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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 4  |  Page : 255-258

“Stop the ticking before it blows:” treatment modalities of peri-implantitis


Department of Periodontology, Gian Sagar Dental College and Hospital, Patiala, Punjab, India

Date of Web Publication27-Dec-2016

Correspondence Address:
Rachna Jain
Department of Periodontology, Gian Sagar Dental College and Hospital, Ramnagar, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-4003.196817

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  Abstract 

The serendipitous discovery of osseointegration and the subsequent development of dental implants have irrefutably marked an epoch-making point of inflection in not only the basic approach of the clinicians toward treating edentulism but also in the attitudes and preferences of the patients in getting their oral rehabilitation issues resolved. This decisive shift also triggered explosive research targeting improvement in various aspects of dental implants. However, initial success in osseointegration does not necessarily translate into success in long-term function. A successfully osseointegrated implant may be afflicted with early or late complications in due course of service. Of these, peri-implantitis (PI) is considered one of the most common causes of implant failure. For the treatment of peri-implant diseases (mucositis and PI), various conservative and surgical approaches are available. Mucositis and moderate forms of PI can be contained effectively using conservative methods. These include the administration of systemic and local antibiotics alone or in conjunction with other treatment modalities such as nonsurgical therapy which consists of mechanical debridement of the affected areas, irrigation with antiseptics (such as chlorhexidine, saline, and 10% hydrogen peroxide) with or without surface decontamination, laser-supported therapy, photodynamic therapy as well as light-activated disinfection also known as photodynamic antimicrobial chemotherapy along with maintaining adequate plaque control. In cases with advanced PI, surgical therapies are more effective than conservative approaches. Open flap debridement can be done, and depending on the configuration of the defect, regenerative therapies such as guided tissue regenerative and the use of bone graft materials may be applicable for defect filling whereas resective surgery can be considered for the elimination of peri-implant lesions.

Keywords: Dental implants, peri-implantitis, treatment modalities


How to cite this article:
Jain R, Soni N, Kansil S, Goyal E. “Stop the ticking before it blows:” treatment modalities of peri-implantitis. Indian J Dent Sci 2016;8:255-8

How to cite this URL:
Jain R, Soni N, Kansil S, Goyal E. “Stop the ticking before it blows:” treatment modalities of peri-implantitis. Indian J Dent Sci [serial online] 2016 [cited 2021 Feb 26];8:255-8. Available from: http://www.ijds.in/text.asp?2016/8/4/255/196817


  Introduction Top


Peri-implantitis (PI) is considered to be “A ticking time bomb in dental implants.”[1] Dental implants have become an indispensable established therapy for the replacement of missing teeth in different clinical situations. However, even an implant with successful osseointegration can develop the most common early as well as late failure complications. Of these, PI is considered one of the most common causes of implant failure [2] and is defined as an inflammatory condition characterized by loss of supporting bone in the tissues surrounding the implant.[3],[4] Therefore, strategies for prevention and treatment of PI should be integrated in modern rehabilitation concepts of dentistry.

“Prevention is better than cure” as per the saying, various multilateral prevention techniques consisting of specific continuous checkups with evaluation and elimination of risk factors (e.g., smoking, systemic diseases and periodontitis, etc.) along with controlling the various aspects of the type and structure of the implant surface have been tried. For the treatment of peri-implant diseases (mucositis and PI), various conservative and surgical approaches are available. Mucositis and moderate forms of PI can be treated effectively using conservative methods. These include the administration of systemic and local antibiotics alone or in conjunction with other treatment modalities such as nonsurgical therapy which consists of mechanical debridement of the affected areas, irrigation with antiseptics (such as chlorhexidine, saline, and 10% hydrogen peroxide) with or without surface decontamination, laser-supported therapy, photodynamic therapy (PDT) as well as light-activated disinfection (LAD) also known as photodynamic antimicrobial chemotherapy (PACT) along with maintaining adequate plaque control.[5] In cases with advanced PI, surgical therapies are more effective than conservative approaches. Open flap debridement can be done, and depending on the configuration of the defect, regenerative therapies such as guided tissue regenerative and the use of bone graft materials may be applicable for defect filling whereas resective surgery can be carried out for the elimination of peri-implant lesions. The above-mentioned strategies are encompassed in cumulative interceptive supportive therapy which serves as a set of guidelines for the treatment of PI.[6]


