R E V I E W A R T I C L E
Use of laser for treating of peri-implantitis: A review
Anahita Shahi, Mana Seyed Hosseinzadeh Ardabili
Department of Periodontics, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran
Abstract
Background: Several methods have been introduced for implantitis treatment and some additional methods including antibiotics, antiseptics, and laser were proposed to enhance the results of nonsurgical treatments. Since laser is highly capable to eliminate microorganisms and bactericidal eff ects and has high detoxifi cation functionality, it is known as one of the best techniques for the treatment of implantitis. Aim: The aim of this study was to collect articles related to use of laser for the so-called treatment. To access the related available articles, an electronic search was performed on several websites, including PubMed, GoogleScholar, ScienceDirect, InterScience, and Scopus.
Conclusion: According to the results of collected papers: (1) CO2, diode, and erbium:yttrium, aluminum, garnet (Er:YAG) lasers could be useful for implant surface radiation. (2) In case of applying low power Nd:YAG laser radiation, it could be used for implant surface detoxifi cation (Inhibition of lipopolysaccharide). (3) The main role of lasers in peri-implant treatment is bactericidal. (4) Based on the clinical observations, Er:YAG lasers were ineffi cient for nonsurgical peri-implant treatment. (5) According to the results of animal studies, use of laser was successful in surgical treatment, in terms of re-osseointegration. (6) Use of photodynamic therapy is promising in treatment. (7) The appropriate use of laser parameters during radiation on implant surface is important in the effi cacy and safety of treatment. (8) Clinical Signifi cance: The impact of lasers on titanium implants is diff erent from zirconium implants. According to the available evidence, laser is used as an alternative method to the treatment of peri-implant tissues and its poignant antibacterial eff ect, with no alteration in implant surface, is the most salient feature of laser (in case of appropriate use).
Keywords: Dental implants, laser, peri-implant tissue disease, peri-implant tissue infl ammation Correspondence
Dr. Mana Seyed Hosseinzadeh Ardabili, Department of Periodontics, Faculty of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran.
Tel: +98-51-38067224, Fax: +98-51-38829500, E-mail: [email protected]
Received 06 December 2016 Accepted 09 January 2017
doi: 10.15713/ins.ijcdmr.111
How to cite the article:
Anahita Shahi, Mana Seyed Hosseinzadeh Ardabili, “Use of laser for treating of peri-implantitis: A review,” Int J Contemp Dent Med Rev, vol. 2017, Article ID: 020117, 2017. doi: 10.15713/ins.ijcdmr.111
Introduction
Although the survival rate of dental implants is high, 5 years after the placement the infl ammatory reaction of peri-implant tissues and variable rates of bone resorption account for up to 14.4% of the implants.[1] Peri-implantitis means the outbreak of an infl ammatory process around osseointegrated implant and alveolar bone loss around the implant.[2] Various methods have been introduced for the treatment of such a disease. Since microbial colonization plays a major role in the outbreak and growth of the disease, removing the microbial plaque from implant surface through diff erent methods (e.g., chemical or mechanical) is known as a prerequisite for treatment. Mechanical debridement is usually performed by tools, which have less hardness than titanium (like, plastic curettes and polishing machines with rubber cup) to avoid the harshness on implant surface and consequently to prevent the bacterial colonization. Since use of mechanical methods is not individually suffi cient to
eliminate the bacteria from implant surface, employing chemical methods (like, washing with disinfectants, washing with acid citric, and prescription of topical and systematic antibiotics) as alternative options are highly recommended for healing after treatment.[3] Moreover, although according to in vitro studies use of air-powder fl ow is successful in disinfection of implant surface, due to some tangible changes in this area and risk of emphysema there are some limitations in its application.[4] Various guided bone regenerations (GBR) techniques are introduced to rebuild the lost bone, though a limited effi cacy was reported.[5]
major role of laser in peri-implant treatment is its bactericidal eff ect. Primarily, laser could fi ght off peri-implant surface bacteria by their two photothermal and photochemical eff ects. In photothermal method, the boundless laser energy causes the destruction of bacteria, while in photochemical method the bacteria would not be killed by the heat, rather the radiation of a linked photosensitizer to bacteria is activated and this would emit the toxic materials and destroy the bacteria.
