Decontamination of Titanium Implant Surface and

Re-osseointegration to Treat Peri-Implantitis:

A Literature Review
Karthikeyan Subramani, BDS, MSc1/Daniel Wismeijer, DDS, PhD2

Purpose: To review the literature on decontamination of titanium implant surfaces following peri-implantitis
and the effect of various cleaning methods on re-osseointegration. Materials and Methods: An electronic
search of the literature at PubMed was conducted on the studies published between 1966 and October
2010. In vitro, animal, and clinical studies were included. Results: Of 597 studies retrieved, 74 manuscripts
were selected for the review. Various implant surface decontamination methods using various chemical
and mechanical agents have been suggested for treatment and re-osseointegration following peri-
implantitis. It has been shown that re-osseointegration of contaminated implant surfaces is possible; this
largely depends upon the surface of the implant and the types of decontamination techniques and bone
regenerative materials used. Complete re-osseointegration cannot be achieved by surface decontamination
alone. Titanium implants with titanium plasma-sprayed or sandblasted and acid-etched surfaces may be
effectively decontaminated by applying chlorhexidine and saline-soaked gauze or by repeated rinsing with
these solutions. Conclusions: Both mechanical and chemical decontamination techniques should be applied
alongside regenerative surgical procedures to obtain optimum re-osseointegration and successfully treat
peri-implantitis. In recent years, lasers and photodynamic therapy have shown minor beneficial results,
which need to be confirmed by long-term clinical studies with comparable groups. Int J Oral Maxillofac
Implants 2012;27:1043–1054

Key words: biofilm removal, chemical and mechanical cleaning, laser, peri-implantitis, photodynamic therapy,
re-osseointegration

A t the First European Workshop on Periodontology,

peri-implantitis was defined as an inflammatory
process affecting tissues around an osseointegrated
implant in function, thereby resulting in the loss of
supporting bone. Peri-implant mucositis was de-
fined as “reversible” inflammatory changes in the
soft tissues surrounding a functional implant, with-
out bone loss.1 These definitions thus imply that the
1Promovendus, Department of Oral Implantology and
Prosthodontics, Academic Centre for Dentistry Amsterdam,
Research Institute MOVE, University of Amsterdam; Vrije
Universiteit, Amsterdam, The Netherlands.
2Professor, Department of Oral Implantology and
inflammatory process that occurs in peri-implantitis
lesions is irreversible. The signs and symptoms of peri-
implantitis include bleeding on probing, increased
probing pocket depth (> 3 mm; generally, noninfected
implants allow a probe to penetrate approximately
3 mm), implant mobility, suppuration, pain, and radio-
logic evidence of vertical destruction of crestal bone
(which is often saucer-shaped). Peri-implantitis affects
5% to 20% of implant patients and is a major cause of
implant failure.2–4
The goal of peri-implantitis treatment is to stop the
progression of bone loss by controlling bacterial infec-
tion and peri-implant tissue inflammation. The follow-
ing five considerations have been suggested for the
treatment peri-implantitis2:

Prosthodontics, Academic Centre for Dentistry Amsterdam,

Research Institute MOVE, University of Amsterdam; Vrije
Universiteit, Amsterdam, The Netherlands.
Correspondence to: Dr Karthikeyan Subramani, Department
of Oral Implantology and Prosthodontics, Academic Centre for
Dentistry Amsterdam (ACTA), Gustav Mahlerlaan 3004, 1081
LA, Amsterdam, The Netherlands. Fax: +31-(0)20-518-8414.
Email: subramani.karthikeyan@googlemail.com
• The disturbance and/or removal of bacterial biofilm
in the peri-implant pocket
• Decontamination and conditioning of the implant
surface
• Correction via reduction or elimination of sites that
cannot be adequately maintained by oral hygiene
measures

