Philipp Sahrmann In vitro cleaning potential of three

Valerie Ronay
Deborah Hofer
different implant debridement methods
Thomas Attin
Ronald E. Jung
Patrick R. Schmidlin

Authors’ affiliations: Key words: air flow, debridement, nonsurgical, peri-implantitis

Philipp Sahrmann, Valerie Ronay, Deborah Hofer,
Thomas Attin, Patrick R. Schmidlin, Clinic of
Preventive Dentistry Periodontology and Cariology,
Center of Dental and Oral Medicine and
Maxillofacial Surgery, University of Zurich, Zurich,
Switzerland
Ronald E. Jung, Clinic of Fixed and Removable
Prosthodontics and Dental Material Science, Center
of Dental and Oral Medicine and Maxillofacial
Surgery, University of Zurich, Zurich, Switzerland
Corresponding author:
Dr. Philipp Sahrmann
Clinic of Preventive Dentistry, Periodontology and
Cariology
Plattenstrasse 11
8032 Z€urich
Switzerland
Tel.:+41 44 634 32 84
Fax: +41 44 634 43 08
e-mail: philipp.sahrmann@zzm.uzh.ch
Abstract
Objectives: To assess the cleaning potential of three different instrumentation methods commonly
used for implant surface decontamination in vitro, using a bone defect-simulating model.
Materials and methods: Dental implants were stained with indelible ink and mounted in resin
models, which represented standardized peri-implantitis defects with different bone defect
angulations (30, 60 and 90°). Cleaning procedures were performed by either an experienced dental
hygienist or a 2nd-year postgraduate student. The treatment was repeated 20 times for each
instrumentation, that is, with a Gracey curette, an ultrasonic device and an air powder abrasive
device (PAD) with glycine powder. After each run, implants were removed and images were taken
to detect color remnants in order to measure planimetrically the cumulative uncleaned surface
area. SEM images were taken to assess micromorphologic surface changes (magnification 10,0009).
Results were tested for statistical differences using two-way ANOVA and Bonferroni correction.
Results: The areas of uncleaned surfaces (%, mean  standard deviations) for curettes, ultrasonic
tips, and airflow accounted for 24.1  4.8%, 18.5  3.8%, and 11.3  5.4%, respectively. These
results were statistically significantly different (P < 0.0001). The cleaning potential of the airflow
device increased with wider defects. SEM evaluation displayed distinct surface alterations after
instrumentation with steel tips, whereas glycine powder instrumentation had only a minute effect
on the surface topography.
Conclusion: Within the limitations of the present in vitro model, airflow devices using glycine
powders seem to constitute an efficient therapeutic option for the debridement of implants in
peri-implantitis defects. Still, some uncleaned areas remained. In wide defects, differences between
instruments are more accentuated.

Implant therapy has become a successful
standard treatment in dentistry (Jung et al.
2008; Romanos et al. 2012), and thus, an
increasing number of implants is being
placed (http://www.aaid.com; Brennan et al.
2010). However, biological and technical
complications are a clinical reality as well,
and peri-implantitis has been shown to occur
in 28-56% of patients with dental implants
(Zitzmann & Berglundh 2008), thereby consi-
tuting the main biologic reason for long-term
implant failure (Aglietta et al. 2009; Jung
Date: et al. 2008). As a consequence, peri-implanti-
Accepted 30 November 2013
tis cases emerge as well in the general dental
To cite this article: practice, and peri-implantitis treatment itself
Sahrmann P, Ronay V, Hofer D, Attin T, Jung RE, Schmidlin
PR. In vitro cleaning potential of three different implant is becoming more and more an integral part
debridement methods.
of standard treatment protocols (Schmidlin
Clin. Oral Impl. Res. 00, 2013, 1–6
doi: 10.1111/clr.12322 et al. 2012).
The primary etiologic factor for these
inflammatory conditions is the establishment
of bacterial biofilms on the implant surfaces
(Heitz-Mayfield & Lang 2010). Within this
biofilm, bacteria show an extreme resistance
to topical disinfectants and systemic antibiot-
ics (Stewart & Costerton 2001). Accordingly,
the aim of any cause-related therapy still
remains the effective mechanical removal of
the intact biofilm (Mombelli & Lang 1994).
For this purpose, manual curettes, ultrasonic
and air-polishing devices are commonly used
(Romanos & Weitz 2012; Mombelli et al.
2012). However, due to the special implant
and defect-specific characteristics, access to
all affected areas is limited. As a conse-
quence, nonsurgical techniques still do not
provide predictable and successful outcomes,

