Treatment of Peri-implantitis Lesions with
Laser-assisted Therapy and a Minimally in
Invasive Approach: A Case Report
Elvan Efeoglua, Gulin T. Eyyupoglub
a Professor, Dr, Department of Periodontology, Faculty of Dentistry, Marmara University, Istanbul,
b PhD Student, Department of Periodontology, Faculty of Dentistry, Marmara University, Istanbul,
In addition to conventional treatment modalities, the use of lasers has been increasingly proposed
for the treatment of periodontal and peri-implant infections. A 56-year-old female patient had 5 implants with se-
vere and painful peri-implantitis lesions. Local and systemic anti-infective therapies were performed as an adjunct
to mechanical treatment but suppuration still persisted. This condition resolved after 3 treatments with diode
laser (810 nm) irradiation (1.0 W, CW). During the operation, 2 failed implants were removed, and Er,Cr:YSGG
(2780 nm) laser was used for decontamination of implant sockets (1.0 W, 20 Hz) and implant surfaces (0.5 W,
20 Hz), then the implant sockets were augmented. After ten months, radiographic findings showed bone fill in
the area of removed implants and no lesions around remaining implants. Laser decontamination provided us with
the opportunity to augment the sites without losing soft and hard tissues.
J Oral Laser Applications 2008; 8: 109-116.
Peri-implantitis has been defined as an inflammatory pathogens, other local, systemic, and genetic factors
process affecting the tissues around an osseointe-
must coexist in order for prolonged, active infection to
grated implant in function, resulting in loss of support-
actually take place. The most remarkable of these fac-
ing bone.1 It has been reported that the microbiota
tors include smoking, non-parallel implant direction,
associated with peri-implantitis corresponds to that ob-
excessive mechanical stresses on the implant, systemic
served at sites with advanced periodontitis, and it has
conditions, long-term treatment with corticoids, and
been suggested that periodontal pathogens present in
radiation and chemotherapy.5
the periodontal pockets of teeth may colonize newly
Diagnosis is based on changes of color on the peri-
inserted implants and give rise to tissue breakdown.2
implant mucosa, bleeding on probing, increased prob-
This is very common in the case of partially edentulous
ing depth, suppuration, peri-implant radiotransparency
patients with active periodontal disease and who also
and gradual loss of bone height around the implant.6
bear implants. In this group of patients, colonization of
Clinically unhealthy implants are classified as "ailing"
the peri-implant sulcus is observed in one month fol-
or "failing".7,8 It is necessary to distinguish between an
lowing the connection of the implant to its prosthetic
ailing vs a failing implant to determine the treatment
abutment.3,4 This colonization does not necessarily
steps necessary to salvage the unhealthy implant. Im-
imply that peri-implantitis will develop with the subse-
plants exhibiting soft tissue problems exclusively are
quent rapid loss of bone height; hence, it is suggested
classified as ailing and have a more favorable pro-
that, in addition to the presence of these periodontal
gnosis.7,9 Peri-implant mucositis involves inflammatory
Vol 8, No 2, 2008
changes confined to the soft tissue surrounding an im-
ria kill rates of up to 99.4% have been attained.18 The
plant.10 Therefore, an implant exhibiting peri-implant
semiconductor 809-nm, the CO2 and Er:YA t
mucositis is an ailing implant. In some instances, the ail-
ecommended, since it appears that they do not
ing implant may have exhibited early bone loss along
exert a negative impact on the implant surface. The
with soft tissue pocketing.7,9
enerates the least amount of heat in the
Clinically, lack of osseointegration leads to implant
bone tissue surrounding the im
mobility and subsequent failure. Therefore, a mobile
mination mechanism of the lasers is based on their
implant is a failed implant. Non-functional, failed im-
thermal effect, which denatures proteins and produces
plants must be removed to prevent the associated
cell necrosis.21 Another type of laser with a low ther-
bone loss from continuing. The option of removing the
mal effect on the bone and implant surface is the
implant, allowing for healing, and then placing a new
Er,Cr:YSGG, which represents an improvement over
implant should not be ruled out.11
the technical properties of the Er:YAG.6
Treatment options for ailing and failing implants are
Further regenerative treatment will depend on the
varied. The clinician should start conservatively and
amount of bone loss and the esthetic impact of the im-
progress to more invasive therapy, based on a system
plant in question. The main problem is augmentation of
of comulative interceptive supportive therapy (CIST).12
the area in intrabony defects surrounding the implant
The overall goal of therapy is to establish a functional
and implant socket after removing the implant; if bone
restoration and acceptable esthetics. Therefore, any
loss is advanced, it will be necessary to surgically de-
therapy provided should arrest further loss of bone
bride the soft, peri-implant tissues affected by the
support and re-establish a healthy peri-implant mucosal
chronic infection, decontaminate the microimplant sur-
face and, finally, apply bone regeneration techniques
Various therapies have been advocated for the reso-
aimed at recovering the lost bone.22 Bone substitutes
lution of the peri-implant infection and in the restora-
should not be placed in infected sites. The clinician
tion of the peri-implant tissues. The most conservative
should be confident that any active or recent infection
approach to treatment involves nonsurgical therapy.
