A total of 13 articles, including 10 in vitro studies, 1 in vitro and clinical study, 1 ex vivo study, and 1 clinical study, were selected. Antibiotic loading capacity and release was confirmed in all studies using doxycycline, gentamicin, linezolid, vancomycin, metronidazole, and penicillin. In addition, the antibacterial effect was obtained mainly against E. coli., P. aeruginosa, S. mitis, H. influenzae, S. pneumoniae, and S. aureus.

CONCLUSIONS

The incorporation of antibiotics into APCs has been proven to facilitate the effective release of antimicrobial agents at optimal concentrations, potentially reducing the incidence of post-operative infections, substituting, or augmenting systemic antibiotic treatment while retaining APCs' inherent healing properties.

Fluconazole-Loaded Ibuprofen In Situ Gel-Based Oral Spray for Oropharyngeal Candidiasis Treatment

Oral candidiasis is a fungal infection affecting the oral mucous membrane, and this research specifically addresses on a localized treatment through fluconazole-loaded ibuprofen in situ gel-based oral spray. The low solubility of ibuprofen is advantageous for forming a gel when exposed to an aqueous phase. The 1% w/w fluconazole-loaded in situ gel oral sprays were developed utilizing various concentrations of ibuprofen in N-methyl pyrrolidone. The prepared solutions underwent evaluation for viscosity, surface tension, contact angle, water tolerance, gel formation, interface interaction, drug permeation, and antimicrobial studies. The higher amount of ibuprofen reduced the surface tension and retarded solvent exchange. The use of 50% ibuprofen as a gelling agent demonstrated prolonged drug permeation for up to 24 h. The incorporation of Cremophor EL in the formulations resulted in increased drug permeation and exhibited effective inhibition against Candida albicans, Candida krusei, Candida lusitaniae, and Candida tropicalis. While the Cremophor EL-loaded formulation did not exhibit enhanced antifungal effects on agar media, its ability to facilitate the permeation of fluconazole and ibuprofen suggested potential efficacy in countering Candida invasion in the oral mucosa. Moreover, these formulations demonstrated significant thermal inhibition of protein denaturation in egg albumin, indicating anti-inflammatory properties. Consequently, the fluconazole-loaded ibuprofen in situ gel-based oral spray presents itself as a promising dosage form for oropharyngeal candidiasis treatment.

Comparative effectiveness of interventions for the treatment of peri-implantitis: A systematic review with network meta-analysis

STATEMENT OF PROBLEM

Extensive research has been carried out on the various aspects of diagnosing and treating peri-implantitis. However, clinical guidelines for the management of peri-implantitis based on high quality evidence are lacking.

PURPOSE

The purpose of this systematic review with network meta-analysis was to analyze the current evidence on nonsurgical and surgical interventions for the treatment of peri-implantitis and synthesize clinical guidelines based on high quality evidence.

MATERIAL AND METHODS

A search was conducted for trials published in Medline, Scopus, PubMed, and Cochrane Central Register of Controlled Trials from inception until July 2023. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023451056). A network meta-analysis was performed on data from randomized controlled trials that assessed nonsurgical and surgical interventions for the treatment of peri-implantitis. The interventions were ranked according to their efficacy using surface under the cumulative ranking (SUCRA) system. The grading of recommendations, assessment, development, and evaluations (GRADE) approach was used to assess the level of certainty of evidence.

RESULTS

A total of 45 articles were included in the quantitative analysis. The GRADE approach determined a moderate to high level of certainty of evidence. Among the nonsurgical interventions, mechanical debridement with adjunctive systemic antibiotics was significant in improving probing depth at 3 months and beyond 6 months, clinical attachment loss at 3 months, and clinical attachment loss beyond 6 months. Mechanical debridement with adjunctive topical antibiotics was significant in improving probing depth beyond 6 months, clinical attachment loss at 3 months, clinical attachment loss beyond 6 months, and radiographic bone loss beyond 6 months. Mechanical debridement with adjunctive photodynamic therapy was significant in improving probing depth beyond 6 months, clinical attachment loss at 3 months, clinical attachment loss beyond 6 months, and radiographic bone loss beyond 6 months. Mechanical debridement with adjunctive systemic antibiotics and photodynamic therapy was significant in improving probing depth beyond 6 months. Among surgical interventions, open flap debridement with implant surface decontamination and open flap debridement with decontamination and adjunctive photodynamic therapy were significant in improving probing depth at 3 months.

CONCLUSIONS

Mechanical debridement with adjunctive systemic antibiotics or photodynamic therapy results in improved clinical outcomes.

A Single Dose of Piperacillin Plus Tazobactam Gel as an Adjunct to Professional Mechanical Plaque Removal (PMPR) in Patients with Peri-Implant Mucositis: A 6-Month Double-Blind Randomized Clinical Trial

OBJECTIVES

This randomized, placebo-controlled, double-masked clinical trial aimed to evaluate the clinical and microbiological efficacy of professional mechanical plaque removal (PMPR) with or without adjunctive application of piperacillin plus tazobactam gel in the treatment of peri-implant mucositis (PiM) for up to 6 months.

MATERIALS AND METHODS

The study included 31 patients with peri-implant mucositis (bleeding on probing (BoP) > 1 at at least one site at baseline, absence of peri-implant bone loss compared with a previous radiograph). After randomized assignment to test and control groups, patients received full-mouth supragingival scaling with or without piperacillin plus tazobactam gel. Clinical examination was performed at baseline and after 3 and 6 months, and a microbiological examination was performed at baseline and after 3 months.

RESULTS

After six months, both treatment modalities resulted in significant reductions and improvements in clinical parameters at the implant sites. Neither study group achieved a complete resolution of PiM (i.e., BoP ≤ 1 per implant). The number of implants with BoP decreased statistically significantly between subsequent time points (p < 0.001) in both the test and the control group. Significant BoP differences (p = 0.039) were observed between groups at 6 months (difference to baseline) following therapy.

CONCLUSIONS

Within the limitations of the present study, the single use of a slow-release, locally applied antibiotic combination of piperacillin and tazobactam gel, adjunctive to PMPR, showed an improvement in clinical variable of implants diagnosed with PiM. The adjunctive treatment resulted in higher BoP reduction when compared to the control, but no significant differences were observed regarding the changes in other clinical and microbiological parameters.

The Efficacy of Ten Different Adjunctive Measures in Patients with Nonsurgically Treated Peri-Implant Disease: A Network Meta-Analysis of Randomized Controlled Trials

Objective: This study aimed to evaluate the impact of 10 adjunctive measures on non-surgical therapy outcomes for peri-implant disease. Methods: We formulated the study question and keywords following the Population, Intervention, Comparator, Outcome framework. Randomized controlled trials were identified through searches in PubMed, Embase, the Cochrane Library, and the Web of Science. Two researchers assessed the quality of included literature according to the Cochrane Risk of Bias Assessment Tool. Data analysis and ranking were performed using Stata 15.0 software. Results: This study, involving 51 pieces of literature and 2660 samples, conducted a network meta-analysis (NMA), which revealed that photodynamic therapy (PDT) significantly reduced probing pocket depth values in patients with peri-implant mucositis (SUCRA = 96.3%) and peri-implantitis (SUCRA = 96.7%). In addition, it showed an improvement in bleeding on probing (BOP) values for peri-implantitis (SUCRA = 91.6%). Furthermore, diode lasers improved BOP values for peri-implant mucositis (SUCRA = 76.5%). Conclusions: According to the NMA results and the surface under the cumulative ranking curve (SUCRA), PDT and diode laser outperform other adjuncts in peri-implant disease.

Heterogeneity of outcomes in randomized controlled trials on implant prosthodontic therapy is hindering comparative effectiveness research: meta-research study

BACKGROUND

Consistency in outcomes across clinical trials allows for comparing and combining results from different studies. A core outcome set (COS), representing a minimally agreed standardized group of outcomes that should be monitored and measured through research in a specific field of medicine, is not yet available for trials in implant prosthodontic (dental implant) therapy. This meta-research study aimed to analyze outcomes used in clinical trials on implant prosthodontic therapy.

