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

The Integration of Advanced Drug Delivery Systems into Conventional Adjuvant Therapies for Peri-Implantitis Treatment

Despite the high success rates of dental implants, peri-implantitis is currently the most common complication in dental implantology. Peri-implantitis has an inflammatory nature, it is associated with the accumulation of plaque in the peri-implant tissues, and its evolution can be progressive depending on various factors, comorbidities, and poor oral health. Prophylaxis and different treatment methods have been widely discussed in recent decades, and surgical and non-surgical techniques present both advantages and disadvantages. In this work, a literature review of different studies on the application of adjuvant treatments, such as local and systemic antibiotics and antiseptic treatments, was conducted. Positive outcomes have been found in the short (up to one year after treatment) and long term (up to ten years after treatment) with combined therapies. However, there is still a need to explore new therapies based on the use of advanced drug delivery systems for the effective treatment of peri-implantitis in the long term and without relapses. Hence, micro- and nanoparticles, implants, and injectable hydrogels, among others, should be considered in future peri-implantitis treatment with the aim of enhancing overall therapy outcomes.

Comparative analysis of the physical, chemical, and microbiological properties of Ti-6Al-4V disks produced by different methods and subjected to surface treatments

STATEMENT OF PROBLEM

To improve the osseointegration of dental implants and reduce microbiological growth, different micro- and nanoscale surface topographies can be used.

PURPOSE

The purpose of this in vitro study was to evaluate the influence of Ti-6Al-4V with 4 surfaces, machined (DU), machined+hydroxyapatite (DUHAp), machined+acid-alkali treatment (DUAA), and additive manufacturing (DMA), on the physical, chemical, and microbiological properties.

MATERIAL AND METHODS

The topography of Ti-6Al-4V disks with the 4 surfaces was evaluated by scanning electron microscopy (SEM), the chemical composition by energy dispersive X-ray spectroscopy (EDS), and the crystalline structure by X-ray diffraction (XRD). Physical and chemical properties were analyzed by using wettability and surface free energy, roughness, and microbial adhesion against Staphylococcus aureus by colony forming units (CFU). One-way ANOVA analysis of variance and the Tukey multiple comparisons test were applied to evaluate the data, except CFU, which was submitted to the Kruskal-Wallis nonparametric test (α=.05).

RESULTS

DU photomicrographs showed a topography characteristic of a polished machined surface, DUHAp and DUAA exhibited patterns corresponding to the surface modifications performed, and in DMA the presence of partially fused spherical particles was observed. The EDS identified chemical elements inherent in the Ti-6Al-4V, and the DUHAp and DUAA disks also had the ions from the treatments applied. XRD patterns revealed similarities between DU and DMA, as well as characteristic peaks of hydroxyapatite (HA) in the DUHAp disk and the DUAA. Compared with DU and DMA the DUHAp and DUAA groups showed hydrophilic behavior with smaller contact angles and higher surface free energy (P<.05). DMA showed a higher mean value of roughness, different from the others (P<.05), and a higher CFU for S. aureus (P=.006).

CONCLUSIONS

DUHAp and DUAA showed similar behaviors regarding wettability, surface free energy, and bacterial adhesion. Among the untreated groups, DMA exhibited higher roughness, bacterial adhesion, and lower wettability and surface free energy.

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.

Effects of Hypochlorous Acid and Hydrogen Peroxide Treatment on Bacterial Disinfection Treatments in Implantoplasty Procedures

