Protect Against Peri-Implantitis: Kill the Bugs in the Implant Channel

It goes in right on top of the screw and it's easy to take in and out. So when you are doing maintenance and you need to remove the restoration, you can literally reuse that silver plug again. Welcome to the Phil Klein Dental Podcast. The reality is a certain percentage of our implant cases will fail due to peri-implantitis. Of course, the level of home care by our patients is a big factor. But what we're learning now is that due to micro movement of the abutment in relation to the implant, the implant channel is a perfect environment to breed bacteria. And research is showing that the bacteria that colonizes there can progress and result in peri-implantitis. So what do we do about it? Specifically, how can we treat the implant channel to help prevent this insidious inflammatory condition? To tell us more about it is our guest Larry Clark. Larry is a well-respected dental researcher who has been involved in the dental industry for over 25 years. We'll be getting to our guest in a second, but first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the TMAC-Z and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the TMac-Z reduces overall cutting time by 30%. That means less share time, reducing the burden on you and your patient. Take a test drive of the TMAX Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. Larry, I'm very glad you can join us today. So let me start the podcast with this question. Why should dentists care about peri-implantitis? Why is it so important? It's not very well known in the United States, but it's very well known in Europe predominantly. And that's because they've been doing implants longer. And so in my recent trip to Europe, I became aware of the situation through a friend that I met. And I came back to the United States to do the research and spoke to many key opinion leaders that I've known for years and found out they had little to no knowledge. about periimplantitis and or what to do about it. And so the reason dentists should really be concerned about it is it's a bacterial situation that can not just evolve around the implant, but also in the implant. In the implant, that bacteria, which is very different from periodontal type bacteria, it has its own life forms, if you will. can definitely affect the amount of mucocytes and also artery implantitis, which ultimately leads to crustal bone loss. And so, you know, all dentists should be concerned about failure. And this is a primary area, as I can show you from different articles that have been written in the last couple of years, particularly by Dr. Marcus Blatz and his cohorts. And it's something that we can prevent. And that's the best part about dentistry. If we know something we can prevent, why not? So before we get into some of the things we can do to prevent periomplantitis, Larry, what are some of the factors that lead to it? What can lead to it is not having a complete understanding of the periodontal biome that's taking place in each patient. In other words, checking for existing periodontal issues, whether they're smokers, how their oral health maintenance takes place, are they good at it? Because maintenance is what we're learning in Europe is very, very important to controlling periimplantitis and mucocytes. What the research has shown, and this was done in 2021, there's different bacteria associated with peri-implantitis with implants. Because of micro-movement in the implant itself, It allows bacteria to enter into the screw channel or tunnel, if you will. And those bacteria that they're finding in there are far different than that of your typical periodontal issues. They find actually that there's a far higher... content of Staphylococcus auroras found on the implant sites, which is not frequently identified with teeth with periodontal disease, and even with healthy implants. Between the micromovement, which opens a gap between the abutment and the implant itself and allows bacteria to enter into the channel, the current products that are being used by dentists to fill that channel or tunnel, if you will, are not antimicrobial and have no ability to even seal. the channel itself. So this bacteria gets in, continues to grow, and it can get access not just at the abutment interface, but it also can get it from the hole, how it's sealed by the composite as well. So to clarify for our audience, the tunnel that you're talking about is that gap, that space in between where the screw is, the head of the screw, which secures the abutment to the implant. and the top of the occlusal surface of the abutment. So what are most dentists using to seal off that channel, that space? Right now, what most dentists are using is what we've, in the surveys I've seen around the country, including with key opinion leaders, is Teflon tape. And Teflon tape, despite what some of the advertisements might show, is not antimicrobial. In fact, does attract biofilm. And in some studies that I've seen, they'll find that vinyl polysiloxane and ZOE actually do a better job of sealing the channel. But they're also difficult to remove. So how is the Teflon tape used? Typically, the dentist would cut off certain sections of it and then pack it in on top of the screw after they've done their tightening. And they pack it until they get to a certain level where then they would place their composite restoration. So what is the research showing about the Teflon tape? Where is the leakage occurring? How does the bacteria colonize around it? Well, because of leakage in the composite itself, the composite margins, and also the movement of the abutment letting in these bacterias, the Teflon tape has no ability whatsoever to be antimicrobial. in fact, is very attractional to biofilm, which leads to the growth of the bacteria. So Larry, with the research that you're doing, and you're doing a lot of research on this topic, what are you seeing as the most important risk factors, the most dangerous risk factors that dentists face once they put that implant in? Well, the risk factors have been actually studied quite a lot. The government of Sweden has been studying implants since 2010, and they are reporting rates of failure in the 7% to 9% range. There's been studies also done in the United Kingdom, and they're showing high... Implant survival rates at about 94%. But in a 13-year follow-up, 90% of the patients experienced some form of mucositis or periimplantitis. And so they were showing that the main implant-based and subject-based periimplant mucositis prevalence was 30% and 46% for periimplant prevalence. And so the mean implant base and subject to the peri-implant prevalence was on average, and we're talking over 9,000 patients, was around 10%. You know, there's 3 million, basically the ADA is saying there's 3 million implants being placed a year, and