METHODS

We searched the Cochrane Oral Health Group (COHG) register to identify systematic reviews of interventions in implant prosthodontic therapy published by October 2023. From the randomized controlled trials (RCTs) included in the relevant reviews, we extracted data on the characteristics of the included trials and the outcomes used. We categorized outcomes into domains.

RESULTS

From 182 systematic reviews in the COHG register, we included 11 systematic reviews on dental implant therapy. The reviews included 117 unique RCTs with 4725 participants, published from 1995 to 2020, which analyzed 74 different outcomes. Using different definitions, implant failure was analyzed in 73 RCTs. Seventeen RCTs did not define implant failure. Failure was most often (30 RCTs) followed up for one year. Only one RCT assessed implant failure after five years. Trials used 17 definitions of implant failure, while 17 trials did not report on the criteria of implant failure. Complications were analyzed in 48 RCTs, although they were not clearly defined in 12 RCTs. Failure of prosthodontic supra-structure was analyzed in 74 RCTs, with definitions of failure and criteria not clearly defined in 44 RCTs. Trials considered adverse events, peri-implant tissue health, patient attitudes, and other outcomes, including cost, aesthetics, or procedure duration. These outcomes were often different between trials. Twenty-six outcomes were used only once per study.

CONCLUSIONS

Clinical trials in implant prosthodontics used different outcomes, different definitions of outcomes and used different times to monitor them. Standardization of outcomes is necessary to allow comparability and evidence synthesis about the effectiveness of implant prosthodontic therapy.

A novel nonsurgical therapy for peri-implantitis using focused pulsed electromagnetic field: A pilot randomized double-blind controlled clinical trial

Pulsed electromagnetic field (PEMF) therapy modulates the immune response and is successfully used in orthopedics to treat osteoarthritis and improve bone regeneration. This may suggest that this treatment may consequently reduce peri-implant soft tissue inflammation and marginal bone loss. To compare clinical, radiographic, and immunological results following nonsurgical treatment for peri-implantitis with or without PEMF therapy. Patients with peri-implantitis were included: pocket probing depth (PPD) between 6 and 8 mm with bleeding on probing (BOP); crestal bone loss between 3 and 5 mm. A novel healing abutment that contained active (test) or inactive (control) PEMF was connected. PEMF was administered via the abutment at exposure ratio of 1/500-1/5000, intensity: 0.05-0.5 mT, frequency: 10-50 kHz for 30 days. Nonsurgical mechanical implant surface debridement was performed. Patients were examined at baseline, 1 and 3 months. Clinical assessment included: plaque index, BOP, PPD, recession, and bone crest level which was radiography measured. Samples of peri-implant crevicular fluid were taken to analyze interleukin-1β (IL-1β). Twenty-three patients (34 implants; 19 control, 15 test) were included. At the follow-up, mean crestal bone loss was lower in the test group at 1 and 3 months (2.48 mm vs. 3.73 mm, p < 0.05 and 2.39 vs. 3.37, p < 0.01). IL-1β levels were also lower in the test group at 2 weeks (72.86 pg/mL vs. 111.7, p < 0.05). Within all the limitation of this preliminary study, the test group improved clinical parameters after a short-term period compared to the control group.

Metronidazole-Loaded Camphor-Based In Situ Forming Matrix for Periodontitis Treatment

Periodontitis is a widespread oral health problem caused by bacterial infections that lead to tooth loss and other systemic diseases. The aim of this study was to provide an alternative treatment for periodontitis by developing a metronidazole-loaded in situ forming matrix (ISM) using camphor as its matrix former. Five-percent w/w metronidazole dissolved in N-methyl pyrrolidone (NMP) with varying concentrations of camphor (30-50% w/w) and triacetin (0-25% w/w) were used. The physicochemical properties and antimicrobial activities of formulations were evaluated. Results showed that as the percentage of camphor increased, viscosity, density, contact angle, surface tension, and force of injection increased, while water tolerance decreased. The same trend was observed when increasing the triacetin concentration. The optimal metronidazole-loaded ISM was obtained at 40% w/w camphor and 5% w/w triacetin, which prolonged the release of metronidazole up to 6 days with Fickian diffusion release profile. The higher concentration of triacetin slowed down the phase inversion that led to an incomplete formation of the matrix and resulted in an inefficiently prolonged release of the metronidazole. Antimicrobial activities demonstrated that the developed formulation efficiently inhibited periodontitis-induced microorganisms including Porphyromonas gingivalis, Staphylococcus aureus, Escherichia coli, and Candida albicans. The metronidazole-loaded camphor-based ISM has potential as a new drug delivery system for periodontitis treatment.

Polymeric in situ forming depots for long-acting drug delivery systems

Polymeric in situ forming depots have emerged as highly promising drug delivery systems for long-acting applications. Their effectiveness is attributed to essential characteristics such as biocompatibility, biodegradability, and the ability to form a stable gel or solid upon injection. Moreover, they provide added versatility by complementing existing polymeric drug delivery systems like micro- and nanoparticles. The formulation's low viscosity facilitates manufacturing unit operations and enhances delivery efficiency, as it can be easily administered via hypodermic needles. The release mechanism of drugs from these systems can be predetermined using various functional polymers. To enable unique depot design, numerous strategies involving physiological and chemical stimuli have been explored. Important assessment criteria for in situ forming depots include biocompatibility, gel strength and syringeability, texture, biodegradation, release profile, and sterility. This review focuses on the fabrication approaches, key evaluation parameters, and pharmaceutical applications of in situ forming depots, considering perspectives from academia and industry. Additionally, insights about the future prospects of this technology are discussed.

Clotrimazole-Loaded Borneol-Based In Situ Forming Gel as Oral Sprays for Oropharyngeal Candidiasis Therapy

Oral candidiasis encompasses fungal infections of the tongue and other oral mucosal sites with fungal overgrowth and its invasion of superficial oral tissues. Borneol was assessed in this research as the matrix-forming agent of clotrimazole-loaded in situ forming gel (ISG) comprising clove oil as the co-active agent and N-methyl pyrrolidone (NMP) as a solvent. Their physicochemical properties, including pH, density, viscosity, surface tension, contact angle, water tolerance, gel formation, and drug release/permeation, were determined. Their antimicrobial activities were tested using agar cup diffusion. The pH values of clotrimazole-loaded borneol-based ISGs were in the range of 5.59-6.61, which are close to the pH of 6.8 of saliva. Increasing the borneol content in the formulation slightly decreased the density, surface tension, water tolerance, and spray angle but increased the viscosity and gel formation. The borneol matrix formation from NMP removal promoted a significantly (p < 0.05) higher contact angle of the borneol-loaded ISGs on agarose gel and porcine buccal mucosa than those of all borneol-free solutions. Clotrimazole-loaded ISG containing 40% borneol demonstrated appropriate physicochemical properties and rapid gel formation at microscopic and macroscopic levels. In addition, it prolonged drug release with a maximum flux of 370 µg·cm^-2 at 2 days. The borneol matrix generated from this ISG obsentively controlled the drug penetration through the porcine buccal membrane. Most clotrimazole amounts still remained in formulation at the donor part and then the buccal membrane and receiving medium, repectively. Therefore, the borneol matrix extended the drug release and penetration through the buccal membrane efficiently. Some accumulated clotrimazole in tissue should exhibit its potential antifugal activity against microbes invading the host tissue. The other predominant drug release into the saliva of the oral cavity should influence the pathogen of oropharyngeal candidiasis. Clotrimazole-loaded ISG demonstrated efficacious inhibition of growth against S. aureus, E. coli, C. albicans, C. krusei, C. Lusitaniae, and C. tropicalis. Consequently, the clotrimazole-loaded ISG exhibited great potential as a drug delivery system for oropharyngeal candidiasis treatment by localized spraying.