Since no alteration in implant surface topography is considered as a salient feature for selecting material or the tool used for cleaning the implant surface, an ideal laser, in addition to the maximum antimicrobial eff ect should have the least impact on its topography and cause more heat of implant and surroundings.
The aim of this article was to evaluate the articles, which are available on laser application in implantitis.
Methods
To fi nd the related foreign literature, all available articles were assessed in diff erent websites, including PubMed, InterScience (www.interscience.wiley.com), ScienceDirect, Scopus, and Google Scholar. The key words applied for this purpose were peri-implantitis, peri-implant disease, implant disease, and laser(s).
The articles were divided into four classes, that are in vitro, animal studies, human studies, and review articles. The aim of in vitro studies was to evaluate the impacts of lasers on temperature increase in implant surface, physical changes in implant surface, decontamination, and detoxifi cation of contaminated implants. In animal articles, they investigated the re-osseointegration, after laser treatment more histologically. In human articles, clinical indexes (such as bleeding during probing and improvement of clinical attachments) were studied.
Review of Literature
In in vitro and in vivo studies, CO2 laser has been one of the leading lasers applied for peri-implant treatment. Kato et al. (1998) conducted one of the earliest articles in this fi eld entitled, “the antibacterial eff ect of CO2 laser on titanium implants.” The aim of that in vitro study was to evaluate the eff ect of CO2 laser on decreasing Streptococcus sanguis and Porphyromonas gingivalis bacteria on titanium disks. Moreover, some additional features, including changes on implant surface, its temperature increase, damage to connective tissue (fi broblast and osteoblast) out of radiation area, as well as the adhesion of cells to the radiation area were assessed, as well. In this paper, the output power of the applied laser was 5 W, the radiation time 3-8 s, energy 15-40 J, and energy density 122-327 J/cm2. The radiation spot size was 3.95 mm. Since the Co2 laser absorbed easily in water, we expected it to be absorbed readily in intercellular water and kill the bacteria. On the other hand, since laser could not be absorbed in titanium implant, it could not raise the temperature; therefore, a hypothesis proposed that the cells of surrounding connective
tissue should not be under the infl uence of laser radiation. According to the results, the CO2 laser killed the S. sanguis and P. gingivalis bacteria at 268 J/cm2 and 245 J/cm2, respectively. Furthermore, this laser could not increase titanium temperature, change its surface, damage the fi broblast and osteoblast cells, and inhibit the cell growth in radiation area. Finally, they concluded that CO2 laser radiation in expanded beam mode could be useful in eliminating the infectious implant bacteria.[9]
Park et al. (2005) carried out a research on the outbreak of surface changes on wet implant using CO2 lasers (pulsed and noncontact) and neodymium:yttrium, aluminum, garnet (Nd:YAG) (pulsed and contact) in various powers (1, 2, 3.5, and 5 W). According to their results, the Nd:YAG laser could cause damage on implant surface in all powers, such that the extent of damage was equal to the radiated laser power. CO2 laser, however, had made no change at 1 and 2 W powers, which showed that CO2 laser could not infl ict damage at low powers and it would be safe.[10]
Mouhyi et al. declared that use of CO2 pulsed laser (with the specifi cations of 8 W, 10 ms, 20 Hz) for 5 s could cause a slight temperature increase (<3°C).[11]
Within another study Mouhyi et al. found that a combination of CO2 laser, citric acid, and hydrogen peroxide could be eff ective in cleaning and restructuring of oxide structure of titanium implant surface. It is noteworthy that titanium oxide enjoys from a high level of histocompatibility and is resistible against surface corrosion, so its presence is highly related to the connecting power of implant to bone during osseointegration.[12]
