Over the past 2 decades, implants have shown high success and survival rates (ranged from 90% to 98%) after at least 10 years in function.1–6 However, dental implants are not immune from biological and/or mechanical complications.7 It is known that peri-implantitis can be caused either by mechanical8 or biological9 factors. In addition, results from clinical and experimental studies indicated that the tissue responses to plaque at dental implants and teeth are similar.10–13
As defined in a consensus report from the first European Workshop on Periodontology, peri-implant mucositis is a reversible inflammatory reaction in the soft tissues surrounding a functional implant, although peri-implantitis describe inflammatory reactions associated with loss of supporting bone around implant in function. More recent studies have attempted to modify this definition, suggesting that the detection of peri-implantitis require a threshold value of bone loss after the first year in function (1.8 mm) in combination with bleeding or suppuration after probing.14 In addition, according to the International Congress of Oral Implantologists Pisa Consensus Conference report, the term “failure” is referred to an implant that has pain on function, mobility, radiographic bone loss greater than half of the implant length, uncontrolled exudates, or if it is no longer in the mouth.15
As implant therapy becomes more widely used, peri-implantitis diseases also becomes more evident. However, information on the prevalence or incidence of peri-implantitis is limited.16 Nonetheless, it has been reported that almost 28% of implant patients had at least 1 implant with progressive bone loss and 12.4% (422/3413 implants) had bone loss extend beyond one third of implant thread.17
Clinical signs of peri-implantitis include increased probing depths, suppuration, mucosal recession, a draining sinus (fistula), peri-implant mucosal swelling,18 and bleeding on probing (BOP).19 Clinical features are key for diagnosing peri-implant diseases.
Once peri-implant disease is diagnosed, clinicians will be challenged to deal with this problem. Many treatment modalities have been suggested and attempted. Mechanical nonsurgical therapy could be effective in the treatment of peri-implant mucositis lesions, and the outcome can be enhanced by the use of antimicrobial mouth rinses.20 However, in peri-implantitis lesions, nonsurgical therapy was found to be uneffective. It this scenario, surgical treatments, such as implantoplasty with apically positioned flap, guided bone regeneration, open flap debridement, and eventually implant removal, have been suggested.21
To ensure a successful surgical outcome, contaminated implant surface must be totally detoxified. Currently, there is a lack of consensus of which agents/techniques should be used in detoxifying the contaminated implant surface.20 Most of the studies differed markedly in design, using different number/brand of implants, types and location of implants placed, different surfaces, and different time allowed for osseointegration. Hence, the aim of this review was to summarize the current understanding in the field of implant surface detoxification. Figure 1 lists mechanical and chemical agents that are currently available for implant surface detoxification.
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Fig. 1: Mechanical and chemical agents for implant surface detoxification.
Current Methods for Implant Surface Detoxification
Table 1 presents the advantages and disadvantages of chemical detoxifying implant surface agents.
Table 1: Advantages and Disadvantages of Chemical Implant Surface Decontamination Agents
Chemical Therapy
Saline
Rationale
The use of this agent has been shown to be effective for peri-implantitis treatment. Burnishing the contaminated titanium surface with a cotton pellet soaked in sterile saline for 1 minute achieved a reduction in lipopolysaccharide levels significantly below untreated implants.22 However, the value of saline used as a detoxification agent for a contaminated implant surface is difficult to assess because saline is always used in combination with other decontamination agents.
Evidence
Persson et al,23 after treating peri-implantitis lesions in a dog with systemic administration of antibiotics (amoxicillin and metronidazole) and surgical debridement using saline in the infected sites, failed to demonstrate re-osseointegration. This was because a contaminated implant surface possesses bacterial by-products and often leads to fibrous encapsulation that jeopardizes the ability of achieving re-osseointegration. Hence, they concluded that re-osseointegration occurs only at sites where pristine implant component was placed in the bone defect after surgical debridement.23 It can be deduced from this study that the quality of the titanium surface is decisive for both osseointegration and re-osseointegration.
Schou et al,24 in an animal study, showed no differences among the applications of air-powder abrasive, citric acid, saline, or chlorhexidine in different combinations with the addition of autogenous bone graft and an expanded polytetrafluoroethylene (ePTFE) membrane. In contrast, the amount of re-osseointegration was significantly higher in a peri-implantitis defect treated with saline and chlorhexidine combined with autogenous bone graft and platelet-enriched fibrin glue when compared with other treatment modalities. The positive result, however, cannot be extracted from saline alone.25
Current understanding
The use of saline as a detoxifying agent has been poorly demonstrated in the literature. Its use is frequently limited as an adjunct to other detoxification methods.