A Systematic Review and Meta-Analysis of the Clinical Outcomes for Adjunctive Physical, Chemical, and Biological Treatment of Dental Implants With Peri-Implantitis

The present systematic review evaluated the efficacy of adjunctive therapies in the treatment of peri-implantitis. Studies comparing the outcome of conventional surgical- or nonsurgical mechanical debridement with the addition of an adjunctive therapeutic modality were identified through an electronic and hand search of available literature. Following data extraction, meta-analyses were performed on the primary outcome measures. The effects of the adjunctive therapies on bleeding on probing (13 studies), probing pocket depth (9 studies), and radiographic bone level changes (7 studies) were analyzed to evaluate potential clinical benefit. Heterogeneity was expressed as the I2 index. Fixed and random effect models were demonstrated. The potential benefit of adjunctive therapies over control procedures was evaluated in 18 studies, representing a total of 773 implants. Quality assessment of the studies found only 3 studies to be at a low risk of bias. Meta-analysis among the different additional modalities revealed chemical therapy demonstrating significant effects in probing pocket depth reduction (0.58 mm; 0.44-0.72) and radiographic bone level gain (0.54 mm; 0.16-0.92). No significant improvements in bleeding on probing reduction were found using any adjunctive therapy. Available evidence on the benefits of adjunctive therapy to nonsurgical or surgical mechanical debridement in the treatment of peri-implantitis is limited by low numbers of standardized, controlled studies for individual therapies, heterogeneity between studies, and a variety of outcome measures. The lack of effect of any adjunctive therapy in reducing bleeding on probing questions the overall effectiveness over conventional treatment. The long-term clinical benefit potential of these therapies is not demonstrated.

Physicochemical and Bioactivity Characteristics of Doxycycline Hyclate-Loaded Solvent Removal-Induced Ibuprofen-Based In Situ Forming Gel

Modulation with the suppression of infection and inflammation is essential to the successful treatment of periodontitis. An aqueous insoluble hydrophobic anti-inflammatory compound, i.e., ibuprofen (IBU), was investigated in this study as the matrix-forming agent of a doxycycline hyclate (DH)-loaded solvent removal-induced in situ forming gel (ISG) using dimethyl sulfoxide (DMSO) and N-methyl pyrrolidone (NMP) as the solvents. Their physicochemical properties, including pH, density, viscosity, surface tension, contact angle, water tolerance, injectability, mechanical properties, gel formation, and drug release, were determined. Their antimicrobial activities were tested using agar cup diffusion, and their anti-inflammatory activity was assessed using thermal inhibition of protein denaturation of egg albumin. Increasing the IBU content decreased the density, pH, surface tension, and contact angle but increased the viscosity, force and work of injection, and gel formation of IBU-based ISG solution. Although their water tolerance values decreased with the increase in IBU content, the addition of DH and the use of NMP led to high water tolerance. The characterization of the dried gel remnants of ISGs presented no change in IBU crystallinity and thermal properties and confirmed no chemical interaction among the components of ISGs. The obtained transformed IBU matrix prolonged the release of DH and IBU from ISGs over 7 days from its tortuously packed IBU matrix with small pores, and conformed well with Fickian diffusion mechanism. The developed DH-loaded solvent removal-induced IBU-based ISGs exhibited efficient antimicrobial activities against Staphylococcus aureus, methicillin-resistant S. aureus, Escherichia coli, Candida albicans, Porphyromonas gingivalis, and Aggregatibacter actinomycetemcomitans. IBU in formulation promoted the antimicrobial activity of ISGs, whereas DH and NMP promoted the anti-inflammatory activity of ISGs. Consequently, the DH-loaded solvent removal-induced IBU-based ISGs proposed in this study show great potential as an effective bioactive drug delivery system for periodontitis treatment by localized periodontal pocket injection.

Antimicrobial efficiency and cytocompatibility of different decontamination methods on titanium and zirconium surfaces

OBJECTIVES

The purpose of this study was to investigate the efficiency of different implant-decontamination methods regarding biofilm modification and potential cytotoxic effects. Therefore, the amount of biofilm reduction, cytocompatibility, and elementary surface alterations were evaluated after decontamination of titanium and zirconium surfaces.

MATERIAL AND METHODS

Titanium and zirconium disks were contaminated with a newly developed high-adherence biofilm consisting of six microbial species. Decontaminations were performed using titanium curette, stainless steel ultrasonic scaler (US), glycine (GPAP) and erythritol (EPAP) powder air-polishing, Er:YAG laser, 1% chlorhexidine (CHX), 10% povidone-iodine (PVI), 14% doxycycline (doxy), and 0.95% NaOCl solution. Microbiologic analysis was done using real-time qPCR. For assessment of cytocompatibility, a multiplex assay for the detection of cytotoxicity, viability, and apoptosis on human gingival fibroblasts was performed. X-ray photoelectron spectroscopy (XPS) was used to evaluate chemical alterations on implant surfaces.

RESULTS

Compared with untreated control disks, only GPAP, EPAP, US, and Er:YAG laser significantly reduced rRNA counts (activity) on titanium and zirconium (p < .01), whereas NaOCl decreased rRNA count on titanium (p < .01). Genome count (bacterial presence) was significantly reduced by GPAP, EPAP, and US on zirconium only (p < .05). X-ray photoelectron spectroscopy analyses revealed relevant re-exposure of implant surface elements after GPAP, EPAP, and US treatment on both materials, however, not after Er:YAG laser application. Cytocompatibility was impaired by CHX, PVI, doxy, and NaOCl. CHX and PVI resulted in the lowest viability and doxy in the highest apoptosis.

CONCLUSIONS

Within the limits of this in vitro study, air-polishing methods and ultrasonic device resulted in effective biofilm inactivation with surface re-exposure and favorable cytocompatibility on titanium and zirconium. Chemical agents, when applied on implant surfaces, may cause potential cytotoxic effects.

Antibiotics as Adjunctive Therapy in the Non-Surgical Treatment of Peri-Implantitis: A Systematic Review and Meta-Analysis

The role of antibiotics as adjunctive therapy in the non-surgical treatment of peri-implantitis is uncertain. The aim of this systematic review of randomized controlled trials was to assess the efficacy of antibiotic therapy, local or systemic, as an adjunctive to the non-surgical therapy of peri-implantitis. Primary outcomes were: implant success rate and complications, changes in radiographic bone level, probing pocket depth (PPD), probing attachment level (PAL), bleeding on probing (BOP) and peri-implantitis resolution. Six studies were included: two using topical and four systemic antibiotics. Adjunctive local antibiotics improved PPD (mean difference (MD) = 0.6 mm; 95% CI 0.42-0.78), BOP (MD = 0.15% (95% CI 0.10, 0.19)) and the success rate (risk ratio = 9.89; 95% CI 2.39-40.84). No significant difference in bone level and success rate were found with the use of systemic antibiotics, although they appeared to improve PPD (MD = 1.15 mm; 95% CI 0.31-1.99) and PAL (MD = 1.10 mm; 95% CI 0.13-2.08). Within the limitations of this review, the adjunctive local antibiotics showed improved outcomes in terms of success rate, PPD and BOP, while adjunctive systemic antibiotics improved PPD and PAL only. Peri-implantitis resolution was about 20-30% using adjunctive local antibiotics, whilst it ranged from 2% to 65% with adjunctive systemic antibiotics. Findings are still controversial, since they are based on few studies with high heterogeneity, at the uncertain or high risk of bias and involve few patients. Non-surgical debridement and maintenance periodontal support therapy remain pivotal and the adjunctive use of antibiotics for peri-implantitis cannot be routinely recommended, even considering the increasing concern on antibiotic resistance.

