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Table of Contents
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 91-97

Adjunctive use of diode lasers in the treatment of peri-implantitis: A case series


Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet, Karnataka, India

Date of Web Publication19-Apr-2014

Correspondence Address:
B S Jagadish Pai
Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.131018

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   Abstract 

Peri-implantitis is defined as an inflammatory process which affects the tissues around an osseointegrated implant in function, resulting in bleeding, suppuration, increased probing depth, mobility and radiographic bone loss. This case report is on two cases of peri-implantitis and their treatment by using lasers. The aim of the article is to describe the added clinical benefits of laser as an adjunct in the treatment of peri-implantitis. This case series showed that the Irradiation with a diode soft laser had positive biostimulating effects, which might be used in treatment of peri-implantitis and osseointegration of dental implants.

Keywords: Biostimulation, diode lasers, peri-implantitis


How to cite this article:
Jagadish Pai B S, Shridhar A, Kamath V, Jaiswal N, Malagi S, Radhika B. Adjunctive use of diode lasers in the treatment of peri-implantitis: A case series. J Dent Implant 2014;4:91-7

How to cite this URL:
Jagadish Pai B S, Shridhar A, Kamath V, Jaiswal N, Malagi S, Radhika B. Adjunctive use of diode lasers in the treatment of peri-implantitis: A case series. J Dent Implant [serial online] 2014 [cited 2022 Aug 12];4:91-7. Available from: https://www.jdionline.org/text.asp?2014/4/1/91/131018


   Introduction Top


Peri-implantitis is defined as an inflammatory process which affects the tissues around an osseointegrated implant in function, resulting in bleeding, suppuration, increased probing depth, mobility and radiographic bone loss. It has been shown that the inflammation is more pronounced and the inflammatory process goes deeper and faster around the dental implant than around the adjacent natural tooth. Implant failure has classically been attributed to bacterial infections, occlusal overload, surgical trauma, faulty or incorrect prosthetic design and/or improper surgical placement. [1]

Peri-implant defects can be classified as: [2]

  • Group I - Demonstrates moderate horizontal bone loss with minimal intrabony component. This represents early stage of peri-implant breakdown
  • Group II - Presents moderate to severe horizontal bone loss with minimal intrabony component
  • Group III - Presents minimal to moderate horizontal bone loss with an advanced circumferential intrabony lesion
  • Group IV - Presents more complicated implant defects with moderate horizontal bone loss with an advanced circumferential intrabony lesion, additionally buccal and/or lingual plate has been lost.


Clinical implant success can be jeopardized by bacterial contamination and infection of the peri-implant soft and hard tissue. Most titanium implants feature a rough surface to increase areas of implant-bone contact and anchorage force in the alveolar bone. [3] Surface roughness, however, makes complete elimination of bacteria from implants surfaces difficult. Several treatment regimens have been proposed for cleaning and decontamination of the implant surfaces: Plastic curettes allow removal of peri-implant plaque without any hazard to implants and abutments. [4] Metal curettes as well as ultrasonic scalers induce surface damage to the implants and are therefore contraindicated. [5] Bactericidal chemicals as well as local and systemic antibiotics can be beneficial in the treatment of peri-implantitis. Sterilization and cleaning of implant surfaces by means of lasers have been described [6],[7] and results published are very promising. [8],[9],[10] A variety of laser systems (CO2, Nd: YAG, Er: YAG, Ho: YAG, GaAlAs and Argon) are available for different dental applications.

Therapeutic goals in the treatment of peri-implantitis are:

  1. Elimination of the peri-implant inflammation
  2. Stabilization of the bony attachment (levels of osseointegration)
  3. Regeneration by means of low-level laser therapy.