  Various Treatment Modalities Top


Antibiotic therapy (local and systemic)

The significance of antibiotic therapy as monotherapy or as adjuncts with the other treatment options for PI remains debatable. The various systemic antibiotics that have been successfully used include tetracycline, doxycycline,[7] amoxycillin with metronidazole,[8],[9] ciprofloxacin,[9],[10] minocycline hydrochloride,[11] clindamycin,[10] etc., On the other hand, the various Food and Drug Administration-approved locally administered antimicrobials that have been successfully used for the treatment of PI include Chlorhexidine Gluconate Chip (PerioChip ®), Doxycycline Bioresorbable Gel (Atridox ®), and Minocycline Microspheres (Arestin ®).[12],[13],[14]

Implant surface decontamination

The diverse methods of implant surface decontamination [15] are classified into two main groups: Chemical (burnishing using water, 35% phosphoric acid gel, citric acid at a pH of 1 for 30–60 s, chlorhexidine gluconate) and physical. The latter is subdivided into mechanical decontamination techniques (i.e., implantoplasty, use of carbon fiber, gold, Teflon, plastic or titanium curettes, air powder abrasive methods with calcium phosphate) and laser decontamination techniques. PDT and PACT fall into either category as it combines light-sensitive chemical agents with lasers used to promote their cytotoxicity toward microorganisms.

The mechanical removal of biofilm from the implant surface is considered a priority for removing the etiology of PI. Its objective is the elimination of toxins from the implant surface [16],[17] to produce a surface compatible with health and hence promote re-osseointegration. The main difficulty lies in the implant's surface roughness, which facilitates bacterial adhesion and colonization. One of the techniques proposed for dealing with this is implantoplasty, i.e., the mechanical elimination of surface roughness together with the implant thread using diamond burs. This technique allows optimizing the maintenance and facilitates the oral hygiene by the patient when implant threads are exposed. Romeo et al.[18] showed 100% of implant survival after 3 years, with improvements in clinical and radiological parameters compared with those without implantoplasty. Even though several approaches for implant decontamination are available, the ideal decontamination technique still remains to be determined.

Photodynamic therapy

This represents a novel therapeutic approach in the management of PI and is a powerful laser-initiated photochemical reaction, involving the use of a photoactive dye (e.g., photosensitizer like hematoporphyrin derivatives, 5-aminolevulinic acid, benzoporphyrin derivatives, temoporfin [mTHPC] and talaporfin sodium [LS11], Foscan [mTHPC]) activated by light of a specific wavelength (e.g. red light between 630 and 700 nm, corresponding to a light penetration depth from 0.5 cm [at 630 nm] to 1.5 cm) in the presence of oxygen. This leads to the formation of toxic oxygen species which can damage proteins, lipids, nucleic acids, and other cellular components of microbes. An example is Periowave , a photodynamic disinfection system developed by Ondine Biopharma Corporation that utilizes low-intensity lasers and wavelength-specific, light-activated compounds to specifically target and destroy microbial pathogens and reduce the symptoms of the disease.

Photodynamic antimicrobial chemotherapy

In recent years, the emergence of antibiotic-resistant strains, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis, stimulated a search for alternative treatments. Therefore, a new field has evolved using the principle of PDT and is called LAD also known as PACT.[19] Photosensitizers used in PACT include: (i) Phenothiazine dyes (Methylene Blue and Toluidine Blue O [tolonium chloride]); (ii) phthalocyanines (aluminum disulfonated phthalocyanine and cationic Zn (II)-phthalocyanine); (iii) chlorines, etc. A large number of in vitro[20],[21],[22],[23] and in vivo studies [24],[25],[26] have supported the effectiveness of PACT against various microorganisms. However, views vary regarding the number of single or multiple applications.[27],[28] Few studies concluded that the use of adjunctive LAD therapy with the mechanical cleaning of implants affected by PI did not improve any clinical outcome up to 4 months after treatment.[19] Further studies to demonstrate the advantages of antimicrobial PDT over conventional chemical methods for implant surface decontamination need to be carried out.