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Subramani/Wismeijer
• Establishment of an effective plaque control regimen
• Regeneration of bone and re-osseointegration
Current treatment modalities include both nonsur-
gical and surgical approaches.5,6 Nonsurgical treat-
ment approaches include7–11:
1. Instruction in more effective oral hygiene practices;
2. Mechanical cleansing using rubber cups, polish-
ing paste, ultrasonic carbon fiber curettes, and/or
acrylic scalers for biofilm removal;
3. Antiseptic therapy with daily rinsing of 0.1% to
0.2% chlorhexidine digluconate solution for 3 to
4 weeks, supplemented by local irrigation with
chlorhexidine solution or gel application; and
4. Antibiotic therapy with either systemic antimicro-
bials (eg, metronidazole or a combination of met-
ronidazole and amoxicillin), or local application of
antibiotics using controlled-release devices (eg,
25% tetracycline fibers).
Surgical treatment of peri-implantitis involves12–18
either (1) resective procedures (bone resection and
apically repositioned flaps) or (2) regenerative proce-
dures (with bone grafts and guided bone regeneration
[GBR] membranes). Resective procedures are preferred
when there is minimal bone loss, while sites with major
bone loss require regenerative procedures. Bone loss
around implants can be classified as mild, moderate, or
severe.3,19,20 Mild bone loss can be treated by cleaning
of the implants, surgical resection, topical antiseptic
treatment, and/or local or systemic antibiotics. Mod-
erate bone loss is usually treated similar to cases with
mild bone loss, but open debridement should be con-
sidered. This surgical approach is associated with re-
cession, possible exposure of the neck of the implant,
and consequent esthetic problems. Advanced bone
loss may require removal of the infected implant, open
debridement, local and/or systemic antibiotic therapy,
and oral hygiene instruction. Once the infection and
inflammation are controlled, placement of new im-
plants with GBR techniques has been the preferred
treatment to fill the peri-implant bone defect.
Although various degrees of bone fill of defect have
been documented, achieving complete re-osseointe-
gration has been a major challenge in the treatment
of peri-implantitis. Numerous in vitro, animal, and
clinical studies have evaluated the decontamination of
infected titanium dental implants by chemical agents
and mechanical cleansing. The purpose of this review
was to evaluate the available published in vitro, in vivo
(animal), and clinical studies to understand the current
data on the decontamination efficacy of various me-
chanical and chemical agents used in the treatment of
peri-implantitis and re-osseointegration.
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Materials and methods
An electronic PubMed literature search was conducted
of studies published from 1966 until February 2010.
The following terms were used in the literature search:
treatment and re-osseointegration/peri-implantitis/
periimplantitis decontamination and titanium im-
plants and peri-implantitis/periimplantitis; decontami-
nation and titanium implants/biofilm removal; biofilm/
plaque bacterial adhesion and peri-implantitis/peri-
implantitis; decontamination/cleaning and titanium
disks and plaque/biofilm; biofilm/plaque removal and
re-osseointegration/peri-implantitis/periimplantitis;
chemical/mechanical cleaning and peri-implantitis/
periimplantitis; and photodynamic therapy/laser and
peri-implantitis/periimplantitis. Literature covering in
vitro, animal, and clinical studies was included in the
review.
Results
Of the 597 studies retrieved from the literature search,
74 manuscripts were selected for the review. The fol-
lowing categorizations of the studies were made: (1)
in vitro studies of various decontamination methods
to assess biofilm removal from implant surfaces, (2)
preclinical animal studies of various decontamination
methods for peri-implantitis treatment and re-osseo-
integration, and (3) clinical studies in human patients
of various decontamination methods for peri-implant
mucositis and peri-implantitis treatment and re-osseo-
integration. The various methods of decontamination
of infected implant surfaces—mechanical methods
and chemical agents, as well as newer techniques such
as photodynamic therapy (PDT) and laser—were com-
pared and correlated for their effectiveness in decon-
taminating an infected implant surface and promoting
re-osseointegration from the in vitro, preclinical ani-
mal, and human studies. The other parameters taken
into consideration were: (1) surface characteristics
of titanium substrates, (2) type of decontamination
agents used, (3) methods of application of these
agents to clean the infected surface, (4) effectiveness
of these various agents in killing and removing peri-
implantitis–causing pathogens, (5) different animal
models used, (6) number of implants studied, (7) num-
ber of patients evaluated, and (8) final results in terms
of bone regeneration, re-osseointegration, and bone-
to-implant contact (BIC).
Studies of Mechanical Decontamination
Management of peri-implantitis generally works on
the principle that there is a primary microbial etiology
in the form of a biofilm on the implant surface. Surface