In order to achieve these goals; the implant surface should be free of any foreign cells and toxins. Consequently, the tissue inflammation resolves and the host cells may contact and adhere to the surface again. Therefore decontamination and detoxification of the implant surface is essential. [11]

Laser technology is developing with phenomenal speed and new lasers with broad characteristics are available for use in different fields of dentistry. Tissue healing is a complex process that involves local and systemic responses. The use of low level laser therapy (LLLT) for wound healing has been shown to be effective in modulating both local and systemic response. Various names for LLLT such as cold laser, soft laser and laser therapy are employed. The biological effects of the therapeutic lasers are laser photobiostimulation, photobiostimulation or biostimulation. The word 'therapeutic laser' describes the purpose and intent of the treatment.

The principle behind the application of low level lasers is the direct application of light energy with biomodulatory capacity on body cells. Photoacceptors (cytochrome C oxidase) can absorb low level lasers irradiation and transfer it inside mitochondria in order to provide cell energy adenosine triphosphate (ATP) which is the product cytochrome C oxidase and Krebs cycle. The stimulation of ATP synthesis results in increased cell activity. These changes influence macrophages, fibroblasts, endothelial cells, mast cells, bradykinin and nerve conduction speed. [12],[13]

Biomodulatory effects of LLLT comprise macrophages, lymphocytes, fibroblasts, endothelial cells and keratinocytes proliferation; increase ATP synthesis and cell respiration, growth factors and other cytokines release, change of fibroblasts to myofibroblasts; change in inflammatory mediators level (histamine and prostaglandins); increase in oxygen transport and improve in glucose consumption; changes in cell membrane potential and permeability, sodium/potassium pomp excitation and more calcium removal; vasodilation and angiogenesis (improve in tissue nutrition); collagen synthesis. [14] To assess the effects of laser therapy on implant tissue interaction is an important field of investigation.

The aim of this case report is to describe/assess the added clinical benefits of laser as an adjunct in the treatment of peri-implantitis.


   Case Reports Top


Case 1

This was a first case of a 29-year-old female patient who reported to the department of Periodontics with the chief complaint of pain in the implant site with a history of implant placement (3.5 × 11 mm) with respect to lower left mandibular first molar 6 months back.

On examination, peri-implant mucosa was inflamed and tender on palpation. Intraoral periapical radiograph revealed crestal bone loss around the implant suggestive of Group II peri-implant defect [Figure 1]a. Peri-implant regenerative therapy was planned following patient consent for the treatment.

After achieving adequate local anesthesia full thickness mucoperiosteal flap was raised following a crestal incision over the implant site and crevicular incision with respect to adjacent teeth [Figure 1]b. Upon reflection, the implant was curetted with IMPLACARE curettes and complete debridement of granulation tissue was performed. The removal of granulation tissue was performed using 810 nm Diode laser in contact and continuous wave mode (0.7 W) as an adjunct [Figure 1]c. The peri-implant defect area was irrigated with the combination of normal saline and 10% povidone iodine. Peri-implant bone was irradiated with low level laser therapy using 810 nm Diode laser in non-contact continuous wave mode (0.1 W) in an apicocoronal direction for 20-30 s. Bone graft was placed and stabilized using GTR membrane [Figure 1]d and e. The flap was re-approximated using 3-0 black braided silk suture and primary closure was achieved [Figure 1]f. Post-operative antibiotics and analgesics were prescribed for 5 days. Patient was advised to rinse with 0.2% chlorhexidine mouthwash.
Figure 1:

Click here to view


Patient was reviewed after 15 days, uneventful healing was observed with no fresh complaints in relation to the treated site.

On 6 months evaluation intraoral periapical radiograph revealed adequate bone fill [Figure 1]g.

Case 2

This was a second case report of a 28-year-old male patient who reported with a chief complaint of edentulous site with respect to upper left first premolar region. The soft and hard tissues were assessed for placement of implant [Figure 2]a. OPG revealed bone height of 8 mm from the maxillary sinus floor. Indirect sinus lift procedure was planned for placement of 3.5 × 10 mm Nobel Biocare implant and patient's consent was obtained for the procedure.