Use of lasers

Another common and widely used treatment modality for PI is lasers which have shown a promising therapeutic effect in the treatment of PI [29] and can be combined with other treatment modalities. One session of laser therapy may not be adequate for achieving optimal clinical outcome. The use of lasers requires a number of decisions regarding: (1) The type of laser (ER: YAG, CO2, diode, erbium, chromium-doped yttrium scandium gallium garnet and neodymium-doped yttrium aluminum garnet (Nd: YAG), (2) power setting which must disinfect the implant surface, while being safe for surface texture. ER: YAG is mostly used with 50–120 mJ at a pulse mode of 10–20 Hz. For CO2, the power of the laser is usually in a range of 2–4 W, with continuous mode of application and duration of laser emission of 1 min. Diode laser (660 nm, 810 nm) with 110 mW power for 6–10 s is used. Most recently, a 6-watt, free-running pulsed Nd: YAG laser (PerioLase ® MVP-7) from Millennium Dental Technologies, Inc., using Millennium's LAPIP protocol is commercially available based on laser-assisted periodontal protocol and shows significant results in the treatment of PI. It is designed to reverse disease by targeting and reducing the dark-pigmented, Gram-negative anaerobic pathogens, such as Porphyromonas gingivalis that cause periodontitis, saving healthy tissue from damage and supporting the body's wound-healing efforts. Yoshino et al.[30] suggested that irradiation by Er: YAG laser was an appropriate approach to cleansing the implant surface and preparing it for regenerative procedures.


  Current Approaches Top


The various treatments discussed above can be combined to achieve more beneficial results. A current approach was suggested by Bergmann (PDT and regenerative bone augmentation)[31] consisting of initial phase debridement of the implant surface followed by pocket rinsing (chlorhexidine digluconate – three times a week). Full-mouth disinfection with antibiotic treatment (amoxicillin 3 × 1000 mg/day) aimed to reduce any active inflammation and de-epithelization of the pocket was done with the diode laser. Mucoperiosteal flap was mobilized up to the edge of the intact bone, all the granulation tissues were removed, and the titanium surface is cleaned with a curette and a titanium brush (Tigran Brush No. 1). Decontamination of the implant and bone was carried out with the help of PDT using the HELBO laser. Finally, regenerative treatment using porous titanium granules to stabilize the soft tissue and to prevent the formation of new pockets was carried out.

Schär et al.[32] and Bassetti et al.[33] successfully used diode laser in combination with phenothiazine chloride (HELBO) 3 min after hand curettage and air powder abrasion and irrigation with hydrogen peroxide. Adjunctive PDT was carried out 1 week later. Schwarz et al. investigated the 4-year clinical outcomes following surgical regenerative therapy of PI lesions using either a nanocrystalline hydroxyapatite (NHA) or a natural bone mineral in combination with a collagen membrane (NBM + CM) and concluded that while the application of NBM + CM resulted in clinical improvements over a period of 4 years, the long-term outcome obtained with NHA without barrier membrane was considered as poor.[34]

Research is going on for approaches and materials consisting of (1) antibiotic releasing coatings,[35] (2) anti-bioadhesion coatings,[36] (3) silver and zinc modified surfaces,[37] (4) photocatalytic surfaces [38] that can promote osseoreintegration and interfere with bacterial adhesion by modifying implants surface energy, release metal ions or antibiotics which are qualities that prevent PI.


  Conclusion Top


The ideal management of peri-implant infections should focus both on infection control of the lesion, detoxification of the implant surface, and regeneration of lost support. The most important part that should be kept in mind is that a healthy periodontal environment is absolutely necessary to achieve desirable treatment outcomes. Failure in controlling plaque is the most serious confounding factor that leads to inconsistencies in the results. Enormous efforts are needed to motivate patients to maintain their oral hygiene and follow instructions for which regular maintenance sessions need to be scheduled. Treatment options can be surgical and nonsurgical. To date, studies suggest that nonsurgical treatment of PI is unpredictable, and the use of chemical agents such as chlorhexidine has only limited effects on clinical and microbiological parameters. Adjunctive local or systemic antibiotics have shown to reduce bleeding on probing and probing depths in combination with mechanical debridement. Beneficial effects of laser therapy on PI have been shown, but this approach needs to be further evaluated. Implant surface bacterial debridement is essential in treating PI. Most studies suggest that establishing an adequate healthy peri-implant tissue environment proved to be difficult since inflammation was still present in a significant number of patients. Future strategies include the development of surfaces that become antimicrobial in response to infection and improvements in the permucosal seal. Further research is still needed to identify strategies to prevent bacterial attachment and enhance normal cell/tissue attachment to implant surface.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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