Treatment of peri-implantitis: Nonsurgical therapeutic approaches

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1 Page 1 of 9 Implantology Treatment of peri-implantitis: Nonsurgical therapeutic approaches M Roncati 1,2, LM Adriaens 3 * * Corresponding Author laurenceadriaens@clinica-ibip.com 1 Lecturer on Laser in Periodontics and Implantology in the European Master Degree on Oral Laser s Applications, Rome University, Italy 2 Lecturer on Laser in Periodontics and Implantology in the Master Degree on Implanto- Prosthesis, Bologna University, Italy 3 Specialist in Periodontology and Implantology, Private Practice, Palma de Mallorca, Spain Abstract Introduction The prevalence of peri-implant complications will increase as dental implant-retained prostheses become routine. Peri-implant diseases are present in two forms: peri-implant mucositis and peri-implantitis. Plaque-induced mucositis is a reversible inflammation of the peri-implant gingiva and responds satisfactorily to nonsurgical treatment. It is generally accepted that mucositis will eventually give rise to peri-implantitis, with inflammation encroaching on the alveolar support. Depending on the severity of the peri-implantitis lesion, surgical or nonsurgical procedures should be implemented. Based on the diagnosis, continuously made during recall visits, a maintenance system termed cumulative interceptive supportive therapy has been followed in this manuscript, further expanding the nonsurgical protocols, including the adjunctive use of the diode laser. Long-term maintenance care for high-risk groups is essential to reduce the risk of peri-implantitis. Informed consents for patients receiving implant treatment must include the need for such maintenance therapy. When surgical treatment is contraindicated or not accepted by the patient, it is essential to implement nonsurgical therapy, well aware, however, of unpredictable results. The aim of this methodology was to discuss the nonsurgical approaches of the treatment of peri-implantitis. Since it is universally accepted that peri-implantitis has a bacterial aetiology, decontamination of the implant surface is crucial. Based on the diagnosis, made during recall visits, a maintenance system called CIST has been followed in this manuscript, with minor adjustments and further expanding the nonsurgical protocols, including the adjunctive use of the diode laser. Conclusion This article presents a protocol for nonsurgical treatment of peri-implant defects using antimicrobials combined with a nonsurgical mechanical treatment and the adjunctive use of the diode laser. Introduction Studies have shown that the placement of endosseous implants is a predictable procedure 1, although dental biological complications arise 2 5. Periimplant diseases are not an uncommon late outcome following implant therapy 6. Long-term maintenance care for high-risk groups is essential to reduce the risk of peri-implantitis 6. With the implant survival as the main criterion for success, the majority of clinical studies showed impressive success rates for dental implants, even in combination with cantilever extensions 7,8. There is evidence of chronic inflammation of peri-implant soft and hard tissues in the range of % 9,10 after 5 years, and peri-implantitis is a frequent clinical finding 10 years after implantation 11. Peri-implant diseases, namely periimplant mucositis and peri-implantitis, have been extensively studied in the literature and are considered the major complication in today s dental implantology 10. Peri-implant mucositis is a gingival inflammation that resides in the soft tissues, with no signs of supporting bone loss (Figures 1 and 2), and it should be routinely treated with a nonsurgical mechanical therapy (Figures 2 4), as it has been proven to successfully reduce the inflammation 3. Moreover, peri-implant mucositis is the precursor of periimplantitis 3 and should therefore be promptly intercepted, as nonsurgical interventions have been demonstrated to give good predictable treatment outcomes Peri-implant diseases have always been associated with the presence of a biofilm 15,16. Therefore, removal of the biofilm is essential to prevent, manage and control peri-implant infections. Patients should be on a regular recall schedule, and maintenance programs should be designed on an individual basis 17. Little is known about the true magnitude of the pathology of periimplantitis, mainly due to the lack of consistent and definite diagnostic criteria used to describe the condition 6. A diagnosed peri-implantitis should be treated without delay 18. Depending on the severity of the peri-implant lesion, surgical or nonsurgical procedures should be implemented (Figures 4 8). Moderate and severe peri-implantitis will require surgical consideration. For the treatment of peri-implant infections, conventional nonsurgical periodontal maintenance therapy