has been properly treated.
This kind of treatment modality includes three subcate-gories: pharmacological therapy, occlusal therapy, andmechanical debridement.8,10 Pharmacological therapies
include subgingival irrigation with disinfecting agents,and topical and systemic antibiotics.9,10 Bacteria associ-
In this case report, a 56-year-old female patient with
ated with failing implants have been found to be sensi-
severe and painful peri-implantitis lesions is presented
tive to the following antibiotics: penicillin G, amoxicillin,
combination of amoxicillin and metronidazole, and
Her chief complaints were continuous and extensive
pain in the mandibular anterior region, extraoral red-
Mechanical debridement of tissues surrounding an
ness, and swelling, which made it painful for the patient
implant using either plastic hand instruments or ultra-
to touch this area. However, there was no lymphoid in-
sonic instruments with a plastic tip has been suggested.
volvement observed. Intraoral examination revealed an
Plastic instruments are necessary to debride plaque
edentulous maxilla and a complete denture. This exam-
from titanium dental implants without damaging the
ination further revealed five implants in the anterior
soft titanium surface.15, 16
mandible, which were inserted five years ago, two of
The clinician may use a surgical approach when non-
which failed with pus discharge and inadequately at-
surgical therapies are not indicated or are unsuccessful.
tached gingiva (Fig 2), one of the implants was dys-
In an implant affected by "infectious failure," the
functional, and the last two were observed to have
assumption is implant surfaces exposed to periodon-
moderate and severe peri-implantitis. In the first and
topathogens have become contaminated with endotox-
second molars of the posterior mandible, gingival in-
ins that may interfere with the repair process.16 The
flammation with deep pockets and Class III furcation
first step in surgical therapy is exposing and treating
defects were seen. Moreover, mobility on left second
the bacterially contaminated implant and bone tissue
premolar and molars were observed.
The patient was prescribed combined antibiotic
In the literature, efficacy studies of surgical lasers as
therapy amoxicillin-clavulanate (1000 mg) and ornida-
a method of decontamination on different implant sur-
zole (500 mg) for five days and instructed to apply
faces depending on power intensities show that bacte-
home care. The mechanical periodontal therapy with
The Journal of Oral Laser Applications
Fig 1a Clinical view at first visit.
Fig 1b Radiographic view at first visit.
Fig 2 Inadequate gingival attachment and diffuse inflammation of
Fig 3 Povidone-iodine irrigation.
peri-implant and lip mucosa.
an ultrasonic device, plastic curettes, and intrapocket
Subsequently, the surgical phase was planned to im-
povidone iodine (10%) irrigation was performed for
prove the success of the augmentation of the implant
several appointments (Fig 3). However, pus discharge
sockets with the help of Er,Cr:YSGG laser (wavelength
was persistent around the two failed implants; there-
2780 nm) decontamination. During the operation, two
fore local metronidazole gel (25%) was applied as an
failed implants were removed (Fig 5), intrabony granu-
additional treatment. Slight improvement and gingival
lation tissues were eliminated (Fig 6), and Er,Cr:YSGG
recession was observed, but pus discharge was still pre-
laser irradiation was used to decontaminate implant
sockets and implant surfaces with a Z3 probe (320
As all of these conventional treatment approaches
μm) in a noncontact mode (Fig 7). The energy settings
failed to stop the suppuration, it was agreed upon to
on the control panel were 1.0 W, 20 Hz, 11% air, 10%
support the treatment with laser decontamination
water for implant sockets and 0.5 W, 20 Hz, 11% air,
therapy. The condition resolved after three exposures
10% water for implant surface, and energy densities of
to subgingival diode laser (wavelength 810 nm) irradia-
37.5 and 25 J/cm2, respectively.
tion with energy outputs of 1.0 W, continuous wave,
Decontaminated implant sockets were augmented
and 600-μm flexible fiber delivery system (Fig 4).
with bone substitutes and collagen membrane (Bio-Oss®, Bio-Gide®) (Fig 8).