One of the main problems in oral implantology today is peri-implantitis, which affects almost 20% of dental implants placed in patients. One of the most commonly used techniques to eliminate bacterial biofilm is the implantoplasty, that consists of the mechanical modification of the implant surface topography followed by treatments with chemical reagents for decontamination. In this study, the main aim is to evaluate the use of two different chemical treatments based on hypochlorous acid (HClO) and hydrogen peroxide (H₂O₂). For this purpose, 75 titanium grade 3 discs were treated with implantoplasty according to established protocols. Twenty-five discs were used as controls, 25 were treated with concentrated HClO and 25 were treated with concentrated HClO followed by treatment with 6% H₂O₂. The roughness of the discs was determined using the interferometric process. Cytotoxicity with SaOs-2 osteoblastic cells was quantified at 24 and 72 h, whereas bacteria proliferation using S. gordonii and S. oralis bacteria was quantified at 5 s and 1 min of treatment. The results showed an increase in the roughness values, the control discs had an Ra of 0.33 μm and those treated with HClO and H₂O₂ reached 0.68 μm. Cytotoxicity was present at 72 h, together with a significant proliferation of bacteria. These biological and microbiological results can be attributed to the roughness produced by the chemical agents that triggered bacterial adsorption while inhibiting osteoblast adhesion. The results indicate that even if this treatment can decontaminate the titanium surface after implantation, the produced topography will generate an environment that will not favor long-term performance.

Effect of sterile tetracycline ophthalmic ointment as an adjuvant to mechanical debridement on the treatment of peri-implantitis: A randomized controlled clinical trial

Background

Peri-implantitis is an infectious disease that affects the tissues around dental implants, with clinical signs of inflammation and irreversible loss of supporting bone. This study aimed to compare the effect of sterile topical tetracycline ophthalmic ointment as an adjuvant to mechanical debridement with mechanical debridement alone in the treatment of peri-implantitis.

Methods

In this single-blind randomized clinical trial, 32 patients (16 patients in each group) with peri-implantitis were treated topically using sterile tetracycline ophthalmic ointment. Four clinical parameters, including modified bleeding index (mBI), modified plaque index (mPI), probing depth (PD), and clinical attachment level (CAL), were measured at baseline and at 3- and 6-month follow-up intervals.

Results

PD reduction was statistically significant after 3 and 6 months in the test and control groups (P=0.001). Also, mPI and mBI reduction rates were significant in the test and control groups (P=0.001) after 3 and 6 months. However, in all the samples in the two groups, the mean of CAL before and after treatment was constant, with no significant difference (P>0.05).

Conclusion

Using sterile ocular tetracycline ointment could be an adjunctive treatment in improving and enhancing the therapeutic effects of mechanical debridement in the treatment of peri-implantitis. (IRCT20210909052418N1)

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.

Assessment of Disinfection Potential of Q-Switch Nd: YAG Laser on Contaminated Titanium Implant Surfaces

Peri-implantitis (PI) is a relatively frequent pathology that compromises the overall survival of the dental implant. Adjunctive approaches for the conventional mechanical debridement are being suggested to optimize the treatment of PI. The goal of the study was the assessment of the disinfection potential of the Q-Switch Nd: YAG laser on contaminated titanium implant surfaces. A total of 72 sterile titanium discs were used and divided into three groups: 24 contaminated titanium discs treated with the laser (study Group L), 24 contaminated titanium discs with no treatment (control 1—Group C), and 24 sterile titanium discs with no treatment (control 2—Group S). Multi-species biofilm was used: Porphyromonas gingivalis, Fusobacterium nucleatum, Aggregatibacter actinomycetemcomitans, Streptococcus mutans, Streptococcus sobrinus, and Prevotella intermedia. Commensal bacteria were included also: Actinomyces naeslundii, Actinomyces viscosus, Streptococcus cristatus, Streptococcus gordonii, Streptococcus mitis, Streptococcus oralis, Streptococcus sanguinis, Streptococcus parasanguinis, and Veillonella parvula. Parameters delivered per pulse on the targeted surfaces of the titanium discs were an energy density of 0.597 J/cm² each pulse, a pulse power of 270 mW, a laser beam spot of 2.4 mm in diameter, and a rate of repetition of 10 Hertz (Hz) for a pulse duration of 6 nanoseconds (ns). The mode was no contact, and a distance of 500 micrometers was used with a total time of irradiation equal to 2 s (s). The collection of microbiological samples was made for all groups; colony-forming units (CFU) were identified by two different practitioners, and the average of their examinations was considered for each sample. The average of the TBC (CFU/mL) was calculated for each group. Values were 0.000 CFU/mL, 4767 CFU/mL, and 0.000 CFU/mL for Group L, Group C, and Group S, respectively. Therefore, the suggested treatment protocol was able to provoke a total disinfection of the contaminated titanium surfaces. A statistical difference was only found between Group L vs. Group C and between Group S vs. Group C. The difference was not significant between Group S and Group L. In conclusion, the present study confirmed that the Q-Switch Nd: YAG laser under our specific conditions can provide a total disinfection of the contaminated titanium surfaces.