2 Page 2 of 9 Figure 1: Peri-implant mucositis. Presence of plaque and bleeding on probing (probing depth 2 mm) at the distal surface of the implant-supported crown in the mandibular second premolar site. Figure 2: Peri-implant mucositis. No radiographically detectable bone loss around the implant. Figure 3: Peri-implant mucositis. Following nonsurgical treatment, absence of bleeding on probing and 1 mm probing depth. has to be slightly adapted and proper methods of plaque and calculus removal and appropriate antimicrobial agents for maintenance around implants should be carefully selected 17. Different maintenance regimens have been suggested, but little reliable evidence exists, suggesting which could be the most effective one for the long-term maintenance 19. Depending on the diagnosis made continuously during recall visits, a maintenance system called cumulative interceptive supportive therapy (CIST) has been proposed by Lang and co-workers 15. The indications for nonsurgical techniques, clearly delineated using the CIST algorithm, are followed in the present manuscript, with minor adjustments and further expanding the nonsurgical protocols, including the adjunctive use of the diode laser. Besides mechanical debridement, combined with antiseptic/antibiotic therapy 1, the adjunctive use of the Figure 4: Peri-implant mucositis. Effective daily home care is also crucial and must be supplemented with the use of gauze. laser (Figures 9, 12 and 13) may be used for treating peri-implantitis The clinical objectives of a nonsurgical approach are: To reduce the total amount of microorganisms on the titanium surface, To decrease probing pocket depth (PPD), To reduce and eliminate bleeding on probing (BOP), To enhance self-performed oral hygiene and peri-implant health,

3 Page 3 of 9 Figure 5: Radiographical view of the second quadrant. In 1991, the bicuspids were extracted because of severe periodontal lesions. In 1992, three implants were inserted. In 2004, presence of inflammation due to plaque accumulation required radiographic evaluation. No bone loss is detectable. Figure 6: Follow-up radiograph. In 2012, no bone loss around the implants is present. Figure 7: Peri-implant inflammation. In 2004, a moderateto-severe plaque-induced inflammation presented in the second quadrant: 9 mm probing pocket depth and presence of bleeding on probing at the mesial aspect of the second premolar implant. To prevent re-infection, To improve implant longevity. The treatment of peri-implant diseases must always include anti-infective measures. As with chronic or aggressive periodontitis, the therapy has focused on two essential approaches: oral hygiene instructions for the supra-gingival plaque control and professional subgingival instrumentation for the reduction and/or elimination of the pathogenic microbiota 6. Since peri-implant mucositis usually responds to oral hygiene instructions and to a nonsurgical periodontal treatment 14,16,19, we will be describing guidelines for Figure 8: Diode laser therapy. Comparing the clinical picture with the radiograph (Figure 5), the presence of a pseudo-pocket is suspected. supportive implant therapy we use in our daily practice once our patients have received a treatment with implants or when they present problems around them. It is important to make the patient aware that the dental health care

4 Page 4 of 9 habits, such as brushing and interdental cleaning, are crucial for long-term maintenance of their implants 23,24. Patients with a history of chronic periodontitis may present a higher incidence of biologic complications in the absence of proper dental hygiene compliance 25. The roll technique with a soft manual or electric toothbrush is safe, although thoroughness and duration of the brushing is more important than the technique It is essential not to traumatize the peri-implant soft tissues while brushing, but to eliminate plaque accumulation 18. The roll technique is especially indicated for thin periodontal biotypes or when implants are surrounded by alveolar mucosa, rather than keratinized tissue. This