Is this an effective way to treat peri-implantitis?

I have a patient with peri-implantitis around an Ankylos implant.  There has been about 3mm of bone loss.  My plan is the following:

1) Mechanical debridement of implant surface with I-BRUSH (But I am concerned that the stainless steel brush might adversely effect the Ankylos surface properties)

2) Decontaminate implant surface with tetracycline alone (5 min of topical application). I do not have a laser.

3)GBR with a mixture of demineralized cancellous bone (60%) and Calcium Sulfate (40%). (The calcium sulfate can act as a covering membrane so I am not planning on using a separate membrane)

What do you think of this plan?

25 thoughts on “Is this an effective way to treat peri-implantitis?

    • Victor Dang says:

      Hi Dr.T
      Would your allograft be cortical or cancellous or both? Do you use anything else beside BMP and what is your ratio of BMP/allograft? How successful have you been with this mixture for GBR?
      VD

  1. Dennis Flanagan DDS MSc says:

    There is no accepted non-surgical treatment of peri-implantitis. Nonetheless, I use a lavage on a coarse paper point of sodium hypochlorite, followed by hydrogen peroxide then Actisite. I do this three times weekly. Monitor radiographically for any further bone loss.
    Dennis Flanagan DDS MSc

  2. David says:

    Consider using Hybenx – from H Shein – to desiccate the area surrounding the implant under very cautious conditions. Then flush with chlohexidine ,add Dentomycin into the area and prescribe Mettronidaxole 400mg 3 x day for 7 days and repeat the Hybenx every 7 days for 3 more times if necessary.

  3. M Montana says:

    Bone loss and “peri-implantitis” can be mutually exclusive. A few questions: Do you have radiographic history of the patient? If so, did the loss occur early, late or progressed slowly? Is there inflammation present?

    • Victor Dang says:

      Hi Montana
      Unfortunately no radiographic hx. Implant was placed 5 years ago. Currently there is suppuration and bleeding on probing.
      VD

  4. CRS says:

    I would avoid peridex on the titanium surface, I am going back to pref gel which is EDTA. Hydrogen peroxide, tetracycline or saline won’t hurt the titanium either. I would lay a flap use bio-OSS and replace the flap. I don’t think the calcium product will work you are trying to regain the epithelial attachment. At best this is 50% successful. The implant is inert the cancellous bone probably won’t work. How long has the implant been restored? Any cement? Problems start to surface around year eight. And lastly stress the oral hygiene.

    • Victor Dang says:

      Hi Peter
      So would you or would you not attempt to do GBR in this case?
      Does it help to mix antibiotics with the graft? I’m considering metronidazole and tetracycline but not sure which one is better.
      VD

  5. Peter Fairbairn says:

    Prophy jet appears to work well in cleaning the surface ……… CRS once place Xenograft you cannot assess any possible resolution as an x-ray will be opaque but possibly no new host bone ….. so nice picture but no solution …
    After trying to deal with these cases ( which are actually not as plentiful as was initially feared ) for over 20 years ….
    The best solution is to change the patient as this is where all the issues lie…

    • Pedro Morais says:

      Dr. Peter Fairbairn, what do you mean by “change the patient”?

      I have a great respect for your opinions and I’d appreciate if you could elaborate a little more on this subject. Thank you!

  6. Peter Fairbairn says:

    Sorry Pedro , I was just trying to state that the patient factors in their host response to inflamation is the the real issue and even when you get a “good ” result the same bone loss can recur years later …. I sat on a European consensus committee 18 months ago with the EDI/BDIZ which you can read . Another area to look into is the work of Tom Van Dyke from the US ….
    Kind Regards
    Peter

    • Andrew says:

      Hi Peter
      My understanding is that in the past you did use allografts mixed it with CaSO4 for GBR procedures and did NOT use any membrane, and had great results. Is this correct?

