|Year : 2015 | Volume
| Issue : 1 | Page : 31-35
Treatment of peri-implantitis using a novel technique
Graded Specialist (Periodontics), 11 CDU, Punjab, India
|Date of Web Publication||13-Jan-2015|
202/15, Heritage Apartments, Near Group Centre, Central Reserve Police Force, On Doddabella Pur Road, Yelahanka, Bengaluru - 560 064, Karnataka
Source of Support: None, Conflict of Interest: None
Orodental rehabilitation through the use of implants offers very high success rates. Peri-implantitis is a site specific disease characterized by bone destruction around dental implants due to the host immune-inflammatory response induced by biofilm accumulation. Several approaches have been proposed to treat peri-implantitis, including mechanical debridement, antimicrobial therapy, and respective or regenerative surgical therapy. Calcium sulfate has multifaceted properties and has versatile use in the field of orthopedics. The present case report describes a peri-implantitis case treated by calcium sulphate which is a simple and easily available alloplastic material.
Keywords: Bone radio-opacity, calcium sulphate, osteoconductive, peri-implantitis, radio-opacity
|How to cite this article:|
Mukherji A. Treatment of peri-implantitis using a novel technique. Int J Health Allied Sci 2015;4:31-5
| Introduction|| |
Implant-based dental rehabilitation using implants techniques have offered long-term predictable results in both totally and partially edentulous patients. However, some complications do occur in this therapy which ultimately leads to implant loss. 
At the First European Workshop on Periodontology, peri-implantitis was defined as an inflammatory process around the tissues around an osseo-integrated implant in function, resulting in loss of supporting bone.  Peri-implantitis is often associated with bleeding, suppuration, increased probing depth, mobility, and radiographical bone loss. ,, Frequency of peri-implantitis has been reported in the range of 1-19%.  Another study found that 0-14.4% of the dental implants demonstrated crestal bone loss due to peri-implant inflammatory reactions.  With respect to peri-implantitis, the non-surgical mechanical therapy has not demonstrated to be equally effective. Therefore, surgical therapies have been proposed for treating peri-implantitis, including open flap debridement as well as resective or regenerative approaches. ,,
Many reports in the literature describe the use of calcium sulfate as a bone substitute in orthopedics. As early as 1892, Dreesman  reported on the results of filling osseous defects with calcium sulfate. Peltier  conducted a thorough literature review of studies which described the successful filling of bone void defects with calcium sulfate materials. In author's knowledge, rarely any studies have been conducted in treating peri-implantitis using calcium sulphate. Hence, this is a unique case reporting usage of calcium sulphate as a regenerative material. In this context, the aim of the present paper is to report a novel technique of treating peri-implantitis with a regenerative approach using calcium sulphate as bone graft.
| Case report|| |
A 39-year-old serving officer presented to this army dental section with the chief complaint of bad breath and bleeding from gums in his lower left molar area. The patient had a non-contributory medical history. The officer had undergone implant treatment 2 years back elsewhere. Clinical examination revealed a dental implant in left first molar region with a crown; the implant presented a probing depth (PD) of 7 mm and bleeding on probing (BoP) [Figure 1]. Intra-oral radiograph showed intrabony defect [Figure 2]. Thus, the diagnosis of peri-implantitis was made. The patient was informed about the pathology and all the treatment options for the case. The phase one therapy consisted of oral hygiene instructions, with intrasulcular brushing and subgingival 10% povidone-iodine irrigation. After 1-month follow-up, there was improvement in general oral health. However, periodontal pocket depth and bleeding in left first molar region persisted. Thus, a surgical approach was proposed which included open flap debridement and filling of peri-implant defect with calcium sulfate bone graft. Prosthesis was removed before going ahead with the surgery. After obtaining written consent, under local anesthesia sulcular incision, followed by two vertical incisions were made mesially and distally to the dental implant. A mucoperiosteal flap was raised to facilitate visualization of implant and bone defect [Figure 3]. It was a three walled-bony defect with three implant screws exposed. Thorough debridement was done and all the granulation tissue was removed. The implant surface decontamination was done with 10% povidone-iodine solution for 10 minutes. Calcium sulphate (Capset, Lifecore Biomedical, Chaska, MN) was used to completely fill the bone defect and the exposed screws, subsequently resorbable barrier membrane (Guidor matrix barrier, Guidor AB, Huddinge, Sweden) was placed to cover the graft and the defect [Figure 4] and [Figure 5]. The flap then repositioned and sutured with resorbable sutures and periodontal pack was placed [Figure 6] and [Figure 7]. Patient was prescribed amoxicillin 500 mg three times daily for 7 days, mefenamic acid 250 mg four times a day for 7 days, metronidazole 400 mg twice daily for 7 days, and chlorhexidine digluconate mouth rinse 0.12% three times a day for 4 weeks. Patient was advised to discontinue toothbrushing around the surgical site for 15 days. Sutures were removed after 7 days and healing was found to be uneventful. A periapical radiograph taken 6 months after the treatment of periimplantitis demonstrated bone fill, increased radiopacity and reduction in probing depth to 3 mm [Figure 8]. The patient was scheduled for a follow-up visit every 6 months. Unfortunately, the officer was posted out and further follow-up was lost. No prosthesis could be place in patient as he was transferred.
