Seyed Hamed Mousavi Almaleki
V year, 14 groupPERIIMPLANTITIS : NONSURGICAL AND SURGICAL TREATMENT OPTIONS
Master’s Thesis
Professor Dr. Stasys Bojarskas
Surgery Department
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
SURGERY DEPARTMENT
PERIIMPLANTITIS: NON SURGICAL AND SURGICAL TREATMENT OPTIONS
Master’s Thesis
TABLE OF CONTENTS
SUMMARY
INTRODUCTION...1
1. SELECTION CRITERIA OF THE ARTICLES...2
1.1 ARTICLES SEARCH STRATEGY...2
2. INCLUSION AND EXCLUSION...4
2.1 INCLUSION CRITERIA...4 2.2 EXCLUSION CRITERIA...4 2.3 RESULTS...5 REVIEW OF LITERATURE ………...9 3. DEFINITIONS...9 3.1 IMPLANT...9
3.2 PERI IMPLANTITIS, MUCOSITIS AND OSSEOINTEGRATION...9
4. TREATMENMETHODS...10
4.1 NONSURGICAL TREATMENT ………...10-12 4.1.1 MECHANICAL METHODS...10
4.1.1.1 IMPLANTOPLASTY...11
4.1.1.2 AIR POWDERABRASIVE...11
4.1.1.3 USING ULTRASONIC WITH AMETAL TIP...11
4.1.1.4 CURETTES...12 4.1.1.5 RUBBER CUP ...12 4.1.2 CHEMICAL METHODS...13-14 4.1.2.1 ANIBIOTICS...13 4.1.2.2 CHLORHESIDIN (CHX)...13 4.1.2.3 HYPOCHLOROUS ACIDS...14
4.1.2.4 LASER AND PHOTODYNAMIC METHODS...14
4.2 SUEGICAL TREATMENT...15 DISCUSSION...16-17
RECOMMENDATION...18 CONCLUSIONS...18 REFERENCES...19-20
ANNEXES...21
SUMMARY
Objective: Implant may involve such diseases which necessitate application of some treatment
regimes at different stages of disorder. The Clinical signs of both dental and implant inflammations emerge with accumulation of Biofilms. Therefore, elimination of biofilm is an essential to prevent disease development and protect the host protection. Moreover, both surgical and nonsurgical procedures have been suggested for improvement of clinical conditions of both implant and preiimplant tissues and for treatment of those affected by periimplantitis.
Material and the Methods: A literature search was performed using the following key words
periimplantitis treatment, nonsurgical treatment and surgical treatment in Pubmed. The publications’ search was restricted to inclusion and exclusion criteria, published from 2007 to 2017 . After revision 23 articles were selected and analysed out of 196 publications (abstracts).
Results: Totally, 23 published works were included in the study. They consisted of
14 papers describing nonsurgical (noninvasive) intervention, 6 papers authored on surgical intervention and 3 papers on periimplantitis, its definition and possible ways of complications’ treatment. This research focused on nonsurgical (noninvasive) method of treatment which encompasses mechanical method and utilization of powder abrasive, ultrasound, curettes and chemical methods, i. e, antibiotic therapy and antiseptic agent, laser therapy and surgical therapy.
Conclusion: A wide part of publications has been dedicated to the discussion of various
types of periimplantitis both surgical and nonsurgical treatments and their beneficial effects. Proper therapy planning before intervention may help us control the factors involved in development of implant complications.
INTRODUCTION
Implants are therapeutic alternatives that replace missing teeth in deferent clinical situations. A
success rate of 95% after 10 years of follow-up has been reported. Nonetheless, some complications have been described in relation with this kind of treatment [1,2].
The most salient of these complications is the progressive loss of alveolar bone surrounding the implant, referred to as peri implant [1]. Periimplantitis refers to the inflammatory process of soft tissues surrounding the osteointegrated implant. Peri implant mucositis is a similar condition not involving bone loss and it is a reversible condition. Risk factors of periimplantitis have been reported to be smoking, periodontitis history , bad oral hygiene, systemic diseases , history of implant failure associated with soft tissue defects [2,3,4]. Peri implant disease studies are more focused on prevention and treatment [3].