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.

Diode laser assisted horizontal bone defect regeneration in the treatment of peri-implantitis

Our findings show the use of a diode laser to remove inflamed tissue and regenerate the horizontal bone defects around the implant. These findings could be applied in the clinic.

Peri-Implant Diseases: Diagnosis, Clinical, Histological, Microbiological Characteristics and Treatment Strategies. A Narrative Review

Since the use of dental implants is continuously increasing, it is imperative for dental practitioners to understand the nature and treatment of peri-implant diseases. The purpose of this manuscript is to comprehensively review peri-implant diseases, their characteristics, as well as their non-surgical and surgical treatment. To that end, the current literature was searched and a narrative review was conducted. It is essential that the case definitions described in the 2017 World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions are used to diagnose and classify peri-implant health, peri-implant mucositis and peri-implantitis. While recent epidemiologic studies on peri-implant diseases exist, there is great heterogeneity in the definition of these conditions. Several risk factors and indicators are reported in the literature, with smoking and diabetes being the most universally accepted. In peri-implant mucositis, non-surgical treatment seems to be sufficient. However, for the treatment of peri-implantitis, a surgical approach, which includes open-flap debridement, apically positioned flap and guided bone regeneration, is considered more appropriate. A great variety of adjuncts to mechanical treatment have been reported with controversial results. Finally, studies comparing results from different peri-implantitis treatments are warranted in randomized controlled clinical trials in order to provide stronger evidence-based approaches.

Therapy for peri-implantitis: Significant radiographic bone fill after keratinized mucosa augmentation surgery with supportive implant therapy (SIT): A novel approach

none.

Effect of an Er,Cr:YSGG Laser on the Surface of Implants: A Descriptive Comparative Study of 3 Different Tips and Pulse Energies

Peri-implant diseases are one of the main complications of dental implants. There are no well-established guidelines regarding laser parameters for implant decontamination. The aim was to compare two different settings of irradiation of the Er,Cr:YSGG laser on dental implants regarding surface alterations and determine the best settings for less damage on the surface. An in vitro study was performed and 30 areas of dental implants were irradiated with two different regimes of energy per pulse 50 and 84 mJ (1.5 W/30 Hz and 2.5 W/30 Hz). A total of 30 sites of implants were irradiated with three different tips (10 surfaces per tip): conical (RTF3-17 mm), side firing (SFT8-18 mm) and cylindrical (MGG6-6 mm). The following descriptive classification on surface damage was employed: no damage (class A), minimal effects (class B), metal fall with melting (class C), and destruction with carbonization (class D). The assessment was made through a descriptive scanning electron microscope (SEM) analysis. Side firing and conical tips at 50 mJ were classified as class A. Side firing at 84 mJ and cylindrical tips 50 mJ and 84 mJ were classified as class B. Finally, class C defects were found in the areas where the conical tip was used at 84 mJ. Side firing and conical tips at 50 mJ do not seem to damage the implant surface.

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.

