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Periimplantitis Treatment: Long-Term Comparison of Laser Decontamination and Implantoplasty Surgery Bernhard Pommer, DDS, PhD,* Robert Haas, DDS, MD, PhD,† Georg Mailath-Pokorny, DDS, MD, PhD,† Rudolf Fürhauser, DMD, MD,‡ Georg Watzek, DDS, MD, PhD,† Dieter Busenlechner, DDS, PhD,§ Michael Müller-Kern, DMD,¶ and Claudia Kloodt, DMD¶
he condition of periimplantitis has been described as infectious pathology of periimplant tissues.1 More specifically, as agreed on at the 1st European Workshop on Periodontology in 1992, it has been described as a destructive inflammatory process around osseointegrated dental implants in function that leads to soft tissue pocket formation and loss of dentoalveolar bone.2 Symptoms of periimplantitis have been defined to involve3,4 bleeding and/or suppuration upon gentle probing, swelling and/or discoloration of the marginal soft tissue, periimplant probing depths of at least 4 mm, and infectious destruction of marginal bone tissue, not to be confused with bone loss following implant placement due to remodeling, without notable signs of implant mobility or loss of osseointegration. Periimplantitis has a prevalence of 10% of implants, and 20% of patients in the period of 5 to 10 years after implant
T
*Associate Professor, Oral Surgeon and Researcher, Academy for Oral Implantology, Vienna, Austria. †University Professor, Oral Surgeon and Founding Partner, Academy for Oral Implantology, Vienna, Austria. ‡Chief Physician, Prosthodontist and Founding Partner, Academy for Oral Implantology, Vienna, Austria. §Associate Professor, Oral Surgeon and Partner, Academy for Oral Implantology, Vienna, Austria. ¶Periodontist, Academy for Oral Implantology, Vienna, Austria.
Reprint requests and correspondence to: Bernhard Pommer, DDS, PhD, Academy for Oral Implantology, Lazarettgasse 19/DG, Vienna A-1090, Austria, Phone: +43 1 402 8668, Fax: +43 1 402 8668 10, E-mail:
[email protected] ISSN 1056-6163/16/02505-646 Implant Dentistry Volume 25 Number 5 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ID.0000000000000461
Purpose: Periimplantitis is the most frequent cause of late implant failure; however, little is known about the long-term success of periimplantitis treatment and the effectiveness of various therapeutic interventions. Materials and Methods: A total of 142 patients were referred to the Academy for Oral Implantology in Vienna for the treatment of recurrent periimplantitis around single-tooth implants. Of them, 72 patients (51%) were treated by laser decontamination, 47 patients (33%) by implantoplasty surgery, and 23 patients (16%) by a combination of both approaches. Results: Overall success of periimplantitis therapy was 89% after 9 years of follow-up, and it did not differ significantly between female and male patients (P ¼ 0.426). The number of implant failures that
could not be prevented by periimplantitis treatment was 6 after laser decontamination (8%), 6 after implantoplasty surgery (13%), and 4 after a combination of both therapies (17%). Implant loss occurred after 4.9 6 1.9 years of therapy, on average. No significant difference between the 3 treatment groups could be observed (P ¼ 0.393). Conclusion: The present results suggest that success rates of periimplantitis therapy with either laser decontamination or surgical implantoplasty are high. These success rates do not appear to be associated with patient gender or treatment strategy. (Implant Dent 2016;25:646–649) Key Words: dental implants, periimplant infection, biological complication, antiinfectious therapy, long-term survival
placement.5 Several clinical approaches for the prevention and treatment of periimplantitis have been proposed, including mechanical debridement, use of antiseptics and local or systemic antibiotics, glycine powder air polishing or laser decontamination,6 and surgical access including implantoplasty and regenerative procedures.7 Sufficient consensus exists that the mechanical removal of biofilm from implant surfaces needs to be supplemented by decontamination
with or without surgical access8; however, it has not yet been substantiated what type of treatment protocol may provide the most favorable outcomes in the long term. Success rates following periimplantitis therapy were evaluated in a recent systematic review by HeitzMayfield and Mombelli9: successful treatment outcomes at 12 months after the start of periimplantitis treatment were reported for 0%–100% of patients
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treated in 9 studies and in 75%–92% of implants treated in 2 studies. These data from the scientific literature go to show that treatment success in periimplantitis therapy is somewhat variable and unpredictable; however, no consensus has yet been reached in terms of outcome prognosis. Furthermore, a recent Cochrane systematic review on the effectiveness of interventions in the treatment of periimplantitis by Esposito et al10 concluded that there is to date no reliable evidence suggesting which could be the most effective intervention for treating periimplantitis, and there is thus an urgent need for larger studies with follow-ups longer than 1 year. The aim of the present investigation thus was to report on long-term success rates of periimplantitis therapy and compare different treatment modalities regarding effectiveness and timing of implant failure.