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Sahrmann et al
Surface access in peri-implantitis defects
especially in advanced cases (Romanos &
Weitz 2012; Renvert et al. 2008). Hence,
mechanical debridement in combination
with a surgical approach is often necessary to
facilitate the mechanical debridement (Rom-
anos & Weitz 2012). However, studies on
periodontal treatment concordantly show
that even when the comparatively easy to
clean root surface is accessible and visible,
instrumentation is still a demanding task
and also relies on the operator’s skills, train-
ing and experience (Brayer et al. 1989;
Ruhling et al. 2002; Kocher et al. 1997).
Another challenge is the fact that ideal sur-
face decontamination should not only reach
all contaminated surfaces, but that the efforts
to effectively clean the surface ideally should
not change the implant surface micromor-
phology in order not to interfere with the
biocompatibility. This is an issue becoming
crucial when regenerative techniques are
planned. Unfortunately, there is still a lack
of evidence regarding the most efficacious
instrumentation modality with regard to the
addressed implant-specific problems, and fur-
ther research on this topic is being demanded
continuously (Esposito et al. 2002; Roos-
Jansaker et al. 2003; Sahrmann et al. 2013).
In a recent study, we showed that an air
powder abrasion device (PAD) with glycine
powder provided good access to implant sur-
faces when using different defect models
(Sahrmann et al. 2013). However, a compari-
son with other methods was not assessed,
and the problem of concomitant surface
changes and the influence of the operator
were also not addressed.
Therefore, it was the aim of this study to
investigate the cleaning potential of three dif-
ferent instrumentation methods in vitro using
a bone defect-simulating model (primary out-
come) by assessing the color removal of
stained implants during open flap debride-
ment. As secondary parameters, the influence
of the operator and changes in the surface
micromorphology were also assessed. The null
hypothesis was that all instrumentations
showed comparable outcomes in terms of the
cleaning potential and that both the defect
morphologies and the operator had no impact
on these treatments and furthermore that
there was a comparable degree of surface alter-
ations after instrumentation.
Materials and methods
Preparation of the implants/in vitro models
Implants with a length of 12 mm, a diame-
ter of 4.8 mm, and a shoulder diameter of
2 | Clin. Oral Impl. Res. 0, 2013 / 1–6
6.5 mm (Tapered Effect WN, Straumann,
Basel, Switzerland) were dip-coated with red
indelible, noncovering ink (Staedler perma-
nent Lumocolor, N€ urnberg, Germany) to
simulate an optically identifiable plaque
accumulation on the machined collar and
the rough surface with the threads accord-
ing to a recently published protocol (Sahr-
mann et al. 2013). After dipping, a complete
and homogeneous, clearly visible red stain
was present on both the rough and the
machined surfaces. Implants were mounted
in resin bases simulating crater-shaped peri-
implantitis defects of three different angula-
tions (30, 60 und 90°, see Fig. 1). The defect
depth was set at 6 mm, and implants were
positioned in such a way that the rough
surfaces leveled with the upper edge of the
defect. Implants were horizontally fixed
using screws, which allowed for an ade-
quate fixation of the implants during the
instrumentation and an easy removal after-
ward.
Test treatments
Twenty implants were used per treatment
modality, defect model and investigator.
Three different instruments were used
(Fig. 1):
• A Gracey steel curette (Deppeler, Rolle,
Switzerland) with slim working tips Nr.
11/12.
• An ultrasonic device with a steel tip
(ADS1, EMS, Nyon Switzerland) at maxi-
mum power settings.
• An air powder abrasive device (Airflow
Master, EMS, Nyon, Switzerland) with
glycine powder (PerioFlow, EMS, Nyon,
Switzerland) at maximum settings for
both “power” and “lavage”. For the treat-
ment, a nozzle for supragingival applica-
tion was used (EMS Air-FlowMaster
nozzle, EMS, Nyon, Switzerland).
(a) (b)
Fig. 1. Defect models with an aperture of 30°, 60°, and 90° (a, b, c) and different debridement instruments: Ultra-
sound tip (steel tip, d), Gracey curette (steel, e) and air powder abrasive device (charged with glycine powder, f).
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
During surface cleaning, the working dis-
tance and angulation of the working piece
were individually chosen by the operators
without any restrictions. After instrumenta-
tion, powder remnants were removed by gen-
tle rinsing with water for 10 s. During the
treatment, the models could be turned and
held in any position, which seemed suitable
for the operators to achieve optimal access to
the surface. The treatment time was
restricted to 2 min for each instrumentation
type, and the working time was controlled
and documented using a stopwatch.
Each cleaning method was performed by a
dental hygienist with over 35 years of clini-
cal experience and a 2nd-year postdoc student
in periodontology.
Scanning electron microscopy of the in-
strumented surfaces was performed. For this
purpose, specimens were cleaned with water
spray, gold sputtered (layer thickness: 6 nm)
and surface topography was evaluated under
a SEM (Carl Zeiss Supra 50 VP FESEM, Carl
Zeiss, Oberkochen, Germany) operating at
10 kV with a working distance of 9 mm.
Pictures of the machined implant shoulder
and the instrumented SLA surface areas of
each treated implant were taken at 5009 and
10,0009 magnification. Surfaces of an
untreated implant served as control.
Assessment of unaccessed surface remnants
After each run, implants were removed from
the bases. Loosened ink particles and water
were removed by gentle rinsing with water
and air. Digital color photos were taken verti-
cally to the implant axis, employing stan-
dardized parameters (dark chamber, ISO 100,
aperture f/32, shutter speed 1/250 s, distance
31.4 cm with a Nikon D200, Tokyo, Japan,
ring flash EM-140 DG; Metz MB 15 MS-1
Makroslave digital flash, Zirndorf, Germany,
with power settings 1/2) from one side and
(c) (d) (e) (f)
 Sahrmann et al
Surface access in peri-implantitis defects