Is There a Better Biomaterial for Dental Implants than Titanium?—A Review and Meta-Study Analysis

This article focuses on preclinical studies and reviews the available evidence from the literature on dental implant and abutment materials in the last decade. Specifically, different peri-implantitis materials and how surface modifications may affect the peri-implant soft-tissue seal and subsequently delay or hinder peri-implantitis are examined. This review analyzed more than 30 studies that were Randomized Controlled Trials (RCTs), Controlled Clinical Trials (CCTs), or prospective case series (CS) with at least six months of follow-up. Meta-analyses were performed to make a comparison between different implant materials (titanium vs. zirconia), including impact on bone changes, probing depth, plaque levels, and peri-implant mucosal inflammation, as well as how the properties of the implant material and surface modifications would affect the peri-implant soft-tissue seal and peri-implant health conditions. However, there was no clear evidence regarding whether titanium is better than other implant materials. Clinical evidence suggests no difference between different implant materials in peri-implant bone stability. The metal analysis offered a statistically significant advantage of zirconia implants over titanium regarding developing a favorable response to the alveolar bone.

The efficacy of systemic antibiotics as an adjunct to surgical treatment of peri-implantitis: a systematic review

BACKGROUND

Microbial biofilm accumulation is the main cause of peri-implantitis. The majority of surgical peri-implantitis treatment protocols suggests adjunctive use of systemic antibiotics to target specific putative bacteria. The aim of this systematic review was to critically evaluate the adjunctive use of systemically administered antibiotics in surgical treatment of peri-implantitis by reviewing previously published systematic reviews and primary studies.

METHODS

A systematic literature search was conducted in four electronic databases (MEDLINE, The Cochrane Library, EMBASE, and Web of Science) for randomised controlled trials, cohort studies, case-control studies, and systematic reviews reporting surgical treatment of peri-implantitis with and without adjunctive systemically administered antibiotic therapy. The included systematic reviews and primary studies were qualitatively assessed using AMSTAR and GRADE, respectively. No restrictions were set for date of publication, journal, or language.

RESULTS

The literature search identified 681 papers. Only seven systematic reviews and two primary studies met the inclusion criteria. Four out of seven included systematic reviews concluded that no evidence exists for use of systemic antibiotics to improve the clinical outcomes in surgical treatment of peri-implantitis. One review did not estimate the level of evidence, one did not clearly state any beneficial effect, whereas one reported a limited adjunctive effect. Further, the two included primary studies did not show a long-term significant benefit of adjunctive use of systemically administrated antibiotics. However, one study reported a short-term adjunctive effect in patients with modified surface implants. Due to heterogeneity in study design, low number of included primary studies, and grade of bias, no meta-analysis was performed.

CONCLUSION

The use of systemically administered antibiotics as an adjunct to surgical interventions of peri-implantitis cannot be justified as a part of a standard treatment protocol. A pervasive problem is the lack of uniform diagnosis criteria for peri-implantitis, deficient information about patient characteristics, absence of high quality long-term randomised controlled trials, and authors' declaration on conflict of interest.

Local/Topical Antibiotics for Peri-Implantitis Treatment: A Systematic Review

Most studies indicate that the mechanical removal of the bacterial biofilm from the implant surface is the central goal of peri-implantitis therapy. However, controversial results in the treatment of peri-implantitis have led to the consideration of additional strategies that include surgical approaches and chemical adjuvants. Local/topical antibiotics, such as minocycline, azithromycin, tetracycline, amoxicillin, doxycycline, and metronidazole, may improve the efficacy of the definitive treatment of the disease, but the lack of conclusive findings prevents their use in clinical practice. This systematic review aimed to evaluate the effect of local/topical antibiotics for peri-implantitis treatment. Randomised controlled studies (RCT) on patients with peri-implantitis and comparing the efficacy of local/topical antibiotics vs. placebo or mechanical debridement were included. A systematic search strategy was carried out using three registered databases (PubMed, Web of Science, and Scopus). RoB2 was used to assess risk of bias. Five RCTs were identified (n = 250 patients and 333 implants). Contrast results emerged among the included studies, and a high heterogeneity level was observed. Risk of bias revealed some concerns for three studies out of five, while one study was judged at high risk. Only one study analysed the limitations of its findings. Overall, local antibiotic use can be considered a valid approach in the treatment of peri-implantitis. Therefore, future long-term clinical trials with standardised protocols and antibiotics with similar biological activity profiles should be tested to achieve a valid and definitive conclusion.

Efficacy of local antibiotic therapy in the treatment of peri-implantitis: A systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to state the efficacy of local administration of antibiotics in the treatment of peri-implantitis in terms of peri-implant probing depth (PPD) and bleeding on probing (BoP) reduction.

DATA, SOURCES AND STUDY SELECTION

Electronic and manual literature searches were conducted. Screening process was done using the National Library of Medicine (MEDLINE by PubMed), Embase and the Cochrane Oral Health. Included articles were randomized controlled trials and observational studies. Weighted means were calculated. Heterogeneity was determined using Higgins (I2). Due to the encountered heterogeneity between the studies being combined, random-effects models were applied in order to analyze effect sizes. Twelve studies (365 patients and 463 implants) were included in the systematic review. After peri-implantitis treatment with local antibiotics, PPD was reduced 1.40 mm (95% confidence interval: 0.82-1.98). When local antibiotics were applied, a 0.30 mm higher reduction of PPD was obtained than in the control group (95% confidence interval: 0.07-0.53). BoP attained an odds ratio value of 1.82 (95% confidence interval: 1.09-3.04), indicating that the likehood of bleeding is almost two-fold when antibiotics are not locally administrated. Adverse effects were not found after applying local antibiotics.

CONCLUSIONS

The local antibiotic administration does reduce, without adverse effects, both peri-implant probing depths and bleeding on probing in patients affected by peri-implantitis, if compared to control groups without local antibiotic application.

CLINICAL SIGNIFICANCE

Patients with dental implants frequently suffer from peri-implantitis. Clinical features of peri-implantitis lesions include the presence of bleeding on probing and increased peri-implant probing depths. Both BoP and PPD have become reduced after local administration of antibiotics.

Network meta-analysis of the treatment efficacy of different lasers for peri-implantitis

The aim of this study was comparing different lasers with conventional non-surgical treatment (CNT) for the management of peri-implantitis, regarding probing depth (PD), plaque index (PLI), clinical attachment level (CAL), and sulcus bleeding index (SBI). Randomized controlled trials (RCTs) on different lasers and CNT for peri-implantitis were searched. Pairwise and network meta-analyses were performed to analyze the PD, PLI, CAL, and SBI outcomes. The risk of bias, evidence quality, statistical heterogeneity, and ranking probability were also evaluated. Eleven studies were included in this study, involving three types of lasers. Diode + CNT had significantly superior efficacy to CNT alone, regarding PD reduction, while Er:YAG + CNT had significantly superior efficacy than CNT in terms of the PLI, CAL, and SBI. The highest probability of being most effective for PD was diode + CNT (49%), while Er:YAG + CNT had the highest probability of improving the PLI, CAL, and SBI (66%, 53%, and 79%, respectively). Diode + CNT was significantly superior for PD management in peri-implantitis compared with CNT alone, while Er:YAG + CNT significantly improved the PLI, CAL, and SBI. Therefore, Er:YAG + CNT might be recommended methods considered for management of peri-implantitis.

Repeated delivery of chlorhexidine chips for the treatment of peri-implantitis: A multicenter, randomized, comparative clinical trial

BACKGROUND

Peri-implantitis is a challenging condition to manage and is frequently treated using non-surgical debridement. The local delivery of antimicrobial agents has demonstrated benefit in mild to moderate cases of peri-implantitis. This study compared the safety and efficacy of chlorhexidine gluconate 2.5 mg chip (CHX chips) as an adjunctive treatment to subgingival debridement in patients afflicted with peri-implantitis.