According to the results of most of studies, Nd:YAG laser is not appropriate for peri-implantitis, in that it could easily remove the titanium at any range of energy.[13,14] Giannini et al. (2006) indicated, however, that in case of correct selection of pulse energy (at low limit) and repetition rate parameters for Nd:YAG pulsed laser, we could see the bactericidal eff ect of this laser at the same normal power (1-1.4 W) with no lesion to the implant surface. In this in vitro study, the Nd:YAG laser has radiated on a sandblast titanium surface coated with Escherichia coli and Aggregatibacter actinomycetemcomitans bacteria. The laser power was between 1 and 1.4 W. Radiation emitted for a minute in noncontact form using a 400 μm glass fi ber. It is worth mentioning that washing with water was done during this study. According to this project, Nd:YAG pulsed laser, at low pulse energy and any amount of repetition rate could cause a considerable decrease in the number of so-called bacteria with no lesion and the implant temperature will always remain under 30°C.[15]
Haas et al. stated that the radiation of diode laser (905 mm) along with toluidine blue could cause the dramatic decrease of Aggregatibacter actinomycetemcomitans, P. gingivalis, and Prevotella intermedia bacteria.[17]
In an in vitro study, Kreisler et al. (2002) investigated the amount of thermal changes on implant surface using CO2 and diode (GaAIAs) (809 nm) lasers. Both lasers were in power range of 1-2.5 W and in the form of continuous wave and laser beams were emitted at the angle of 90° to the surface. Temperature increased to more than 47°C, which the critical threshold to hurt the surrounding bone, was seen in the following situations: In GaAIAs laser with output power of 2.5 W for 8 s, output power of 2.0 W for 13 s, output power of 1.5 W for 18 s, and output power of 1.0 W for 42 s. In case of CO2 laser, output power of 2.5 W for 15 s, output power of 2.0 W for 23 s, output power of 1.5 W for 35 s, and output power of 1.0 W for 56 s. In other words, at equal laser powers, the GaAIAs laser has always caused more temperature increase than the CO2 laser. Hence, though both lasers could be useful at low and medium powers with no temperature increase, the radiation time is also a signifi cant factor that should not be taken for granted. At the end, they suggested that in cases when longer radiation time is needed (e.g., for cleaning the whole surface of an implant in deep pockets), a minimum of 5 s. interception is required to hold the temperature of titanium implant below the threshold and then pursue the process.[18] The results of this study are in line with that of the Deppe et al.,[19] by a diff erence that Deppe reported the maximum safe time for the radiation of CO2 laser with 2.5 W power, as 10 s, but Kreisler et al.[18] considered it as 8 s. Diff erence in results can be attributed to diff erence in place of measuring the temperature.
A study published in 2010 evaluated the temperature increase due to radiation at various implant levels using ErCr:YSGG and CO2 lasers. In this study, implants were placed at various levels in pork ribs, and then thermocouples were set in apical portion of implants. CO2 laser with power of 4 W in the form of continuous wave and ErCr:YSGG laser with 1.5 power in pulse mode were emitted at the coronal level of implants at 20 Hz for 60 s. According to the results, if the ErCr:YSGG laser emits with water spray, it would cause no temperature increase at apical level and the adjacent bone. Therefore, in case of correct application, this laser could be used at the second stage of implant surgery and treatment of peri-implant disease.[20]
Kreisler et al. (2002) indicated that erbium:yttrium, aluminum, garnet (Er:YAG) laser (0.6-1.2 W or 60-120 mJ/110 pps) could kill more than 99% of bacteria with no damage to titanium level.[21] Miller also found the same results using the Er,Cr:YSGG laser with the same specifi cations.[22]
The Er:YAG with the wavelength of 290 nm emitted to 71% of titanium and by increasing the wavelength to 10690 nm (CO2 laser) this amount could be reached to 96%.[23] On the other hand, the CO2 laser is probably works safer than Er:YAG in this
fi eld.