the opposite aspect (180° turn). Ink remnants

on the surface were detected using an image
processing software (Adobe Photoshop Ele-
ments Vs. 9.0.3, Adobe Systems Inc., San
Jose, CA, USA). The cumulative remnant
area per implant was calculated using a cus-
tom-programmed planimetry software (PPK,
Z€urich, Switzerland) (Rasband 1997) (see
Fig. 2).
Implant surfaces were then completely
cleaned by twofold tilting in ethanol (97%).
After optical control of complete ink removal
(magnifying lenses 4.39, Carl Zeiss AG, Feld-
bach, Switzerland), the air-dried implants
were restained in the same way as described
before. Air flow debridement was performed
first on all implants, followed by the ultra-
sonic and the curette debridement.
Fig. 2. Assessment of the residual stains from digital photo to planimetric calculation of the cumulative residual-
stained area within the field of interest after instrumentation with a curette.
Statistics
Normality of data distribution was tested
using Kolmogorov–Smirnov and Shapiro– horizontal defects (90°), superior results of air smooth and rough surfaces exhibited no sur-
Wilk tests. Means and standard deviations of powder abrasion were more evident (Tables 1 face changes except for sporadic glycine parti-
the percentages of uncleaned surface were and 2). cles and grease spot-like surface infiltrations
calculated. Differences between different With curettes and ultrasound, operators of the titanium (Figs 3 and 4).
defect angulations, operators, and instru- consistently used the maximum time of 120
ments were tested by nonparametric two-way s for surface debridement. With the PAD,
ANOVA with Bonferroni correction. In all however, they stopped earlier (mean working Discussion
tests, all p-values lower than 5% were time 95  16 s).
regarded as statistically significant. SEM electron microscopic images revealed Mechanical implant surface debridement
significant changes in the surface morphol- remains the gold standard in peri-implantitis
ogy after 2-min working time when curettes therapy (Romanos & Weitz 2012) as long as
Results or ultrasound scalers had been used. After the shortcomings of accessibility to the
treatment with glycine powder for 2 min, colonized surface are not yet bypassed by
Regardless of the instrument used, remaining
ink stain was discernible on all samples. The
cumulative surface with ink remnants Table 1. Means ± standard deviations (%) and medians (interquartile ranges) (the latter as second
lines in rows) of residually stained surface areas after treatment with different methods. The
showed considerable deviation in each sub- results are presented separately for different instruments and defect angulations
group analyzed. 30° 60° 90°
The accessibility of the implant surfaces in
Curette 21.6  3.19 B 25.3  3.9 A 25.2  6.7 A
terms of stain removal showed significant 21.4 (4.3) 25.3 (4.2) 25.3 (8.4)
differences depending on the employed device. Ultrasound 20.1  3.7 B 19.5  2.9 B 15.9  3.6 C
The testing for normality indicated no 19.1 (5.8) 19.4 (3.6) 15.0 (5.0)
Air powder abrasion 16.1  3.7 C 12.7  2.8 D 5.0  1.4 E
violation of the assumption of normality.
15.6 (4.6) 11.9 (1.8) 5.2 (2.4)
Powder abrasion showed the least rem-
nants (11.3  5.4%), followed by ultrasonic Different capitals indicate groups with statistical significant differences (P < 0.001, nonparametric
two-way ANOVA with Bonferroni correction).
(18.5  3.8%) and manual (24.1  4.8%)
instrumentation. These results were statisti-
cally significantly different (P<0.0001). The Table 2. Means ± standard deviations (%) and medians (interquartile ranges) (the latter as second
null hypothesis was rejected. lines in rows)of residually stained surface areas after treatment with different methods. The
results are presented separately for different instruments and operators I (dental hygienist) and II
The results obtained by the different opera- (postdoc student)
tors showed small but still significant differ-
I II
ences for the different instruments. The
Curette 24.8  4.3 A 23.6  5.0 A
experienced dental hygienist showed slightly 23.9 (5.4) 23.5 (7.3)
better results with the curettes, whereas the Ultrasound 20.3  3.5 B 16.7  3.3 C
postdoc student achieved lower residual 20.0 (5.0) 16.9 (5.0)
Air powder abrasion 12.7  6.0 D 9.8  4.4 E
stains with ultrasound and air powder abra-
12.6 (10.0) 11.0 (7.8)
sion. This qualitative order was consistent in
all different defects, although the differences Different capitals indicate groups with statistical significant differences (P < 0.001, nonparametric
one-way ANOVA with Bonferroni correction).
were more pronounced in wider defects: In

