Less Is More When It Comes to Peri-Implant Disease Management

The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions echoed many of these concerns and, in fact, recognized peri-implant disease as its own entity. It is neither the same as periodontitis, nor should it be treated as such. Only in recent years has the approach to managing peri-implant disease changed.¹

Many antimicrobial and mechanical treatments that successfully treated periodontitis were first employed against peri-implantitis. For example, osseous resective surgery was adapted from teeth to implants. In a randomized clinical trial, patients received resective surgery with or without recontouring of the implant surface (ie, implantoplasty). Survival rates ranged 87.5% to 100% after 3 years, with significantly greater reduction in probing depths and attachment levels in the implantoplasty group from baseline.² With current thinking, implantoplasty must be used judiciously to prevent metallosis and overheating. In a recent retrospective study, implantoplasty was performed as an adjunct to resective and reconstructive surgeries after nonsurgical debridement, with an implant survival rate of 97.8% reported after 24 months. However, only 66% of total cases had complete disease resolution with no residual pocketing or progressive bone loss.³

Several regenerative approaches later grew in popularity as new materials came to market. A prospective study grafted intrabony defects around ailing implants with deproteinized bovine bone mineral containing 10% collagen and found that probing depths were stable (less than 5 mm) with supportive maintenance at the 10-year follow-up. However, 15 of the original 26 patients required further antibiotic or surgical intervention or implant removal.⁴ A more aggressive protocol, respectfully dubbed the “kitchen sink,” included flap access; debridement of the implant surface with titanium scalers; a timed, six-step decontamination protocol with sodium bicarbonate air abrasives, saline, tetracycline, and 0.12% chlorhexidine gluconate; bovine or solvent-dehydrated bone grafting with enamel- or platelet-derived growth factors; connective tissue grafting or resorbable collagen membrane placement; and coronal flap advancement. After mean follow-up at four years, probing depth reduction of 5.1 mm and bone gain of 1.8 mm were noted. Nevertheless, 15% of implants required further surgery.⁵

While the above studies had limited, widespread therapeutic success, it is now understood these materials and techniques damage the implant surface and wound-healing cells.¹ Osseous resective surgery and implantoplasty strip the implant’s protective dioxide layer, leading to dysbiosis and chronic inflammation.⁵ Ultrasonic scalers formerly used during debridement also release titanium particles into the mucosa and damage implant surfaces.⁶ Chemical agents (such as hydrogen peroxide, citric acid, antibiotics and sodium fluoride) applied to implants during regenerative procedures cause severe discoloration, pitting and surface corrosion from mechanical friction.⁷ In fact, no chemotherapeutic has been found superior to normal saline.⁸ Additionally, 0.12% chlorhexidine exhibited cytotoxic effects on osteoblasts and fibroblasts when used for implant decontamination. Nylon brushes and waterjets significantly reduced the bacterial load and best maintained corrosion resistance.⁹ It is clear that in the treatment of peri-implantitis today, less is actually more.

A targeted, anti-infective surgical therapy should therefore be considered. In a prospective study, patients received nonsurgical and surgical debridement with titanium scalers and saline. An amoxicillin/​metronidazole regimen was prescribed during the perioperative period. Though 100% of implants had probing depths less than 5 mm without bleeding and progressive bone loss after the first year, 63% of implants met these criteria at 5 years.¹⁰ Regardless of the approach, surgical flap access exposes the implant to the oral cavity and potentially initiates corrosion. Beta-lactam antibiotics are also less effective against implant-bound biofilms.⁹ Laser irradiation and videoscope-assisted surgery can minimize trauma and surface damage, but requires further investigation to establish superiority.^11,12

References

1. Schwarz F, Derks J, Monje A, Wang H-L. Peri-implantitis. J Clin Periodontol. 2018;45(Suppl 20):S246–S266.
2. Romeo E, Ghisolfi M, Murgolo N, Chiapasco M, Lops D, Vogel G. Therapy of peri-implantitis with resective surgery. Clin Oral Implants Res. 2005;16:9–18.
3. Monje A, Pons R, Amerio E, Wang H-L, Nart J. Resolution of peri-implantitis by means of implantoplasty as adjunct to surgical therapy: A retrospective study. J Periodontol. April 26, 2021. Epub ahead of print.
4. Roccuzzo M, Fierravanti L, Pittoni D, Dalmasso P, Roccuzzo A. Implant survival after surgical treatment of peri-implantitis lesions by means of deproteinized bovine bone mineral with 10% collagen: 10-year results from a prospective study. Clin Oral Implants Res. 2020;31:768–776.
5. Froum SJ, Froum SH, Rosen PS. A regenerative approach to the successful treatment of peri-implantitis: A consecutive series of 170 implants in 100 patients with 2- to 10-year follow-up. Int J Periodontics Restorative Dent. 2015;35:857–863.
6. Harrel SK, Wilson TG Jr, Pandya M, Diekwisch TG. Titanium particles generated during ultrasonic scaling of implants. J Periodontol. 2019;90:241– 246.
7. Wheelis SE, Gindri IM, Valderrama P, Wilson TG Jr, Huang J, Rodrigues DC. Effects of decontamination solutions on the surface of titanium: investigation of surface morphology, composition, and roughness. Clin Oral Implants Res. 2016;27:329–340.
8. Berglundh T, Jepsen S, Stadlinger B, Terheyden H. Peri-implantitis and its prevention. Clin Oral Implants Res. 2019;30:150–155.
9. Kotsakis GA, Black R, Kum J, et al. Effect of implant cleaning on titanium particle dissolution and cytocompatibility. J Periodontol. 2021;92:580–591.
10. Heitz-Mayfield LJ, Salvi GE, Mombelli A, et al. Supportive peri-implant therapy following anti-infective surgical peri-implantitis treatment: 5-year survival and success. Clin Oral Implants Res. 2018;29:1–6.
11. atto ZS, Aladmawy M, Levi PA Jr, Wang HL. Comparison of the efficacy of different types of lasers for the treatment of peri-implantitis: a systematic review. Int J Oral Maxillofac Implants. 2015;30:338–345.
12. Harrel SK. Videoscope-assisted minimally invasive surgery (VMIS) for bone regeneration around teeth and implants: a literature review and technique update. Dent J (Basel). 2018;6:30.

This information originally appeared in Saltz A. Evolving management of peri-implant disease. Decisions in Dentistry. 2021;7(11)16-21.