In Vitro Evaluation of Antimicrobial Activity of Minocycline Formulations for Topical Application in Periodontal Therapy

Periodontal therapy using antimicrobials that are topically applied requires slow or controlled release devices. The in vitro antimicrobial activity of biodegradable polymer formulations that contain a new minocycline lipid complex (P-MLC) was evaluated. The new P-MLC formulations that contained 11.5% minocycline were compared with pure minocycline or an existing commercial formulation, which included determination of minimal inhibitory concentration (MIC) values against two oral bacteria and activity on six-species periodontal biofilm. Moreover, the flow of gingival crevicular fluid (GCF) was modeled up to 42 d and the obtained eluates were tested both for MIC values and inhibiting biofilm formation. In general, MICs of the P-MLC formulations were slightly increased as compared with pure minocycline. Biofilm formation was clearly inhibited by all tested formulations containing minocycline with no clear difference between them. In 3.5 d old biofilms, all formulations with 250 µg/mL minocycline decreased bacterial counts by 3 log10 and metabolic activity with no difference to pure antimicrobials. Eluates of experimental formulations showed superiority in antimicrobial activity. Eluates of one experimental formulation (P₅₀₃-MLC) still inhibited biofilm formation at 28 d, with a reduction by 1.87 log10 colony forming units (CFU) vs. the untreated control. The new experimental formulations can easily be instilled in periodontal pockets and represent alternatives in local antimicrobials, and thus warrant further testing.

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.

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.

Microbiological and clinical effects of adjunctive systemic metronidazole and amoxicillin in the non-surgical treatment of peri-implantitis: 1 year follow-up

The aim of this study was to evaluate the effects of adjunct systemic antibiotic treatment with metronidazole (MTZ) and amoxicillin (AMX) in patients receiving non-surgical subgingival debridement (NSD) for peri-implantitis. Forty subjects presenting with at least one implant with severe peri-implantitis were randomized into an experimental group [treated with NSD plus MTZ (400 mg) and AMX (500 mg) three times a day for 14 days] and a control group treated with NSD plus placebo. Clinical parameters and submucosal biofilm profiles were evaluated up to 1 year post-treatment. Overall, both treatments improved clinical parameters over time. At 1 year, mean probing depth (PD), mean clinical attachment (CA) level and proportions of red complex pathogens did not differ significantly between the two groups. In addition, mean PD and CA changes to 1-year posttreatment did not differ significantly between the two groups between baseline and 1-year post-treatment. These results suggest that the addition of MTZ and AMX to the treatment protocol of patients undergoing NSD for with severe peri-implantitis does not improve the clinical and microbiological outcomes of NSD. The fact that half of the implants in both groups did not achieve clinical success (PD < 5 mm, no BoP, no bone loss) suggest that neither of the tested protocols were effective for treating severe peri-implantitis.

A prospective study of the clinical outcomes of peri-implant tissues in patients treated for peri-implant mucositis and followed up for 54 months

BACKGROUND

Peri-implant mucositis is very common and, when left untreated, can progress to the more serious condition of peri-implantitis. Therefore, early diagnosis, adequate treatment and, in particular, adherence to a peri-implant supportive therapy are extremely important for the management of peri-implant mucositis.

PURPOSE

Characterize the clinical conditions of peri-implant tissues in patients diagnosed with peri-implant mucositis after undergoing peri-implant supportive therapy for 54 months.

MATERIALS AND METHODS

Thirty-eight patients (131 dental implants) who received peri-implant supportive therapy, associated with oral hygiene instructions, were assessed at baseline and at 54 months for visible plaque and gingival bleeding indexes, probing depth and bleeding on probing. Data were statistically analyzed using the Chi-square test and relative risk assessment using a significance level set at 5%.

RESULTS

None of the independent variables evaluated (age, gender, smoking, type of prosthesis, time using the prosthesis, keratinized mucosa, phenotype peri-implant, classification of visible plaque index and classification of gingival bleeding index) presented significant associations with "worsening" or "improvement" of clinical parameters.

CONCLUSION

The implementation of peri-implant support therapy was not sufficient for the resolution of peri-implant mucositis, although reductions in clinical parameters with respect to baseline were observed and maintained during follow-up.

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.