Citric acid
Rationale
The use of citric acid to treat peri-implantitis was based on the positive effect in treating periodontitis rather than any scientific findings that supports its use.26 This positive effect of citric acid has been widely observed in periodontitis revealing that this chemical agent can increase cementogenesis and may increase the rate of success of new attachment procedures on the root surface.27–30 In addition, citric acid has been shown to inhibit the growth of bacteria on periodontally diseased root surfaces.31
Evidence
As regard to the treatment of peri-implantitis, citric acid has the ability to detoxify endotoxin-contaminated hydroxyapatite (HA) surfaces22 at 30-second and 1 and 3-minute intervals. Perhaps the optimum application time is 30 to 60 seconds for detoxification with minimal coating demineralization.32 However, even though citric acid has been demonstrated to reduce the total amount of microorganisms accumulating on titanium surfaces,33 its use is supported by a limited number of studies.
Hanisch et al34 treated peri-implantitis defects in monkeys using recombinant human bone morphogenetic protein-2 (rhBMP-2). In this study, a yarn-saturated in citric acid solution for 60 seconds and air-powder abrasive applied for 15 seconds were used for implant surface decontamination. Results showed that rhBMP-2 has potential to promote bone formation and re-osseointegration in advanced peri-implantitis defect.34 However, the benefit of citric acid cannot be deducted from this study. It could be speculated that altered implant-surface characteristics following citric acid and air-powder abrasive detoxification protocol might play a significant role in the ability of how rhBMP-2 promotes re-osseointegration.34
Alhag et al35 in 2008 and Kolonidis et al36 in 2003 compared 3 different surface treatment modalities in dogs. Treatments included: (1) swabbing with supersaturated citric acid for 30 seconds on a cotton pellet followed by rinsing with physiological saline, (2) cleansing with a toothbrush and physiological saline, and (3) swabbing with 10% hydrogen peroxide for 1 minute followed by rinsing with physiological saline. Both studies achieved the same conclusions that all treatment modalities were associated with new bone to implant contact and that rough surfaces, which were contaminated by plaque and cleaned after, can re-osseointegrate.
Ntrouka et al37 compared different chemotherapeutic agents in their ability to remove Streptococcus mutans biofilm that was grown on the titanium disc. The efficacy of EDTA, citric acid, cetylpyridinium chloride Ardox-X, hydrogen peroxide, chlorhexidine, and water were tested. Citric acid at 40% was shown to have the greatest decontamination capacity with respect to killing and removal of biofilm cells.
Current understanding
Due to its results over natural dentition, the use of citric acid started as a method for implant surface detoxification. Although it has shown to have a great capacity for implant surface decontamination, more studies are needed to test its efficacy.
Chlorhexidine
Rationale
The use of chlorhexidine gluconate (CHX) is well documented in periodontal therapy. Its use has been proved to be effective in reducing periodontal inflammation and in controlling subgingival plaque.38 This agent is thought to be nonspecific and directly interferes with the cell walls of bacterium so that lysis occurs.32,39 The use of CHX is advantageous due to its substantivity, which allows the agent to be absorbed into hard and soft oral tissues and be released over time. This effect can last up to 12 hours.
In addition, CHX has been shown in an in vitro study to attach to the titanium and plasma sprayed HA implant substrate,40 possibly acting as a reservoir for plaque control, and has also demonstrated the ability to inhibit fibroblast in vitro.41 Nonetheless, several disadvantages are related to its use, like taste alterations, staining, and slight increase in calculus formation.39
Evidence
CHX have been widely used to treat the peri-implantitis disease. In a dog study, after mechanical and chemical cleaning with 0.12% CHX and metronidazole (20 mg/kg body weight per day) for 10 days, they compared 4 different surface configurations. These included titanium plasma sprayed (TPS), sandblasted, acid-etched (SLA), machined smooth surface (M), and TPS furcation (TPS with coronally placed perforation to mimic a furcation). They showed that SLA surface has the highest degree of defect bone fill, whereas machined surface has the lowest degree of re-osseointegration. Furthermore, it was concluded that bony defect around peri-implant infections may achieve bone fill if the infection is controlled through effective antibacterial therapy. True re-osseointegration, however, seems to be difficult to achieve.42,43 In a 3-year follow-up study, again it was shown that having no surgery is an ineffective therapy for peri-implantitis lesions. Flap open surgery with autogenous bone graft alone, or with the addition of a membrane, was an appropriate treatment regimen to fill the defect formed around implants.43 For this study, authors used 0.2% CHX, citric acid (pH = 1) for 1 minute, hydrogen peroxide, and 0.9% saline for the implant decontamination. Hence, the true benefit of each individual decontamination agent cannot be evaluated.