METHODS

A multicenter, randomized, single-blind, two-arm, parallel Phase-3 study was conducted. Peri-implantitis patients with implant pocket depths (IPD) of 5-8 mm underwent subgingival implant surface debridement followed by repeated bi-weekly supragingival plaque removal and chlorhexidine chips application (ChxC group) for 12 weeks, or similar therapy but without application of ChxC (control group). All patients were followed for 24 weeks. Plaque and gingival indices were measured at every visit whereas IPD, recession, and bleeding on probing were assessed at 8, 12, 16, 24 week.

RESULTS

A total of 290 patients were included: 146 in the ChxC group and 144 in the control. At 24 weeks, a significant reduction in IPD (P = 0.01) was measured in the ChxC group (1.76 ± 1.13 mm) compared with the control group (1.54 ± 1.13 mm). IPD reduction of ≥2 mm was found in 59% and 47.2% of the implants in the ChxC and control groups, respectively (P = 0.03). Changes in gingival recession (0.29 ± 0.68 mm versus 0.15 ± 0.55 mm, P = 0.015) and relative attachment gain (1.47 ± 1.32 mm and 1.39 ± 1.27 mm, P = 0.0017) were significantly larger in the ChxC group. Patients in the ChxC group that were < 65 years exhibited significantly better responses (P < 0.02); likewise, non-smokers had similarly better response (P < 0.02). Both protocols were well tolerated, and no severe treatment-related adverse events were recorded throughout the study.

CONCLUSIONS

Patients with peri-implantitis that were treated with an intensive treatment protocol of bi-weekly supragingival plaque removal and local application of chlorhexidine chips had greater mean IPD reduction and greater percentile of sites with IPD reduction of ≥2 mm as compared with bi-weekly supra-gingival plaque removal.

Non-surgical peri-implantitis treatment using a pocket irrigator device; clinical, microbiological, radiographical and patient-centred outcomes-A pilot study

Aim

The aim of this prospective cohort study was to assess the effect of a pocket irrigator/evacuator device (IED) in the non‐surgical treatment of peri‐implantitis.

Material and Methods

In total 24 patients having 38 implants diagnosed with peri‐implantitis were included in this study. Peri‐implant pockets were irrigated six times in three consecutive weeks. The primary outcome was bleeding on probing (BoP). Secondary outcome parameters included plaque index (Pl), suppuration on probing (SoP), probing pocket depth (PPD), marginal bone loss (MBL), presence and numbers of periodontal pathogens. Parameters were assessed at baseline and 3 months after the last treatment. Treatment pain perception was scored using the visual analog scale (VAS) after the first and last treatment.

Results

At 3 months, IED treatment revealed significant reduction of peri‐implant BoP (71% [±20] vs 57% [±28] [P = .014]) and peri‐implant plaque scores (10 [±14] to 5 [±9] [P = .039] [T0 vs T3 respectively]). Significant reduction in mean peri‐implant PPD from 4.92 mm (SD ± 1.28) to 4.66 mm (SD ± 1.35) (P = .041) was observed. In addition, a reduction in VAS pain score between the first and the last (6th) treatment was found (P = .039). No reduction in SoP (P = .088) was found. No changes in mean periodontal full mouth plaque, BOP, SOP and PPD levels, MBL and microbiological outcomes were found.

Conclusion

Beneficial clinical effects in terms of BoP, PPD and PI were found at 3 months after IED treatment. However, the IED does not seem to effectively treat peri‐implantitis in terms of disease resolution.

Efficacy of growth factors for the treatment of peri-implant diseases: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to conduct a systematic review and meta-analysis on the efficacy of growth factors (GF) on clinical outcomes after treatment (surgical/non-surgical) of peri-implant diseases (peri-implant mucositis and peri-implantitis).

MATERIALS AND METHODS

A protocol was developed to answer the following focused question: Is there any difference for the use of GF for treatment of peri-implant diseases versus comparative GF treatment or without GF? Electronic database and manual searches were independently conducted to identify randomized controlled trials (RCTs). Publications were selected based on eligibility criteria and then assessed for risk-of-bias using the Cochrane Handbook. The primary outcome was probing depth (PD) and bleeding on probing (BOP) reduction along with changes in vertical defect depth (VDD). Changes in clinical attachment level, gingival recession, and plaque index, among others, were studied as secondary outcomes. Based on primary outcomes, random-effects meta-analysis was conducted.

RESULTS

A total of five RCTs were included. GF enhance the reduction of PD (standardized mean difference (SMD) = - 1.28; 95% confidence interval (CI) - 1.75, - 0.79; p = < 0.0001) and BOP (SMD = - 1.23; 95% CI - 1.70, - 0.76; p = < 0.0001) in the management of peri-implant mucositis. For the treatment of peri-implantitis, the use of GF yielded to significantly greater improvement in VDD (SMD = 0.68; 95% CI 0.22, 1.14; p = 0.004); however, there were no significant differences in terms of PD (SMD = 0.08; 95% CI - 1.08, 1.26; p = 0.887) and BOP (SMD = 0.211; 95% CI - 0.20, 0.63; p = 0.317). The overall risk of bias of the included studies was low to unclear.

CONCLUSION

The results of the present systematic review suggest that the addition of GF might enhance the outcomes in the treatment of peri-implant mucositis. However, there is a lack of evidence for supporting additional benefit of GF managing peri-implantitis.

CLINICAL RELEVANCE

Within the limitations of the current systematic review and based on the meta-analyses, (1) the addition of GF for the treatment peri-implant mucositis might be associated with better outcomes in terms of PD and BOP, and (2) an additional benefit of GF for the treatment peri-implantitis could not be determined on the basis of the selected evidence.

Application of totarol as natural antibacterial coating on dental implants for prevention of peri-implantitis

Peri-implantitis is the most important issue threatening the long-term survival rate of dental implants. Various efforts have been made to reduce implant surface plaque formation, which is one of the essential causes of peri-implantitis. In our study, we applied the natural antibacterial agent totarol as a coating on experimental silicon wafer and titanium implant surfaces. To analyze the interaction between the totarol coating and the oral primary colonizer S. gordonii and isolates of mixed oral bacteria, samples were incubated in a model system simulating the oral environment and analyzed by Live/Dead staining, crystal violet staining and scanning electron microscopy (SEM). After 4 d, 8 d, 12 d, 16 d, and 24 d salivary incubation, the stability and antibacterial efficiency of totarol coating was evaluated through SEM. The results indicated that totarol coatings on both silicon wafer and Ti surfaces caused efficient contact killing and an inhibition effect towards S. gordonii and mixed oral bacterial film growth after 4 h, 8 h, 24 h, and 48 h incubation. After longtime salivary incubation of 12 d, the bactericidal effect started to weaken, but the anti-adhesion and inhibition effect to biofilm development still exist after 24 d of salivary incubation. The application of a totarol coating on implant or abutment surfaces is a promising potential prophylactic approach against peri-implantitis.

Cleaning potential of different air abrasive powders and their impact on implant surface roughness

BACKGROUND

Implant surface roughness after air abrasive therapy has not been measured precisely in previous research. Debridement with air abrasion facilitates the mechanical removal of bacterial biofilms but may damage implant surfaces on a microscopic level.

PURPOSE

This study aimed to investigate the cleaning potential of various air abrasive powders and their effect on titanium implant surfaces.

MATERIALS AND METHODS

Twenty implants coated with red ink were inserted into three-dimensional printed circumferential bone defect models. Treatment was completed with three types of air abrasive powders: sodium bicarbonate (SB), glycine, and erythritol for 60 seconds. Water alone was used as control. The percentage of remaining ink was assessed using digital photography and graphic software. Implant surface topography/roughness was quantified using optical profilometry and examined via scanning electron microscopy. The microscopic analysis was performed at two implant areas: collar (Laser-Lok surface) and threads.