chemistry, roughness, and design features of the im-
plant-abutment complex play significant roles in biofilm
formation.21 The microorganisms and their by-products
lead to infection of the peri-implant tissues and subse-
quent destruction of the alveolar bone surrounding the
implant.22–26 Therefore, the removal of biofilm from the
implant surface is a priority. For such purposes, the im-
plant should be cleaned by instruments that are softer
than titanium to avoid surface roughening (which may
encourage bacterial colonization). Mechanical cleans-
ing using different prophylaxis procedures (ultrasonic
scalers, plastic tip ultrasonic scalers, stainless steel cu-
rettes, titanium curettes, expanded polytetrafluoroeth-
ylene [e-PTFE] curettes, air-powered systems, abrasive
rubber cups, polishing rubber cups, and brushes)
have been studied in vitro to evaluate surface altera-
tions on titanium implant necks.27 Abrasive pumices,10
airborne particle–abrasion units (sodium bicarbo­
nate),28 plastic scalers,29,30 and ultrasonic carbon fiber
curettes31,32 have also been evaluated.
Investigations of Chemical Decontamination
Chemical decontamination techniques via local appli-
cation of antimicrobial solutions such as chlorhexidine
solution or gel,8,33–36 stannous fluoride,37 tetracy-
cline,38,39 minocycline,40,41 citric acid,9,42–45 hydrogen
peroxide,2,42,44,46 and 35% phosphoric acid etching
gel32 have been reported. Findings of in vitro studies are
summarized in Table 1.28,43,45,47–55 The decontamination
of titanium cylinders with machined, plasma-sprayed,
and hydroxyapatite-coated surfaces contaminated
with radioactive endotoxin from Porphyromonas
gingivalis was evaluated with cotton pellets soaked
with water, citric acid, 0.12% chlorhexidine, and an
airborne particle–abrasion system.43 The study con-
cluded that citric acid treatment was equally effective
on both surfaces in the removal of the bacterial endo-
toxin, while machined and plasma-sprayed implants
were decontaminated effectively by all types of treat-
ment (Table 1).
Clinical studies have shown that chlorhexidine,
which is an effective bactericidal, can be used to de-
stroy bacteria and prevent biofilm formation for
treatment of peri-implantitis.33–35 The 12-week use of
stannous fluoride mouthrinse was shown to be effec-
tive in controlling the amount of supragingival plaque
deposits in patients with generalized aggressive perio-
dontitis.56 A recent study has suggested that the use
of stannous fluoride could decrease the production
of proinflammatory molecules like interleukin-1 beta,
prostaglandin E2, and vascular endothelial growth
factor, which aid in peri-implantitis–induced bone re-
sorption.37 Local delivery of tetracycline via polymeric
fibers significantly reduced the numbers of microbes
causing peri-implantitis.39
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Subramani/Wismeijer
Topical application of minocycline microspheres has
also been shown to be effective in reducing microbial
count and bleeding scores.40,41 Citric acid was effective
in reducing bacterial growth when applied at a pH of 1.2
It was also shown that contaminated hydroxyapatite-­
coated titanium surfaces could be treated equally well
with airborne-particle abrasion or citric acid.43,45 Pre-
clinical studies on the re-osseointegration of rough im-
plant surfaces previously coated with bacterial biofilm,
following cleaning with citric acid and hydrogen perox-
ide, showed favorable results in terms of osseointegra-
tion.42,44 Preclinical study findings are summarized in
Table 2.10,30,42,44,57–63
Clinical studies of decontamination treatments are
summarized in Table 3.12,29,31,32,46,64–67 One study con-
cluded that hydrogen peroxide treatment of titanium
implants (from advanced peri-implantitis lesions) was
successful for 58% of the treated implants in terms of
surgical and antimicrobial treatment aspects during a
5-year follow-up period.46 In a 5-month clinical trial,
the cleaning efficacy of 35% phosphoric acid etching
gel (pH 1) was evaluated and compared with mechani-
cal cleaning methods using carbon fiber curettes and
a rubber cup.32 Both treatment modalities instantly
reduced the number of colony-forming units, but the
reduction following the application of phosphoric acid
was greater.
Examinations of PDT and Laser Treatment
PDT has been employed for decontamination of im-
plant surfaces in the treatment of peri-implantitis for
microbial reduction and biofilm control.29,55 PDT is a
technique that uses a photosensitizer drug that is ca-
pable of binding to the microbes in biofilm and, when
excited with high-energy laser light, cytotoxic singlet
oxygen molecules are produced, which can destroy
bacterial cells. PDT using photosensitizer solutions
such as toluidine blue55 and chlorine e6 with BLC1010
(a water-soluble derivative of chlorine e6)68 in combi-
nation with a diode laser and azulene photosensitizer
solution with gallium-aluminum-arsenide (GaAlAs)
laser69 have been reported.
Along with the use of PDT over the past few years,
lasers have garnered great interest for their potential
in implant decontamination for treatment of peri-
implantitis. Different lasers, including erbium-doped
yttrium-aluminum-garnet (Er:YAG) lasers,30,52,54,70
erbium,chromium–doped yttrium-scandium-gallium-
garnet (Er,Cr:YSGG) lasers,50 neodymium:yttrium-­
aluminum-garnet (Nd:YAG) lasers,71 and carbon
dioxide (CO2) lasers,51,72–74 have been studied in vitro
and in animal and human trials.
The International Journal of Oral & Maxillofacial Implants 1045
Subramani/Wismeijer

Table 1  In Vitro Studies of Various Decontamination Methods to Remove Biofilm from Implant Surfaces
Study Substrate Decontamination methods
Duarte et al Titanium disks with smooth machined 1. Er:YAG laser
(2009)28 surfaces and SAE surfaces 2. Metal curette
3. Plastic curette
4. Airborne particle–abrasion system (sodium bicarbonate)
Goncalves et al Titanium implants with machined 1. 980-nm GaAlAs laser
(2009)47 surfaces, surfaces sandblasted with 2. 1,064-nm Nd:YAG laser
titanium oxide (TiO2), and SAE surfaces