According to the results of most of in vitro studies, CO2, diode, and Er:YAG lasers could work appropriately for titanium
implant levels, in that the absorption of that wavelengths is weak in titanium, so as a result of the laser radiation, the titanium implant and the adjacent bone will only expose to a slight temperature increase.[13,18]
Since the inception of zirconium implants and their increasing usage, the outbreak of implantitis like what happens to titanium implants, is inevitable. Since these types of implants are newer, few studies evaluated the eff ect of laser on their functions. Stubinger et al. (2008) carried out an in vitro research on the impact of CO2, Er:YAG, and diode laser on zirconium implants. They concluded that only diode laser could be the proposed laser for the microbial enumeration of implant surface at any power.[24] Since the result of this study is in confl ict with the results of titanium implants, it seems that implant material is also a signifi cant feature in choosing an appropriate laser for cleaning the surface.
Histological studies
Persson et al. (2004) revealed that the amount of re-osseointegration and formation of a bone using the CO2 laser along with hydrogen peroxide during experimental peri-implantitis in dog is similar to the application of gas coated with normal saline on the implant surface. Based on this study, use of CO2 laser was ineff ective for peri-implantitis treatment.[25]
Within an empirical study in 2006, various surgical methods of peri-implantitis were compared. After three months, it was observed that (1) submerged surgery + application of Er:YAG laser for cleaning implant surface, compared with (2) submerged surgery + use of ultrasonic, and (3) nonsurgical method (cleaning the implant surface next to plaque with plastic tools) could lead to better results in radiographic and histological view of a dog. This occurred while the bone-implant contact in each group was 1%, 14%, and 44.8%, respectively. Surprisingly, the range of bone-implant contact in laser group was similar to the results of previous studies on the application of graft materials and membranes. Moreover, in this study, the amount of residual microbial plaque in laser parameters is equal to the previous studies of this research group (Schwarz et al.) in (12.7 J/cm) 100 mJ/pulse, 10 Hz, and energy pulse was set at peak on 85 mJ/ pulse.[26]
Shibli et al. (2006) within an animal study investigated the eff ect of photosensitization and GBR on improvement of re-osseointegration in dogs infected with experimental implantitis. In this project, GaAIAs diode laser were used at the wavelength of 832 nm for 80 s with 4J/cm2 energy density (total energy of 4 joules). Laser was emitted in contact form on mesial, distal, buccal, and lingual levels (for 20 s). Furthermore, toluidine blue was used as absorbent. Based on the results, the results of laser group was considerably better than the control group. In other words, use of such a method is a useful antibacterial topical treatment along with GBR.[27]
laser was 62 mJ/pulse, such that energy density at the peak was 10.0 J/cm2. In addition, the repetition rate of pulses was 20 Hz. Laser beam was emitted along with saline spray and in direct contact with implant and bone surface, such that the tip of the tool was placed obliquely on the surface with the angle of 30-45°. According to the results, this laser study with such specifi cations was eff ective in removing the granulation tissue as well as the debridement of implant surface. However, the diff erence of laser group in terms of new bone formation and implant-bone contact was statistically better than the control group.[28]
Clinical studies
Nonsurgical treatments
According to the results of conducted studies, use of Er:YAG laser with (12.7 J/cm2) 100 mJ/pulse (pulse energy at the peak approximately equal to 85 mJ/pulse) and 10 Hz for treating implantitis in nonsurgical method, especially in single dosage is diagnosed ineffi cient even after 6 months.[29-31]
Surgical treatments
Using the CO2 laser, Romanos could successfully treat 14 patients by placing the bone graft materials and absorbent membranes of 18 implantitis cases, such that the pocket depth decreased considerably. The average applied power was 2.77 W. The average follow-up time was 17.5 months.[32]
Rismanchian et al. conducted a case study in Isfahan and showed that use of Er:YAG laser along with GBR is eff ective in implantitis treatment. In this study, the place of lesion and implant surface was decontaminated by 150 mJ/20 Hz laser and normal saline. The radiation time and type of beam contact was not mentioned. No recurrence was observable 18 months after this clinical and radiographic study.[33]