|Figure 1: Deep periodontal pocket present in relation to implant placed in first molar region|
Click here to view
|Figure 8: Intraoral radiograph showing radio-opacitycaption and bone fill after six months|
Click here to view
| Discussion|| |
The primary goal of peri-implant disease treatment is the reduction of microbial challenge and control of the inflammatory reaction to re-establish a healthy peri-implant tissue.  The therapeutic modalities for peri-implantitis comprises of non-surgical approach and surgical approach. The non-surgical approach includes mechanical debridement alone or combined with antiseptic agents or laser devices. The surgical approach includes open flap debridement that may be associated with resective or regenerative techniques. In peri-implantitis, the surgical approach has shown to perform better than non-surgical techniques. ,
Decontamination of implant surface is a must in order to enable bone regeneration to take place, but also to enhance osseointegration.  A wide range of methods have been proposed in the literature in order to decontaminate the implant surface, such as mechanical debridement, the use of antiseptics/antibiotics and laser therapy. , Zablotsky et al.  concluded that air abrasion, using bicarbonate particles with saline solution was the best way to eliminate endotoxins and remains from all surfaces, and that 40% citric acid with a pH of 1 for 30-60 seconds is an effective means of decontamination for hydroxyapatite coated implants; however chlorhexidine was found to be ineffective. However, there is no evidence in the literature to demonstrate a superior decontamination method.  Povidone-iodine solution is considered an inexpensive and non-hazardous broad-spectrum antiseptic that has been used as an adjunct in periodontal therapy; various reports have demonstrated improved pocket depth reduction during scaling and root planning. 
Calcium sulfate has been used in dentistry for more than 30 years. The use of plaster of paris to fill defects in bone was introduced to the dental profession by Bahn  , who concluded: "In dentistry, plaster of paris may be particularly useful as a vehicle to carry medicaments into infected areas where absorption may cause prolonged release of the medicament." It is totally bioabsorbable  and osteoconductive, does not cause an inflammatory or foreign-body reaction, , allows fibroblast migration, and does not elevate serum calcium levels. 
Calcium sulfate acts as osteoconductive bone void filler that completely resorbs as newly formed bone remodels and restores anatomic features and structural properties. Calcium sulfate acts as resorbable osteoconductive scaffold that provides structural framework for angiogenesis and osteogenesis while preventing soft tissue invasion by acting as space filler. The first mechanism involves the release of calcium and sulfur ions in the biological environment, which results in carbonate apatite formation and calcium ion stimulation of cellular activity. The second mechanism is the precipitation of calcium phosphate, which leads to a transient local drop in pH. This causes surface demineralization of existing bone resulting in exposure of bioactive molecules and the release of growth factors such as transforming growth factors and bone morphogenetic proteins, which stimulates the growth of bone in defects filled with calcium sulphate.  Calcium sulphate resorbs in 4-12 weeks, thus making it one of the quickest osteoconductive product to resorb.
Literature is replete with studies advocating the use of bone grafts and barrier membrane to achieve successful regeneration. Mellonig and Triplett  treated 12 lesions with grafts of demineralised freeze-dried allogenic bone and e-PTFE membranes and reported "complete success - coverage of all threads" in 10 lesions, and "partial success - maximum two threads or 2 mm left uncovered" in the remaining two lesions. Haas et al.  treated 24 lesions with grafts of autogenous bone and e-PTFE membranes and reported an average radiographic bone fill of 2.0 mm. Two lesions showed 0.5 mm bone loss.
In another study related with barrier membrane, Michele Paolantonio et al.,  compared the beneficial effects of three surgical techniques in the management of periodontal intrabony defects, which indicated that all of the treatments were effective in improving clinical and intrasurgical parameters. Nevertheless, the collagen membrane and calcium sulfate groups showed significantly greater probing depth reductions and clinical attachment level and defect bone level gains than open flap debridement alone. Since, there are no case reports which advocated the use of calcium sulphate, it was decided to use calcium sulphate and barrier membrane to achieve the best possible result. Barrier membranes placed on bone and periodontal ligament temporarily separates them from gingival epithelium, this not only prevents epithelial migration into wound, but also favors the repopulation of area by cells from the periodontal ligament and the bone. The barrier membrane was used as space maintainer for bone augmentation. Calcium sulphate used along with barrier membrane not only supported it but also maintained space thus serving as osteoconductive scaffold to facilitate better and faster bone healing of the defect.