brushing technique is also adequate in case of thick tissue biotypes and keratinized peri-implant gingiva. The use of disposable gauze embedded with chlorhexidine 0.12% (Digital Brush, Enacare, Micerium, Avegno, Ge, Italy) is recommended: the gauze is wrapped around the index finger of the dominant hand and used to clean the gingival mucosa, teeth and implants with a rolling motion in an apico-coronal direction (Figure 4). Oral hygiene should be completed with an appropriate interproximal device that could be either an interdental brush or floss, depending on the interproximal width. The key parameter for diagnosing peri-implant mucositis is bleeding upon gentle probing 2 5. This technique is used to assess the status of the peri-implant mucosal health (Figures 1, 3, 7, 9, 10 and 15). A probing pressure of 0.15 N represents the threshold force to be applied to avoid false-positive BOP readings around oral implants 30. The probe is also used for calculus and plaque detection, prior to instrumentation. Since it is universally accepted that peri-implantitis has a bacterial aetiology, decontamination of the implant surface is crucial. Based on the diagnosis, made during recall visits, a maintenance system called CIST has been followed in this manuscript, with minor adjustments and further expanding the nonsurgical protocols, including the adjunctive use of the diode laser. In case of PPD 5 mm, BOP and no bone loss, the essential therapeutic approach, based on strict home care reinforcement and professional mechanical and manual instrumentation, is usually sufficient to restore clinical health (Table 1) (Figures 1 4). However, when there is a PPD > 5 mm, BOP, no bone loss and presence of pus on probing (Figures 5 9), nonsurgical therapy is indicat- Table 1 Nonsurgical procedures Diagnosis 5 mm probing pocket depth Bleeding on probing No bone loss (Figures 1 4) > 5 mm probing pocket depth Bleeding on probing No bone loss Presence of pus on probing (Figures 5 9) > 5 mm probing pocket depth Bleeding on probing Bone loss Presence of pus on probing (Figures 10 15) Nonsurgical procedures ed, including highly recommended essential procedures as well as optional methods (Table 1). In case of PPDs > 5 mm, BOP, radiographic evidence of bone loss, with presence of pus on probing (Figures 10 15), surgical treatment is highly indicated 18. However, systemic and general health impairments could make periodontal surgery contraindicated, or sometimes the patient does not want or cannot afford the ideal therapy. In such cases, nonsurgical periodontal therapy becomes the only alternative treatment option. It should be made clear to the patient that this is a supportive strategy with no predictable outcomes. Therapy Essential: Strict home care reinforcement Professional mechanical and manual instrumentation Optional: Adjunctive use of diode laser Adjunctive use of antimicrobials Essential: Strict home care reinforcement Professional mechanical and manual instrumentation Highly recommended: Adjunctive use of diode laser Optional: Adjunctive use of antimicrobials Essential: Strict home care reinforcement Professional mechanical and manual instrumentation Strongly recommended: Adjunctive use of diode laser-adjunctive use of antimicrobials Systemic antibiotics These procedures are summarized, depending on the initial diagnosis and listed as essential, highly recommended, strongly recommended and optional. In the first two situations, nonsurgical therapy is always indicated, versus the third case where surgical treatment is the proper therapeutic option. However, if surgery is not possible, nonsurgical therapy becomes the only alternative. Nevertheless, this nonsurgical approach is a supportive strategy, with no predictable outcomes.

5 Page 5 of 9 Table 2 Detailed description of the nonsurgical protocol Nonsurgical protocol summary First appointment day 0: a. Circumferential probing to determine pocket depth. b. Calculus detection. c. Diode laser treatment: 2 W in pulsating mode (pw), for 20 s twice on each site, with a fluence of 124 J/cm 2, total energy 20,000 mj and a frequency 10 Hz. d. Power-driven instrumentation with dedicated inserts: ultrasonic piezoelectric (EMS Piezomaster 700) with PI insert (plastic fused to metal) or ultrasonic magnetostrictive (Dentsply Cavitron) insert capped with a plastic disposable tip and manual instrumentation with a titanium curette (Roncati Implant Care, by Martin, KLS). e. Subgingival air polishing with glycine or