Schou et al,44–46 in several monkey studies used CHX for the peri-implant surface in combination with different types of membranes and grafts. After mucoperiosteal flap elevation and granulation tissue removal, the implant surface was cleaned with gauze soaked alternately in 0.1% aqueous CHX and saline. This procedure was repeated 20 times. Authors concluded that autogenous bone or Bio-Oss graft material with or without ePTFE membrane resulted in considerable bone regeneration after treatment.
Current understanding
So far, none of these studies have direct evidence to demonstrate the advantages of use chlorhexidine when compared with other decontamination agents. However, microbiological benefit was found in any of the treatment listed above.
Hydrogen peroxide
Rationale
Hydrogen peroxide is effective against bacteria due to its oxidizing action.32 It has shown to suppress Actinomyces actinomycetemcomitans (Aa) when used for subgingival irrigation.47 Hydrogen peroxide and sodium hypochlorite represent traditional dental disinfectant widely used for reducing biofilm accumulation on removable prosthesis.48
Evidence
When 10% of hydrogen peroxide in combination with antibiotics was used to clean peri-implantitis in humans under the flap exposure, a significant drop of mean gingival bleeding was obtained in 58% of the implants that had at least 5 years of follow-up.49 However, as happened with other agents for implant surface decontamination, the efficacy of hydrogen peroxide cannot be deduced.50 Carbon dioxide laser and hydrogen peroxide conditioning were studied in the treatment of peri-implantitis in the dog.50 A combination of CO2 laser and hydrogen peroxide was used in comparing with implant surfaces cleaned with cotton pellets soaked in saline. Both approaches, laser + hydrogen peroxide or saline solution, achieved similar re-osseointegration rate for both saline-treated turned-surface (21%–22%) and SLA surface implants (82%–84%).
Current understanding
The hydrogen peroxide has been used in private clinic to clean contaminated implant surface; however, no control study so far has looked into its ability to perform implant surface detoxification. More studies are needed in understanding the effectiveness of this agent.
Antimicrobials
Rationale
Reduction of the bacterial load to a level allowing healing is difficult with mechanical therapy alone. Consequently, adjunctive use of antibiotics, antiseptics, and laser treatment has been proposed to improve the nonsurgical treatment of peri-implant mucositis and peri-implantitis.20
Antimicrobial agents can be delivered locally or systemically to treat peri-implantitis lesions, and they are usually combined with other treatment modalities such as laser therapy, hydrogen peroxide, CHX, or surgical debridement. Hence, it is difficult to arrive an overall definitive conclusion of how effective antimicrobials are. However, studies have concluded that antimicrobial agents are capable of reducing the overall bacterial load.
There are many different antimicrobial agents that can be applied either systemic or locally. These antibiotics include but not limited to: doxycycline, minocycline microspheres and tetracycline, probably the most common antibiotics used for implant surface decontamination.
Tetracycline (TCN) is a broad-spectrum, bacteriostatic antibiotic. Metabolic inhibition at the ribosomal level is its mechanism of action. TCN inhibits the epithelial growth factor laminin and enhances fibronectin, which promotes fibroblast spreading and attachment.51Figure 2 illustrates the application of TCN over the titanium surface.
Fig. 2: Application of TCN over the implant surface.
Evidence
The influence of antimicrobial treatment over peri-implantitis lesions was investigated by Mombelli and Lang.52 They performed mechanical cleaning, irrigation of peri-implant pocket with CHX, and systemic antimicrobial therapy using 1000 mg of ornidazole for 10 consecutive days. Results showed reduction in pocket depth, reduction in BOP, and overall reduction of bacterial load. This was later confirmed by Persson et al,53 who showed in a human study that Aa, Tannerella forsythia, Porphyromonas gingivalis, and Treponema denticola were reduced under local administration of 1 mg of minocycline hydrochloride microspheres (Arestin, OraPharma, Warminster, Pennsylvania). Despite the overall reduction of these pathogens, at 1 year only the levels of Aa were lower than at baseline. Nonetheless, although 5-year data suggest that mechanical debridement with systemic antibiotics is partially successful in the control of peri-implantitis,49 there is a lack of information in the literature about long-term results of treatment of peri-implantitis using systemic antibiotics.
In addition, Ericsson et al,54 in experimentally induced peri-implantitis lesions, using 1% water solution of delmopinol for local detoxification concluded that systemic antimicrobial therapy (amoxicillin and metronidazole), combined with implant cleaning, curettage of the bone defect, and regular plaque control resulted in resolution of the peri-implantitis lesion.