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 3 | Clin. Oral Impl. Res. 0, 2013 / 1–6
Sahrmann et al
Surface access in peri-implantitis defects
Fig. 3. Scanning electron microscopy images of an untreated control and surfaces treated by the different instru-
ments at a magnification of 5009.
Fig. 4. Scanning electron microscopy images of an untreated control and surfaces treated by the different instru-
ments at a magnification of 10,0009.
promising – but not yet clinically applicable
– novel approaches (Sahrmann et al. 2012).
Therefore, we assessed the accessibility of
implant surfaces with different cleaning
devices in an in vitro peri-implantitis model
with three different defect angulations.
For each of the three defect angulations,
the data revealed a superior accessibility in
terms of ink removal when PAD was used.
This superiority was pronounced in horizon-
tal (90°) and wide defect apertures (60°).
Nonetheless, complete stain removal was not
achieved in any of the defect morphologies.
A recent study evaluated the removal of a su-
pragingival biofilm ex vivo by a novel tita-
nium brush and compared it with that
achieved with steel curettes on titanium
disks (John et al. 2013). These disks had the
same surface morphology as the implants in
the present study (machined and SLAâ,
Straumann). The remnant area of 29  5.6%
after instrumentation with a steel curette (vs.
8.6  5.9% with the titanium brush) corrobo-
rated the findings of the present study.
The data after air powder abrasion corre-
spond well with the findings of our previous
4 | Clin. Oral Impl. Res. 0, 2013 / 1–6
study using only PAD instrumentation on
implant surfaces in different defects, which
resulted in residual stain in the range of
3–24% (Sahrmann et al. 2013). In this latter
evaluation, it was shown that especially the
lower aspects of the threads in narrow defects
are most difficult to clean (Sahrmann et al.
2013). Although not quantified, we found
this finding reaffirmed in the current study.
An obvious limitation of this study is the
use of indelible ink for the assessment of
accessibility instead of true biofilm: Firstly,
red ink in an in vitro model is very easy to
detect during surface debridement. This fact,
however, is the same for all three assessed
instrumentation techniques, and their
comparison does not become invalid by this
limitation. Then, ink remnants have the
advantage of being easily detected in a direct
assessment of photographs, which makes this
technique less prone to confounders than the
area-specific assessment of biofilm that
requires several analytical steps (Ntrouka
et al. 2011). On the other hand, it remains
questionable whether ink is more difficult to
remove than oral biofilms. Especially after air
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
powder abrasion, we observed areas with
weakened stain, indicating an access by the
respective instrument, which was apparently
too weak to remove the stains completely.
Although one might argue that an oral bio-
film might have been removed by this access,
we decided to allocate those areas as “residu-
ally stained”. Accordingly, the cleaning
potency might have been underestimated in
these cases. In preliminary experiments, we
ascertained that ink stains could not be
removed by carbon or plastic curettes. The
use of steel tips, however, though more inva-
sive, performed well in terms of clearly
detectable ink removal. In turn, this was
proof of instrument access to the sample sur-
faces, which was the primary goal of this
study. Given that curettes of the same shape
– irrespective of their composition – are
likely to have the same access to the sur-
faces, our data might be valid for any curettes
and ultrasonic tips, no matter what material
they are made of. Another limitation of the
study is the reuse of the implants. Although
we began with the nearly noninvasive pow-
der abrasion, microstructural changes during
ultrasonic and curette debridement were evi-
dent. This change in roughness could have
led – once more – to an underestimation of
remnants with the latter methods as ink
might have been more difficult to remove on
virgin surfaces.
From a clinical point of view, the use of
steel tips on soft grade 2 implant surfaces has
been disadvised, as both smooth and rough
surfaces have been altered after their use
(Unursaikhan et al. 2012; Mengel et al. 1998,
2004). Accordingly, our SEM images also
showed a detrimental effect on the microanat-
omy of both the rough and machined surface
areas. Formerly, mainly two corruptive effects
of surface changes had been anticipated: One
was a reduced cytocompatibility regarding the
eucaryot cells involved in the healing process,
and the other was the problem of facilitated
recolonization of the surfaces by nocuous bac-
teria. However, a recent study on implant sur-
faces instrumented with steel tips showed
neither an increase in roughness of formerly
rough surfaces, nor increased bacterial re-
growth on previously smooth surfaces in vitro
(Duarte et al. 2009). In addition, there is also
evidence of material abrasion from the tips if
softer, less altering instruments like resin cu-
rettes are used (Mann et al. 2012). The effect
on biocompatibility and infection control due
to left curette material remains a matter of
concern.
After surface debridement with the PAD,
scanning electron microscopy did not detect

