Implant Rescue: Non-Surgical and Surgical Treatment of Peri-implantitis

The third stage of implant health is peri-implantitis, which is analogous to peritontitis in teeth. Peri-implantitis is basically irreversible, loss of bone, loss of attachment, and sometimes having aesthetic concerns, especially when these dental implants having peri-implantitis are in the anterior region of the dentition, in the, quote, the smile zone. Welcome to the Phil Klein Dental Podcast. Implants have changed the game for patients and clinicians, but when complications like peri-implantitis come up, things can get tricky. The good news? There are more tools than ever to help us manage it, both non-surgically and surgically. In this episode, we'll talk about everything from local drug delivery systems and at -home rinses to the right and wrong tools for cleaning implant surfaces. And when non-surgical approaches just aren't enough, we'll explore surgical options like resective and regenerative procedures. Plus, why laser therapy, especially NDAG, may be one of the best effective treatments we have. Our guest will answer the big clinical questions. When is it best to use local drug delivery? How long should patients stay on chlorhexidine? What makes implant regeneration different from periodontal regeneration? and why it matters. And why is laser therapy showing such promise in peri-implant care? So if you're looking for real-world strategies you can bring back to your practice, stick with us. This episode is packed with practical insights to help improve implant success and patient outcomes. Our guest is Dr. Jon Suzuki. He's a professor of microbiology and immunology and of periodontology and oral implantology at Temple University. A former dean at the University of Pittsburgh, he has chaired the FDA Dental Products Panel, led the ADA Council on Scientific Affairs, and served on numerous NIH committees. A diplomat of the American Board of Periodontology, he has published over 200 papers and a textbook, and continues to teach and educate dentists all around the world. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Suzuki, it's a pleasure to have you on the show. Thank you very much for having me, Phil. So to begin this podcast, let's talk about the progression of the disease process. that ends with peri-implantitis. It actually ends with extraction of the implant, but we're not going to get into that in this episode. So it begins with what in a natural tooth is gingivitis, but it's not called that with an implant. It's called mucositis. So let's talk about the three different stages, the progression of this disease, and that will set us up for what we're going to talk about further into the podcast episode, which is non-surgical and surgical intervention in order to preclude this disease from... getting to the point where the implant will fail and it would have to be removed? The implant health, I believe, can be designated into three different stages in terms of clinical presentation and overall prognosis. But the first stage is the stage of dental implants that we wish all our patients would have, and that's a healthy, maintained dental implant. The second stage is the earliest stage of disease, and that's referred to as peri-implant mucositis or peri-mucositis or sometimes implant peri-mucositis. Those are all synonyms with what I refer to as peri-implant mucositis. This is generally a soft tissue disease. It is readily reversible with improved oral hygiene and hygiene care. The third stage of implant health is periimplantitis, which is analogous to peritontitis in teeth. Periimplantitis is basically irreversible, loss of bone, loss of attachment, and sometimes having aesthetic concerns, especially when these dental implants having periimplantitis are in the anterior region of the dentition, in the, quote, the smile zone. Those are basically the three different levels that I consider the levels of implant health. Yeah, and we talked about on other episodes that we've done, Dr. Suzuki, how because of the lack of PDL in the implant architecture, the way it integrates with bone directly into the metal surface of the implant, we don't have that natural protection that we normally get with the periodontal ligament. And the soft tissue as well, because of the way, just the architecture of the way the implant is situated with our natural bone. So we have to be particularly careful about the progression of disease once we get out of stage one. And if it does go out of stage one into peri-implant mucositis, we certainly want to catch it there early as possible and treat it so that it doesn't... and progress into stage three, which is what you call peri-implantitis. And we all know that term, which is obviously detrimental to the implant survival, which we can actually lose the case if it's not treated. So let's talk about stage three for a minute. And we're talking about peri -implantitis. When do you find it most effective to use as a non-surgical approach, local drug delivery systems? And for my audience, What we're talking about here, local drug delivery systems, is actually putting the antimicrobial agent directly at the scene or the site