Surgical Treatment of Periimplantitis With Non–Augmentative Techniques

Evaluation of the effect of adjunctive diode laser application on peri-implant crevicular fluid biomarker levels: a randomized controlled trial

OBJECTIVES

To assess both the clinical and immunological effectiveness of diode laser therapy when used as an adjunct to non-surgical mechanical therapy in managing peri-implantitis.

MATERIALS AND METHODS

A cohort of 27 participants, comprising 21 females and 6 males, agreed to take part in this investigation. 37 dental implants with peri-implantitis diagnosis were randomly allocated to either the laser group (n = 19) or the control group (n = 18). Evaluation of peri-implant clinical parameters and collection peri-implant crevicular fluid (PICF) samples occurred at baseline, as well as at 3 and 6-month follow-up intervals. The level of various biomarkers (TWEAK, IL-1β, sclerostin, IL-17, RANKL, OPG and IL-10) within the PICF were quantified using enzyme-linked immunosorbent assay.

RESULTS

Significant time-dependent decreases in clinical and biochemical parameters were detected in both groups compared to the baseline. There were marked differences between the groups in terms of periodontal parameters, except probing depth, and IL-1β, IL-17, sclerostin levels in PICF at 3rd month follow-up. However, no statistically significant difference was detected at 6th month.

CONCLUSIONS

Diode laser seems to be a reliable tool as an adjunct for supporting the nonsurgical mechanical treatment during the early stages of peri-implantitis. Furthermore, the findings suggest that IL-17, sclerostin and IL-1β may serve as promising biomarkers for assessing efficacy of peri-implantitis treatment.

CLINICAL RELEVANCE

Based on these outcomes, clinicians may consider the application of adjunctive use of diode laser to non-surgical peri-implantitis treatment to achieve better clinical and immunological improvements than nonsurgical peri-implantitis therapy alone in just early healing period. However, it should be noted that there was no difference between the two methods in the long term.

Patterns of antibiotic prescription in implant dentistry and antibiotic resistance awareness among European dentists: A questionnaire-based study

OBJECTIVES

Antimicrobial resistance is an alarming global public health concern, threatening the effective treatment of common infections. This phenomenon is driven by the improper prescription of antibiotics. This study aimed to elucidate the patterns of antibiotic prescription in implant dentistry among European dentists and their awareness of antibiotic resistance.

MATERIALS AND METHODS

An anonymous online validated questionnaire was distributed via e-mail to 6431 recipients through the European Association for Osseointegration. It comprised of 17 structured questions investigating demographic variables, working environment, clinical experience, attitude towards antibiotic prescription in particular in relation to implant dentistry and COVID-19 pandemic, and awareness of antibiotic resistance. Data were collected from April to May 2023.

RESULTS

281 dentists from 33 European countries completed the survey. Almost 80% affirmed to routinely prescribe antibiotics as prophylaxis as well as after dental implant placement, especially in medically compromised patients or in cases of bone grafting. Amoxicillin, alone (61%) or in combination with clavulanic acid (56%), was the most common antibiotic of choice. Awareness of penicillin resistance among respondents was high. For peri-implantitis treatment, more than half reported the use of systemic antibiotics. The large majority (95%) did not prescribe more antibiotics since the beginning of COVID-19 pandemic. Less than 40% declared to follow national guidelines for antibiotic prescription.

CONCLUSION

This survey revealed a high prescription rate of antibiotics in implant dentistry, despite the awareness about antibiotic resistance among the respondents. The development and adherence to European guidelines has been identified as a potential strategy for improving antimicrobial stewardship.

Utilization of Low-Magnitude High-Frequency Vibration (LMHFV) as an Aid in Treating Peri-Implantitis: Case Presentations

Peri-implantitis is an inflammatory process initiating in the soft tissue and then progressing to the hard tissue surrounding dental implants leading to loss of osseous support and potential loss of the implant if not identified early in the process. This process initiates in the soft tissue, which become inflamed spreading to the underlying bone leading to decreases in bone density with subsequent crestal resorption and thread exposure. In the absence of treatment of the peri-implantitis, the bone loss at the osseous implant interface progresses with inflammatory mediated decrease in the bone density that moves apically, eventually leading to mobility of the implant and its failure. Low-magnitude high-frequency vibration (LMHFV) has been shown to improve bone density, stimulate osteoblastic activity, and arrest progression of peri-implantitis with improvement of the bone or graft around the affected implant with or without surgery as part of the treatment. Two cases are presented using LMHFV to augment treatment.

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.

