Treating Peri-implantitis

INTRODUCTION
Treatment for peri-implantitis using traditional methods has been marginal at best. The dawning of laser dentistry has changed treatment from guarded to hopeful to successful. This article will present a case study that used numerous lasers to treat peri-implantitis.

The First European Workshop defines peri-implantitis as “inflammatory reactions in the hard and soft tissues, with loss of supporting bone, surrounding a dental implant exposed to the oral environment.”¹ A successful dental implant is defined as immobile when tested clinically. Vertical bone loss is less than 0.2 mm annually following an implant’s first year of service, as well as the absence of pain, infection, neuropathies, and paresthesia.

There are a number of reasons that an implant may fail: (1) the implant was overstressed due to hyper-occlusion, (2) apical pathology from an adjacent tooth, (3) retained cement after cementation of the prosthesis, (4) residual bacteria that was left from either an endodontic or a periodontal pathology, (5) overheated bone at the osteotomy preparation, and (6) microfracturing of the crest upon implant placement.² Peri-implantitis is becoming a major healthcare problem. In 2012, an estimated 1.26 million dental implants were placed in the United States. The dental implant market in the United States is expected to grow to more than $2 billion by 2021. Some studies state that 15% to 30% of all implants will develop peri-implantitis.^3,4 An accurate diagnosis is paramount, and developing long-term treatment is critical. Treatment modalities using chemicals such as phosphoric acid, citric acid, and tetracycline have been inconsistent at best. In 2004, Miller⁵ reported on the use of Er,Cr:YSGG to disinfect the implant surface. Miller’s publication showed that the laser could disinfect more than 1,000 µm as opposed to around 100 µm via a chemical.

On April 8, 2017, at the annual meeting of the Academy of Laser Dentistry, a group of clinicians gave their recommendations for treating peri-implantitis. The group included Nick Complanis, DDS, MS, DABOI, FAAID, Diplomate of AAP, past president of AAID; Sam Low, DDS, MS, Med, past president of AAP, professor emeritus at University of Florida, College of Dentistry; Eric Lindon, DMD, MSD, assistant attending professor section of Oral Diagnostic and Rehabilitation Sciences Division of Periodontics and Implantology, at the Colombia University of Dental Medicine; Hamilton Sporborg, DDS, DABOI, FAAID; and myself. The conclusions of this group were as follows:

• Use a flap reflection to gain access for treating a 3- or 4-wall defect; these are the only ones that have been shown to be consistently treatable.
• Biofilm must be removed by either a glycerin air polisher (Air Flow [Brenchley Dental] or Hu-Friedy AIR-FLOW) or a titanium brush (Salvin Dental).
• Erbium and CO₂ lasers have been shown to be the best lasers to detoxify implant surfaces without creating excess heat that would lead to debonding of the implant/bone contact.
• The worst lasers to use are diode and Nd:YAG lasers, as they create excess heat in metal implants.
• Caution is warranted with the use of Nd:YAG lasers, as these lasers will melt the surface of the implants.⁶
• Perform decortication of the bone surrounding the implant (Erbium) or Piezo and de-epithelization of soft tissues outside of the flap (CO2 or Erbium).
• Use biologics (plasma-rich fibrin [PRF]) in combination with a slowly resorbing particulate graft (usually a xenograft) or a slow, resorbable graft material.
• Use collagen membrane that is interwoven to prevent tissue invagination, and then place a PRF membrane over this collagen membrane before closing.
• The use of photo biomodulation aids in the healing process.
• Occlusal adjustments should be done at the time of surgery and 2 weeks after surgery.
• Consider the use of an occlusal guard.

CASE REPORT
Treatment of Peri-implantitis Using 9,300-nm CO₂ and 2,780-nm Erbium Lasers
This case showed early stages of bone loss and exudate present around the implant in position No. 9 (Figure 1). The area is flapped with a CO₂ laser (Solea [Convergent Dental]) with a setting of 0.25-mm spot size and 20 pulses on soft-tissue setting, with no water at 100% rheostat use (control Hz) (Figure 2). Granulation tissue is quickly removed by use of a surgical bur; this device will quickly grab the granulation tissue (Figure 3). Next, a titanium brush (Salvin Dental) is used at a slow speed to scrub the remaining remnants of granulation tissue around the implant (Figure 4). The next step is to use a CO₂ laser (Solea) to detoxify the implant (Figure 5) that may be infected with bacteria.⁷ This is done until the surface topography is changed. The setting to use is 1.0-mm spot size, 60 pulses, and 100% water spray. This emits approximately 14 W of energy, according to the manufacturer (Table 1).

Figure 1. Exudate present.	Figure 2. Flap reflection was completed using a 9,300-nm CO2 laser.
Figure 3. Surgical handpiece.	Figure 4. Titanium brush being used at a slow speed to scrub the remaining remnants of granulation tissue around the implant.
Figure 5. A 9,300-nm CO2 laser (Solea [Convergent Dental]) was used to detoxify the implant.	Figure 6. BioOss bone/collagen material (Geistlich Pharma) with plasma from plasma-rich fibrin (PRF).