of where the inflammatory response is. So how does that play a role and how does that fit into the overall treatment plan for periimplantitis? Well, in my opinion, the earliest stages of periimplantitis were, for example, there's one or two threads showing radiographically, or perhaps the probing depths are five to six millimeters of soft tissue. I believe, and once again, I want to emphasize in my opinion, local drug delivery systems may be beneficial in helping reverse or treat the disease. I also wanted to indicate, though, this is not an FDA -approved of this drug. They are primarily FDA approved for teeth in the dentition to treat periodontitis. So I wanted to emphasize that point, but it has worked selectively in many, many cases and other clinicians around the world have also successfully used it only in the earliest stages of periimplantitis. Coupled together, of course, with proper antimicrobial mouth rinses and improved oral hygiene. Yeah, so let's talk about the actual antimicrobial agent itself. What are we talking about specifically? Is it like a doxycycline or a minocycle? 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There's different types of local antimicrobial drugs that are, in fact, FDA-approved. Doxycycline is, of course, one of them. The chlorhexidines is another one. Minocycline is a third one. And there's no clinical publication that I know of that compares head -to-head each, any one of these three. I tend to use minocycline because it's the easiest to clinically manage and deliver to a periodontal pocket. an implant pocket. So once we identify the patient is in the stage of peri-implantitis, walk us through the clinical steps, including using local drug delivery in order to do our best non-surgically to treat this case. First of all, assuming that there are six... probings taken around that failing dental implant and carefully recorded of course the first step is to very carefully debride the area as much as possible using mechanical means and by mechanical means i mean either an ultrasonic or a piezo or perhaps even a nylon bristle brush to halt to mechanically remove any plaque any calculus that might be there then irrigate properly, and then as the final step before the patient goes home is to insert, inject a local drug delivery system like minocycline, very carefully selecting the deepest pocket of those six readings around the failing dental implant and injecting that particular drug according to the manufacturer's directions into that deepest area. And within the next 10 to 14 days, there is a circumferential dispersion of that local drug delivery system around the entire dental implant and an X antimicrobial for up to about two weeks of time. Let's say two weeks have passed. And during those two weeks, I'm sure they were given instructions to be fairly stringent, right, with home care, especially in that area. What's the prognosis look like in many of these cases, and what does it depend on? Does it depend on the pocket depth when it's first being treated? Is it more dependent on patient compliance at home, or is it the combination? How do we figure out a prognosis where we think we can get this peri-implantitis on this tooth under control? So from my clinical experience on this, among others that have used the local drug delivery system, DECD, the absolute determining factor is going to be the patient's home care. They have to very carefully enter proximate clean and, of course, possibly even using power brushes and other local irrigating devices in and around that area. Just a theoretical question, Dr. Suzuki. If someone had stringent, perfect, absolutely meticulous home care, being that's the main factor that is contributing towards a better prognosis, and no antibiotics were delivered. Is there any indication in your mind that the results would be the same without the antibiotics? It's my opinion that the local drug dealer system would be a great enhancement to the clinical success. Any experience with molecular iodine? Because I know that's becoming popular among periodontists for use in the pocket with periodontitis. I was wondering if you use that with periimplantitis. No, I have limited experience with molecular iodine, publications that support it, but I have not directly used it. Okay. And what about the, there's a term called substantivity, which basically, as you know, means how long something lasts effectively where it's being placed. Like mouthwash is very low substantivity. So you can rinse with it. It's antimicrobial, but 20, 30 minutes later, bacterial buildup starts to come back very quickly. Do we get some You mentioned two weeks on the local drug delivery system like minocycline. Can we get two weeks where it's actually effectively keeping the microbes at bay? Yes, two of these three local drug delivery systems, meaning minocycline, and doxycycline have up to 10 days to 14 days substantivity. The third product, which releases chlorhexidine, has a more limited substantivity of about 8 to 12 hours. What's your recommendation regarding the continued rinse of chlorhexidine? So I assume that they're rinsing during the period of substantivity of the actual