Vol 8, No 2, 2008
Fig 4 Diode laser irradiation.
Fig 5a Removal of the bridge and spontaneous extraction of
Fig 5b The axes of the implants were not parallel.
Fig 6 Infected implant sockets and peri-implant bone defect.
Fig 7a Implant surface decontamination with Er,Cr:YSGG irradia-
Fig 7b Socket decontamination with Er,Cr:YSGG irradiation.
The Journal of Oral Laser Applications
Fig 8a Alveolar augmentation with bone substitutes.
Fig 8b Placement of collagen membrane.
Fig 9 Placement of the e-PTFE membrane over the collagen
Fig 10 Appearance of the augmented area after six weeks.
Due to inadequately attached gingiva, a second layer
satisfactory for the patient in terms of function and es-
consisting of e-PTFE membrane was placed for protec-
thetics (Fig 14). Follow-up is planned after the first
tion of the augmented area (Fig 9). The healing period
phase of treatment, with intervals of three months.
was uneventful (Fig 10).
After ten months, radiographic findings showed
bone fill in the area of the removed implants and therewere no lesions around the remaining implants (Fig
This case presents the possible clinical consequence of
11). Consequently, the first phase of the main therapy
incorrect treatment planning, including keeping peri-
was completed. The patient preferred to postpone the
odontally affected teeth, improper prosthetic restora-
tions, and non-parallel implant direction on the long-
The mobile premolars and molars on the left side of
term stability of dental implants. Fardal et al4 also pre-
the mandible were splinted with fiber-supported com-
sented a case with severe peri-implantitis in a patient
posite restorations (Fig 12). The patient's current fixed
with refractory periodontitis. They suggested that the
partial denture with implant abutment was not re-
remaining teeth had acted as a reservoir for periodon-
placed, but was cemented again temporarily.
tal pathogens involved in the peri-implantitis lesions.
Occlusal adjustment was performed (Fig 13), due to
There is considerable evidence to support a cause
combination syndrome. This part of the therapy was
and effect relationship between microbial colonization
Vol 8, No 2, 2008
Fig 11 Bone fill and preservation of bone level at tenth months.
Fig 12a Fiber splint material.
Fig 12b Fiber-supported
uni-composite restoration to
stabilize mandibular left pre-
molar and molar.
Fig 13 Occlusal adjustment to eliminate primary contacts.
Fig 14 Esthetic appearance.
and the pathogenesis of implant failures.23-25 Deconta-
done iodine (10%) was also used as an adjunct to sys-
mination of structured implant surfaces is difficult to
temic antibiotics, and although subsequent local
achieve, since conventional mechanical treatment ap-
metronidazole gel failed to stop the suppuration, it did
proaches, such as plastic curettes, sonic/ultrasonic
somewhat decrease it. At the same time, mechanical
scalers, and air-powder flow, have been proven to be
debridement was performed at every appointment.
insufficient for obtaining a complete removal and elimi-
During the nonsurgical phase of therapy, ceasing the
nation of both plaque biofilms and bacteria on rough-
disease activity and elimination of infection was thus
ened implant surfaces.26,27 The use of topical antiseptic
achieved by diode laser (810 nm) irradiation.