erythritol (EMS). f. Tetracycline for 3 min + physiologic solution for 30 s. g. Application of chlorhexidine (CHX) gel with a disposable syringe and a blunt needle, three times. h. Motivation and oral hygiene instructions: use of a medicated gauze soaked in 0.12% chlorhexidine gluconate (Digital Brush, Enacare Micerium, Italy) (four to five times daily between meals), rolling stroke brushing technique with an ultra soft toothbrush (three times a day), interdental brush bathed in CHX gel (three times a day). i. Biostimulation by diode laser (LLLT): Diode laser treatment; the same diode laser is used with a different 6.0 mm fiber and with a different power setting: 0.5 W in pulsating mode (pw), for 60 s twice on each site, for a total time of 360 s, with a fluence of 1 J/cm 2, total energy 6,000 mj and a frequency 20 Hz. j. Doxycycline 20 mg, oral dosage, twice daily, during 3 months. Second appointment day 1: (the next day if possible) a. Diode laser treatment: 1 W in pulsating mode (pw), equivalent to 0.5 W in continuous mode (cw), for 30 s twice at each site, for a total time of 360 s, with a fluence of 62 J/cm 2, total energy 15,000 mj and a frequency 10 Hz. b. Power-driven and manual instrumentation, as appropriate, with the same instrument described at day 0. c. Subgingival air polishing with glycine or erythritol (EMS), application of CHX gel with a disposable syringe and a blunt need, three times. d. Motivation and reinforcement of home care instructions given on day 0. e. Biostimulation by diode laser (LLLT): diode laser treatment as described at day 0 (i). Third appointment 30 days later: a. Plaque removal as needed. b. Application of CHX gel with a disposable syringe and a blunt needle, three times. c. Motivation and reinforcement of home care instructions given on day 0. d. Biostimulation by diode laser (LLLT): diode laser treatment as described at day 0 (i). Fourth appointment at 3 months: a. Diode laser treatment: 1 W in pulsating mode (pw), equivalent to 0.5 W in continuous mode (cw), for 30 s twice at each site, for a total time of 360 s, with a fluence of 62 J/cm 2, total energy 15,000 mj and a frequency 10 Hz. b. Power-driven and manual instrumentation as needed, with the same instrument described at day 0. c. Subgingival air polishing with glycine or erythritol (EMS), application of CHX gel with a disposable syringe and a blunt needle, three times. d. Motivation and reinforcement of home care instructions given on day 0. e. Biostimulation by diode laser (LLLT): diode laser treatment as described at day 0 (i). 5. Recall appointment every 3 months. 6. Once a year a peri-apical radiograph is needed. Therefore, the proposed clinical protocol summarized in Table 2 includes a 810 nm diode laser therapy, power-driven instrumentation (ultrasonics with proper inserts), manual instrumentation using titanium curettes, polishing (air-flow with glycine or erythritol powder), locally delivered antimicrobials (tetracycline and chlorhexidine digluconate 0.2%), biostimulation/photodynamic therapy and/or systemic antibiotics (subantimicrobial dosage of doxycycline). Laser treatment may serve as an adjunctive treatment to conventional mechanical therapy in periodontology, including supportive care of peri-implant inflammation 31,32. Recent studies show promising results in the treatment of

6 Page 6 of 9 Figure 9: Follow-up after diode laser therapy. Clinical view of the second quadrant. Periodontal re-evaluation shows 3 mm probing pocket depth and absence of bleeding on probing at the mesial aspect of the second premolar implant. Figure 10: Peri-implant inflammation. 7 mm probing pocket depth and presence of bleeding on probing at the mesial aspect of the second premolar implant in the third quadrant. Figure 11: Peri-implant inflammation. Bone loss is detectable on the intra-oral radiograph. peri-implantitis 33,34. However, the laser is not a substitute for mechanical or manual instrumentation of the root/implant surfaces. The diode lasers ( nm wavelength) are preferentially absorbed in pigmented tissues (with high percentage of endogenous chromophores: haemoglobin, melanin), such as inflamed peri-implant tissues 31. The diode and pulsed Nd:YAG lasers (Figures 8, 12 and 13), when used adjunctively with nonsurgical periodontal instrumentation, have been showing to have an additive effect in reducing subgingival bacterial populations in periodontal pockets of 4 mm 35,36. Both lasers seem to weaken the calculus chemical bond to roots