Quaranta et al Titanium implants with machined Er:YAG laser

(2009)48 ­surfaces, TPS implants, and SAE
implants
Giannelli et al Titanium disks cut from dental implants Nd:YAG laser
(2009)49 (Bicon)
Schwarz et al SAE titanium disks worn as intraoral Er,Cr:YSGG laser
(2006)50 splints for 24 h
Park et al Titanium surface (smooth) and coated Nd:YAG and CO2 lasers
(2005)51 with resorbable blast material
Schwarz et al Acrylic resin splints with SAE titanium 1. Er:YAG laser
(2005)52 disks worn for 24 h 2. Ultrasonic system
3. Plastic curettes and rinsing with chlorhexidine digluconate
4. Unworn titanium disks
Pereira da Silva Machined titanium sheets and titanium High-pressure sodium bicarbonate device (Dentsply Prophyjet)
et al (2005)53 sheets blasted with aluminum oxide
Schwarz et al Explanted titanium SAE implants Er:YAG laser
(2003)54
Haas et al Commercially pure titanium disks with Treated with a toluidine blue solution and irradiated with a diode
(1997)55 machined surface, TPS surface, SAE, soft laser with a wavelength of 905 nm for 1 min
and HA-coated plasma-sprayed surface
Dennison et al Titanium cylinders with machined, TPS, Burnishing with a cotton pellet soaked in water, citric acid
(1994)43 and HA-coated surfaces contaminated solution, and 0.12% chlorhexidine; or treated with airborne-
with radioactive endotoxin particle abrasion
Zablotsky et al Grit-blasted titanium alloy and HA- Burnishing with citric acid, stannous fluoride, tetracycline
(1992)45 coated test strips contaminated with ­hydrochloride, chlorhexidine gluconate, hydrogen peroxide,
radioactive endotoxin chloramine T, sterile water, a plastic sonic scaler tip, and an
airborne p
­ article–abrasion unit
A actinomycetemcomitans = Actinobacillus actinomycetemcomitans; CO2 = carbon dioxide; E coli = Escherichia coli; E faecalis = Enterococcus
faecalis; Er,Cr:YSGG = erbium,chromium-doped yttrium-scandium-gallium-garnet; Er:YAG = erbium-doped yttrium-aluminum-garnet;
GaAlAs = gallium-aluminum-arsenide; HA = hydroxyapatite; Nd:YAG = neodymium-doped yttrium-aluminum-garnet; P intermedia = Prevotella
intermedia; SAE = sandblasted/acid-etched; S sanguis = Streptococcus sanguis; TPS = titanium plasma sprayed.

Discussion nizers in a peri-implant biofilm) from machined and

Effectiveness of Mechanical Decontamination
For the treatment of periodontitis and peri-implant
infections, mechanical cleansing has been supple-
mented with chemical decontamination. The use of
airborne-particle abrasion to clean grit-blasted tita-
nium surfaces decontaminated with radioactive endo-
toxin from Escherichia coli was shown to be effective
in vitro when compared to other chemical agents45
(Table 1). It was also effective in vitro in removing
Streptococcus sanguis biofilm (one of the initial colo-
aluminum oxide–blasted titanium surfaces.53 Airborne
particle–abrasion units have been used for the surgi-
cal treatment of peri-implantitis in animals59,63 and
humans.12 No adverse effects were reported in these
studies. Emphysema and pneumoparotitis caused by
the use of airborne particle–abrasion units in den-
tistry have been very rare.75,76 One clinical case study
reported that an airborne particle–abrasion instru-
ment was not recommended for the maintenance
care of osseointegrated titanium implants to remove
calculus and debris from titanium abutments.75 An

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 Subramani/Wismeijer

Results Microbes studied

Er:YAG laser treatment and plastic curette instrumentation caused no or minimal changes S sanguis
on the smooth and rough titanium surfaces studied. Surfaces treated with metal curette and
airborne-particle abrasion were less susceptible to bacterial adhesion, probably a result of
texture modification and the presence of abrasive deposits.
Different laser wavelengths used in this study reduced bacteria without damaging implant E faecalis and P gingivalis
surfaces. GaAlAs laser showed 100% bacteria reduction on the implants irradiated at 3 W.
Irradiation at 2.5 W and 3 W achieved 100% of bacteria reduction on P gingivalis–­
contaminated implants. Decontamination was not complete for the sandblasted TiO2 (78.6%)
and SAE surfaces (49.4%) contaminated with E faecalis and irradiated at 2.5 W.
No surface alterations were observed. Decontamination values of 76.2% of total bacterial P gingivalis
count for machined test implants, 90.9% for TPS implants, and 98.3% for SAE implants.
Minimal residual bacterial presence was observed in all groups.
Significantly reduced bacterial endotoxin lipopolysaccharide -induced inflammatory P gingivalis
response leading to peri-implantitis.
Laser exhibited a high efficiency of biofilm removal in an energy-dependent manner, Not reported
but failed to reestablish the biocompatibility of contaminated titanium surfaces.
CO2 laser was more useful than Nd:YAG laser treatment. Nd:YAG laser caused implant Not reported
­surface alterations.
Er:YAG laser was most suitable for the removal of supragingival early plaque biofilms grown Not reported
on SAE titanium implants, but it failed to restore the biocompatibility of contaminated
­titanium surfaces.