agents and locally applied antibiotics is recommended
During surgical-phase planning, it is essential for the
for implant detoxification. Povidone iodine is widely
clinician to recognize unhealthy implants and to deter-
used as a topical antiseptic in medicine and potentially
mine whether they are ailing, failing, or failed. Ailing
beneficial in the management of some periodontal dis-
and failing implants are amenable to therapy. Implants
eases.28,29 Controlled release devices that contain
diagnosed as failed should be removed. Extraction of
metronidazole (25%) are also beneficial agents in an-
implants may result in a severely deformed alveolar
timicrobial periodontal therapy.30 In this case, povi-
ridge, and restoration of these cases is usually difficult,
The Journal of Oral Laser Applications
because of oral hygiene, esthetic, and prosthetic prob-
lems. The most important measure to this end is to de-
1. Albrektsson T, Zarb G, Worthington P f
contaminate implant and tissue surfaces beforehand, in
, Eriksson AR. The long-
term efficacy of currently used dent
plants: a review and pro-
order to enable bone regeneration to take place. With
posed criteria of success. Int J Oral Maxillofac Im
the help of Er,Cr:YSGG laser, decontamination was
provided without producing any increase of tempera-
2. Leonhardt A, Adolfsson B, Lekholm U, We
om M, Dahlen G.
ture on the irradiated area.
A longitudinal microbiological study on osseointegrated titanium
The combination of bone substitutes and a collagen
implants in partially edentulous patients. Clin Oral Impl Res 1993;4:113-120.
membrane seems to be preferable in the surgical treat-
3. Danser MM, Van Winkelhoff AJ, Graaff J, Loos BG, Van der
ment of peri-implantitis defects and socket augmenta-
Velden U. Short-term effect of full-mouth extraction on peri-
tion. In this context, it must also be emphasized that
odontal pathogens colonizing the oral mucous membranes. J Clin
membrane exposure has been reported to be a fre-
quent complication.31 In the present case, successful
4. Fardal Ø, Johannessen AC, Olson I. Severe, rapidly progressing
peri-implantitis. J Clin Periodontol 1999;26:313-317.
decontamination was achieved by laser. Subsequently,
5. Quirynen M, Listgarten MA. Distribution of bacterial morpho-
augmentation of peri-implantitis defects was performed
types around natural teeth and titanium implants ad modum
with bone substitutes and double-layer membrane,
Branemark. Clin Oral Impl Res 1990;1:8-12.
which resulted in decreased radiolucency within the im-
6. Sanchez-Garces MA, Gay-Escoda C. Periimplantitis. Med Oral
plant sockets and gain in the alveolar bone height.
Patol Oral C›r Bucal 2004;9(supplement):63-74.
7. Meffert RM. Treatment of the ailing, failing implant. J Calif Dent
8. Meffert RM, Langer B, Fritz ME. Dental implants: a review. J Peri-
9. Meffert RM. Maintenance and treatment of the ailing and failing
The development of laser assisted techniques in peri-
implant. J Indiana Dent Assoc 1994;73:22-24.
odontology and implantology is directed towards mini-
10. Jovanovic SA. The management of peri-implant breakdown
mally invasive procedures, with high success rates,
around functioning osseointegrated dental implants. J Periodontol1993:64(supplement):1176-1183.
which result in shorter healing periods, high patient
11. Torosian J, Rosenberg ES. The failing and failed implant: a clinical,
comfort, and predictability of the final result. In the
microbiologic, and treatment review. J Esthet Dent 1993;5:97-
presented case, both diode and Er,Cr:YSGG lasers in
the nonsurgical and surgical steps of the treatment
12. Branemark PI, Hansson B, Adell R, et al. Osseointegrated im-
were used. The highest risk factor in the augmentation
plants in the treatment of the edentulous jaw. Experience from a10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1-
procedure and in regenerative periodontal surgery is
infected implantation defects/sockets. Placement of the
13. Danesh-Meyer MJ. Dental Implants. Part I: Biological basis, im-
bone substitutes and membranes into infected alveolar
plant types, and the peri-implant sulcus. J N Z Soc Periodontol
sockets would result in an unsuccessful treatment. In
this case, laser decontamination was the only option
14. Matarasso S, Quaremba G, Coraggio F, et al. Maintenance of im-
plants: an in vitro study of titanium implant surface modifications
for a minimum-risk treatment, without losing soft and
subsequent to the application of different prophylaxis proce-
hard tissues and without the need for a second surgical
dures. Clin Oral Impl Res 1996;7:64-72.
operation. Finally, proper attention to personal and
15. Rams TE, Link CC jr. Microbiology of failing dental implants in hu-
professional plaque removal will allow the maintenance
mans: electron microscopic observations. J Oral Implantol 1983;11:93-100.