RESULTS

The cleaned surfaces (%, mean ± SD) after treatment with SB, glycine, and erythritol accounted for 49.3 ± 3.6%, 33.1 ± 1.2%, and 25.1 ± 0.7%, respectively. Statistically significant differences were found between all groups (P < .001). SB was the only powder that significantly increased the implant roughness (S_a ) on both the implant collar (1.53-2.10 μm) and threads (3.53-4.20 μm). Regardless of the abrasive powder used, the collar, emerging implant surfaces from the defect base, and surfaces beneath implants threads exhibited more post-treatment residual ink.

CONCLUSION

Large-sized powder showed the greatest cleaning capacity, but caused more alterations to the implant surface. Glycine and erythritol displayed no significant changes in surface roughness, however, demonstrated a limited ink removal capacity.

Nonsurgical Treatment of Periimplantitis

PURPOSE

Periimplantitis has become an emerging challenge faced by practicing dentists worldwide. When treating periimplantitis, we should attempt to manage this problem via nonsurgical therapies that include addressing all modifiable systemic risk factors and local contributing factors. Hence, the aim of this narrative review was to examine published studies on nonsurgical treatment of periimplantitis and evaluate their effectiveness and limitations.

MATERIALS AND METHODS

A literature search was performed in MEDLINE via PubMed database up to December 31, 2017. Current published clinical approaches focused on mechanical debridement, adjunctive antiseptic therapy, adjunctive antibiotic therapy, laser-assisted therapy, and combination approaches were included in this analysis.

RESULTS

Nonsurgical therapy of periimplantitis may result in complete healing of the disease and the patient is then placed on a supportive maintenance program. If the disease is not resolved and surgical intervention is not an option, active nonsurgical retreatment may be considered. In many cases where disease is not resolved, surgical therapy or implant removal could be considered.

CONCLUSIONS

Nonsurgical treatment of periimplantitis usually provides clinical improvements in reducing bleeding tendency and in some cases pocket reduction. Early diagnosis, detection, and intervention remain the key for managing periimplantitis.

Bone Remineralization around Dental Implants following Conservative Treatment after Peri-Implantitis

The aim of this case report is to show that bone remineralization around dental implants with a history of peri-implantitis is possible after irritant factors are removed and only conservative treatment is performed. Patient came to the clinic after three years of dental implant placement complaining about swelling, sensitivity and gingiva color changes at the posterior part of the maxilla. During radiographic and intraoral examinations peri-implantitis of the #24 implant site was diagnosed. The surgical treatment method was rejected and performed conservative treatment instead. The outcome is promising; periapical radiographs three months later showed bone remineralization as well as stable bone after 10 years. A key clinical message: Bone remineralization around dental implants with a history of peri-implantitis is possible after irritant factors are removed and conservative treatment performed.

Is Peri-Implantitis Curable?

Peri-implant mucositis and peri-implantitis are clinically associated with inflammation of soft tissue around implants; however, peri-implantitis is associated with radiographic bone loss. Recently a new classification scheme-peri-implant health, peri-implant mucositis, peri-implantitis, and peri-implant soft-tissue and hard-tissue deficiencies-was introduced. Although various clinical interventions to treat peri-implant diseases have been suggested, early diagnosis and treatment is the key to successful outcomes. Clinicians can select nonsurgical or surgical techniques according to the clinical parameters present, although surgical intervention seems to be more effective in treating peri-implantitis. The best approach to treat peri-implantitis remains controversial.

Doxycycline Release of Dental Implants With Nanotube Surface, Coated With Poly Lactic-Co-Glycolic Acid for Extended pH-controlled Drug Delivery

When dental implants become infected, the progression of the disease is rapid. Commercially available dental implant surfaces can be easily contaminated, resulting in rapid progression of peri-mucositis and peri-implantitis. The aim of this study was to evaluate, in vitro, the pattern of doxycycline release from by dental implants with titanium nanotube surface (DINS) at different pHs to examine novel drug loading and chemical coating techniques. Nine DINS were loaded with doxycycline and subsequently coated with polylactic-co-glycolic acid (PLGA). High-performance liquid chromatography (HPLC) was used to measure the amounts of released doxycycline in a 30-day period. Cytotoxicity of the DINS was evaluated by an assay using 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT). The results showed that the experimental DINS coated with doxycycline and PLGA showed a mean drug release during the experimental period for the groups: pH 7.4 (8.39 μg/mL), pH 6.4 (8.63 μg/mL). The pH 5.4 (15.18 μl/mL) doxycycline release from DINS was faster at pH 5.4 than those at pHs 6.4 and 7.4 (P = .0031 and .0034, respectively). This new surface treatment of dental implants with titanium nanotubes and subsequent drug loading demonstrated biocompatibility and sustained doxycycline release over a 30-day period. Additional studies are needed in order to adopt a stable drug release at neutral pH environment while warranting a constant drug release in an acidic pH environment.

Nonsurgical therapy for teeth and implants-When and why?

As periodontal and peri-implant diseases represent opportunistic infections, antiinfective therapy is the method of choice. Correctly performed, the treatment outcomes will include resolution of the inflammation concomitant with shrinkage of the tissues, reflected in reduced probing depths. Depending on the patient data obtained after initial antiinfective therapy, further - mostly surgical - treatment may be rendered to reach the goals of a healthy periodontium and peri-implant tissues. Patient compliance is as important as operator skills for optimal treatment outcomes. Regenerative therapy may be applied in compliant patients and for appropriate defects. This article depicts the historical development of periodontal therapy during the 20th century and addresses the various outcome parameters to be used in daily decision making. Obviously, nonsurgical therapy has gained clinical relevance, resulting in highly satisfactory treatment outcomes in many cases. The critical probing depth above which positive attachment gain is registered varies from one treatment modality to another. It is a concept that helps facilitate decision making for additional therapeutic measures after initial therapy. Treatment of peri-implant mucositis prevents development of peri-implantitis. Hence, nonsurgical treatment of mucositis is frequently performed during the continuous monitoring of oral implants. This chapter of Periodontology 2000 presents evidence for the prevention and therapy of peri-implant diseases.

A New Controlled-Release Material Containing Metronidazole and Doxycycline for the Treatment of Periodontal and Peri-Implant Diseases: Formulation and In Vitro Testing

Background

Several locally administered antimicrobials have been studied in the literature as adjunctive or primary treatments for periodontitis and peri-implantitis with conflicting results.

Objective

The aim of this study was twofold: (1) the formulation of a controlled-release material containing metronidazole and doxycycline; (2) an in vitro evaluation of its antibacterial properties against planktonic and biofilm species involved in periodontal and peri-implant diseases.

Methods

Doxycycline (10 mg/ml) and metronidazole (20 mg/ml) were incorporated into a hydroxyethylcellulose-polyvinylpyrrolidone-calcium polycarbophil gel. Three milliliters of gel were dialyzed against Dulbecco's phosphate-buffered saline for 13 days. Antibiotics release at 3, 7, 10, and 13 days was determined spectroscopically. The inhibitory activity of the experimental gel was tested against A. actinomycetemcomitans, S. sanguinis, P. micra, and E. corrodens with an agar diffusion test, an inactivation biofilm test, and a confocal laser scanning microscope study (CLSMS) for S. sanguinis up to 20 days.

Results

After 13 days, the released doxycycline was 9.7% (at 3 days = 1.2 mg; 7 days = 0.67 mg; 10 days = 0.76 mg; 13 days = 0.29 mg), while metronidazole was 67% (30 mg, 6.8 mg, 2.5 mg, and 0.9 mg at the same intervals). The agar diffusion test highlights that the formulated gel was active against tested microorganisms up to 312 h. Quantitative analysis of biofilm formation for all strains and CLSMS for S. sanguinis showed a high growth reduction up to 13 days.