The reduction in bleeding and probing depth have been also reported with local delivery of tetracycline,26 topical minocycline microspheres,55 chlorhexidine plus minocycline microspheres,56 and doxycycline57 treatment. However, the true clinical effect of these agents remains to be determined.
Current understanding
Antimicrobials have been widely used for surface decontamination, but no agent has been proved to be superior.7
Mechanical Therapy
Table 2 presents the advantages and disadvantages of mechanical detoxifying implant surface agents.
Table 2: Advantages and Disadvantages of Mechanical Implant Surface Decontamination Agents
Abrasive pumicide
Rationale and evidence
There is a lack in the literature regarding this treatment modality for peri-implantitis. However, Persson et al58 in 1999 evaluated the outcomes of abrasive pumice over peri-implantitis lesions in 4 beagle dogs. They compared the effect of abrasive pumice administered via a rotating brush or cotton pellets soaked in saline. Results showed similar outcomes in both techniques and concluded that even though the inflammatory lesion was resolved and new bone formation occurred, the amount of re-osseointegration was small. In addition, on all the implants placed, a thin connective tissue capsule was found separating implant surface form newly formed bone.
Current understanding
The use of abrasive pumice over the contaminated implant surface has been poorly studied. More studies are needed to prove its usefulness.
Air powder abrasive
Rationale
Air-powder abrasive systems were originally developed to remove stain from enamel surfaces. Nonetheless, later on the effects of such systems were evaluated on root surfaces, restorative materials, and periodontal flaps.59 Several studies have illustrated the potential for efficient removal of stains and plaque, root detoxification, and creation of smoother surface, without detrimental effect on exposed soft tissues.59 Because this technique was proved to be effective upon natural dentition, its use was transferred to the implant field.
Evidence
Parham et al59 performed an in vitro study to truly observe the effect of air-powder abrasive system over plasma-sprayed titanium implant surface. They used this technique from a 4-mm distance and perpendicular to the surface for 5 seconds. Results demonstrated minimal alterations of the plasma-spray-coated surface with slight rounding of surfaces edges and angles, and occasional surface pitting. Regarding numbers of attached fibroblast, favorable reaction was observed with uniform attachment over the entire implant surface. Finally, 100% removal of bacteria from the surfaces exposed to the air-powder abrasive was found, concluding that this tool is effective in removing bacteria that is attached to implant surface.
An in vitro study concluded that CO2 laser alone or in combination with air-powder abrasive for 60 seconds can be utilized for implant sterilization in a dog model.60 Four more studies comparing different types of grafts, with or without membranes, reported bone fill and pocket depth reduction at peri-implant defect when an air-powder abrasive instrument for 30 seconds either alone or with sodium carbonate solution.61–64
Re-osseointegration of 26.8%62 and 7.8%65 were reportedwhen air-powder abrasive system and force air debridement were used. However, only 35.6% of the total amount of bone fill in the peri-implant defect was osseointegrated, whereas the remaining 64.4% of the regenerated bone fill had a soft tissue interface between bone.65
Current understanding
Air-powder abrasive was suggested to be a detoxifying method because of its ability to forcefully clean the contaminated implant surface while avoid deleterious surface damage. However, as happened with other methods for detoxification, the outcomes of these trials cannot be deducted from this approach alone. The drawback of using air-powder abrasive is its potential for trigger surgical emphysema and break the soft tissue seal between implant and surrounding mucosa.66
Laser and photodynamic therapy
Rationale
Dental lasers and photodynamic therapy have been suggested for implant surfaces decontamination for the management of peri-implantitis lesions.67 Several types of laser are currently available, these include but not limited to: carbon dioxide; Nd:YAG; Er:YAG, and diode. Lasers in their different wavelengths have been used in dentistry mainly because of its interaction with soft tissues and its therapeutic and antimicrobial effects.68
Evidence
CO2 laser possesses potential for sterilization due to its excellent absorption in water. In a dog model, laser decontamination was shown to enable sterilization of exposed implant surface so the re-osseointegration can be achieved.60 This is because the energy produced by CO2 laser is not absorbed to any significant extent by metallic surfaces, which reduces thermal injury to surrounding tissues and damage to the implant fixture.69
Carbon dioxide laser was found to be effective in removing Streptococcus sanguis and P. gingivalis from titanium implant surfaces without causing surface alterations or raising the temperature.70 In addition, Deppe et al60 found that when using CO2 laser emitting a beam of monochromatic light with a wavelength of 10.6 nm, it can be more efficacious than conventional technique in deep, narrow bony defects.