      Also i’m very interested in Ethoss, but it’s not yet available in Canada. Is the BetaTCP in Ethoss any different from other pure phase BetaTCP, for example Bioresorp (a BetaTCP from ImplantDirect) which is available in Canada?

      Thank you,
      Andrew

  7. Peter Fairbairn says:

    Yes have mixed them in the past and as said before I have not used a membrane once in 14 years and thousands of grafts ……… as long as the material is stable ( due to the particle shape and CS element ) there is no issue . Contrary to what a number of eminent Dentists have said the periosteum is very efficient in promoting bone regeneration and the most important BMP , Stromal cell derived factor is induced by the periosteum . This is responsible to the presence of Mesenchymal cell in the healing site .
    So no inhibiting membrane leads to improved host healing …
    Yes BTcP can vary a lot and the performance and stability thus varies from brand to brand …you can buy a sack of poor BTcP for nothing but well manufactured product makes the difference …
    Yes EthOss is still in FDA approval apparently …. may take time ?? but try that ( Bioresorp ) and mix with CS ( Bond Bone , 3D , or any good CS ) ..
    Hope all goes well …… can read our research in Pubmed .
    Regards
    Peter

    • Andrew says:

      Thank you very much Peter. I just found out that Bioresorp is available in US, but not in Canada. The only synthetic product available to me, which has BTcP in its composition, is BoneCeramic (from Straumann). It is 60% HA and 40% BTcP. Do you think this is a better material (compared to an allograft) to use in combination with CS?
      Regards,
      Andrew

      • Sam says:

        If you are looking for a good synthetic composite, you should look into Bond Apatite. It is available in the US, here. It combines biphasic calcium sulfate with a formula of hydroxyapatite granules in a pre-filled syringe. You can check out the videos at the links above.

        If you are interested in understanding why Augma chose HA over bTCP for the composite graft with CS, you can see this response to that question on another thread on OsseoNews.

        • Andrew says:

          Thanks very much Sam for the links. Augma stated that HA was chosen to “act as an innocuous space maintainer and it has no influence on the bone growth”. BTcP on the other hand, I think, has positive influence on the bone formation process… (Peter can confirm and explain further on this).

          So it seems for smaller bony defects where space maintenance is less critical, BTcP mixed with CS might be a better choice than Bond Apatite?

          Regards,
          Andrew

          • Sam says:

            Hi Andrew,

            Thanks for the interesting discussion. My long-winded layman response, after reading alot of research on these materials:

            Not sure what you mean to say with “positive influence on bone formation.” With the exception of autogenous bone, I think it is proven that all graft materials, even bTCP, are only osteoconductive. So none of the materials actually positively influence bone formation, if by that you mean osteoinduction. The question here is really about resorption rate. I do no think one mixture is proven to be better than other, as far as bone formation, and I’m not aware of any studies that compare the two composites (i.e. bTCP + CS vs HA+CS) on that factor. It’s just that HA+CS has a certain resorption profile, which Augma wanted so the material could be used in a large diversity of bone defects. In smaller defects site, I guess a faster resorption profile is not an issue???

            Anyway, the main difference between bTCP and HA is the resorption profile. bTCP seems to resorb alot more quickly than HA. CS absorbs even more quickly, which is why it needs to be used in a composite and not alone. So a composite of HA+CS, should in theory, resorb more slowly, than bTCP+CS. This is also why BoneCeramic with Straumann mixes bTCP and HA. It’s simply done to create a certain kind of resorption profile because bTCP resorbs quickly relative to HA. So the extent that HA resorbs more slowly, I would think that it should provide higher osteoconductivity. However, the truth is that I do not think there is any clear research or conclusions on the relationship between resorption rate and bone formation, even intuitively it makes sense to think there should be some sort of relationship.