and implant surfaces 36. A temperature increase of more than 10 C can compromise the bone Figure 12: Diode laser therapy. In addition to the reinforcement of a strict home care and professional mechanical and manual instrumentation, it is strongly recommended to use the diode laser as an adjunctive treatment tool in two consecutive appointments. vitality 37. Within the appropriate parameters, the diode laser does not cause any visible surface alterations 37, as would an Er:YAG laser(s), which may produce a temperature increase above the critical threshold (10 C) after 10 s of continuous irradiation 35. Also a Neodymium YAG may produce some damage (melting and titanium surface cracking 35 ). The diode laser used within the correct

7 Page 7 of 9 Figure 13: Diode laser therapy. The day after the first diode laser treatment, a significant oedema reduction is apparent. Figure 14: Radiographic follow-up. In 2012, improved bone quality and density seem detectable on the radiograph. parameters does not generate a temperature rise exceeding 47 C 35,38. The suggested clinical protocol is as follows: two 810 nm diode laser clinical applications are scheduled in two consecutive appointments (Figures 12 and 13). A 810 nm diode laser is utilized prior to, and after, mechanical and manual implant instrumentation 31,32. The patient is asked to rinse with chlorhexidine 0.2% undiluted for 1 min. After insertion of the optical fibre parallel to the long axis of the implant, up to 1 mm from the most apical portion of the pocket, the diode laser insert is moved in an apico-coronal and mesio-distal direction for 30 s at each inflamed implant site. This procedure will be repeated twice in the same session. The 810 nm diode laser is used with a 0.32 mm fibre (see description in Table 2 during first and second appointment). Each implant site is subjected to nonsurgical instrumentation, using both manual and ultrasonic instruments to remove all soft and calcified deposits. Professional prophylaxis should utilize both manual and power-driven instrumentation: a piezoelectric ultrasonic device (EMS, Nyon, Switzerland) with PI insert (plastic fused to metal), or a magnetostrictive ultrasonic device (DENTSPLY International, York, PA, USA) with a proper insert capped with a plastic disposable tip and a titanium curette (Roncati Implant Care, KLS Martin, Tuttlingen Germany). Plastic or carbon manual instruments are only indicated to remove soft deposits. The authors recommend the use of an air-flow system associated with glycine or erythritol powder 39 (EMS, Nyon, Switzerland). Finally, a 0.2% chlorhexidine gel is applied into the sulcus, with a disposable syringe and a blunt needle. Chlorhexidine shows a significant bactericidal effect against adhering bacteria on titanium surfaces 40,41. Even if citric acid is the chemotherapeutic agent with the highest potential for the removal of the biofilm from contaminated titanium surfaces in vitro 42, tetracyclines are preferred since they have a less acid ph. The enzymatic inhibition and related anti-inflammatory properties of the tetracyclines are well documented 41,42. At the end of the appointment, the same 810 nm diode laser is used with a different insert: 6.0 mm and with a different power (see description in Table 2). The use of antimicrobial photodynamic therapy adjunctive to conventional treatment provides short-term benefits: significant differences in clinical attachment level (P=0.006) and probing depth reduction (P=0.02) 43,44. A substantial dose of doxycycline (SDD) of 20 mg (Periostat or a generic preparation) has been found to be a safe and effective adjunct when taken twice daily for at least 3 months and up to 24 months in randomized placebo-controlled clinical trials 45. The meta-analysis results seemed to support the long-term effectiveness of adjunctive SDD therapy 46. Doxycycline has a selective collagenase activity on polymorphonuclear cells, whose numbers are increased in peri-implant lesions, along with plasma cells and lymphocytes 3. No evidence is available to suggest the frequency of recall intervals or specific hygiene treatments 1,47 for peri-implant mucositis or periimplantitis. Routine periodontal maintenance should be performed every 3 to 4 months reinforcing the patient s own efforts in daily plaque control 26. Adjunctive use of the diode laser associated to conventional supportive periodontal therapy (SPT) can be applied, once or twice a year, during the follow-up period, only if needed.