Contamination by bacteria in the peri implant microenvironment is believed to be a major factor in the etiology of periimplantitis. These bacteria belong to the biofilm that coats the oral surface. Removal and decontamination of this microenvironment can be achieved by surgical and nonsurgical techniques. Nonsurgical techniques include utilization of antibiotic and antiseptic agents either locally or systematically, laser therapy and mechanical debridement. The choice between surgical treatment and nonsurgical treatment depends on such variables as smoking, preexisting periodontal disease, oral hygiene, quality of prosthetic reconstruction, systemic conditions and use of certain medications [5, 6].
The aim of this study is to assess the different surgical and nonsurgical procedures applied in the treatment of periimplantitis.
The objective of this study is to compare between these different procedures and discuss their advantages and long-term results.
1. SELECTION CRITERIA OF THE ARTICLES
1.1 ARTICLES SEARCH STRATEGY
A literature search was performed in Medline (PubMed) using the key words periimplantitis treatment nonsurgical treatment and surgical treatment, various number of articles can be found according the key word that should be typed in search box. The search was restricted to English language articles, published from 2007 to 2017. In the result it was shown approximately 196 publications (abstracts). If full text publications were not accessible without purchasing, they were excluded. 46 articles were analyzed, of which 23 consistent with the subject of this review were qualified. Articles were read and verified. After all information’s having collected and exclusions that have been made, the gathering information was sufficient and efficient for research project. According to PRISMA guidelines, conducted an electronic search using MEDLINE (pub med) database and Google scholar to locate articles concerning periimplantitis treatment in dentistry (Figure 1).
Figure1: Flow diagram for studies involvement
Records identified through database searching (n = 196 ) Scr e e n in g In cl u d e d El ig ib ili ty Id e n ti fi cat ion
150 Publications excluded due to - No access to full text
17 Publications excluded due to - Title and abstract was not
following this review subject - Systematic reviews
3 Publication excluded due to - Duplicated articles
Records screened (n = 26 )
Full-text articles assessed for eligibility
(n = 26 )
Full-text articles excluded, (n = 3 )
- Insufficient volume - Animal study - Litruture rewive
Studies included in qualitative synthesis
(n = 23 ) - Periimplantitis therapy - Surgical and non surgical Intervention
- Antimicrobial used in periimplantitis treatment
2. INCLUSION EXCLUSION CRITERIA
2.1 INCLUSION CRITERIA
The following type of reports were included: - English language articles.
- Studies performed in vivo and vitro. - Human studies.
- Articles were Mostly clinical studies. - Case reports.
- Clinical studies reporting on the surgical and non surgical treatment of peri-implantitis. - Management of the periimplantitis.
- Peri-implantitis treatment and decontamination and debridement of implant surface ,were included.
2.2 EXCLUSION CRITERIA
The following types studies or reports were excluded: - Abstracts.
- Systematic review and review articles. - insufficient volume.
- Studies performed on animal.
- Articles not familiar to topic ‘periimplantitis treatment’. - Etiological factors of peri implant diseases.
- Chemical changes on implants causes the periimplantitis. - Conference proceedings.