            A good article about bTCP vs HA is available here (it’s about spinal fusion, but still relevant as a general discussion of bTCP and HA): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762171/
            “Commercially available hydroxyapatite is resorbed very slowly, under normal physiological conditions, whereas beta-tricalcium phosphate is generally resorbed within 6 weeks after implantation”

            This is another good article on bTCP vs HA:
            http://www.joionline.org/doi/pdf/10.1563/AAID-JOI-D-11-00061

  8. Peter Fairbairn says:

    Hi Sam , As you know in your layman knowledge the materials vary hugely in resorption rate you can make a HA that resorps very quickly and aBTcP that stays there forever …… no no black and white ….
    Yes HA is better for pontic preservation but after 14 years of daily clinical case using these materials and doing numerous animal studies as well as multi-center clinical studies BTcP is my preference due to the material performance …
    There are animal studies showing the turnover of BTcP and the rate of bone formation … Google Pubmed and look under Fairbairn P…..
    All CaP materials both HA and BTCP have been seen to be osteo-conductive for many years and the is extensive research in countless high Impact factor medical journal again just nee to use Pubmed …. but main work is by Pamela Habobvic ( grew bone on Muscle tissue ) and also Zhao and Watanabe ( Showed Genetic Up- regulation of 3,500 genes for increased Osteoblastic presence .)
    But the first Dental paper published by Miron , Sculean and Buser again confirmed that CAp are osteo-inductive …… I have just started another study to show this as well …..
    Again in the research by Habovic it is seen that HA in least inductive , then BCP ( HA and BTcP ) and BtcP is the most inductive
    This is why clinically we routinely see 50% new host bone in graft site in as little as 8-!0 weeks ……… again awaiting publication
    I think Apatite is a great Product ( I recommend it ) and respect and admire Amos work immensely but as a clinician I have been looking at it a slightly different way…… I want to return my patient back to the previous state of health with no residual graft material just true host bone .
    If BTCP would resorp at 6 months I would be delighted but alas it stays around a fair bit longer ( again dependant on the material and the Host physiology )
    Regards
    Peter

    • Andrew says:

      Thank you Peter for the info. I’m very interested in reading the paper by Habovic that shows “HA is least osteoinductive, then BCP and BTcP is the most osteoinductive”. Could you please tell me where I can look it up?

      Is it true that CS (hemihydrate or dihydrate) is also osteoinductive to some extent? Any published paper on this?

      • Peter Fairbairn says:

        Hi Andrew on the Beach at moment , Pubmed will show there are many papers on this with her name on …..
        “Osteoinductive Biomaterials : current knowledge ……” Barradas A , Habobviv P et al European Cells and materials Vol 21 2011 ( pgs 407-429 ) is a start

      • Peter Fairbairn says:

        New Paper out that really sums up all the years of her work in this area in Trends in Biotechnology ( Impact factor 12.025 )
        Review CaP and angiogenesis ; Implications and advances in Bone Regeneration by Anghrad Molhatra and Pamela Habibovic just published … and really good read if interested in this area .
        Regards
        Peter

  9. David says:

    I would say that CS is “indirectly” osteoinductive because it helps increasing the differentiation of mesenchymal cells to osteoblasts (by stabilizing the graft material), which in turn leads to increased rate and quality of bone regeneration. Also, CS eliminates the need for a membrane, which enhances periosteal blood supply to the graft site, thus improving angiogenesis and bone regeneration.

    Dr. Peter Fairbairn, I’m very interested in knowing more about the differences between Fortoss Vital and Ethoss. You are very familiar with both, so I would much appreciate your input re the following:

    1- The Beta-TCP in Fortoss Vital has a negatively charged surface chemistry which enhances osteogenic response. Does Ethoss also have this feature, or better yet improve on that?

    2- What are the differences in the Beta-TCP between these two products and how do they translate into clinical performances?

    3- What are the differences in handling characteristics/ease of use between these two products?

    Thanks very much,
    David

  10. Peter Fairbairn says:

    Hi David , feel a bit guilty as we are miles off topic on this discussion and I have had and have interests in these materials so …..best to move on , so please pm me …
    Regards
    Peter

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