it's growing at about 500,000 a year, at a rate of 500,000 a year. Some reports are showing 4% all the way to 10% failure. Although the implant companies are replacing the implants at no charge to the clinician, the patient factor and the expense for the clinician to replace these implants is significant. So after interviewing a lot of dentists who do implants on this podcast show, most of what I heard was that the culprit, the main culprit was cementing in the abutment. I know we're not doing that much anymore. obviously sticking to screw retained abutments, but you're saying that that channel that exists, that space, due to micro leakage can harbor bacteria that could still cause peri-implantitis in spite of being a screw retained system. So it's really not only the excess cement in the days where we used to cement these abutments in. Yes, this has been very well studied in the last 10 years in Germany. They've done a lot of cone beam technology showing with multiple manufacturers of implants, showing how they flex at the gingival, excuse me, at the crustal surface. And so they're actually opening up gaps at the abutment and allowing and basically sucking in the bacteria. And so it doesn't matter if your screw retained or if you're above the bone line or below the bone line, they're going to flex because of forces through occlusion. But as a researcher, Larry, on this topic, you agree that the excess cement of a cemented abutment into an implant system is certainly a major culprit for peri-implantitis and should be avoided at all costs if possible using a screw retained system. In fact, at the University of Washington, there's a professor there that I attended a lecture of his, and he went to every American dental manufacturer of dental implants. brought and pulled the failed dental implants to show that the highest percentage of implant failure was with cemented implants. So at the time, I was actually manufacturing a cement to be destined to be an implant cement. And we basically backed out of that entire project as a result of his lecture and his findings. So let's get into talking about What our audience really wants to hear about, and that is what could we do to prevent peri-implantitis? What kind of products and materials are available? Well, first and foremost, I think, is education of the dentist, but more importantly to the patient as well in their own oral hygiene. So that always has to be said. In terms of the application, it's very important that as you... assemble the abutment and go into seeding etc that you use proper technique and proper products for the antimicrobial products for cleansing and so as you apply these products for sealing the implant channel you're using your best septic techniques It's very, very important. Over the years, some people have used cotton pellets soaked with thymol or maybe CHG, but studies have shown that they don't last very long, maybe 30 to 90 days at best, and their ability to fight off antibacterial growth. It's one of the reasons that Dr. Antonini in Italy... his plug which is incorporates a nano silver special zeolite silver in nano sized particles into a polymer that is shaped like the canal and or the tunnel that are in all all implant manufacturers or used by all the implant manufacturers and so you just essentially cut this product to length after you've done your asepsis technique and seed it, leaving enough space for your restoration at the top. So it goes in right on top of the screw and it's easy to take in and out. So when you are doing maintenance and you need to remove the restoration, you can literally reuse that silver plug again. If you would, Larry, describe the consistency of this silver plug that is placed in this channel and how it's applied. It's essentially a slightly rubberized polymer that's dentin-colored, and it's impregnated with nanosilver that does not come out of the product. So there's no release of silver. What happens is when it's cut to length and then sealed under the composite, when... the bacteria is able to contact the silver plug, it dies on contact. So no biofilm or bacteria can form on it. So this plug gets placed right over the screw in that channel. What is the substantivity of this material? How long is it effective, essentially? Well, Dr. Antonini and others are tracking it now at 6 to 10 years. taking it in and out and still seeing its effects. Because when you take it out, you know, one of the most, the simplest ways to identify if it's working or not is by the smell. If you're not using, if you haven't used silver plug before, then you'll know that when you remove the Teflon tape or anything else that you've placed in there, there's always an important smell indicating that bacteria was growing there. With silver plug, there will never be that smell. That's probably the easiest way for the clinician to identify it. If you would, Larry, tell our audience where they could see a video on how this silver plug is actually used. Well, the videos are at the website, which is www.silverplug.us. And there are others in Europe as well. There's the BioM group. It's a big Facebook group of implantologists are using it consistently in posting. So what's the track record on this product, Silverplug? What data supports the fact that it's successful long-term? Dr. Antoniti went to the EU for approval and to the American FDA. He had 10 years of clinical documentation to show it worked. I was stunned by this. Having been in the manufacturing world for many years and having gone through the FDA many, many times, this is unheard of for anybody to go to the FDA or the MDR organization with clinical evidence that the product works. Tell us about the handling characteristics of this product. It's very important to dentists because one of the most important criteria, for instance, in the use of composites preventative products etc is the handling so when it comes to handling silver plug how easy is it to adjust and get into that implant channel? Well, the polymer has a really nice smooth surface. It literally slides easily into the channel and then you can compress it with an instrument of any sort and just as easily is removed. Just stick an explorer into the occlusal element of the plug and pull it out. It's easy to use, easy to place, and easy to remove. So these silver plugs are available at silverplug.us. That's the website. They're sold direct, not through distribution. And how are they packaged and what is the cost? For a pack of 20, it retails for about $199. So retail is about 10 bucks a piece. Right now they're 25% off and they probably will be for the first quarter of 24. Thank you, Larry, for your insight. Really appreciate your time and look forward to having you on future podcasts. Thank you, Phil. Appreciate your service very much. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.