Results:
From 23 articles, 4 sources were those of the year 2014, one belonged to 2011, one to 2009,2017 and 2013 with the remaining sources chosen from 2015 and 2016 years depending on our need. They were publications of one, three and four years before. The case reports and clinical reports used commonly, surgical and non surgical or combination of them, surgical way was mostly opening flap and using bone graft to reestablish the hard tissues and for soft tissues reestablishment, buccal free pads were used. following figure shows the general characteristic of the included experimental studies (Figure 2)
Figure 2: General characteristic of the included experimental studies
Authors year Study type Number of subject/ implants Type of defect/
bacteria Treatment /study material of treatment Considered parameters and follow up period Results Lombar do et al . [5] 2015 Case report 2patients Bleeding On brushing apical lesion, bone loss probing depth 7 to 9 mm
- buccally and palatally incision --- smoothening buccally with rotation burs
- HYBENX (a topical desiccant)
application on implant surface 60 sec irrigation with salin solution bicarbonate air powder abrasive to decontaminate 60sec
-defect filled composite mixed with inorganic bio oss with biphasic calcium material
Large apical lesion on neighboring molar Bone loss in implant area 12 13 teeth - 2 years follow up After 2 years follow up, by intraoral radiographs ,clinical evaluation evaluated healthy hard and soft tissues Absence of bleeding on probing - perfect healing represent successful procedure Kedkho da et al. [14] 2016 CHX effect s on biofil m 13 patients Sub gingival biofilm And periimplantiti s bleeding , depts. Of pocket 4 mm
Using fine sterile paper point (#30),sample extraction from sub gingival pocket, removing oxygen from media(I ml thioglycolate) by boiling 10 minutes ,
culturing sample ,CHX added to sample to see effect of it on bacteria . 48 hours follow up of sample Significant change in A. actinomycetemcom itans diameter after adding 0.2% CHX
Ju chen et al. [16] 2016 vitro HOCL NaOCL CHX Gram-negative(E.col i and P.gigivalis) Gram- positive (E.faecalis and S.sanguinis) Lipopolysaccharide(LPS) were examined on biofilm contaminated titanium alloy after treatment with the 3 chemotherapeutic agents Antimicrobi al effects of 3 antimicrobi al agents on each bacteria types The result indicated the HOCL with increasing of volume exhibited better antimicrobial effects than NaOCL and CHX Umbert o Romeo et al. [18] 2016 clinic al 40 patients -Plaque index -Probing pocket depth -Bleeding on probing
2 groups test and control group treatments control group received only pereiodontal therapy, test group received photodynamic therapy Plaque control Pocket depth and bleeding/ 6 weeks 12 weeks 24 weeks 70% reduction in the plaque,60% reduction in pocket depth observed in test group bleeding on probing were not detectable (2 mm pocket depth in average). significant reduction in plaque index and pocket depth observed in control group (3 mm average pocket depth) .as a result of this study the antimicrobial photodynamic therapy is a reliable adjunctive treatment conventional therapy.
Kalban et aL. [19] 2016 Retro 8 patients 22 pri implant lesion mild -bleeding probing depth -swelling pocket depth(5 mm), severe bone loss - moderate and severe peri implantitis regenerative treatment , free fat graft from other buccal site fat pad. curette mechanical debridement.
placing the bone substitute and free buccal fat graft over the bone.
Cleaning and disinfection of implant removing
granulation tissues by YAG laser Depth of pockets and soft tissues improveme nt Bleeding on probing esthetic outcome of final fixed prostheses significant improveme nt of bone tissues around the implant 2 months 4 months 10 months 14 months 18 months follow up
Buccal free pads healed very well without esthetic disturbance , significantly probing depth decreased (5-6 mm to 2-3mm). soft tissues attachment around implants was well adopted .
regeneration of new bone around treated implants. In conclusion FBFG was simple procedure and best healing and with minimal morbidity. McCrea et al. (21) 2014 Case repor t 2 patients Periimplantiti s loss of buccal tissue and bone in a site of implant gum recession in anterior to implant horizontal bone loss
In first case removal of tooth adjacent to implant ,removal of implant in both cases GBR , to reestablish height and width of hard tissues, placement of implant from one tooth adjacent to another one in other site of old implant site one hour before surgery intervention systemic coverage of 2 g amoxicillin and ibuprofen 400mg and 2 mg
dexamethasone and second case the same treatment but according severity ,was just removal of defective implant . Depth of pockets and soft and hard tissues around implant site and adjacent teeth due to severity of peiimplanti tis outcomes Every six months And 2years Determination of treatment of periimplantitis should be due to severity of defect and loss of soft and hard tissues In conclusion radiographic follow up minimize risk of periimplantitis . Replacement of dental implant ,avoids later developments of advanced periimplantitis .
REVIEW OF LITERATURE
3. DEFINITIONS
3.1 Implants
A cylindrical and/or tapered post, usually made of titanium, which serves as a substitute for the tooth root and provides a strong, sturdy foundation for one or more replacement teeth, and loss of it can be attributed to implant overloading ,techniques and material faults, and poor conditions of the bone around the implant[6,2].