Efficacy of surgical methods for peri-implantitis: a systematic review and network meta-analysis

BACKGROUND

Peri-implantitis is the most difficult biological complication associated with dental implants, often requiring surgical treatments in advanced stages. This study compares the effectiveness of different surgical methods for peri-implantitis.

METHODS

Randomized controlled trials (RCTs) of different surgical treatments for peri-implantitis were extracted from EMBASE, Web of Science, Cochrane Library databases, and PubMed systematically. Pairwise comparisons and network meta-analyses (NMA) were conducted to analyze the effect of surgical treatments on probing depth (PD), radiographic bone fill (RBF), mucosal recession (MR), bleeding on probing (BOP), and clinical attachment level (CAL). In addition, risk of bias, quality of evidence, and statistical heterogeneity of the selected studies were evaluated. A total of 13 articles were included in this study, involving open flap debridement (OFD), resective therapy (RT), and augmentative therapy (AT) with and without adjunctive treatments (laser therapy, photodynamic therapy, local antibiotics, phosphoric acid, and ozone therapy).

RESULTS

AT improved RBF and CAL more than OFD, but does not outperform OFD in reducing peri-implant soft-tissue inflammation. AT, OFD and RT did not significantly alter the levels of MR. Addition of ozone therapy improved the effect of AT, but addition of photodynamic therapy did not affect PD reduction and CAL gain significantly. Similarly, adjuvant treatment with phosphoric acid during RT did not significantly change the outcome of BOP.

CONCLUSIONS

Within the limitation of this systematic review and NMA, AT was superior to OFD in improving peri-implantitis outcomes. While adjunct use of ozone therapy may further improve the efficacy of AT, the limited evidence supporting this combination therapy argues for cautionary interpretation of these results.

Local and Systemic Antibiotics in Peri-Implantitis Management: An Umbrella Review

The present umbrella review aimed to characterize the type and regimen of antibiotics administered locally and/or systemically, alone or in combination with surgical and nonsurgical treatments, for peri-implantitis and to evaluate and compare the associated clinical, radiographic, and crevicular peri-implant outcomes. The secondary objective was to determine the most effective antibiotic type, route of administration, regimen, and protocols (antibiotics alone or in combination with other approaches) for treating peri-implantitis. The study protocol, which was developed in advance under the PRISMA statement, was registered at PROSPERO (CRD42022373957). BioMed Central, Scopus, MEDLINE/PubMed, the Cochrane Library databases, and the PROSPERO registry were searched for systematic reviews through 15 November 2022. Of the 708 records found, seven reviews were included; three were judged of a critically low and four of low quality through the AMSTAR 2 tool. Locally administered antibiotics alone or as an adjunct to surgical or nonsurgical treatments for peri-implantitis showed favorable outcomes, albeit with limited evidence. The administration of systemically-delivered antibiotics in combination with nonsurgical or surgical treatments remained questionable. Local plus systemic antibiotics have not been shown to have durable efficacy. Due to the heterogeneity of reported antibiotic types, routes, regimens, and protocols, no definitive conclusions could be drawn regarding the most effective antibiotic use in treating peri-implantitis.

Surgical interventions for the treatment of peri-implantitis

BACKGROUND

Peri-implantitis constitutes one of the most frequent late dental implant complications. The disease is initiated by bacterial infection; therefore, anti-infective peri-implantitis treatment strategies are required to arrest the progressive marginal bone loss and maintain the affected implant in function. Although nonsurgical treatment strategies appear to be of limited predictability, treatment outcomes have been frequently improved following surgical interventions.

PURPOSE

The present narrative review describes various surgical peri-implantitis treatment modalities, with respect to their indications, performance, and effectiveness.

MATERIALS AND METHODS

The present narrative review considered the most relevant studies in the field published in the English language.

RESULTS

Surgical peri-implantitis treatment approaches can be categorized as nonreconstrucive therapy, reconstructive therapy, and combined therapy (ie, reconstructive and resective therapy). In addition to disease resolution, reconstructive approaches also seek to regenerate the bone defect and achieve reosseointegration.

CONCLUSIONS

The severity of the disease, the regenerative potential of the defetc and esthetic demands of the patient are the factors determining the surgical peri-implantitis treatment modality.

Effects of implant surface mechanical instrumentation methods on peri-implantitis: An in vitro study using a circumferential bone defect model

Background/purpose

Although several mechanical and chemical debridement techniques have been reported for the management of peri-implantitis, there is no consensus on the most effective method at present. This in vitro study aimed to examine the effects of different mechanical instrumentation techniques on the debridement of hard calcified materials, which are present on the implant surface, as well as the effect of the defect morphology.