Under adequate local anesthesia, full thickness mucoperiosteal flap was elevated [Figure 2]b and osteotomy site was prepared in a sequential manner up until 3.5 × 8 mm, the osteotomy was stopped at 8 mm. Using the osteotome, the sinus floor was elevated by approximately 2 mm followed by simultaneous placement of Perioglass bone graft. The implant was placed and primary stability was achieved [Figure 2]c. The flap was re-approximated and primary closure was obtained [Figure 2]d. Intra oral peri-apical (IOPA) showed a properly placed implant [Figure 2]e. Post-operative antibiotics and analgesics were prescribed for 5 days. Patient was advised to rinse with 0.2% chlorhexidine mouthwash.
Figure 2:

Click here to view


Patient reported back after 1 month with pus discharge in relation to the site. On examination exudate was present. Intra oral periapical radiograph revealed crestal bone loss all around the implant suggestive of Group IV peri-implant defect. On achieving adequate local anesthesia full thickness mucoperiosteal flap was raised and the implant was found to be mobile. The implant was retrieved [Figure 2]f. The defect was curetted using IMPLACARE curettes and removal of granulation tissue was performed using 810 nm Diode laser in contact and continuous wave mode (0.7W) as an adjunct [Figure 2]g. After complete debridement, the defect was irrigated using a combination of normal saline and 10% povidone iodine. The defect was packed with Perioglass bone graft. Low level laser was applied using 810 nm Diode laser in non-contact mode, continuous wave mode (0.1W) for 20-30 s along the occlusal and buccal surface [Figure 2]h. Bone graft was stabilized using GTR membrane [Figure 2]i. The flap was re-approximated and primary closure was achieved [Figure 2]j. Post-operative antibiotics and analgesics were prescribed for 5 days. Patient was advised to rinse with 0.2% chlorhexidine mouthwash.

At 6 months, there was uneventful healing and adequate bone fill seen in the intra oral periapical radiograph [Figure 2]k. An implant was successfully placed at the site. Patient is under review for prosthetic phase [Figure 2]l.


   Discussion Top


The use of LLLT for oral and periodontal purposes has been the subject of numerous in vitro and in vivo studies. This case report describes the added clinical benefits of photobiomodulation as an adjunct in the treatment of peri-implantitis. Dörtbudak et al., investigated LLLT's effect on osteocyte viability and bone regeneration in superficial peri-implant bone tissue. Their histomorphometric analysis resulted in a significantly higher percentage of stainable peri-implant osteocytes in samples that were subjected to laser irradiation immediately after implant site drilling and implant insertion in comparison with control sites; they concluded that LLLT might have a positive effect on osseointegration of implants. In their study a 100 mW diode laser with a wave length of 690 nm was used. [15]

Jakse et al. concluded LLLT possibly has a positive effect on osseointegration of dental implants inserted after sinus augmentation. [16]

Dörtbudak and Haas concluded that irradiation with a pulsed diode soft laser has a biostimulating effect on osteoblasts in vitro, which might be used in osseointegration of dental implants. [17]

A study by Markovic et al. showed that the use of low-power laser can have a significant influence on the speed of healing bone defects. [18]

Animal studies also have shown consistently that LLLT stimulates implant-bone interaction, resulting in greater mechanical strength of the interface between the implant and bone over the first 8 weeks.

In the present case report, peri-implant infrabony defects showed adequate bone fill 6 months post-operatively after laser decontamination and bone augmentation. Using the described protocol, the authors were able to decontaminate the implant surface efficiently and augment infrabony defects with bone grafting materials. The IOPA showed osseous fill by the end of 6 months. The aim and rationale of repeated biostimulation immediately after surgery would be to enhance the attachment and proliferation of cells on the implant surfaces and in particular to induce higher levels of cytokines such transforming growth factor beta-1 which drives the latter phases of wound healing in soft-tissue and promotes bone healing and bone mineralization.


   Conclusion Top


This case series showed that diode laser (810 nm) can be used for the debridement of the soft tissues around the implants. Low Level Laser Therapy using diode laser has possible biostimulating effects which might be used in treatment of peri-implantitis and re-osseointegration of dental implants. Further studies on the application of this method will show the beneficial effects of laser therapy in treatment of peri-implantitis.