Dortbudak et al. found that using low-power laser with diode (690 nm) for 60 s, after placing toluidine blue on the implant surface could decrease the amount of bacteria up to 92%. Although bacteria were eliminated, in this wavelength, in the wavelength of 905 nm the diode laser could kill the bacteria.[34]
In noteworthy that to remove the granulation tissue during surgery, a laser should be used that produces the lowest thermal damages to the surrounding bone (like, erbium group lasers). In case of using diode laser for this purpose, it should be performed with care to prevent the thermal damage. Thus, water spray could be used during the operation.[35]
Review articles, meta-analysis, and comprehensive review
Martin (2004) carried out a review entitled, “laser in implantology” and declared that knowledge of laser specifi cations and the eff ects of diff erent lasers on bacteria and implant surface is necessary for surgeon before any usage.[36] Within another study, Romanos et al. (2009) assessed the use of CO2 laser in treating peri-implantitis and concluded that although the CO2 laser has a slight risk for the patient, the surgeon should regulate the safety issues precisely and be expert in this fi eld. In addition, the cost of laser apparatus and wavelength should be considered, as well. Finally, they recommend that to evaluate the
long-term success of the CO2 laser in treating the implantitis, further clinical and histological studies is required.[37] No clear conclusion, however, was drawn of the results of CO2 application in implantitis treatment in this paper.
According to Becker and Schwarz (2005), the Er:YAG laser, compared with conventional mechanical methods is more eff ective in removing initial plaque on SLA implants.[23]
Kotsovilis et al. (2008) within a comprehensive review article on implantitis treatment stated that although the available articles are few and mostly short-term in this fi eld, mechanical debridement methods along with antiseptic/antibiotic treatment, Er:YAG laser or regenerative techniques could be used in implantitis treatment.[38]
In a study, entitled “laser in healing periodontal and peri-implant wounds” in 2009, which is published in periodontology by Schwartz et al., they expressed that the nonsurgical treatment of peri-implantitis lesions with Er:YAG laser, at least for six months, could improve the clinical indexes. However, the survival of treatment results was not assessed.[39]
Discussion and Conclusion
According to the results of conducted studies on laser application in treatment of peri-implantitis, the following issues were explored:
1. The most prevalent lasers in peri-implantitis treatment are CO2, diode, Er:YAG. The Nd:YAG laser, due to absorption in titanium, could cause temperature increase and change in surface topography of an implant. However, according to the results of a study in case of correct selection of pulse energy and repetition rate parameters (at low limit) at the usual range of power (1-1.4 W), we could benefi t from the bactericidal eff ects of this laser with no damage to implant surface.
2. In case the Nd:YAG laser is used at low power, it would be helpful in detoxifi cation of implant surface in future.
3. The primary function of laser in treating peri-implantitis is its bactericidal eff ect. Moreover, they are used for removing the granulation tissue, as well.[40]
4. According to the results of clinical studies, high level Er:YAG lasers were ineffi cient in nonsurgical treatment of peri-implantitis.
5. Few histological studies have been conducted on the eff ect of high-level Er:YAG lasers in re-osseointegration and their results could not be reliable.
6. Use of photodynamic therapy is promising in peri-implantitis treatment.
7. Using appropriate laser parameters during radiation on implant surface to achieve the maximum of eff ects along with minimum of damage to the implant surface is the matter of the utmost importance.
peri-implantitis treatment, so far. Concerning the available evidence, however, use of laser as one of the alternative methods is recommended for peri-implantitis treatment. Among the most important advantages of laser (in case of appropriate use), we could refer to its poignant bactericidal eff ect with no change in implant level.
Suggestions
Since the number of randomized clinical trials on laser application in peri-implantitis treatment is highly limited, the conclusion of clinical results and deciding on clinical treatment was not possible. To achieve the fi nal objective that is decision-making based on observation such studies are necessary.
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