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22 ◊Page 21 RESTORATIVE Dental Tribune Middle East & Africa Edition | 5/2017 stainless steel and plastic-coated ul- trasonic devices, two types of glycine powders and one of erythritol) on implant necks through a scanning electron microscope. They found out that air-polishing treatment resulted in the least surface modifications. Amongst the powders tested, the erythritol was proven to be the most respectful of the implant surface. Furthermore, the introduction of specifically designed flexible nozzles able to reach the deeper portion of the pockets has increased the decon- tamination power of this kind of de- vices. Ronay et al.24 in a in-vitro study simulated different peri-implant defect morphologies around rough implants with simulated biofilm and tested the cleaning effectiveness of steel curette, ultrasonic device with steel tip, air-powder abrasive device with glycine powder and nozzle for sub-gingival use. The air-abrasive device provided a superior cleaning efficacy, followed by ultrasonic in- strumentations. The major advantage of the sub- gingival nozzles is the flexibility that eases the access to the peri-implant pockets and to the implant surfaces, mostly when the access is hindered and the removal of the prostheses is not possible. Even if the in-vitro results are en- couraging, in-vivo evidence is still insufficient. Sahm et al.25 in a ran- domized controlled clinical trial showed that the treatment of initial/ moderate peri-implantitis through an air-abrasive device with glycine powder can achieve the same PD re- duction of carbon curettes and chlo- rexidine digluconate. It could also achieve a significantly higher BOP reduction. Randomized controlled clinical trials are required to asses the real in-vivo efficacy of air-polishing devices for the resolution of peri- implantitis, focusing on severe cases. Antibacterial and antiseptic mol- ecules have been proposed to boost the bacterial elimination and to help decontaminating the implant porous surface. Chlorexidine has shown to be ineffective in peri- implant lesions decontamination. Porras et al.20 could not find any PD reduction and only a limited BOP re- duction after additional use of local 0.12% chlorexidine irrigation and gel plus 10 days of 0.12% chlorexidine mouth-rinse. Antibiotics constitute an additional option. Since peri-im- plantitis is a very localized disease, we wouldn’t take into consideration systemic antibiotic therapy with all the side effects it can bring. It’s im- portant to notice that, to date, there are no controlled clinical trials evalu- ating the effects of any systemic an- tibiotic therapy.9 Locally delivered antibiotics can be released in a high dose of for many days, killing the bac- teria in the un-removed biofilm. Tet- racyclines have been widely investi- gated in periodontology given their broad action spectre. Mombelli et al.18 tested locally delivered 25% tetra- cycline as monolithic ethylene vinyl acetate fibers to be located around implants after a scaling phase with plastic curette and to be removed 10 days after. Clinical, radiographic and microbiological parameters im- proved in a good part of the subjects. Unfortunately, the lack of control group does not allow to understand the real magnitude of the antibiotic action. Amongst the difficulties met by the authors, it’s notable the strug- gle in assuring a contact between the fibers and all the implant surface, in particular in narrow and deep defects. The use of different biode- gradable carriers can give a better and easier contact with the implant structure and can cut out the need of fibers removal. Renvert et al.22 tested a single dose of locally delivered mi- nocycline as a coadjuvant of manual debridment with curettes, compared to chlorexidine gel application. The additional effect of minocycline was small but significantly higher both on PD and BOP. Butcher et al.4 inves- tigated biodegradable slow-release 8.5% doxycycline as an adjunction to debridment with plastic curettes plus motivation and oral hygiene instructions. The results were prom- ising showing a significantly greater gain in mean attachment level, PD and BOP improvement for the doxy- cycline group. In conclusion, doxycy- cline seems to be the most effective local antibiotic available. Schwarz et al.30,31 summarised the most recent evidence about peri- implant disease treatment through plaque removal and adjunctive or al- ternative measures. Regarding peri- implantitis, a meta-analysis showed that glycine powder as an alternative biofilm removal measure and lo- cal antibiotic therapy as an adjunct to mechanical debridment allow to achieve a higher BOP reduction over respective control treatments. These are the reasons why we decided to bring in our clinical experience the use of PEEK ultrasonic tips associ- ated with supra- and sub-gingival air-polishing systems with glycine or erythritol powder and a controlled- release 14% doxycycline hyclate (Li- gosan®). So far, there is no scientific evidence supporting the efficacy of this coad- juvant. The tested protocol consist of a Multiple Anti Infective Non Surgi- cal Therapy (MAINST) that involves the use topical 14% doxycycline to solve the peri-implantitis acute phase and, after 7 days, a session of Full Mouth Air Polishing Therapy (FM-EPAPT) through erythritol pow- der (Fig.7), a piezo-ceramic device with a PEEK tip (Fig.8), the curettage of internal pocket line (Fig.9) and a second application od Doxy. The patients were further followed with quarterly maintenance sessions car- ried on with the same FM-EPAPT protocol. Up to 12 months BOP and mean PD decreased significantly and successfully, accompanied by a gain of attachment level up to 12 months. The first case-series about MAINST is waiting to be published and the results are encouraging. Figure 10 and 11 show the healing at 6 and 12 months after MAINST pro- tocol of the peri-implantitis case dis- played at the beginning of this article (Fig.1,2,3,4) and figure 12-21 show a complete MAINST case. - A first effective implant pocket de- contamination with respect of soft tissues though a topical antibiotic to solve the acute phase of peri-implan- titis; - A decontamination and detoxifica- tion phase though erythritol powder and piezo-electric device that covers the entire oral cavity (FM-EPAPT); - A strict professional maintenance protocol based on EPAPT. - A strict home care maintenance protocol. The home-care maintenance is fun- damental for the maintenance of the treatment results.9 The facilities given to the patients include: sonic tooth brush, interdental brushes, floss and air-floss (Philips Sonicare AirFloss Ultra). References 1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of suc- cess. Int J Oral Maxillofac Implants, 1986;1:11–25. Editorial note: The article was orgin- ially published in PLAQUE N CARE 11, 2, 70-80 (2017). Periimplantitis: von der Diagnose zur Therapie. Ein neues Behandlungsprotokoll mit Pulver- strahlsystemen The references list is available from the publisher.