 
   References Top

1.Gupta HK, Amit G, Navjot BK. Peri-implantitis: A risk factor in implant failure. J Clin Diagn Res 2011;5:138-41.  Back to cited text no. 1
    
2.Newman MG, Takei, Carranza. Diagnosis and treatment of periimplant complications. Carranza′s Clinical Periodontology. St Louis Missouri. 9 th ed., Ch. 73;2003. p. 937  Back to cited text no. 2
    
3.Carlsson L, Röstlund T, Albrektsson B, Albrektsson T. Removal torques for polished and rough titanium implants. Int J Oral Maxillofac Implants 1988;3:21-4.  Back to cited text no. 3
    
4.Fox SC, Moriarty JD, Kusy RP. The effects of scaling a titanium implant surface with metal and plastic instruments: An in vitro study. J Periodontol 1990;61:485-90.  Back to cited text no. 4
    
5.Thomson-Neal D, Evans GH, Meffert RM. Effects of various prophylactic treatments on titanium, sapphire, and hydroxyapatite-coated implants: An SEM study. Int J Periodontics Restorative Dent 1989;9:300-11.  Back to cited text no. 5
    
6.Mason ML. Using the laser for implant maintenance. Dent Today 1992;11:74-5.  Back to cited text no. 6
    
7.Walsh LJ. The use of lasers in implantology: An overview. J Oral Implantol 1992;18:335-40.  Back to cited text no. 7
    
8.Haas R, Dörtbudak O, Mensdorff-Pouilly N, Mailath G. Elimination of bacteria on different implant surfaces through photosensitization and soft laser. An in vitro study. Clin Oral Implants Res 1997;8:249-54.  Back to cited text no. 8
    
9.Kato T, Kusakari H, Hoshino E. Bactericidal efficacy of carbon dioxide laser against bacteria-contaminated titanium implant and subsequent cellular adhesion to irradiated area. Lasers Surg Med 1998;23:299-309.  Back to cited text no. 9
    
10.Deppe H, Horch H-H, Donath K, Hiemer I, Henke J. Experimental investigations on laser-assisted treatment of peri implantitis. Z Zahnarztl Implantol 1999;15:97-104.  Back to cited text no. 10
    
11.Rechmann P, Sadegh HM, Goldin DS, Hennig T. On the surface morphology of oral implants after laser irradiation. 2000;55:371-6.  Back to cited text no. 11
    
12.Moshkovska T, Mayberry J. It is time to test low level laser therapy in Great Britain. Postgrad Med J 2005;81:436-41.  Back to cited text no. 12
    
13.Sun G, Tunér J. Low-level laser therapy in dentistry. Dent Clin North Am 2004;48:1061-76.  Back to cited text no. 13
    
14.Reza F, Chiniforush N, Stephane BA, Maryam V, Marjan A, Mohammed Z, et al. Low level laser therapy in management of complications after intra oral surgeries. J Laser Med Sci 2012;3:135-40.  Back to cited text no. 14
    
15.Dörtbudak O, Haas R, Mailath-Pokorny G. Effect of low-power laser irradiation on bony implant sites. Clin Oral Implants Res 2002;13:288-92.  Back to cited text no. 15
    
16.Jakse N, Payer M, Tangl S, Berghold A, Kirmeier R, Lorenzoni M. Influence of low-level laser treatment on bone regeneration and osseointegration of dental implants following sinus augmentation. An experimental study on sheep. Clin Oral Implants Res 2007;18:517-24.  Back to cited text no. 16
    
17.Dörtbudak O, Haas R, Mallath-Pokorny G. Biostimulation of bone marrow cells with a diode soft laser. Clin Oral Implants Res 2000;11:540-5.  Back to cited text no. 17
    
18.Markovic A, Kokovic V, Todorovic L. The influence of low-power laser on healing of bone defects: An experimental study. J Oral Laser Appl 2005;5:169-72.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]


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