| Conclusion|| |
Alloplastic graft materials may have their greatest usefulness as autograft extenders, being added to available autogenous bone to provide a sufficient total volume of graft material. Calcium sulphate is osteoconductive, easy to handle, suitable for an in situ application, available on a large scale, safe, and cost-effective. It may also be used as carriers for growth factors, antibiotics, or other substances. Calcium sulphate should be widely used in more clinical studies to know its efficacy.
| References|| |
Bergbundh T, Persson L, Klinge B. A Systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol 2002;29:197-212.
Roos-Jansåker AM, Renvert S, Egelberg J. Treatment of peri-implant infections: A literature review. J Clin Periodontol 2003;30:467-85.
Lindhe J, Berglundh T, Ericsson I, Liljenberg B, Marinello C. Experimental breakdown of peri-implant and periodontal tissues. A study in the beagle dog. Clin Oral Implants Res 1992;3:9-16.
Heitz-Mayfield LJ. Peri-implant diseases: Diagnosis and risk indicators. J Clin Periodontol 2008;35:292-304.
Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1998;10:387-416.
Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of interventions to treat peri-implantitis: A cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implantol 2008;1:111-25.
Renvert S, Roos-Jansåker AM, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: A literature review. J Clin Periodontol 2008;35:305-15.
Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. J Clin Periodontol 2008;35:316-32.
Dreesman H. Over bone lead sealing. Beitr Klin Chir 1892;9:804-10.
PELTIER LF. The use of plaster of paris to fill large defects in bone. Am J Surg 1959;97:311-5.
Schou S, Berglundh T, Lang NP. Surgical treatment of peri-implantitis. Int J Oral Maxillofac Implants 2004;19 Suppl:140-9.
Schwarz F, Jepsen S, Herten M, Sager M, Rothamel D, Becker J. Influence of different treatment approaches on non-submerged and submerged healing of ligature induced peri-implantitis lesions: An experimental study in dogs. J Clin Periodontol 2006;33:584-95.
Dennison DK, Huerzeler MB, Quinones C, Caffesse RG. Contaminated implant surfaces: An in vitro
comparison of implant surface coating and treatment modalities for decontamination. J Periodontol 1994;65:942-8.
Zablotsky MH, Diedrich DL, Meffert RM. Detoxificacion of endotoxin contaminated titanium and hydroxyapatite-coated surfaces utilizing various chemotherapeutic and mechanical modalities. Implant Dent 1992;1:154-8.
Sahrmann P, Puhan MA, Attin T, Schmidlin PR. Systematic review on the effect of rinsing with povidone-iodine during nonsurgical periodontal therapy. J Periodontal Res 2010;45:153-64.
Bahn SL. Plaster: A bone substitute. Oral Surg Oral Med Oral Pathol 1966;21:672-81.
Scarano A, Orsini G, Pecora G, Iezzi G, Perrotti V, Piattelli A. Peri-implant bone regeneration with calcium sulfate: A light and transmission electron microscopy case report. Implant Dent 2007;16:195-203.
al Ruhaimi KA. Effect of adding resorbable calcium sulfate to grafting materials on early bone regeneration in osseous defects in rabbits. Int J Oral Maxillofac Implants 2000;15:859-64.
Guarnieri R, Grassi R, Ripari M, Pecora G. Maxillary sinus augmentation using granular calcium sulfate (surgiplaster sinus): Radiographic and histologic study at 2 years. Int J Periodontics Restorative Dent 2006;26:79-85.
Elkins AD, Jones LP. The effects of plaster of Paris and autogenous cancellous bone on the healing of cortical defects in the femurs of dogs. Vet Surg 1988;17:71-6.
Alexandrina L. Dumitrescu. Bone grafts and bone grafts substitutes in periodontal therapy. In : AL. Dumitrescu (ed). Chemicals in Surgical Periodontal Therapy. Vol. 11. Springer. Berlin: 2011;115-6.
Mellonig JT, Triplett RG. Guided tissue regeneration and endosseous dental implants. Int J Periodontics Restorative Dent 1993;13:108-19.
Haas, R, Baron, M, Dortbudak O, Wazek G. Lethal photosensitization, autogenous bone, and e-PTFE membrane for the treatment of peri-implantitis: Preliminary results. Int J Oral Maxillofac Implants 2000;15:374-82.
Intini G, Andreana S, Intini FE, Buhite RJ, Bobek LA. Calcium sulfate and platelet-rich plasma make a novel osteoinductive biomaterial for bone regeneration. J Transl Med 2007;5:13.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]