Peri implantitis treatment protocol

Fadi Al-Zaitoun

Mohammad Al-Tari

• 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.

• 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

• 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.

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.

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.

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

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.

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.

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).

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.