3.2 Periimplantitis , Mucositis and Osseointegration
The clinical condition associated with radiologically observable loss of bony support of implant, together with an inflammatory reaction of the periimplant mucosa and mucositis is the clinical condition around implant characterized by the appearance of inflammatory changes restricted to the periimplant mucosa. If treated properly, it is a reversible process. Osseointegration is defined as the direct connection between live bone and a functioning endosseous implant, the term “functioning” implying that the contact between live bone and the surface of the implant is sustained while it is active or bears a load [6,7].
4. TREATMENT METHODS
4.1 Nonsurgical treatment
Whether performed solely or in combination, non- surgical therapy is aimed at removing local irritants from the implant surface with or without surface decontamination. Some additional adjunctive therapies can possibly be added. Periimplant infections present a microbiota very similar to that found in such periodontal disease as, Prevotella nigrescens, Campylobacter rectus and
Aggregatibacter actinomycetemcomitans, as well as Staphylococcus aureus, enteric bacilli and Candida albicans. To deal with these types of microbial periimplant infection the following
methods can be used [7,2].
4.1.1 Mechanical methods
The mechanical removal of biofilm and tartar from the implant surface is considered a priority for the etiological treatment of peri-implantitis. The elimination of toxins from the implant surface is performed with Teflon curettes and abrasive sodium carbonate air-powder, performing full thickness flap elevation, bicarbonate air-powder abrasion systems and physiological saline provide the best results in eliminating endotoxins and detritus from all surfaces[8].
Mechanical debridement as mentioned above refers to:
4.1.1.1 Implantoplasty
Is the Techniques to flatten/smooth the contaminated implant surface using rotary instruments, as experienced using the diamond bur by 30 microns (particles size )then carbide bur (12 plus 16 bladed ). Reducing the roughness of implant surface is the main goal, because the biofilm colonization first started in these surfaces instead of smoother
surfaces [8,9].
4.1.1.2. Air powder abrasive
The Technique working with a mixture of the powder and sodium bicarbonate, sodium hydrocarbonate or amino acid glycine propelled by a stream of compressed air and water [9]. The aforesaid technique was used during a surgical procedure carried out on a nonsmoker 58 year old patient ,with symptoms of periimplantitis , showing + 2 mobility after planning by CBCT scan, full-thickness flap was elevated and after removing granulation infective tissues,decontamination of implant surface was done by using AP technique , consisting of powder erythritol ,a morph silica and also 0.3% chlorhexidine , for 3 (three) minutes at a point 1 cm from implant surface[10] .
4.1.1.3. Using ultrasonic with a metal tip
Using ultrasonic device with metal tip is an efficient way to smooth the rough surface of implant and to eliminate bacteria. This technique provided for a reduction in plaque rate by 53-73 percent. Considering the availability of cooling system no increase is observed in temperature. The method involving the use of metal tip is much more effective in reducing bacteria than the method using plastic tip. Roughness can appear in surface after instrumentation by the metal tips and make some scratches [11].
4.1.1.4. Curettes
Curettes are offered both in the form of metallic and nonmetallic devices. Those utilized in manual treatment may be made of Teflon-carbon and plastic. They bring such changes as irregularity to the smooth surface and they can also remove materials from the surface. To avoid such irregularities, they should be made of softer materials than titanium. Acrylic type curettes were tested on patient with per-implant mucositis. This curette reduced the contamination and rubber cup (it shall be discussed later) for polishing. It provided good clinical results and minimized the. Meanwhile, treatment result obtained by using carbon fiber curettes and ultrasonic system, showed only little difference between the two techniques after a 6-month follow up [12, 2, 9]. In other experiment and compartment between carbon fiber curettes and antiseptic therapy with amino acid glycine powder, after 6 mouths follow up was different clinical attachment gained by each of them [12].
4.1.1.5. Rubber cup
A technique which takes use of an abrasive polishing agent and a slowly revolving polishing cup
to abrade stain from the titanium surfaces of contaminated implant and significantly decreases roughness of surface by removing the debris. Rubber cup combined with irrigation using chlorhexidine and systemic antibiotics results in a reduction of anaerobic bacteria and bleeding scores in patients with peri-implantitis [12,9]
4.1.2 Chemical Methods
4.1.2.1 Antibiotic
Systemic and local antibiotics provide a desirable rate of reduction in pocket depths. Over the time (1-6years), experienced by Javed et al. and the doxycycline (resorbable) releasing agents (Nano spheres) over the time (15month)\, experienced by muora et al. periimplantitis treatment success rate by using the combination of antibiotics such as clindamycin, amoxicillin + metronidazole, tetracycline and ciprofloxacin is increasing by 58 % [12,6,2]
Hallstrom et al. uses of Systemic antibiotic in the non surgical treatment of peri-implantitis would be logical to take [12,6].