8 Page 8 of 9 Figure 15: Clinical follow-up. In 2012, absence of bleeding on probing and a probing pocket depth of 1 mm at the mesial aspect of the distal implant. Discussion The outcome of nonsurgical periodontal treatment of peri-implantitis is inconsistent and unpredictable 3. The decision as to whether a questionable implant should be treated and maintained nonsurgically or surgically is complicated due to variables related to patient behaviour. Nonsurgical periodontal treatment is indicated when a patient has medical or psychological contraindications. In peri-implant infections, 5 and 6 mm probing depths are frequently found and initially treated nonsurgically. Laser therapy is not only beneficial because of its bactericidal effect 31,32, but it can also reduce bacteremia with less post-treatment swelling and oedema In some cases, implant removal is the only treatment option. Conclusion This article presents a protocol for nonsurgical treatment of peri-implant defects using antimicrobials combined with a nonsurgical mechanical treatment and the adjunctive use of the diode laser. Abbreviations list BOP, bleeding on probing; CIST, cumulative interceptive supportive therapy; PPD, probing pocket depth; SDD, substantial dose of doxycycline; SPT, supportive periodontal therapy References 1. Iacono VJ. Dental implants in periodontal therapy. J Periodontol Dec;71: Lang NP, Berglundh T. Peri-implant diseases: where are we now? Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol Mar;38(11 Suppl): Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol Sep;35(8 Suppl): Roos-Jansåker AM. Long time follow up of implant therapy and treatment of periimplantitis. Swed Dent J. 2007;188: Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol Sep;35(8 Suppl): Atieh MA, Alsabeeha NH, Faggion CM Jr, Duncan WJ. The frequency of peri-implant diseases: A systematic review and meta-analysis. J Periodontol Dec (Epub ahead of print). 7. Blanes RJ, Bernard JP, Blanes ZM, Belser UC. A 10-year prospective study of ITI dental implants placed in the posterior region. II: Influence of the crown-to-implant ratio and different prosthetic treatment modalities on crestal bone loss. Clin Oral Implants Res Dec;18: Aglietta M, Siciliano VI, Zwahlen M, Brägger U, Pjetursson BE, Lang NP, Salvi GE. A systematic review of the survival and complication rates of implant supported fixed dental prostheses with cantilever extensions after an observation period of at least 5 years. Clin Oral Implants Res May;20: Pjetursson BE, Tan K, Lang NP, Brägger U, Egger M, Zwahlen M. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res Dec;15: Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M, Lang NP. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res Feb;19(2): Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions. J Clin Periodontol Apr;33: Lang NP, Bosshardt DD, Lulic M. Do mucositis lesions around implants differ from gingivitis lesions around teeth? J Clin Periodontol Mar;38(11 Suppl): Heitz-Mayfield LJ, Salvi GE, Botticelli D, Mombelli A, Faddy M, Lang NP. Anti-infective treatment of peri-implant mucositis: a randomised controlled clinical trial. Clin Oral Implants Res Mar;22(3): Berglundh T, Zitzmann NU, Donati M. Are peri-implantitis lesions different from periodontitis lesions? J Clin Periodontol Mar;38(11 Suppl): Lang NP, Wilson TG, Corbet EF. Biological complications with dental implants: their prevention, diagnosis and treatment. Clin Oral Implants Res. 2000;11(1 Suppl): Roncati Parma Benfenati M, editor. Il paziente impiantare, in Igiene Orale Personalizzata. Milano:Masson, 2005 Italian.

9 Page 9 of Supportive Periodontal Therapy (SPT) (consensus paper). J Periodontol Apr;69(4): Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri-implantitis: a systematic review. J Clin Periodontol Jul;35(7): Grusovin MG, Coulthard P, Worthington HV, Esposito M. Maintaining and recovering soft tissue health around dental implants: a Cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implantol Spring;1(1): Gonçalves F, Zanetti AL, Zanetti RV, Martelli FS, Avila-Campos MJ, Tomazinho LF, et al. Effectiveness of 980-mm diode and 1064-nm extra-long-pulse neodymium-doped yttrium aluminum garnet lasers in implant disinfection. Photomed Laser Surg