Conclusions

The in vitro efficacy of the newly formulated gel was confirmed both on planktonic species and on bacterial biofilm over a period of 13 days. The controlled-release gel containing metronidazole and doxycycline had an optimal final viscosity and mucoadhesive properties. It can be argued that its employment could be useful for the treatment of periodontal and peri-implant diseases, where conventional therapy seems not successful.

Microbial Etiology and Antimicrobial Therapy of Peri-implantitis: A Comprehensive Review

Introduction:

Implants have turned out to be a well-established therapy in dental practice for the replacement of missing teeth and restoration of function.

Peri-implant disease denotes the inflammatory condition of surrounding soft and hard tissues.

Two terminologies are covered under the impression of peri-implant pathology; peri-implantitis and mucositis. Peri-implant mucositis is a reversible inflammatory process limited to soft tissues around an implant. Peri-implantitis is an inflammatory condition of hard and soft tissue around the dental implant.

Microbial Etiology:

Bacterial infections are the most common cause of peri-implantitis. It is a variable poly-microbial infection, although generally dominated by Gram-negative anaerobic bacteria Anti-infective therapy should be included in the treatment regime, while treating the peri-implant disease. Antimicrobial therapy includes local debridement, antibiotic therapy and surface decontamination of the implant.

Conclusion:

The current article gives a detailed overview of microbial etiology, antimicrobial therapy and its limitations for the treatment of peri-implant Pathology.

Development of a simvastatin loaded injectable porous scaffold in situ formed by phase inversion method for bone tissue regeneration

INTRODUCTION:

The use of injectable scaffolds as a minimally invasive method is a good choice in tissue engineering applications. A critical parameter for the tissue engineering scaffolds is a suitable morphology with interconnected pores. We present the development of a simvastatin loaded scaffold that forms in situ and provides the porous structure with interconnected pores.

METHODS:

The formulation of these scaffolds includes a polymeric solution of poly lactic-co-glycolic acid (25 wt%) in N-methyl-2-pyrrolidone containing 6 wt% deionized water and porogen (mannitol, four times the weight of the polymer). We have grafted simvastatin to poly lactic-co-glycolic acid by the esterification reactions. Simvastatin or simvastatin-grafted poly lactic-co-glycolic acid in different levels was added to polymer solution and finally the solution was injected into phosphate buffered saline. The simvastatin-grafted poly lactic-co-glycolic acid was characterized by attenuated total reflection Fourier-transform infra-red and ¹H-nuclear magnetic resonance spectroscopy. The morphology, porosity, and biocompatibility of the scaffolds were evaluated. The in vitro simvastatin release from the various formulations was studied. Osteogenic differentiation of the adipose-derived stem cells was investigated using alkaline phosphatase activity assay and cell mineralization was evaluated using Alizarin red staining.

RESULTS:

The morphology results showed the resultant scaffold was porous with the interconnected pores. The scaffolds presented 91% porosity. Non-toxic doses of simvastatin in the scaffolds were determined by methyl-thiazolyl diphenyl-tetrazolium bromide assay. The released simvastatin from the scaffolds continues over 80 days. Alkaline phosphatase activity and Alizarin red results indicated that cell osteogenic differentiation is promoted.

CONCLUSION:

The results demonstrated that release of simvastatin from the injectable scaffolds can have positive effects on osteogenic differentiation of the adipose-derived stem cells.

A doxycycline-treated hydroxyapatite implant surface attenuates the progression of peri-implantitis: A radiographic and histological study in mice

BACKGROUND

Oral rehabilitation with dental implants has become increasingly common; however, the increase of peri-implantitis is a great concern. Doxycycline (DOX) is a widely used antibiotic that inhibits bacteria growth, inflammation, and bone resorption.

OBJECTIVES

To evaluate the progression of peri-implantitis of hydroxyapatite (HA)-coated implants with (5 mg/mL, DOX group) or without (HA group) DOX treatment on the surface.

MATERIALS AND METHODS

The maxillary first molars of 20 male mice were extracted. Eight weeks later, small titanium screw implants coated with thin HA and treated with or without DOX were placed at the extracted sites. Four weeks after implant placement, half of the animals in both groups were sacrificed, and ligatures were placed around the implant necks in the other half. These mice were sacrificed 4 weeks later. The bone around the implants was examined radiologically and histologically.

RESULTS

Four weeks after the ligature placement, the radiographic measurements revealed that peri-implant bone levels of palatal and mesial sites, and histological measurements showed that bone levels of mesial and distal sites in the DOX group were significantly higher than those in the HA group.

CONCLUSIONS

The present results indicating that the DOX-treated HA implant surface attenuates the progression of peri-implantitis.

Simplified nonsurgical treatment of peri-implantitis using chlorhexidine and minocycline hydrochloride

Purpose

The present study investigated the outcomes of a newly-developed, simple, and practical nonsurgical treatment modality suitable for most forms of intrabony defects around failing dental implants using intrasulcular delivery of chlorhexidine solution and minocycline hydrochloride (HCl).

Methods

Forty-five dental implants in 20 patients diagnosed with peri-implantitis were included. At baseline and the study endpoint, the probing pocket depth (PPD), clinical attachment level (CAL), and the presence of bleeding on probing (BOP) at 6 sites around each implant were recorded. The radiographic osseous defect morphology at the mesial or distal proximal aspect of each implant was classified as 1) narrow or wide and 2) shallow or deep. For a comparative analysis of bone changes according to the defect morphology, the distance from the implant shoulder to the most coronal bone-to-implant contact point (DIB) at the mesial and distal aspects of each implant was measured at baseline and the endpoint. Patients were scheduled to visit the clinic every 2–4 weeks for intrasulcular irrigation of chlorhexidine and delivery of minocycline HCl.

Results

We observed statistically significant decreases in PPD, CAL, and BOP after treatment. At the endpoint, bone levels increased in all defects, regardless of the osseous morphology of the intrabony defect. The mean DIB change in deep defects was significantly greater than that in shallow defects. Although the mean bone gain in narrow defects was greater than in wide defects, the difference was not statistically significant.

Conclusions

We propose that significant and sustainable improvements in both clinical and radiographic parameters can be expected when intrabony defects around dental implants are managed through a simple nonsurgical approach involving combined intrasulcular chlorhexidine irrigation and local delivery of minocycline HCl.

Vancomycin and tobramycin impregnated mineralized allograft for the surgical regenerative treatment of peri-implantitis: a 1-year follow-up case series

OBJECTIVES

To assess the clinical and radiographic outcomes of the regenerative treatment of peri-implantitis using a vancomycin and tobramycin impregnated allograft (VTA) after a 12-month period.

MATERIAL AND METHODS

Thirteen consecutive patients who required a regenerative treatment of peri-implantitis were recruited. For the 17 implant sites, a flap was raised, and after mechanical and chemical implant decontamination, a vancomycin and tobramycin impregnated allograft was placed in the defect and then covered with a collagen membrane. Soft tissues were sutured allowing a non-submerged healing. Clinical and radiographic variables were evaluated at baseline and at 12 months after treatment.

RESULTS

No signs of continuous bone loss were observed and no implant was lost, yielding a 100% survival rate. All patient's clinical examination at 12 months revealed peri-implant health showing absence of suppuration and a statistically significant reduction in terms of bleeding on probing scores (70.6%, P = 0.001). Initial probing pocket depth (7.88 ± 1.22 mm) was significantly reduced at 12 months healing, a mean reduction of 4.23 ± 1.47 mm (P = 0.001) was achieved. The mean radiological infrabony defect at baseline reached 4.33 ± 1.62 mm, and was significantly reduced up to 0.56 ± 0.88 mm, which represents an 86.99 ± 18.2% bone fill from the original infrabony defect.

CONCLUSIONS

Within the limits of the study, the application of VTA with a collagen membrane yielded positive outcomes in terms of radiographic bone fill, pocket depth reduction, and attachment gain after a 12-month period. Thus, VTA plus a collagen membrane seem to be suitable for the regenerative treatment of peri-implantitis.