4.1.2.2. Chlorhexidin
Chrorhexidin has been used to reduce the bacteria during peri-implantitis treatment. It showed that irrigation with CHX (0.12%) would reduce the bacteria upon a combined use during mechanical debridement. Also an experiment showed that CHX (0.2%) has its effects on some species such as candida albicants and Streptococcus sanguinis within 1 minute [13 ,14, 15].
It has been reported that CHX stops formation of biofilms by 60% ,and it was effective by about 50%-80% depending on serverity of gingivitis. Also the CHX (0.12%) digluconate has been effective on anaerobes and total aerobes streptococci and actinomyces in courses of 3 and 6 months[15].
4.1.2.3. Hypochlorous Acid
The present in vitro study evaluated the effects of hypochlorous acid for elimination of gram positive and gram negative bacteria: an increase in length of treatment hapochlorous antibacterial efficiency improved and it destroyed majority of bacteria on titanium alloy surface of baiofim contaminated implants, and evaluated the significant effects of haypochlorous acid to decrease the amount of lipopolysaccharide of p.gingivalis, compared with CHX[16].
The result indicated the HOCL with increasing of volume exhibited better antimicrobial effects than NaOCL and CHX studied by ju chen et al.
4.1.2.4. Laser and photodynamic method
Nowadays, different types of laser therapy, are not merely limited to diode, Neodynamic doprd yttrium aluminum garnet (ND: YAG), carbon dioxide (Co2) and erbium yttrium aluminium garnet (Er:YAG) gallium aluminum arsenide (Ga AlAs). In-vitro studies showed the ability of laser to eliminate the bacteria from titanium surface of implants. The same study showed elimination of
Prophyromonas gingivalis and Escherichia faecalis from implant surface without any topographic
change of surface with (Er:YAG and GaAlAs) forms of laser therapy [17,9].
Photodynamic therapy is an alternative way to decontaminate the implant surface. It is a convectional treatment methods and includes utilization of a low-powder diode laser combined with photosensitizing compounds which contact with bacteria membrane and react with substrate. Photosensitizer binds with target cells and with specific wave length irradiated with light, and with oxygen, transition going from a low energy ground state to excited singlet state. Singlet state and other reactive agents are toxic to the target cells [9,18]. Application of photosensitive dyes into pockets along with light activation of them, promotes killing of existing pathogens. This technique was also surveyed on dogs and the result was reduction of the Prevotella intermedia/nigrescens,
4.2 Surgical treatment
Surgical therapy is aimed at removing any residual subgingival deposits and additionally reducing the peri-implant pockets depth (Early periimplantitis is 2-3 mm in depth, moderate one measures 4-5 mm, and advanced one more is more than 5mm in depth. This can be done solely or in conjunction with either osseous resective therapy or the contrary regenerative approach [19,6]. Kalban et al.
Surgical treatment done combined with other nonsurgical methods in Resective or regenerative surgery procedures. During the first phase, the Oral hygiene condition improves first and subsequently mechanical cleaning Applies, if non-surgical treatment is not successful. Then surgical intervention with open debridement in ways of respective or regenerative applies and is recommended[19,2]. The basic principle in resective therapy, the elimination of periimplant bone defect using osteoplastic and osteotomy, and bacterial decontamination along with polishing and smoothing of surface may be applied. Regenerative approach is the condition to gain fully reossteointegration, as experienced on various animal models using various graft material of guided bone regeneration and combination of membrane and bone graft in terms of bone regeneration resulted in a better rate of re-osseointegration [20,19,9]. As kalban et al. experienced surgical treatment using mechanical debridement and buccal fat graft for regenerating soft tissues around implant .