of a successful treatment outcome. Within the limits of
16. Rapley JW, Swan RH, Hollman WW et al. The surface character-
the present case, it can be concluded that laser decon-
istics produced by various oral hygiene instruments and materials
tamination may be a favorable choice for elimination of
on titanium implant abutments. Int J Oral Maxillofac Implants
17. Meffert RM. How to treat ailing and failing implants. Implant Dent
18. Kreisler M, Kohnen W, Marinello C, Schoof J, Langnau E, Jansen
B et al. Antimicrobial efficacy of semiconductor laser irradiationon implant surfaces. Int J Oral Maxillofac Implants 2003;18:706-
The authors would like to thank Enver Atali, Electronic Engi., for
his kindest technical support.
19. Walsh LJ. The use of laser in implantology: an overview. J Oral
20. Kreisler M, Al Haj H, d´Hoedt B. Temperature changes at im-
plant bone interface during simulated surface decontaminationwith an Er:YAG laser. Int J Prosthodont 2002;15:582-587.
Vol 8, No 2, 2008
21. Goldman MJ. Bone regeneration around an ailing implant using
27. Greenstein G. Povidone-iodine's effects and role in the manage-
guided bone regeneration. A case report. J Periodontol 1992;
ment of periodont
al diseases: a review C
22. Alcoforado GA, Rams TE, Feik D, Slots J. Microbial aspects of
28. Rosling B, Hellström MK, Ramberg P
, Socransky SS, Lindhe J. The
failing osseointegrated dental implants in humans. J Parodontol
-iodine as an adjunct to non-surgical treatment of
chronic periodontitis. J Clin P
23. Becker W, Becker BE, Newman MG, Nyman S. Clinical and mi-
29. Stelzel M, Flores-de-Jacoby L. T
opical metr r
crobiologic findings that may contribute to dental implant failure.
compared with subgingiv
al scaling. J Clin P nce
Int J Oral Maxillofac Implants 1990;5:31-38.
24. Mombelli A, Buser D, Lang NP. Colonization of osseointegrated
30. Nociti FH Jr, Machado MAN, Stefani CM, Sallum EA, Sallum AW.
titanium implants in edentulous patients. Early results. Oral Mi-
Absorbable versus nonabsorbable membranes and bone grafts in
crobiol Immunol 1988;3:113-120.
the treatment of ligature-induced peri-implantitis defects in dogs.
25. Schwarz F, Sculean A , Romanos G, Her ten M, Horn N,
Part I. A. clinical investigation. Clin Oral Impl Res 2001;12:115-
Scherbaum W, Becker J. Influence of different treatment ap-
proaches on the removal of early plaque biofilms and the viabilityof SAOS2 osteoblasts grown on titanium implants. Clin Oral In-vestig 2005;9:111-117.
Contact address: Professor E. Efeoglu, Buyukciftlik Sok.
26. Kreisler M, Kohnen W, Christoffers AB, Gotz H, Jansen B,
No.6 Nisantasi/ Istanbul 34365, Turkey. Tel: +90-532-334-
Duschner H, d'Hoedt B. In vitro evaluation of the biocompatibil-
03-58, Fax: +90-212-291-74-15. e-mail: e.efeoglu@superon-
ity of contaminated implant surfaces treated with an Er: YAG
line.com or [email protected]
laser and an air powder system. Clin Oral Implants Res 2005;16:36-43.
The Journal of Oral Laser Applications
Somatostatin and Epidermal Growth Factor Receptors: Implications in Breast Cancer Geetanjali Kharmate and Ujendra Kumar Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada. Received on May 30, 2013; Accepted on June 8, 2013; Published on June 22, 2013 Correspondence should be addressed to Ujendra Kumar; Phone: (604) 827-3660 , Fax: (604) 822-3035 , Email: [email protected]
NICOTINE AND DRUG INTERACTIONS lung physician Tartu University Lung Clinic ABRUPT SMOKING CESSATION CAN AFFECT THE METABOLISM OF DRUGS. When patients enter hospital they may have to stop smoking abruptly if the hospital has a ‘no smoking' policy. Cigarette smoking induces the activity of human cytochromes P450 (CYP) 1A2 and 2B6. Decreased CYP1A2 activity after smoking cessation