Efficiently removed all bacterial cells from all surfaces tested. S sanguis

Nonsurgical instrumentation with Er:YAG laser resulted in effective removal of subgingival Not reported
calculus without any thermal damage.
Combined dye/laser treatment resulted in the destruction of bacterial cells in all the A actinomycetemcomitans,
­surfaces studied. P gingivalis, and P intermedia

Machined implants were decontaminated more effectively by all treatments than the other Radioactive endotoxin from
surfaces, with the ­exception of citric acid treatment, which was equally effective on either P gingivalis
machined or hydroxyapatite surfaces.
Airborne-particle abrasion removed significantly greater amounts of lipopolysaccharide Radioactive endotoxin from E coli
than all other treatment modalities on titanium. Citric acid was superior in the removal of
­­lipopolysaccharide from HA-coated surfaces.

acute clinical reaction characterized by pain, submu-
cosal emphysema, and breakdown of marginal bone
surrounding the implants was reported. The use of
metal curettes and airborne particle–abrasion sys-
tems on smooth and rough (sandblasted/acid-etched
[SAE]) surfaces showed that these surfaces were less
susceptible to bacterial adhesion, probably because of
the texture modification and the presence of abrasive
deposits.28 Moreover, the use of metal curettes can
alter the surface roughness, encouraging additional
bacterial colonization. Plastic curette instrumenta-
tion caused no or minimal changes on the titanium
surfaces in the cited study. A considerable amount of
re-osseointegration (39.4%) was reported in an animal
study when implant surfaces were decontaminated
using plastic scalers and saline irrigation,30 and a sig-
nificant reduction in counts of Actinobacillus actinomy-
cetemcomitans, P gingivalis, and Prevotella intermedia
species was achieved in a clinical study when a soft di-
ode laser (PDT) was added to the treatment regimen.29
In a clinical and radiographic study, decontamination
with mechanical debridement using ultrasonic carbon
fiber curettes did not consistently result in healing of
peri-implant lesions.31

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Subramani/Wismeijer

Table 2  Animal Studies of Various Decontamination Methods for Peri-implantitis Treatment and
Animal
Study model Implant surface Decontamination and treatment protocol
Parlar et al Dogs Machined; SAE and TPS 1. Exchanging for a pristine implant cylinder
(2009)57 titanium implant cylinders 2. Spraying in situ with saline
3. Removal, cleansing outside the mouth by spraying with saline,
steam-sterilization, and remounting
Alhag et al Dogs Ti-Unite, Nobel Biocare 1. Swabbing with citric acid for 30 s followed by rinsing with
(2008)42 physiologic saline
2. Cleaning with a toothbrush and physiologic saline for 1 min
3. Swabbing with 10% hydrogen peroxide for 1 min followed by
rinsing with physiologic saline
Takasaki et al Dogs SAE surface 1. Er:YAG laser + saline irrigation
(2007)30 2. Plastic scaler + saline irrigation
Persson et al Dogs Machined Ti surface, SAE 1. CO2 laser + hydrogen peroxide
(2004)58 surface 2. Saline soaked in cotton pellets

Schou et al Monkeys TPS surface (Straumann) 1. Airborne-particle abrasion (sodium bicarbonate) + citric acid on
(2003)59 cotton pellet 2 min + saline irrigation 20 times
2. Airborne-particle abrasion
3. Five min of cleaning with gauze soaked in saline + citric acid
applied for 2 min followed by 20 times irrigation with saline
4. Gauze soaked alternately in chlorhexidine (0.1% aqueous) and
saline and irrigated repeatedly 20 times with both solutions
Schou et al Monkeys TPS surface (Straumann) Treatment with gauze soaked alternatively in chlorhexidine and saline,
(2003)60 followed by irrigation plus:
1. Flap surgery with autogenous bone, e-PTFE membrane for 3 months
2. Flap surgery and autogenous bone
3. Flap surgery and e-PTFE membrane for 3 months
4. Flap surgery alone
Kolonidis et al Dogs Commercially pure Ti 1. Citric acid (30 s) on cotton pellet and rinsing with saline
(2003)44 (Brånemark) implant 2. Toothbrush and saline rinsing for 1 min
3. Hydrogen peroxide (10%) on cotton pellet
Persson et al Dogs 1. Turned surface Saline-soaked cotton pellets and systemic antibiotic therapy with
(2001)61 2. SAE surface amoxicillin and metronidazole
(ITI implants)
Persson et al Dogs Commercially pure Ti 1. Abrasive pumice with rotating brush
(1999)10 (Brånemark) implants 2. Cotton pellets soaked with saline

Ericsson et al Dogs Ti (Brånemark) implants 1. Curettage + 1% delmopinol detergent and abutments ­autoclaved
(1996)62 2. No decontamination
Hurzeler et al Dogs Ti (Brånemark) implants Airborne-particle abrasion debridement (control group) along with
(1997)63 GBR (test groups)
CO2 = carbon dioxide; e-PTFE = expanded polytetrafluoroethylene; Er:YAG = erbium-doped yttrium-aluminum-garnet; SAE = sandblasted/acid-etched;
Ti = titanium; TPS = titanium plasma sprayed.