Recently, 1064-nm neodymium doped yttrium aluminum garnet (Nd:YAG) laser was also shown to be effective in removing contamination from infected implants without damaging the implant surfaces.68 Similarly, Er:YAG laser with different wavelengths was also demonstrated with a high bactericidal potential and as an effective treatment in peri-implantitis lesions without alteration of morphological features of the fixtures.71,72 Er:YAG laser was tested for its decontamination in 3 different implant surfaces: sandblasted and acid-etched (SLA), TPS, and HA coated. Results showed mean bacterial reductions with a wavelength of 2940 nm of 99.16% at a pulse energy of 60 mJ and 99.9% at 120 mJ for all 3 surfaces without excessive temperature elevation or implant morphology alterations.71 In addition, in a split mouth design study performed in beagle dogs, Er:YAG seemed to be more suitable to promote re-osseointegration than ultrasonic devices or plastic curettes plus local metronidazole.73
Finally, the effectiveness of diode soft laser has been demonstrated in a study performed over 15 patients who showed clinical and radiographic signs of peri-implantitis. After bacterial samples were taken before and after application, the result concluded that diode laser with a wavelength of 690 nm for 60 seconds resulted in a significant reduction on the initial values of Aa, P. gingivalis, and Prevotella intermedia. However, complete elimination of bacteria was not achieved.74
Current understanding
Laser therapy seem to be a useful tool for surface decontamination without damage the morphology of the implant, and, in combination with augmentation procedures can be an effective treatment approach for management of peri-implantitis.75 However, the long-term laser treated results seems to show no difference between laser and conventional decontamination method.76
Implantoplasty
Rationale
Implantoplasty is a form of surface decontamination that include smoothing and polishing the rough surface and eliminating the implants threads with rotary instruments to decontaminate and reduce the ability of plaque to adhere.77,78
Evidence
There are several clinical difficulties associated with this technique; nevertheless, the increase in temperature is the most common. For this reason, implantoplasty must be carried out with caution to avoid overheating of the implant body, affecting the strength of the implant and the surrounding tissues.79 A study was performed to evaluate the efficacy and thermal changes during implantoplasty concluding that under appropriate water spray condition, only minimal increase in the temperature are expected (∼1.5°C) and, hence, implantoplasty can be considered a safe procedure from the temperature standpoint.80
The second concern will be the modification of implant strength due to narrowing of implant diameter. This has not yet been addressed in the literature.
There is a lack of studies that assesses this technique. Schwarz et al81 treated peri-implantitis lesions with either laser or plastic curettes after open flap debridement and implantoplasty. The results showed that both techniques have the potential to achieve bone fill at the intrabony defect. Nonetheless, they failed to demonstrate a significant impact on surface decontamination in the treatment of peri-implantitis. Another study assessed the efficacy of implantoplasty and concluded that it is an effective technique for removing peri-implant infections and preventing peri-implantitis progression.78
Current understanding
Up to the writing of this article, implantoplasty remains one of the tools that has been shown to be effective in removing contaminated implant surface. However, its effectiveness with regards to re-osseointegration and the impact of downsizing the implant diameter upon implant strength remain to be determined. Figure 3 illustrates the clinical and radiographic outcomes of an implantoplasty procedure.
Fig. 3: Implantoplasty over the contaminated implant surface. A, Radiography before the procedure. B, Implantoplasty procedure after open flap debridement. C, Clinical outcome. D, Radiographic outcome.
Conclusions
- A developed peri-implantitis lesion cannot be successfully and predictably treated with nonsurgical therapy alone.
- Any of the decontamination methods, such as air-powder abrasive, saline wash, citric acid, or the combination of these methods, did not show any significant difference regarding bone regeneration or ability to re-osseointegrate.
- Regardless the different methods of decontamination (mechanical debridement, chemical agents, air-powder abrasive, laser, saline wash, and ultrasonic), access flap surgery in combination with implant surface decontamination may be the best treatment in resolving inflammation, reconstruction of an ideal contour around implant, and arresting further bone loss.
- Beside various methods proposed for peri-implantitis treatment, it has been reported that the techniques used are effective in eliminating the inflammatory lesion but that re-osseointegration in the previously contaminated surface has been difficult or impossible to achieve.
- Despite all the treatment modalities have shown a minimum of bone fill in the peri-implant defect, it is known that true re-osseointegration is difficult to achieve.
Disclosure
The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the paper.
Acknowledgments
This work is partially supported by the University of Michigan, School of Dentistry, Periodontal Graduate Student Research Fund.
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