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.

Investigation of the antibacterial effect of laser irradiation and chemical agent on human oral biofilms contaminated titanium discs

INTRODUCTION

A main challenge in treatment of peri-implant disease is the effective decontamination of the implant surface. This challenge has always been a problem, associated with the treatment of these diseases with regard to the difficulty in removing and eliminating bacterial biofilm from the surface of dental implants, especially rough surfaces. The aim of this in-vivo study was to evaluate the effect of five different antimicrobial methods in reducing bacteria adhering to titanium surfaces.

MATERIALS AND METHODS

In the present in-vivo study, the contaminated discs, except for the negative control group, randomly underwent one of five treatments: Erbium: Yattrium Aluminum Garnet (Er-YAG) laser, plastic curette, 0.12% chlorhexidine, aPDT, and 810 nm diode laser. A pectrophotometer was used to measure Optical Density (OD) in case of aerobic microorganisms. Colony-Forming Units (CFUs) were used for anaerobic bacteria. Then, all the analyses were carried out at a significance level of α = 0.05 through SPSS software.

FINDINGS

One-way analysis of variance (ANOVA) of aerobic bacteria showed a significant difference among 6 groups in terms of OD variations during a 0-24 h time interval (P < 0.001). The results of Kruskal-Wallis test were used to investigate the effect of study methods on anaerobic bacteria after 48 h, and the results showed a significant difference among 6 groups in terms of CFUs (P < 0.001).

CONCLUSION

The results of the present study showed that all five mechanicals (plastic curette), chemical (CHX), laser (810 nm diode and Er: YAG), and aPDT methods could reduce oral biofilms from roughed surfaces of titanium discs. Er: YAG laser and plastic curette had the highest and the lowest effects respectively.

Characteristics of Local Delivery Agents for Treating Peri-Implantitis on Dental Implant Surfaces: A Preclinical Study

Local delivery agents (LDAs) are widely used in peri-implantitis treatments. The aim of this study was to identify LDAs remaining on the dental implant surfaces and to analyze the components of these residues after applying various cleaning methods. Implants were prepared with a sand-blasted, large-grit, acid-etched surface. Four kinds of LDAs were applied on the implant surfaces: chlorhexidine gel (group 2), tetracycline solution (group 3), and 2 kinds of minocycline hydrochloride agents (groups 4 and 5). Group 1 received normal saline as a control. Two cleaning methods were applied for different durations as follows: (1) running distilled water for 10 seconds (subgroup A), 5 minutes (subgroup B), and 15 minutes (subgroup C); and (2) water spray of a dental-unit chair for 10 seconds (subgroup D) and 5 minutes (subgroup E). Scanning electron microscopy and energy-dispersive x-ray spectroscopy were used to analyze the surface morphology and residue components for all implants. The amount of LDA removed from the implant surfaces in groups 1, 2, 3, and 5 increased with the cleaning duration and pressure. However, Minocline remained coated on the implant surfaces in group 4 under all cleaning conditions. Minocline could not be cleaned off well by water due to its hydrophobicity. Therefore, directly using this agent on implant surfaces with peri-implantitis should be carefully considered. The presence of LDA residues without drug efficacies on implant surfaces might interfere with reosseointegration and act as a reservoir of microorganisms.

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.

The Effect of Different Implant Surfaces and Photodynamic Therapy on Periodontopathic Bacteria Using TaqMan PCR Assay following Peri-Implantitis Treatment in Dog Model

Introduction

Peri-implantitis is one of the late complications that leads to implant failure and is associated with specific microorganisms identified as periodontopathic bacteria. The objective of this study was to evaluate the relationship between the different implant surfaces and number of Porphyromonas gingivalis, Tannerella forsythia, and Treponema denticola using TaqMan PCR assay after peri-implantitis treatment using photodynamic therapy.