antibiotics, and then that will extend after that, I assume? Yes, I recommend chlorhexidine 0.12% in the United States, 0.2% in the rest of the world, BID, according to manufacturer's directions. And I urge the patient to use this for two to three weeks after the debridement and the delivery of a local drug delivery system. So let's assume a clinician is listening to this podcast and they already have a good idea of how to treat these. cases of peri-implantitis, and they do everything as you suggest, including the local delivery of the antimicrobial drug, the sustained rinse of chlorhexidine. When they come back for their three-month recall, assuming compliance is high at home, what are we looking at as far as success rate? And I know it depends on how bad the peri -implantitis is, but let's assume that it's early stage. What are we looking at as far as getting this thing healthy again? The prediction of success for treating peri-implantitis, I believe, is at least 50%, if not higher, predicated upon the patient's home oral care and home oral hygiene, and also following directions and using the post-operative care mouth rinsing. So to me, it is more the patient's responsibility at this point in time. Before we continue, I've got to give a shout out to our sponsor, NSK. These folks are the real deal. 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I know they're hard to compare because, you know, a very severe case of periodontitis obviously has a less prognosis than a mild case of peri -implantitis, but... The bottom line is once it gets to a stage where there is bleeding on probing, separation, threads are visible, that's kind of more difficult to reverse and manage than periodontitis, is it not? Yes, it is. And you've also explained it biologically, Phil, with the lack of a periodontal ligament in dental implants, there is also a lack of vascularity around the implant for nutrients, for oxygen. There's also a lack of the immune response and other protective defense mechanisms around the dental implant. So those all fall into play at making the implant higher risk and more difficult to treat. The second factor is that the soft tissue adhesion to a dental implant is only the epithelial attachment. There is no soft tissue attachment in dental implants like there is the network of gingival connective tissue fibers with teeth. probably remember the term biological width of teeth. Well, there is no biological width of epithelial connective tissue and PDL to dental implants. So there's a vast anatomical and physiological difference between the two. Yeah. And that's why dental hygienists are scared to death to probe these implants because they're afraid they're going to tear right through the hole. Whatever soft tissue is there, they're going to go right through it. What is your recommendation about probing? Is there some sort of gentle? approach to getting those six readings that you talked about earlier? My general rule of thumb is that after surgical placement, that the restorative dentist and the dental hygienist wait nine months of time before you probe or before you scale that particular area. I'm giving you a nine-month benchmark. based primarily on the University of Maryland Hanna studies where they did block sections of bone grafts around teeth looking for regeneration but dental implant osteointegration is really not on the same level but with the zone of safety that I like to give my patients I generally recommend waiting nine months because that's when regeneration is complete around teeth and that's when I We'll proceed with regeneration complete around dental implants. So getting into the instruments themselves, typically we use stainless steel for our scaling and root planing. Obviously, stainless steel is not the ideal material on implants, I assume. And please clarify that. And what instrument materials do you recommend? do not recommend stainless steel instruments at all around dental implants one of my graduate students and i did a research project early on in 2012 looking at stainless steel and the impact on dental implants and we determined the large gouges result from using stainless steel implants on titanium necks. But secondly, also, in addition to that, they have a great impact of stainless steel and other types of metal curettes and other types of ultrasonic and piezo devices. So I would refrain from using any type of stainless steel on dental implants. I do recommend resin scalers and I do recommend titanium scaler curettes around dental implants. And these tips that you're saying on the piezo ultrasonics and on the magnetostrictive ultrasonics, what is that material made out of those tips? Basically, they're stainless steel tips, but the manufacturers have... designed an acrylic or a plastic sleeve to put over the stainless steel tips as a safety mechanism. And that probably is very safe to use if you use these plastic sleeves over the stainless steel tips. So the goal, of course, is not to scratch the surface of the implant, which is titanium. And stainless steel will do that. And in those scratches, you get this colonization of bacteria. And I assume that's a... culprit to periimplantitis. Colonization