Materials and methods

From a total of 15 implants, five each were assigned to one of three decontamination groups (Rotary titanium brush [Ti], tricalcium phosphate air powder abrasive treatment [Air], and titanium ultrasonic scaler [US] groups); the exposed hydroxyapatite (HA)-coated portion was divided into three 1-mm sections (coronal, middle, and apical). The residual-HA of each portion was measured using a digital microscope.

Results

The overall percentage of residual HA coating was significantly lower in the US group than in the Ti or Air groups (p < 0.01). The percentage of residual HA in the coronal portion was significantly lower in the Ti and US groups than in the Air group (p < 0.05 and p < 0.01, respectively). The percentage of residual HA in the middle portion was significantly lower in the US group than in the Air group (p < 0.01). The percentage of residual HA in the apical portion was significantly lower in the Ti group than in the Air or US groups (p < 0.01).

Conclusion

Ti and US were more effective for shallow defects, whereas US was more effective for deeper defects.

Surgical therapy of peri-implantitis

Peri-implantitis is caused by a bacterial challenge; therefore, anti-infective treatment strategies should be employed to manage the disease. As nonsurgical approaches demonstrate limited efficacy in most cases of peri-implantitis, surgical interventions are often required. Treatment outcomes improve following access flap surgery, with or without adjunctive resective and/or augmentation measures. Whereas nonaugmentative therapies (ie, access flap surgery and resective techniques) primarily aim to resolve inflammation and arrest further disease progression, augmentation approaches also seek to regenerate the bony defect and achieve reosseointegration. Currently, limited evidence supports the superiority of augmentative surgical techniques for peri-implantitis treatment over nonaugmentation methods, and human histologic evidence for reosseointegration is sparse. For patients involved in regular postoperative maintenance programs, success of peri-implantitis surgical treatment based on various definitions of success was obtained in over half of the cases after 5-7 years. Despite surgical treatment, cases of further disease progression that required retreatment or led to implant loss were reported.

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.

Photoacoustic removal of Enterococcus faecalis biofilms from titanium surface with an Er:YAG laser using super short pulses

Biofilms that grow on implant surfaces pose a great risk and challenge for the dental implant survival. In this work, we have applied Er:YAG photoacoustic irrigation using super short pulses (Er:YAG-SSP) to remove biofilms from the titanium surfaces in the non-contact mode. Mature Enterococcus faecalis biofilms were treated with saline solution, chlorhexidine, and hydrogen peroxide, or photoacoustically with Er:YAG-SSP for 10 or 60 s. The number of total and viable bacteria as well as biofilm surface coverage was determined prior and after different treatments. Er:YAG-SSP photoacoustic treatment significantly increases the biofilm removal rate compared to saline or chemically treated biofilms. Up to 92% of biofilm-covered surface can be cleaned in non-contact mode during 10 s without the use of abrasives or chemicals. In addition, Er:YAG-SSP photoacoustic irrigation significantly decreases the number of viable bacteria that remained on the titanium surface. Within the limitations of the present in vitro model, the ER:YAG-SSP seems to constitute an efficient therapeutic option for quick debridement and decontamination of titanium implants without using abrasives or chemicals.

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.

A nonsurgical treatment of peri-implantitis using mechanic, antiseptic and anti-inflammatory treatment: 1 year follow-up

Aims

The study's aim was to assess the clinical outcome 6 and 12 months after a nonsurgical treatment of peri‐implantitis per se or in conjunction with a combination of local antiseptic and anti‐inflammatory treatment.

Materials and methods

Included were 69 patients with periodontitis, with 106 implants, diagnosed with peri‐implantitis. Peri‐implantitis was defined as radiographic bone loss ≥3 mm, probing depth (PD) ≥ 6 mm, with bleeding on probing. Group M peri‐implantitis was treated with ultrasonic debridement and soft tissue curettage. Group P had additional implant surface treatment with rotatory hand piece composed of chitosan bristle, soft tissue curettage combined with application of 0.95% hypochlorite and 1 mg minocycline HCl.

Results

After 6 months, both groups demonstrated significant reduction of mean plaque index, PD, and clinical attachment level (0.71 ± 0.57, 0.81 ± 0.55; 4.77 ± 0.73 mm, 4.42 ± 0.5 mm; 5.03 ± 0.86 mm, 5.13 ± 0.73 mm; respectively) and bleeding on probing. After 6 and 12 months, group P showed significantly better PD results compared to group M. The bleeding was significantly less in group P after 12 months (15.3% ± 6.2, 25.1% ± 8.2, respectively).

Conclusions

Adjunctive treatment with local antiseptic and anti‐inflammatories during mechanical phase was positively associated with inflammation reduction and connective tissue reattachment.