Efficacy of Chemical Decontamination
Mechanical debridement can be combined with chem-
ical agents to remove hard (calculus, bone debris) and
soft deposits (tissue remnants and bacterial biofilm)
from the infected implant surface. Citric acid has been
shown to be effective in reducing bacterial growth at a
pH of 1.2 However, clinical application of citric acid at a
highly acidic pH may affect peri-implant tissues. A few
animal studies swabbed sites with citric acid for 30 sec-
onds and followed this with physiologic saline rinse to
remove peri-implant biofilm.42,44 Hydrogen peroxide
swabbing for 1 minute followed by rinsing with physi-
ologic saline was another treatment protocol used in
these studies. Direct BIC and re-osseointegration were
reported. It should be taken into consideration that
these studies involved the removal of contaminated

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Re-osseointegration
Results
SAE implants and in situ cleansing with saline resulted in
more re-osseointegration: 62.3% ± 18.2% BIC.
Direct BIC in all treatment groups. The results showed that
rough surfaces, which were plaque contaminated and cleaned
by different methods, can re-osseointegrate.
Re-osseointegration with laser: 69.7%; with saline: 39.4%.
Re-osseointegration with saline on SAE (84%), with CO2 laser
on SAE (82%), with CO2 laser on machined surface (21%), with
saline on machined surface (22%).
Total bone regeneration and considerable re-osseointegration
using autogenous bone grafts and ­e -PTFE membrane;
39% to 46% BIC in group 4.
Re-osseointegration:
1. 45%
2. 22%
3. 21%
4. 14%.
Implants were removed and placed in opposite group.
Osseointegration and direct BIC were observed in all groups.
84% re-osseointegration at SAE sites, 22% at turned sites.
Bone regeneration:
1. 59%
2. 64%.
No re-osseointegration.
Airborne-particle abrasion debridement showed
re-osseointegration of 0.3 mm.
implants from one quadrant of the mandible, decon-
tamination with citric acid and hydrogen peroxide,
and placement of implants in freshly prepared sites
in the opposite mandibular quadrant. The absence
of infection at the new site could have aided in re-
osseointegration and direct BIC. However, a clinical
study in nine patients that used 10% hydrogen perox-
ide debridement with saline rinsing supplemented by
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0.2% chlorhexidine mouthrinse and systemic antibi-
otics (amoxicillin and metronidazole) found that this
treatment strategy was 58% successful in the treat-
ment of 26 implants.46 Four implants continued to lose
bone and seven implants were lost in patients who
were smokers. The study concluded that smoking was
a negative risk factor for the treatment outcome. In ani-
mal studies of the surgical treatment of peri-implantitis
defects using GBR with autogenous bone and e-PTFE
membranes, swabbing with saline and chlorhexidine,
and then irrigation with these solutions 20 times,
considerable re-osseointegration was achieved: 39%
to 46% BIC with bone grafts59 and 14% re-osseoin-
tegration60 (Table 2) in the decontaminated implant
group without bone grafts were attained. These stud-
ies showed that repeated irrigation with antimicrobial
agents such as chlorhexidine can be beneficial in de-
contaminating an implant surface.
Few animal studies have shown that debridement
of an infected implant with saline alone can improve
re-osseointegration capacity. Commercially pure tita-
nium implants (Brånemark), when cleaned with cotton
pellets soaked in saline, showed 64% bone regenera-
tion.10 SAE implants cleaned with saline-soaked cot-
ton pellets showed 84% re-osseointegration.58,61 A
recent study comparing machined surfaces with SAE
and titanium plasma-sprayed (TPS) surfaces showed
that in situ cleansing with saline resulted in higher re-
osseointegration (62.3% ± 18.2%) and BIC in the SAE/
TPS implant group57 (Table 2). In an earlier human
study, a mandibular hollow-screw implant (ITI) was
cleaned by rinsing with 0.1% chlorhexidine and saline
solution, followed by placement of an e-PTFE mem-
brane for GBR.67 The treatment was supplemented
with a 10-day systemic antibiotic regimen (amoxicillin
and ornidazole). Five months after membrane remov-
al, radiographic analysis showed a mean bone gain of
4 to 5 mm. In another human study, implants with TPS
surfaces (ITI) were decontaminated by rinsing with sa-
line and 0.2% chlorhexidine digluconate, followed by
e-PTFE membrane placement for GBR. The radiograph-
ic analysis showed a mean bone gain of 1.5 to 3.6 mm
at 1 year after membrane removal.66
From these studies, it can be concluded that rins-
ing with chlorhexidine and saline solution has been
the better method to decontaminate implants with
SAE and TPS surfaces. However, these results should
be confirmed by long-term human trials. Detergents
like delmopinol have also been used to decontaminate
titanium implant surfaces, but no re-osseointegration
was observed.62 The reason suggested was the pres-
ence of a thin layer of delmopinol, which could have
prevented re-osseointegration. The use of 35% phos-
phoric acid gel in the treatment of peri-implant mu-
cositis has also been reported to have a significant
The International Journal of Oral & Maxillofacial Implants 1049
Subramani/Wismeijer

Table 3  Human Studies of Various Decontamination Methods for Peri-implant Mucositis and Peri-
No. of patients
Study and implants Implant surface Decontamination and treatment protocol
Schwarz et al 12 patients, SAE implants (ITI) Nonsurgical treatment with Er:YAG laser
(2006)64 12 implants