MATERIALS
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METHODS
Patient Search and Selection
Patients were included in the present analysis if they fulfilled the following criteria: (1) patients referred at the Academy for Oral Implantology in Vienna for the treatment of recurrent symptoms of periimplantitis, (2) presenting with not more than 1 single-tooth implant affected by periimplant disease during the entire observation period to avoid statistical cluster effects due to the presence of multiple implants treated in a single patient, (3) records of recall visits following periimplantitis therapy for a follow-up period of up to 9 years without interruption, and (4) treatment of periimplantitis by laser decontamination and/or implantoplasty surgery. Periimplantitis was defined as the presence of periimplant probing depths of $ 4 mm and bleeding-on-probing associated with clinical signs of inflammation (swelling, rubor, secretion, loose, or necrotic papillae) and radiologic evidence of bone loss around the implant.11 The database at the Academy for Oral Implantology was screened retrospectively using the impDAT software (version 3.58; Kea Software GmbH, Pöcking, Germany). The final selection involved 142 patients treated for periimplantitis between the years 2004 and 2013; of which, 78 (54.9%)
were female patients with a mean age of 54.7 6 22.6 years (range, 33–89 years) and 64 (45.1%) were male patients with a mean age of 48.9 6 18.3 years (range, 29–87 years). Therapeutic Procedures
Before intervention, all patients were subjected to initial therapy involving diagnosis of periimplant mucosal health and marginal bone level according to a standardized procedure as well as motivation and briefing of the patients. The choice of therapeutic approach was dependent on severity of clinical and radiologic parameters, time interval between first signs of periimplant pathology and referral to the specialist clinic, and impact of periimplantitis on the patient’s wellbeing and oral health-related quality of life. One group of patients (n ¼ 72) received nonsurgical treatment via laser decontamination at a wavelength of 2940 nm (K.E.Y. Laser 3+; KaVo, Biberach, Germany). The second group of patients (n ¼ 47) was subjected to implantoplasty surgery using an open-flap approach and a set of diamond drills (PerioSet; Intensiv Swiss Dental Products, Montagnola, Switzerland). A third group of patients (n ¼ 23) were treated with a combination of the abovementioned therapies. The bimodal approach involved nonsurgical laser decontamination at a first stage and implantoplasty surgery as a second intervention after at least 6 months. The study protocol was approved by the responsible ethics committee of Vienna Medical University (EK Nr. 1200/ 2014).
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Statistical Analysis
The primary outcome measure constituted implant loss following the treatment of periimplantitis by laser decontamination and/or implantoplasty surgery. Descriptive statistics involved absolute and relative frequencies of implant failures as well as mean values and standard deviations of patient age and time between the start of periimplantitis therapy and implant loss. Comparison between the 3 treatment groups was performed using Fischer exact tests regarding treatment success and Wilcoxon rank sum tests regarding timing of implant failure. Subgroup comparison regarding patient gender was performed using Pearson chi-squared test. All analyses were performed at a significance level of 0.05 using R-project statistical software version 3.1.0 (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS Out of 142 single-tooth implants in 142 patients experiencing recurrent symptoms of periimplantitis, a total of 16 implants failures could not be prevented. Eleven failures occurred in female patients and 5 in male patients. The overall success of periimplantitis therapy was 88.7% after 9 years of follow-up (Table 1). Implant loss occurred after 4.9 6 1.9 years of therapy, on average (Fig. 1), and it did not differ significantly in frequency between the 3 treatment groups investigated (P ¼ 0.303): 6 implant failures (8%) after laser decontamination (5 women and 1 man), 6 implant failures
Table 1. Success Rates of Periimplantitis Therapy After a Treatment Duration of 1 to 9 Years Following Laser Decontamination, Implantoplasty Surgery, or a Combination of Both Therapeutic Approaches Treatment Duration (y) 1 2 3 4 5 6 7 8 9
Laser Therapy (%)
Implantoplasty Therapy (%)
Both Therapies (%)
Total (%)
100.0 98.6 97.2 94.4 93.1 93.1 91.7 91.7 91.9
100.0 97.9 97.9 93.6 91.5 89.4 87.2 87.2 87.2
100.0 100.0 100.0 95.7 95.7 91.3 87.0 87.0 82.6
100.0 98.6 97.9 94.4 93.0 91.5 89.4 89.4 88.7
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Fig. 1. Implant failures that could not be prevented by the treatment of periimplantitis occurred after 4.9 6 1.8 years of therapy (range, 2–9 years), and it did not differ in timing and frequency between laser decontamination, implantoplasty surgery, or a combination of both treatment approaches.