and bacteria coupled together with what we now realize is the release of metal corrosion products and metal shards from that particular series of devices. Implant regeneration, the whole concept of implant regeneration is modeled after periodontal regeneration. And you could understand why, because that's what we've studied for decades and decades. But as we mentioned, several times in this podcast and others that we've done that implants do not have a ligament like natural teeth do. They don't have a PDL. So how does this difference change your approach to regenerative procedures around implants? Because the implants do not have a PDL, in my opinion, they're much more susceptible to occlusal disharmonies, including prematurities during different excursive movements, and especially for bruxism and parafunctional habits. So I highly recommend a retainer or a night guard for all implant patients because that implant does not have the give or the, quote, the forgiveness that a PD-L around a tooth might give the dentition. So let me ask you this. When we're in the stage of peri-implantitis and we went non-surgical in the beginning, which we always want to be conservative, and we did all the stuff that you recommended. We used targeted therapy with antimicrobial agents like doxycycline or minocycline delivered right at the site. We had them on chlorhexidine rinses for two weeks, stringent home care protocol, good home care education and everything else. And it's not hitting the mark. And we're starting to see the threads of the implant more apical than we would like. And it's not progressing in the right direction. It's actually going in the wrong direction. So when do you make that decision where we have to go surgery? And what does the periodontist actually plan to do in most of these cases as a surgical procedure to save this implant? If you're looking for speed, beauty, and strength in a zirconia block, check out Katana One Speed. It is a game changer in CAD CAM dentistry. To learn more, visit curaridental.com. Well, there's three approaches that... uh a periodontist a specialist or restorative dentist can use when the particular peri-implantitis stage is triggered from mild stage to more moderate stage and i'm defining that moderate peri -implantitis as two to five threads of exposure into the oral cavity or scene radiographically so between two and five threads showing or up to 50 percent of bone loss around a dental implant then there's three different avenues of approach that I believe a clinician can use to manage the periimplantitis. One of them is a resective approach, which is apically positioning the flaps, removing the threads of an implant, and making the implant surface smooth so that the patient can at least keep it clean and free of plaque. The second approach is a regenerative approach and using the decades of research about tooth regeneration, bone grafts coupled together with membranes and other types of biologics can also rebuild that lost attachment apparatus of the dental implant. The third approach, which is relatively a novel approach, new approach, are the use of dental lasers. More recently, I've been using the neodymium YAG laser at 1064 nanometers to treat many cases of periimplantitis as well. So those are the three approaches that clinicians can use. Are any of these surgical approaches performed concurrently? The answer is no. Once a decision, once a clinical decision has been made as to how to best approach the management of this periimplantitis, you pretty much have laid out the treatment plan. A resector procedure, for example, when you're removing threads and bone, that's totally irreversible and cannot be reversed in any way. And patients just have to live with it and try to keep that area clean in the long term. of that particular dental implants that's been treated with the resective approach is highly questionable in my opinion. With the resective approach, the ratio is not favorable as it was obviously when the implant was put in and it was fully integrated because you're smoothing out the coronal portion of that implant so that it's more cleansable, I assume, right? Because it's no longer, that thread is no longer benefiting the patient because there's no integration there anymore. Yes, you're dramatically changing the crown root ratio, which restorative dentists and prosthodontists know very, very well. And secondly, you're causing a large impaction area for food. As some of my patients claim, they get a second helping of food, even when they go home from a restaurant. And then the third approach, it could be very unaesthetic, especially if it's in the smile zone. So what is the determining factor that influences the periodontist to either go resective or regenerative in their approach to the surgery of that implant? Well, it's a clinical... decision at that time but in my opinion the regenerative approaches are favored by the topography of the osseous defect so what we know in bone grafting and probably an extraction socket is the best example of it phil that when there's four walls or five walls around an osseous defect it serves as a very very nice collection point for a