Method

Forty-eight dental implants with four different surface treatments (M: machined; SA: sandblasted acid-etched; S: 1 µm sputter HA-coated; and P: plasma spraying HA-coated) were inserted in six beagle dogs. After nine months of peri-implantitis induction, a split mouth design was used; on control side decontamination was performed using open flap mechanical debridement OFD with plastic curette, while photodynamic therapy PDT using diode laser (Ga Al As 830-nm) was used in the test side. For the following 2 weeks low-level laser therapy LLLT (10mW) was applied for the test side on alternative days for 6 sec on each implant side. Peri-implant microbial samples were collected using paper points and analyzed using TaqMan PCR before peri-implantitis treatment, immediately after treatment and 5 months posttreatment.

Results

Both treatment modalities showed significant decrease in all bacterial count from baseline to immediately after treatment (P< 0.0001). The count increased between immediately after treatment to 5 months after treatment (P< 0.0001); however, the count after 5 months was significantly lower than at baseline. PDT had a stronger effect on reducing P. gingivalis count than T. denticola and T. forsythia compared to OFD. For T. forsythia, implant surface treatment had the greatest effect which was also statistically significant (P= 0.02) with considerably lower effect of PDT or their interaction.

Conclusion

The results suggest that PDT and OFD have significant benefits in peri-implantitis treatment by reducing bacterial count. The presence of bacterial complex with different response to therapeutic modality suggests the use of combined decontamination methods for peri-implantitis treatment.

Evaluation of Effectiveness of Photodynamic Therapy With Low-level Diode Laser in Nonsurgical Treatment of Peri-implantitis

Introduction: Side effects related to antibiotic therapy for peri-implantitis are rare in laser therapy (LT); therefore, the aim of this study was to evaluate the effectiveness of LT and photodynamic therapy (PDT) on patients with primary peri-implantitis. Methods: In this randomized clinical trial, 40 implants presenting primary peri-implantitis in 20 patients with a mean age of 52.6 years old were included using the simple sampling technique. Periodontal treatment comprising scaling and root planing (SRP) was accomplished for the whole mouth while mechanical debridement with titanium curettes and air polishing with sodium bicarbonate powder was accomplished around the implants. The implants were randomly divided into two groups and treated with LT (control) and PDT (test). The clinical indices were measured at baseline, 6 weeks and 3 months after treatment. Real-time polymerase chain reaction (PCR) was used for analysis of microbial samples at baseline and 3-month follow-up. Data were analyzed with SPSS 20, using repeated-measures analysis of variance (ANOVA) and Friedman's and Mann-Whitney tests (α = 0.05). Results: Both groups showed statistically significant improvements in terms of bleeding on probing (P < 0.001), probing pocket depth (PPD) (P = 0.006) and modified plaque index (P < 0.001), with no significant differences between the 2 groups (P > 0.05). The number of Aggregatibacter actinomycetemcomitans (P = 0.022), Tannerella forsythia (P = 0.038) and Porphyromonas gingivalis (P = 0.05) in the test group and Porphyromonas gingivalis (P = 0.015) in the control group significantly decreased. Conclusion: The results suggested that LT and PDT have significant short-term benefits in the treatment of primary peri-implantitis.

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 Antimicrobial Photodynamic Therapy as an Adjunctive to Mechanical Debridement in the Treatment of Peri-implant Diseases: A Randomized Controlled Clinical Trial

Introduction: The purpose of the present study was to assess the clinical effects of anti-microbial photodynamic therapy (PDT) after closed surface scaling in the treatment of peri-implant diseases. Methods: Ten patients with a total of 15 pairs of dental implants, showing clinical and radiographic signs of peri-implant diseases, were included in this study. In each patient, one implant randomly served as control implant and the other served as test implant. The control implants were treated with closed surface scaling only and the test implants received additionally PDT, using light with a wavelength of 630 nm and intensity of 2000 mw/cm² for 120 seconds after application of photosensitizer in peri-implant sulcus. Clinical parameters were evaluated before and 1.5 and 3 months after treatment. Results: Statistical analysis showed significant differences in probing pocket depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP), and gingival index (GI) at each time point between the two groups. There were no statistically significant changes with respect to any of the parameters in the control group. Complete resolution of BOP at 3 months was achieved in 100% of test implants. At 1.5 and 3 months, there were significant differences in the mean probing depth and CAL gain measurements at implants in the test group. Conclusion: The present study revealed that adjunctive use of PDT following closed surface scaling could lead to clinical improvement of peri-implant diseases. Further studies are necessary to confirm our results.