Apr;28(2): Slot DE, Kranendonk AA, Paraskevas S, Van der Weijden F. The effect of a pulsed Nd:YAG laser in non-surgical periodontal therapy. J Periodontol July;80(7): Gosau M, Hahnel S, Schwarz F, Gerlach T, Reichert TE, Bürgers R. Effect of six different peri-implantitis disinfection methods on in vivo human oral biofilm. Clin Oral Implants Res. 2010;21: Pastagia J, Nicoara P, Robertson PB. The effect of patient-centered plaque control and periodontal maintenance therapy on adverse outcomes of periodontitis. J Evid Based Dent Pract Mar;6(1): Drisko CH. Nonsurgical periodontal therapy. Periodontol ;25: Hultin M, Komiyama A, Klinge B. Supportive therapy and the longevity of dental implants: a systematic review of the literature. Clin Oral Implants Res Jun;18(3 Suppl): Van Der Weijden F, Slot DE. Oral hygiene in the prevention of periodontal diseases: the evidence. Periodontol Feb;55(1): Ciancio SG. Chemical agents: plaque control, calculus reduction and treatment of dentinal hypersensitivity. Periodontol Jun;8: West NX, Moran JM. Home-use preventive and therapeutic oral products. Periodontol ;48: Flemmig TF, Beikler T. Control of oral biofilms. Periodontol Feb;55(1): Schwarz F, Mihatovic I, Ferrari D, Wieland M, Becker J. Influence of frequent clinical probing during the healing phase on healthy peri-implant soft tissue formed at different titanium implant surfaces: a histomorphometrical study in dogs. J Clin Periodontol Jun;37(6): Cobb CM. Lasers in periodontics: A review of the literature. J Periodont Apr;77: Moritz A, Gutknecht N, Doertbudak O, Goharkhay K, Schoop U, Schauer P, et al. Bacterial reduction in periodontal pockets through irradiation with a diode laser: A pilot study. J Clin Laser Med Surg Feb;15(1): Kreisler M, AL Haj H, Daubländer M, Götz H, Duschner H, Willershausen B, et al. Effects of diode laser irradiation on root surfaces in vitro. J Laser Med Surg Apr;20(2): Izumi Y, Aoki A, Yamada Y, Kobayashi H, Iwata T, Akizuki T, et al. Current and future periodontal tissue engineering. Periodontol Jun;56(1): Radvar M, Creanor SL, Gilmour WH, Payne AP, McGadey J, Foye RH, et al. An evaluation of the effects of an Nd:YAG laser on subgingival calculus, dentine and cementum. An in vitro study. J Clin Periodontol Jan;22(1): Stubinger S, Etter C, Miskiewicz M, Homann F, Saldamli B, Wieland M, et al. Surface alterations of polished and sandblasted and acid-etched titanium implants after Er:YAG, carbon dioxide, and diode laser irradiation. Int J Oral Maxillofac Implants Jan Feb;25(1): Geminiani A, Caton JG, Romanos GE. Temperature increase during CO(2) and Er:YAG irradiation on implant surfaces. Implant Dent Oct;20(5): Moëne R, Décaillet F, Andersen E, Mombelli A. Subgingival plaque removal using a new air-polishing device. J Periodontol Jan;81(1): Petersilka GJ. Subgingival air-polishing in the treatment of periodontal biofilm infections. Periodontol Feb;55(1): Ntrouka VI, Slot DE, Louropoulou A, Van der Weijden F. The effect of chemotherapeutic agents on contaminated titanium surfaces: a systematic review. Clin Oral Implants Res Jul;22(7): Terranova VP, Franzetti LC, Hic S, Di- Florio RM, Lyall RM, Wikesjö UM, et al. A biochemical approach to periodontal regeneration: tetracycline treatment of dentin promotes fibroblast adhesion and growth. J Periodontal Res Jul;21(4): de Sousa FO, Blanco-Méndez J, Pérez- Estévez A, Seoane-Prado R, Luzardo- Álvarez A. Effect of zein on biodegradable inserts for the delivery of tetracycline within periodontal pockets. J Biomater Appl Aug;27(2): Soukos NS, Goodson JM. Photodynamic therapy in the control of oral biofilms. Periodontol Feb;55(1): Sgolastra F, Petrucci A, Gatto R, Marzo G, Monaco A. Photodynamic therapy in the treatment of chronic periodontitis: a systematic review and meta-analysis. Lasers Med Sci Feb;28(2): Caton J, Ryan ME. Clinical studies on the management of periodontal diseases utilizing subantimicrobial dose doxycycline (SDD). Pharmacol Res Feb; 63(2): Sgolastra F, Petrucci A, Gatto R, Giannoni M, Monaco A. Long-term efficacy of subantimicrobial-dose doxycycline as an adjunctive treatment to scaling and root planing: a systematic review and meta-analysis. J Periodontol Nov; 82(11): Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res. 2012;23(Suppl. 5):39 66.