Karring et al 11 patients, ITI, Brånemark, and Astra Oral hygiene instruction plus:
(2005)31 22 implants implants 1. Vector system (carbon fiber tip with HA aerosol spray)
2. Carbon fiber curette
Leonhardt et 9 patients, Branemark implants 10% hydrogen peroxide + rinsing with saline followed by
al (2003)46 26 implants 0.2% CHX mouthrinse twice daily and systemic antibiotics
­(amoxicillin and metronidazole )
Dortbudak et 15 patients; no Plasma-spray-coated IMZ Plastic scalers, curettage, toluidine blue (100 µg/mL)–soft diode
al (2001)29 details about no. (Friatec) implants laser irradiation (905 nm for 60 seconds)
of implants used
Behneke et al 17 patients, ITI screw-type implants Airborne-particle abrasion with powder + saline irrigation on test
(2000)12 25 implants groups filled with autogenous bone grafts (bone chips and bone
blocks)
Haas et al 17 patients, TPS cylindric implants Toluidine blue (100 µg/mL) and laser irradiation at a wavelength
(2000)65 24 implants of 906 nm, followed by grafting with autogenous bone supported
with e-PTFE membranes
Strooker et al 16 patients, Implant-supported 1. Mechanical therapy + monthly 35% phosphoric acid gel (pH 1)
(1998)32 64 implants overdentures; no details for 1 minute. 2. Monthly mechanical debridement (with carbon
about the implant surface fiber curettes and rubber cup)
Hammerle et 2 patients, ITI implants (TPS surface) Wound debridement, rinsing with saline and 0.2% CHX, followed
al (1995)66 2 implants by e-PTFE membranes placed around the implants to aid GBR
Ten-day systemic antibiotic regimen (metronidazole and
amoxicillin) and 0.12% CHX mouthrinse twice daily
Lehmann et al 1 patient, Mandibular hollow-screw 0.1% CHX and saline rinsing, e-PTFE membrane for GBR, 10-day
(1992)67 1 implant implant (Bonefit, ITI) systemic antibiotic regimen (amoxicillin and ornidazole)
A actinomycetemcomitans = Actinobacillus actinomycetemcomitans; CHX = chlorhexidine digluconate; e-PTFE = expanded polytetrafluoroethylene;
Er:YAG = erbium-doped yttrium-aluminum-garnet; HA = hydroxyapatite; P intermedia = Prevotella intermedia; SAE = sandblasted/acid etched;
TPS = titanium plasma sprayed.

influence on the reduction of microbial counts.32 There
are no long-term follow-up studies to confirm the re-
sults. The use of acids for decontaminating implant
surfaces also must be evaluated further through in vi-
tro and in human studies with more patients.
The Value of PDT
In recent years, photosensitization using toluidine
blue solution and soft laser irradiation has been shown
to be effective in eliminating peri-implant pathogens
such as A actinomycetemcomitans, P gingivalis, and
P intermedia from different titanium surfaces with-
out modifying the surfaces studied55 (Table 1). This
method was assessed in a clinical study with 24 peri-
implantitis–affected implants (TPS surface) grafted
with autogenous bone supported by e-PTFE mem-
branes.65 Mean bone regeneration of 2 ± 1.90 mm after
a healing period of 9.5 months was observed, but this
procedure was not compared with other decontami-
nation methods. A recent clinical and microbiologic
study confirmed that the use of toluidine blue solution
and soft laser irradiation resulted in a significant re-
duction of A actinomycetemcomitans, P gingivalis, and
P intermedia on a TPS surface.29 However, there have
been no long-term clinical studies on the use of PDT.
PDT has shown to be effective in reducing bleeding on
probing and inflammation in beagle dogs.68 Preclinical
studies of PDT for the treatment of ligature-induced
peri-implantitis conditions and GBR have shown it to
be effective in terms of microbial reduction69 and re-
osseointegration77,78 in dogs. Re-osseointegration of
41.9% for a commercially pure titanium surface and
31.19% for a TPS surface was observed. These results
also need to be validated by human trials.
Effectiveness of Laser Treatment
Use of the Er:YAG laser has been widely reported in the
literature in recent years. Nonsurgical instrumentation
with the Er:YAG laser effectively removed subgingival
calculus without any thermal damage to explanted

1050 Volume 27, Number 5, 2012

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 Subramani/Wismeijer

implantitis Treatment and Re-osseointegration

Evaluation method Results

Histopathologic examination of
­peri-implant tissue
Clinical and radiographic evaluation
Mixed chronic inflammatory cell infiltrate found. A single course of nonsurgical treat-
ment of peri-implantitis using Er:YAG laser may not be sufficient for the maintenance
of failing implants.
Both mechanical debridement methods did not consistently result in healing of the
peri-implant lesions.

Clinical, microbiologic, and radiologic Despite the loss of seven implants and continuous bone loss around four implants
evaluation during the 5-year follow-up period, the treatment strategy was successful in 58% of
implants treated.
Microbiologic evaluation A actinomycetemcomitans, P gingivalis, and P intermedia were reduced significantly.

Clinical and radiographic evaluation Improved bone fill of 3.9 mm and 4.2 mm.

