Peri-implantitis treatment protocol in the GP office

1. Fadi Al-Zaitoun
Mohammad Al-Tari

2. • It is the destructive inflammatory process
affecting the soft and hard tissues surrounding
dental implants. The array of periodontal
pathogens found around failing implants are very
similar to those found in association with various
forms of periodontal disease.

4. • Peri-implantitis is classified according to the
pocket depth around the implant as follows:
• 1. Early: PD ≤ 3mm
• 2. Moderate: PD 4-5mm
3. Advanced: > 5mm

5. • Peri-implantitis: a destructive inflammatory lesion
that affects the surrounding gingiva and
supportive bone.
• Peri-implant mucositis: an inflammatory lesion
limited to the surrounding mucosa.

6. There is considerable argument on the best way to treat
peri-implant mucositis and peri-implantitis.
For this reason, the Cumulative Interceptive Supportive
Therapy (CIST) protocol was presented during a 2002
Consensus Workshop in Berne, Switzerland. The CIST
protocol is a systematic approach for monitoring hard and
soft tissue around implants for the prevention and
treatment of peri-implant inflammatory diseases.

7. There are 4 components in the CIST Protocol, conveniently
labeled A-D. Proper diagnosis through probing and
periapical radiographs is critical. Each step in this protocol
is used in a sequential manner with increasing antibacterial
intervention, combined with regenerative surgical treatment
if necessary.

8. In part A, typically initiated when plaque and bleeding on
probing (BOP) are present, but pocket depths (PD) are
3mm or less, oral hygiene instructions are reviewed and
patients are motivated to initiate and continue
maintenance; mechanical debridement and polishing takes
place

9. Protocol B is indicated when BOP and plaque are present
and PDs are 4-5 mm. In addition to mechanical
debridement and polishing, a typical antiseptic regimen
might consist of irrigating with chlorhexidine digluconate
and then prescribing it (rinse or gel) to be used by the
patient for 30 seconds, 2 times a day for 3-4 weeks.

10. Protocol C involves the addition of systemic or local
antibiotic treatment to A and B therapies, and is initiated
when PDs are greater than 5 mm. A typical systemic
antibiotic treatment is metronidazole (250 mg tid) for 10
days, or a combination of amoxicillin (500 mg tid) and
metronidazole (250 mg tid) for 10 days. Local antibiotic
treatment might include placing a controlled-release device
for 10 days.

11. When bone loss is present and protocols A, B, and C have
been implemented without resolution, a surgical approach
(protocol D) is often necessary. The surgical options
discussed, per the CIST protocol, are regenerative treatment
(bone graft, membrane, and biologic modifiers, often with
removal of the superstructure to allow primary closure) or
resective treatment (defect osteoplasty/ostectomy, possible
implantoplasty, with an apically positioned flap).

12. If the peri-implant defect morphology is not conducive to
regeneration. We have seen especially promising results in a
practice utilizing LAPIP (Laser Assisted Peri-Implantitis
Procedure) as a minimally invasive strategy in the treatment of
peri-implantitis. The LAPIP protocol uses the PerioLase MVP-7
to target and remove the dark pigmented gram-negative
anaerobic pathogens that cause periodontitis. LAPIP saves
healthy tissue and supports the body's healing efforts.