The CO₂ laser is more effective than the other dental lasers discussed because it has a lower affinity to metal,⁸ thus allowing the use of more energy without creating any heat that could cause further problems with bone re-growth. In addition, CO₂ lasers have shown better efficacy in the removal of bacteria around an implant⁹ (Figure 5).

The next step is to use a 2,780-nm erbium laser (BIOLASE) to decorticate the bone and create the regional acceleratory phenomenon (RAP) to allow fibroblasts into the site. Following this, the area of bone loss is grafted with the use of BioOss bone/collagen material (Geistlich Pharma) that is soaked with PRF and placed into the defect (Figure 6). Using the plasma with BioOss material has been shown to increase healing.¹⁰

Then a collagen, interwoven membrane is placed over this to prevent tissue invagination (Figure 7). Next, a PRF membrane is placed over this (Figure 8) and sutured using 3.0 PTFE sutures (Salvin Dental). The final step is to use the erbium laser to de-epithelialize the tissue over the surgical site (Figure 9).

Figure 10 shows the healing process at only 2 months. It seems as though, if bone incorporates, the tissue will return almost back to its original form. Figure 11 shows the case at 6 months and 2 years. As of the submission of this article for publication, it has been 4 years since this case was completed, and the tissue health is excellent. It should be noted that the patient uses an oral irrigator (Hydrofloss [Oral Care Tech]) with a chlorhexidine (CHX) solution (Peridex [3M] or CloSYS [Rowpar Pharm]) twice daily, which will assist in keeping the bacterial levels down.

Figure 7. Interwoven collagen membrane.	Figure 8. PRF membrane.
Figure 9. The tissue is epithelialized using an erbium laser.	Figure 10. At 2 months postoperative.

CLOSING COMMENTS
Peri-implantitis requires a surgical protocol. Prevention is found in establishing a baseline of the patient’s healthy mouth. This includes probing and a taking a radiograph at least on an annual basis. Bleeding upon probing means inflammation has started, and treatment in our office includes the use of an oral irrigator such as Hydrofloss with a CHX solution 2 times per day. The presence of exudate represents bone loss along with an infection. The surgical protocol is a must at this point.

This article was written to aid other clinicians in preventing complications associated with peri-implantitis. It is the author’s anecdotal interpretation that lasers give the most consistent results, and the need to use multiple types of lasers is dictated by each laser’s properties that are most beneficial for treatment. The author has found that the treatment of 3- and 4-wall defects is successful with the protocol presented herein.

References

1. Albrektsson T, Isidor F. Consensus report of Session IV. In: Lang NP, Karring T, eds. Proceedings of the 1st European Workshop on Periodontology. London, England: Quintessence Publishing; 1994:365-369.
2. Kusek ER. Retrospective on treating peri-implantitis. Dentistry. 2015;5:1-7.
3. DiMatteo AM, Latanyshyn K. Guide to implant dentistry. Inside Dentistry. 2014;10:94-100.
4. Grand View Research. Dental implants market size to reach $6.81 billion by 2024 [press release]. September 2016. https://www.grandviewresearch.com/press-release/global-dental-implants-market. Accessed April 26, 2019.
5. Miller RJ. Treatment on the contaminated implant surface using the Er,Cr:YSGG laser. Implant Dent. 2004;13:165-170.
6. Fornaini C, Passaretti F, Villa E, et al. Intraoral laser welding: ultrastructural and mechanical analysis to compare laboratory laser and dental laser. Lasers Med Sci. 2011;26:415-420.
7. Nagasawa M, Takano R, Maeda T, et al. Observation of the bone surrounding an overloaded implant in a novel rat model. Int J Oral Maxillofac Implants. 2013;28:109-116.
8. Quirynen M, Naert I, van Steenberghe D. Fixture design and overload influence marginal bone loss and fixture success in the Brånemark system. Clin Oral Implants Res. 1992;3:104-111.
9. Merin RL. Repair of peri-implant bone loss after occlusal adjustment: a case report. J Am Dent Assoc. 2014;145:1058-1062.
10. Tawil G. Peri-implant bone loss caused by occlusal overload: repair of the peri-implant defect following correction of the traumatic occlusion. A case report. Int J Oral Maxillofac Implants. 2008;23:153-157.

Dr. Kusek received his DDS degree from the University of Nebraska School of Dentistry. He has been a practicing general dentist for more than 25 years in Sioux Falls, SD. Dr. Kusek is an adjunct professor at the University of South Dakota. He holds the titles of Diplomate of the American Board of Oral Implantology, Honored Fellow of the American Academy of Implant Dentistry, MAGD as a member of the AGD, Mastership in the Academy of Laser Dentistry, and Diplomate of the International Congress of Oral Implantologists. He can be reached at edkusek@me.com.

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Disclosure: Dr. Kusek reports no disclosures.