CLINICAL RELEVANCE

The use of locally delivered antibiotic together with the bone graft may reduce the undesirable effects related to the systemic administration and the risk of resistances. In the light of the results obtained, these grafting materials might offer new treatment strategies in the surgical regenerative treatment of peri-implantitis.

Combination of ultrasonic decontamination, soft tissue curettage, and submucosal air polishing with povidone-iodine application for non-surgical therapy of peri-implantitis: 12 Month clinical outcomes

BACKGROUND

The aim of this study is to evaluate clinical outcomes of a concept for non-surgical peri-implantitis combining stepwise mechanical debridement measures with adjuvant povidone-iodine application with and without systemic antibiotics.

METHODS

Forty-five patients with chronic periodontitis and a total of 164 screw-typed implants with peri-implantitis were included. Peri-implantitis was defined as radiographic bone loss of > 2 mm, probing depth (PD) ≥5 mm with bleeding on probing (BOP). Stepwise treatment of implants was performed with ultrasonic debridement, soft tissue curettage (STC), glycine powder air polishing (GPAP), and a repeated submucosal application of povidone-iodine. Teeth with PD > 4 mm were treated simultaneously according to the same concept except STC. In cases with severe periodontitis (n = 24), amoxicillin and metronidazole (AM) were prescribed for 7 days.

RESULTS

After 12 months, implants treated without AM showed significant reductions (P < 0.05) of mean PD (1.4 ± 0.7 mm), clinical attachment level (CAL) (1.3 ± 0.8 mm), and BOP (33.4% ± 17.2%). In deep pockets (PD > 6 mm) changes of mean PD (2.3 ± 1.3 mm), CAL (2.0 ± 1.6 mm), and BOP (44.0% ± 41.7%) were more pronounced. Intake of AM did not significantly influence the changes in these parameters. However, the reduction of implant sites with PD > 4 mm and BOP was significantly higher in patients with AM than in those without AM (31.8% ± 12.6% versus 20.8% ± 14.7%; P < 0.05).

CONCLUSIONS

The combination of ultrasonic debridement, STC, and GPAP with adjuvant povidone-iodine led to significant clinical improvements at implants. Systemic antibiotics had limited effects on the reduction of persisting implant sites with treatment need.

Effectiveness of Mechanical Debridement Combined With Adjunctive Therapies for Nonsurgical Treatment of Periimplantitis: A Systematic Review

OBJECTIVE

This study aimed to perform a systematic review of the effectiveness of nonsurgical treatment associated with different adjuvant therapies on periimplantitis.

MATERIALS AND METHODS

Different individuals, following a research process, performed a network research of controlled and randomized controlled clinical trials on PubMed, Embase/MEDLINE, with 20 years' time constraint and the last search in January 2016.

RESULTS

From 108 articles found by the first search, they analyzed 10 full texts, and in none did they find a standard control group. When compared, mechanical therapies combined with adjuvant therapy decreased prevalence of periimplant ratios; however, some groups showed unsatisfactory results, mainly related to the probing depth and bleeding index. When comparing debridement with other nonsurgical therapies (Er:YAG, Vector, air abrasive with amino acid glycine powder), increased periimplant levels were noticed in the test and control groups, although in different periods.

CONCLUSION

Despite the improvement in the periimplant indices, there is no sufficient evidence to score the best results or even to choose the best association for nonsurgical treatment of periimplantitis; hence, more trials are necessary to answer this question.

Surgical Treatment of Implants Affected by Periimplantitis After 15 Years of Loading: A Case Report

PURPOSE

The aim of this case report is to describe the surgical treatment of 2 implants affected by periimplantitis after 15 years of loading.

MATERIALS AND METHODS

The treatment included mechanical and chemical decontamination with topical application of tetracycline associated with a regenerative approach. Both defects were filled with particulate autogenous bone from tuber and covered with resorbable collagen membrane.

RESULTS

The follow-up of 30 and 13 months of the implants 24 and 14, respectively, showed an absence of clinical signs of periimplant inflammation and near-complete bone regeneration.

CONCLUSIONS

The therapy approach was effective in eliminating periimplant inflammation and promoting bone gain around the implants.

Microbiome of dental implants and its clinical aspect

Although dental implants are most common prosthetic treatment used to replace missing tooth, it gained considerable importance over a decade owing to the availability of advanced imagery techniques that can help in achieving a greater success rate and much better osseointegration. However, the chances that the implanted tooth can be rejected due to inflammation caused by oral microflora still persist. This review gives the viewers an overall idea of the dental implants, role of advanced imaging in implantation and instances of peri-implantitis that occur after implantation process. This review also entails the latest research on the different treatment modalities against peri-implantitis documented in peer-review journals.

Injectable formulations of poly(lactic acid) and its copolymers in clinical use

Poly(lactic acid) and its copolymers have revolutionized the field of drug delivery due to their excellent biocompatibility and tunable physico-chemical properties. These copolymers have served the healthcare sector by contributing many products to combat various diseases and for biomedical applications. This article provides a comprehensive overview of clinically used products of poly(lactic acid) and its copolymers. Multi-dimension information covering product approval, formulation aspects and clinical status is described to provide a panoramic overview of each product. Moreover, leading patented technologies and various clinical trials on these products for different applications are included. This review focuses on marketed injectable formulations of PLA and its copolymers.

Peri-implantitis. Part 3: current modes of management

Peri-implantitis is an inflammatory condition fuelled by the presence of bacteria on the implant surface. As such, in a similar manner to periodontal disease management, the removal of biofilm from the implant surface should result in regression of the disease process. The optimal manner with which this is achieved has yet to be realised. This may be unsurprising due to the relative surface complexity of the implant surface when compared to natural tooth root. Other management strategies include surface decontamination, the removal of implant threads known as implantoplasty, and in severe cases the need to explant. Favourable defects can be reconstructed utilising guided bone regeneration techniques. The current review appraises some of the techniques for the management of peri-implantitis.

Efficacy of alternative or adjunctive measures to conventional treatment of peri-implant mucositis and peri-implantitis: a systematic review and meta-analysis

In patients with peri-implant mucositis and peri-implantitis, what is the efficacy of nonsurgical (i.e. referring to peri-implant mucositis and peri-implantitis) and surgical (i.e. referring to peri-implantitis) treatments with alternative or adjunctive measures on changing signs of inflammation compared with conventional nonsurgical (i.e. mechanical/ultrasonic debridement) and surgical (i.e. open flap debridement) treatments alone? After electronic database and hand search, a total of 40 publications (reporting on 32 studies) were finally considered for the qualitative and quantitative assessment. The weighted mean changes (WM)/ and WM differences (WMD) were estimated for bleeding on probing scores (BOP) and probing pocket depths (PD) (random effect model). Peri-implant mucositis: WMD in BOP and PD reductions amounted to -8.16 % [SE = 4.61] and -0.15 mm [SE = 0.13], not favouring adjunctive antiseptics/antibiotics (local and systemic) over control measures (p > 0.05). Peri-implantitis (nonsurgical): WMD in BOP scores amounted to -23.12 % [SE = 4.81] and -16.53 % [SE = 4.41], favouring alternative measures (glycine powder air polishing, Er:YAG laser) for plaque removal and adjunctive local antibiotics over control measures (p < 0.001), respectively. Peri-implantitis (surgical): WMD in BOP and PD reductions did not favour alternative over control measures for surface decontamination. WM reductions following open flap surgery (±resective therapy) and adjunctive augmentative therapy amounted to 34.81 and 50.73 % for BOP and 1.75 and 2.20 mm for PD, respectively. While mechanical debridement alone was found to be effective for the management of peri-implant mucositis, alternative/adjunctive measures may improve the efficacy over/of conventional nonsurgical treatments at peri-implantitis sites. Adjunctive resective and/or augmentative measures are promising; however, their beneficial effect on the clinical outcome of surgical treatments needs to be further investigated.