(13%) after implantoplasty surgery (3 women and 3 men), and 4 implant failures (17%) after a combination of both therapies (3 women and 1 man). Overall, the success rate of periimplantitis treatment did not differ significantly (P ¼ 0.426) between female (85.9%) and male (92.2%) patients. After laser decontamination 1 implant loss occurred after 2 years (1.4%), 1 after 3 years (1.4%), 2 after 4 years (2.8%), 1 after 5 years (1.4%), and 1 after 7 years (1.4%). After implantoplasty surgery, 1 implant loss occurred after 2 years (2.1%), 2 after 4 years (4.3%), 1 after 5 years (2.1%), 1 after 6 years (2.1%), and 1 after 7 years (2.1%). After a combination of laser decontamination and implantoplasty surgery, 1 implant loss occurred after 4 years (4.3%), 1 after 6 years (4.3%), 1 after 7 years (4.3%), and 1 after 9 years (4.3%). The mean period between the start of the periimplantitis therapy at the Academy for Oral Implantology and potential implant failure was 4.2 6 1.6 years in cases of laser decontamination compared to 4.7 6 1.6 years in cases of implantoplasty surgery. No significant difference could be observed between the 2 therapeutic approaches (P ¼ 0.629). Implant loss after a combination of laser disinfection and implantoplasty
surgery occurred after 6.5 6 1.8 years, on average. However, no significant difference could be observed compared to neither exclusive laser disinfection therapy (P ¼ 0.089) nor exclusive implantoplasty surgery (P ¼ 0.170).
DISCUSSION The overall success rate of periimplantitis treatment at the Academy for Oral Implantology in Vienna was 89% after 9 years of follow-up and compares well with success rates reported in the scientific literature of 75% to 92% of implants 1 year after the therapy.9 However, long-term results are scarce in the international literature, and no reference data for comparison with the present results could be identified. Therapy via laser decontamination yielded the highest success rate of 92% compared to 87% after implantoplasty surgery and 83% after a combination of both treatment approaches. The bimodal approach, on the other hand, resulted in the longest delay of implant loss (6.5 years, on average) compared to exclusive laser therapy (4.2 years) or implantoplasty surgery (4.7 years). However, none of the above-mentioned differences between the 3 treatment modalities turned out to
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be statistically significant. When interpreting these data, it should also be considered that the time between start of periimplantitis therapy and implant loss may have been greater in the patient group that was treated by the bimodal approach, due to the 2 different therapeutic interventionsdfirst the nonsurgical laser decontamination and second the surgical implantopasty proceduredand some patients with implant failures in the group that was exclusively treated with laser decontamination may have as well been treated with implantoplasty surgery if their implants would have survived longer. Potential limitations may arise from the unbalanced gender distribution between the 3 treatment groups. The percentage of female patients varied between 83% in the laser decontamination group, 50% in the implantoplasty surgery group, and 75% in the group receiving a combination of both therapeutic approaches. In total, the proportion of women was only slightly higher (55%) than that of male patients (45%); however, the majority of implant failures that could not be prevented by periimplantitis therapy (69%) occurred in female patients. The overall treatment success rate was slightly higher in men (92%) compared to women (86%); however, no statistically significant difference could be substantiated (P ¼ 0.426). Therefore, it remains uncertain whether female patients demonstrate higher susceptibility to periimplant disease, less favorable chances of positive treatment outcomes, or rather increased compliance to have their periimplantitis diagnosed and treated in the first place. In this regards, it seems worth mentioning that a recent study on interrater agreement in the diagnosis of mucositis and periimplantitis by Merli et al12 found that variability in the diagnosis of periimplant disease is high and complete agreement between 3 observers could be obtained in only 52% of cases. In part, this could be due to the unclear definitions of mucositis and periimplantitis; however, it goes to show that there may even be no consensus in judging the necessity for periimplantitis treatment. The present study certainly benefits from patient treatment at a single specialist clinic according to a standardized protocol.
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In a 5-year comparative study of conventional versus laser-assisted therapy of periimplantitis,13 only 1% of implants were lost; however, the relapse rate (defined as probing depths .4 mm, implant mobility, or bleeding on probing) was 34% after conventional and 11% after laser-assisted treatment. Long-term results up to 9 years after periimplantitis therapy are scarce in the literature to the best of the authors’ knowledge; however, the present study clearly shows that half of all implant failures occur after 5 years of treatment or even later. Future research on the effectiveness of periimplantitis therapy is therefore highly indicated.
CONCLUSIONS The overall success rate of the treatment of periimplantitis at the Academy for Oral Implantology in Vienna was 89% after 9 years of follow-up. Treatment success did not differ between laser decontamination and/or implantoplasty surgery as well as patient gender. The bimodal approach resulted in the longest delay of implant loss (6.5 years) compared to exclusive laser therapy (4.2 years) or implantoplasty surgery (4.7 years).
DISCLOSURE The authors claim to have no financial interest, either directly or indirectly, in the products or information listed in the paper.
APPROVAL The study protocol was approved by the responsible ethics committee of Vienna Medical University (EK Nr. 1200/2014).
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