Thermal effects of λ = 808 nm GaAlAs diode laser irradiation on different titanium surfaces

Diode lasers are widely used in dental laser treatment, but little is known about their thermal effects on different titanium implant surfaces. This is a key issue because already a 10 °C increase over the normal body temperature can induce bone injury and compromise osseo-integration. The present study aimed at evaluating the temperature changes and surface alterations experienced by different titanium surfaces upon irradiation with a λ = 808 nm diode laser with different settings and modalities. Titanium discs with surfaces mimicking different dental implant surfaces including TiUnite and anodized, machined surfaces were laser-irradiated in contact and non-contact mode, and with and without airflow cooling. Settings were 0.5-2.0 W for the continuous wave mode and 10-45 μJ, 20 kHz, 5-20 μs for the pulsed wave mode. The results show that the surface characteristics have a marked influence on temperature changes in response to irradiation. The TiUnite surface, corresponding to the osseous interface of dental implants, was the most susceptible to thermal rise, while the machined surfaces, corresponding to the implant collar, were less affected. In non-contact mode and upon continuous wave emission, the temperature rose above the 50 °C tissue damage threshold. Scanning electron microscopy investigation of surface alterations revealed that laser treatment in contact mode resulted in surface scratches even when no irradiation was performed. These findings indicate that the effects of diode laser irradiation on implant surfaces depend on physical features of the titanium coating and that in order to avoid thermal or physical damage to implant surface the irradiation treatment has to be carefully selected.

Erythritol-Enriched Air-Polishing Powder for the Surgical Treatment of Peri-Implantitis

Peri-implantitis represents a major complication that can compromise the success and survival of implant-supported rehabilitations. Both surgical and nonsurgical treatment protocols were proposed to improve clinical parameters and to treat implants affected by peri-implantitis. A systematic review of the literature was performed on electronic databases. The use of air-polishing powder in surgical treatment of peri-implantitis was investigated. A total of five articles, of different study designs, were included in the review. A meta-analysis could not be performed. The data from included studies reported a substantial benefit of the use of air-polishing powders for the decontamination of implant surface in surgical protocols. A case report of guided bone regeneration in sites with implants affected by peri-implantitis was presented. Surgical treatment of peri-implantitis, though demanding and not supported by a wide scientific literature, could be considered a viable treatment option if an adequate decontamination of infected surfaces could be obtained.

Health, Maintenance, and Recovery of Soft Tissues around Implants

BACKGROUND

The health of peri-implant soft tissues is one of the most important aspects of osseointegration necessary for the long-term survival of dental implants.

PURPOSE

To review the process of soft tissue healing around osseointegrated implants and discuss the maintenance requirements as well as the possible short-comings of peri-implant soft tissue integration.

MATERIALS AND METHODS

Literature search on the process involved in osseointegration, soft tissue healing and currently available treatment modalities was performed and a brief description of each process was provided.

RESULTS

The peri-implant interface has been shown to be less effective than natural teeth in resisting bacterial invasion because gingival fiber alignment and reduced vascular supply make it more vulnerable to subsequent peri-implant disease and future bone loss around implants. And we summarized common procedures which have been shown to be effective in preventing peri-implantitis disease progression as well as clinical techniques utilized to regenerate soft tissues with bone loss in advanced cases of peri-implantitis.

CONCLUSION

Due to the difference between peri-implant interface and natural teeth, clinicians and patients should pay more attention in the maintenance and recovery of soft tissues around implants.

