Treating Peri-implantitis in a Predictable Way: Review of Literature and An Er: YAG Laser Based Case Report Sahar-Helft Sharonit 1 , Findler Mordechai 2 , David Polak 3 1 Department of Endodontics, Hadassah School of Dental Medicine, The Hebrew University, Israel, 2 Department of Oral Medicine, Hadassah School of Dental Medicine, The Hebrew University, Israel, 3 Department of Periodontology, Hadassah School of Dental Medicine, The Hebrew University, Israel Abstract Treatment options for peri-implantitis varies and often unpredictable. The current article delineates treatment modalities available for peri-implantitis and discusses evidence of their long-term predictable outcome. In addition, evidence of adjunctive use of laser therapy in dentistry is discussed. Finally, a peri-implantitis case which was treated with erbium-doped yttrium aluminium garnet (Er: YAG) laser and a regenerative procedure is presented, including long term follow-up. In the case, treatment included intra- sulcular incisions with full thickness flap, mechanical debridement of the osseous defect and decontamination of implant` surfaces with Er: YAG. Bone regeneration was done using biphasic calcium phosphate bone substitute and a resorbable collagen membrane. The outcome of the case show radiographic bone formation, healthy clinical periodontal pockets and no bleeding. The case presents the advantage of adjunctive usage of Er: YAG as a disinfecting agent which provides optimal environment for regeneration in peri- implantitis cases. Key Words: Dental implants, Laser, Peri-implantitis Introduction Dental implants have been recognized for more than 30 years as a predictable, long-term option in the treatment of edentulous areas [1,2]. One of most grave complications related to dental implant is peri-implantitis. This condition is defined as a localized inflammatory lesion involving bone loss around an osseointegrated implant [3]. It is believed that the onset of peri-implant disease occurs following formation of dysbiotic biofilm on implant surfaces, which leads to chronic inflammation and bone loss [4,5]. As such, most treatment modalities are founded on anti-microbial concepts, aiming to clear the pathological biofilm at the infected dental implant. Evidence based practice for predictable treatment modality for peri-implantitis Treatment modalities for peri-implantitis include non-surgical and surgical approaches. Most of these modalities aim to eliminate plaque and calculus, and achieve decontamination of the infected implant` surfaces. Non-surgical approach is similar to the principals of periodontal non-surgical treatment. Fundamentally, these approaches include mechanical debridement with or without the use of adjunctive chemical agents. The mechanical debridement is done with ultrasonic devises, air abrasion systems and various hand instruments like curettes. In an effort to refrain from damaging implant` surfaces, new generation hand curettes have been introduces, and include titanium, plastic and Teflon curettes. Nonetheless, in 2014, Faggion et al. in a systematic review showed that non-surgical treatment based solely on mechanical debridement showed the least favorable clinical improvement [6]. Adjunctive approaches to the mechanical debridement show some evidence of superior results compared with mechanical treatment alone. Tang et al. showed that the additional use of 25% metronidazole gel improved clinical parameters compared with mechanical debridement [7]. Similar effect was observed by Büchter et al. using 8.5% doxycycline hyclate slow release devise (Atridox) [8]. Both Karring et al. in 2005 and Renvert et al. in 2009 found that the Vector system lead to additional improvement in clinical parameters compared with mechanical debridement [9,10]. Glycine-based powder air polishing system were also found beneficial over mechanical treatment alone [11,12]. Machtei et al. found that the addition of chlorhexidine slow release devise (PerioChip®) had a significant superior results compared with mechanical debridement alone [13]. Still, Faggion et al., in their systematic review, concluded that the differences between non-surgical treatments options were small and that there is insufficient evidence to support that any specific non-surgical treatment approach is superior to debridement alone. Surgical treatments include a number of approaches, such as open flap debridement, pocket reduction/elimination, soft tissue augmentation and regenerative treatment. Similar to the non-surgical approaches, the surgical treatments are often accompanied by a chemical treatment. A systematic review by Chan et al. discussed surgical approaches and their outcome [14], and found that open flap approach leads to mean reduction of 2.38 mm in pocket depth following surgery while resective approach led to less favorable outcome with a mean pocket reduction of 2.04. Regenerative approach with grafting and barrier membranes led to the most promising results with a mean improvement of 3.16 mm in pocket depth. Nevertheless, similar to non-surgical treatment approach, Chan et al. [14] concluded that there is a lack of high-quality comparative studies to support a favorable modality. Finally and in accordance with Cochrane publication from 2011 regarding the available evidence of peri-implantitis treatments, concluded that there is insufficient quality and quantity of data regarding long term treatment outcome prognosis [15]. Corresponding author: Sharonit Sahar-Helft, Department of Endodontic, Hebrew University Hadassah School of Dental Medicine, Jerusalem, Israel, Zip code 91120, Tel: 972-52-2686553; E-mail: helft1@bezeqint.net 1