Radiographic evaluation Peri-implant bone gain was 2 ± 1.90 mm after 9.5 months.

Clinical and microbiologic evaluation Both treatment groups showed reduction in colony-forming units, with greater
reduction in 35% phosphoric acid gel group.

Radiographic analysis Mean bone gain of 1.5 to 3.6 mm, 1 year after membrane removal.

Radiographic analysis Mean bone gain of 4 to 5 mm, 5 months after membrane removal.

titanium SAE implants following peri-implantitis.54 A
later in vitro study using the Er:YAG laser showed effec-
tive removal of supragingival plaque biofilms grown
on SAE titanium implants, but the treatment failed to
restore the biocompatibility of contaminated titanium
surfaces.52 A similar study using the Er,Cr:YSGG laser
showed high efficacy of biofilm removal in an energy-
dependent manner, but this technique also failed to
reestablish biocompatibility of contaminated titanium
surfaces.50 A recent in vitro study on the bactericidal
effect of the Er:YAG laser on titanium implants with
machined surfaces, TPS implants, and SAE implants
was reported.48 The results showed no surface altera-
tion and decontamination values of 76.2% of total bac-
terial count (P gingivalis) for machined test implants,
90.9% for TPS implants, and 98.3% for SAE implants.
A minimal residual bacterial presence was observed
on all the surfaces evaluated. However, a clinical and
histopathologic study in a group of 12 patients with
SAE implants using nonsurgical treatment with Er:YAG
laser showed a mixed chronic inflammatory cell in-
filtrate in peri-implant biopsy specimens64 (Table 3).
The study concluded that a single course of nonsurgi-
cal treatment of peri-implantitis via the Er:YAG laser
may not be sufficient for the maintenance of failing
implants. Treatment with the Er:YAG laser followed
by saline irrigation on infected SAE surfaces in a dog
study revealed a higher re-osseointegration value of
69.7%.30 These studies show that laser therapy should
be combined with chemical decontaminants like
chlorhexidine or saline solution to achieve higher re-
osseointegration.
In an in vitro study, titanium implants with ma-
chined surfaces, surfaces sandblasted with titanium
oxide (TiO2), and SAE surfaces contaminated with
Enterococcus faecalis and P gingivalis were treated with
980-nm GaAlAs laser and 1,064-nm Nd:YAG lasers.47
Different irradiation outputs were used to explore
the effect on bacterial killing and surface alterations.
GaAlAs laser provided 100% bacteria reduction on

The International Journal of Oral & Maxillofacial Implants 1051

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Subramani/Wismeijer
implants irradiated at 3 W. Irradiation at 2.5 W and
3 W achieved 100% bacteria reduction on P gingivalis–
contaminated implants. However, decontamination
was not complete for the sandblasted TiO2 (78.6%)
and SAE surfaces (49.4%) contaminated with E faecalis
and irradiated at 2.5 W. A recent study on the effect
of Nd:YAG lasers on bacterial endotoxin–mediated
peri-implant inflammation showed that the Nd:YAG
laser significantly reduced the bacterial endotoxin
lipopolysaccharide-induced inflammatory response
leading to peri-implantitis.49 An earlier in vitro study
had shown that a combination of citric acid, hydro-
gen peroxide, and CO2 laser irradiation was effective
in cleaning bacteria-contaminated titanium surfaces.73
It has been concluded that the CO2 laser does not dam-
age titanium implant surfaces. CO2 laser treatment is
more useful than Nd:YAG laser treatment,51 and de-
contamination of implant surfaces with CO2 laser in
combination with augmentative techniques can be an
effective treatment method for peri-implantitis.74 The
use of lasers and PDT should be evaluated in long-term
human trials with comparable test groups. Moreover,
the use of acids and their efficacy in biofilm removal
should also be tested in vitro and in preclinical and
human studies.
Conclusion
It is understood that the establishment of an implant
surface that favors bone formation and re-osseo­
integration is a prerequisite for the treatment of peri-
implantitis. Contaminants such as bacterial biofilm,
hard (calculus) deposits, and soft deposits should be
removed without modifying the implant surface. For
this purpose, decontamination methods using various
chemical and mechanical agents have been suggested.
Studies have shown that re-osseointegration of a con-
taminated implant surface is possible. However, this
depends largely on the type of decontamination tech-
nique, the bone regenerative materials, and the surface
of the implant. Complete re-osseointegration cannot
be achieved by surface decontamination alone. Tita-
nium implants with titanium plasma-sprayed or sand-
blasted and acid-etched surfaces may be effectively
decontaminated by applying chlorhexidine- and sa-
line-soaked gauze or with repeated rinsing with these
solutions. In recent years, lasers and photodynamic
therapy have also shown minor beneficial results. How-
ever, these results must be confirmed by long-term
clinical studies with comparable groups. The combi-
nation of mechanical and chemical decontamination
techniques should be applied, along with regenera-
tive surgical procedures, to obtain optimum re-osseo­
integration in the treatment of peri-implantitis.
1052 Volume 27, Number 5, 2012
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