bone graft material to be placed into it and to result in regeneration. When there's less walls available, like one wall or two walls, or even no walls at all, then a regenerative approach will not work as predictably. And so therefore you may favor another approach. Now you mentioned Dr. Suzuki lasers as one of the surgical approaches to handling peri-implantitis. ND YAG laser, I think 1064 nanometers, what you mentioned. Tell us about that. Yes. And it's the one that I am a certified instructor of currently. But the neodymium YAG laser at 1064 nanometers, in my view, actually has more predictable results than either of the first two. If that particular laser approach is moderate or does not work completely to your satisfaction, the clinician still can use one of those other two modalities. But when you choose the other two modalities, generally speaking, you don't go and use the laser. So to me, the laser approach is relatively conservative based upon the first two. So tell us what you're actually doing with the laser. And is there a need to flap the tissue? It's no flap at all. It's a procedure called LAPIP, Laser Assisted Periimplantitis Protocol, virtually a non-surgical approach coupled together with the two different settings of the laser with a piezo debridement in between, entirely non -surgical approach for in my opinion, pretty good favorable regeneration around a failing dental implant. What is that laser doing besides decontaminating? Is it encouraging bone growth? As I published in 2017 in the compendium, this laser has the capability of four different approaches. First of all, of removing the pocket lining of epithelium, which is frequently laced with contaminating bacterial and chronic inflamed tissue. The second is basically an antimicrobial approach, killing especially. the most putative periodontal pathogens, such as the black pigmented bacteroides. And then third, a very, very strong anti-inflammatory component. It releases and reduces the arachidonic acid pathway. And there is much less prostaglandin being produced and therefore translating to less pain, less discomfort for the patient, less inflammation for the patient. And fourth is biostimulation. The laser stimulates. The wound healing cells, the laser stimulates the immune response. So therefore, the outcome is more accelerated in terms of a normal wound healing response. So on principle, when we're treating patients with periodontal disease that can't be handled at the GP level, the general practitioner level, they send it out to a periodontist and they do what they can to make the pockets manageable by the patient. so they could be cleansable, right? I mean, if the pockets are too deep, you could scale and root plan all day long at the general dentist. The patient can't maintain eight millimeters, so something has to be done about it, so they send it to a periodontist. And correct me if I'm wrong anyway, I'm an endodontist, so I'm talking from a different perspective. But when you're talking about this laser here, and let's say that that particular implant has a deep pocket around it, what is that laser doing to reduce pocket depth to make it more cleansable? The laser is, first of all, removing the pocket lining of epithelium in that pocket. Secondly, the laser is killing bacteria. The third is that once there's bleeding in and around that site of wound healing, the laser by a process called hemostasis, traps that particular osteogenic molecules in the site, which is similar to a PRP or PRF. And the fourth is stimulating the wound healing cells and the bone and fibroblast healing cells inside of that pocket. So those are the different steps of what the laser is potentially capable of doing inside of that healing pocket. With the research showing all this, Dr. Suzuki, it would seem to me that every periodontist should be exploring this technique using the laser so that it can accomplish these physiologic changes to the inflamed area. It's a clinical choice, and it's the choice that I've already made clinically and the one that I teach, Phil. Right, so it's just a matter, you can't change everybody, right? Even though it could be proven to be the best solution ever, clinicians tend to go with the way they want to go. Let's hope more of these doctors out there, these specialists, and I guess general dentists can also use a laser. I'm sure there are many out there that may be rural dentists that don't have periodontists that they could send to that's close by. They should have a laser in their office and do these treatments themselves, right? Absolutely. Actually, in the boot camps that I've given in Saritas, California, probably at least 50% of my docs that have registered for the course are periodontists, but the other 50% are restorative dentists. So it's probably a pretty even mix at this point in time. And of course, we do have a collection of oral and maxillofacial surgeons taking it because oral and maxillofacial surgeons are also faced with failing dental. implants yeah absolutely absolutely again thank you very much Dr. Suzuki have a great evening and uh we look forward to having you on future programs thank you phil for having me again