DISCUSSION
The treatment way differs depending on whether it is peri-implant mucositis or peri-implantitis. No particular treatment way has shown to be effective. There are some of ways of treatment for the elimination of diseases. This study was more focused on non surgical treatment . Peri-implant mucositis can be treated by non-surgical treatment [ 21,15,9]. If the peri-implantitis is diagnosed then the treatment protocol depends on the intraosseous defect. If the bony defect is minimum then implantoplasty can improve the bony defect [21,9].
McCrea et al. determined treatment of priimplantitis due to severity of defects and lossof soft hard tissues in their study was two cases , first treatment done by removingimplant and teeth near implant ,which severity of bone loss cause loss of bone atadjacent natural teeth, that if early diagnosis was done disease was not progresses toadvanced periimplantitis .
With Non-surgical treatment, an improvement of clinical condition was observed , but bacterial pathogens were not reduced. Kedkhoda et al. showed that CHX 0.2% just had changes in bacteria diameter . Treatment standard of peri-implantits can be improved by decreasing the bacterial pathogen; hence it is effective if resective surgery is followed in the incipient case of peri-implantitis as well. Both nonsurgical and surgical therapies was done solely or as a combined treatment , however non surgical way was found to be less effective [21,20,5].
Lombardo et al. experienced combination of nonsurgical and surgical therapy , by using a topical desiccant ( HYBENX ) to apply on contaminated surface for 60 second and irrigating the surface with salin solution and then decontaminating the surface ,using bicarbonate air powder abrasive for 60 second plus using bone graft material (bio oss) after exposing the contaminated area in surgical way, and the result of this study showed perfect healing and represented successful procedure . The surface characteristic of implant shows successful osseointegration, and it is highly Predictable because the implant is embedded in bone tissues. In the advanced peri-implantitis combined treatment of resective and regenerative surgical procedure followed by surface decontamination yields good osseointegration .
The study concluded that surface decontamination/debridement reduces bacterial count but there was no superior improvement in clinical parameters; hence guided bone Regeneration and the application of bone substitute [ 22,21](nanocrystalline hydroxyapetite) can be efficacious for the treatment of peri-implantitis.
The majority of surgical protocols include preoperative or post-operative systemic antibiotics followed by postoperative chlorhexidine rinse. Postsurgical Maintenance is also important which includes oral hygiene instructions and surface biofilm removal[22,21,14].
The initial severity of disease may affect the treatment outcome for certain interventions. In an advanced periimplantitis, the nonsurgical method of treatment is ineffective ,because access to contaminated area of the implant is limited [23]. Kedkhoda et al. studied about antimicrobial effects of chlorhexidine (CHX )on a sample extracted from sub gingival biofilm , and the result was significant change in A. actinomycetemcomitans diameter after adding 0.2% CHX.
As a major factor affecting treatment outcome, smoking was not mentioned properly in some part of the literatures , Other factors that may play a role in the success of peri-implanitis treatment and warrant further investigation include the proximity of adjacent implants, the position of implants within the arch, and the absence of keratinized peri-implant mucosa. Therefore, there is no ideal therapy for periimplantitis just prevention is the most important kind of therapy.
RECOMMENDATION
Certain medical issues can also contribute to bone loss, and, subsequently, peri-implantitis. Diabetes and osteoporosis are known conditions that affect bone density and bone strength. Pre treatment phase : Proper treatment planning ,oral hygiene , prosthesis assessment for plaque control and removal and adjustment of prosthesis , antimicrobial debridement .
Surgical intervention: full thickness flap (mucoperiosteal ) and stabilization of the interaosseous defect of peri implant (bone graft).
Post treatment phase: Systemic Antibiotic, chlorhexidine rinses (pre and post surgical treatment).Follow up: 3 to 6 months biofilm removal and oral hygiene instruction
CONCLUSION
Evaluation of the literatures has shown that both surgical and nonsurgical treatment strategies have some beneficial effect on peri implant diseases . All therapies can cause changes in implant surface. In conclusion, there is no ideal therapy and it depends on doctor, clinical condition of patient’s mouth and choice due to comfort of patient.
As a preventive method, use of CHX 0.2% which has antibacterial effects on bacteria species isolate from the periimplantitis . The air powder abrasive represents a viable way in treatment of periimplantitis , however combination of nonsurgical therapy is best of choices . As surgical part of this combination of therapies (nonsurgical and surgical), I can named the implantotomy and osteotomy.
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