Prevalence of antibiotic resistance genes in subjects with successful and failing dental implants. A pilot study

OBJECTIVES

To investigate the prevalence of the bacterial genes encoding resistance to beta-lactams, tetracyclines and metronidazole respectively, in subjects with successful and failing dental implants and to assess the presence of Staphylococcus aureus and the mecA gene encoding for Methicillin Resistant Staphylococcus aureus (MRSA) in the same samples.

MATERIALS AND METHODOLOGY

The subject sample included 20 participants with clinically healthy osseointegrated implants and 20 participants with implants exhibiting peri-implantitis. Clinical parameters were assessed with an automated probe, samples were collected from the peri-implant sulcus or pocket and analyzed with Polymerase Chain Reaction for bla TEM , tetM, tetQ and nim genes, S. aureus and MRSA using primers and conditions previously described in the literature.

RESULTS

Findings have shown high frequencies of detection for both groups for the tetracycline resistance genes tetM (>30%), tetQ (>65%) with no statistical differences between them (z-test with Bonferroni corrections, p<0.05). The bla TEM gene, which encodes resistance to beta-lactams, was detected in <15% of the samples. The nim gene, which encodes resistance to metronidazole, S.aureus and the mecA gene encoding for MRSA were not detected in any of the analyzed samples.

CONCLUSIONS

Healthy peri-implant sulci and peri-implantitis cases often harbor bacterial genes encoding for resistance to the tetracyclines and less often for beta-lactams. Thus, the antimicrobial activity of the tetracyclines and to a lower extent to beta-lactams, might be compromised for treatment of peri-implantitis. Since no metronidazole resistance genes were detected in the present study, its clinical use is supported by the current findings. S.aureus may not participate in peri-implant pathology.

Peri-implant diseases: a review of treatment interventions

The ideal management of peri-implant diseases focuses on infection control, detoxification of implant surfaces, regeneration of lost tissues, and plaque-control regimens via mechanical debridement (with or without raising a surgical flap). However, a variety of other therapeutic modalities also have been proposed for the management of peri-implantitis. These treatment strategies encompass use of antiseptics and/or antibiotics, laser therapy, guided bone regeneration, and photodynamic therapy. The aim of this article was to review indexed literature with reference to the various therapeutic interventions proposed for the management of peri-implant diseases.

A Retrospective 3- to 5-Year Study of the Reconstruction of Oral Function Using Implant-Supported Prostheses in Patients With Hypohidrotic Ectodermal Dysplasia

The aim of this study was to evaluate oral function rehabilitation in patients with hypohidrotic ectodermal dysplasia (HED) using implant-supported prostheses based on bone augmentation. From September 2005 and March 2009, 25 HED patients were chosen for clinical data analysis in this study. The criteria for patient selection included the following: the display of clinical features of HED, the number of congenitally missing teeth (&gt;5), the patient age (&gt;16 years), the patient's willingness, and the patient's tolerance for bone graft surgery and implant placement. Follow-up evaluations were initiated from the time of implant prosthetic placement and scheduled annually for 3–5 years. The effects of oral function reconstruction were assessed based on the cumulative survival and success rates of implants, the health of the peri-implant area, and the degree of patient satisfaction. Twenty-five HED patients received 169 conventional implants and 10 zygomatic implants (179 total implants). During 3–5 years of post-loading evaluations, 5 of the 179 implants failed and 3 implants were removed. The 3-year success and cumulative survival rates were 97.2% and 98.3%, respectively. Furthermore, periodontal probing and radiographic assessments showed that the 3-year incidence of peri-implantitis was 4.5%. Finally, HED patients expressed high degrees of satisfaction with their facial contours, masticatory function, pronunciation ability, and comfort with the implant-supported prostheses. The results of this 3- to 5-year retrospective study indicate that the oral function of HED patients can be effectively reconstructed using bone augmentation and implant-supported prostheses; however, longer term results are warranted in the future.