any significant changes in the implant micro-
anatomy. This finding is in accordance with
the existing literature. However, studies
investigating the effect of PAD on implant
surfaces vary regarding instrumentation time
and implant surface type (Duarte et al. 2009;
McCollum et al. 1992; Brookshire et al.
1997). Glycine particles that remain on the
surface have shown an inhibiting effect on
bacterial regrowth (Duarte et al. 2009). As
glycine is easily degradable by the body, the
presence of these particles seems rather
unproblematic.
In view of the fact that biofilm is the pri-
mary etiologic factor for peri-implant inflam-
mation (Heitz-Mayfield & Lang 2010), a
recent study by Sahm et al. (Sahm et al.
2011) corroborated our findings: In the latter
study, clinical parameters were assessed
6 month after peri-implantitis treatment per-
formed with curettes or PAD. A better reso-
lution of inflammation, as measured by
bleeding on probing was found after PAD
use, even though chlorhexidine (CHX) rinse
was used during curette debridement.
Although the impact of antiseptic effects of
both CHX and glycine on that study setup
References
Aglietta, M., Siciliano, V.I. & Salvi, G.E. (2009) A
systematic review of the survival and complica-
tion rates of implant supported fixed dental pros-
theses with cantilever extensions after an
observation period of at least 5 years. Clinical
Oral Implants Research 20: 441–451.
Brayer, W.K., Mellonig, J.T., Dunlap, R.M., Mari-
nak, K.W. & Carson, R.E. (1989) Scaling and root
planning effectiveness: the effect of root surface
access and operator experience. Journal of Peri-
odontology 60: 67–72.
Brennan, M., Houston, F., O’Sullivan, M. & O’Con-
nell, B. (2010) Demographics of implant place-
ment and complications of a patient subgroup in
a dental hospital population. Journal of the Irish
Dental Association 56: 85–92.
Brookshire, F.V., Nagy, W.W., Dhuru, V.B., Ziebert,
G.J. & Chada, S. (1997) The qualitative effects of
various types of hygiene instrumentation on com-
mercially pure titanium and titanium alloy
implant abutments: an in vitro and scanning elec-
tron microscope study. Journal of Prosthetic
Dentistry 78: 286–294.
Duarte, P.M., Reis, A.F., de Freitas, P.M. & Ota-
Tsuzuki, C. (2009) Bacterial adhesion on smooth
and rough titanium surfaces after treatment with
different instruments. Journal of Periodontology
80: 1824–1832.
Esposito, M., Worthington, H.V., Coulthard, P. &
Jokstad, A. (2002) Interventions for replacing
missing teeth: maintaining and re-establish-
ing healthy tissues around dental implants.
Cochrane Database of Systematic Reviews
CD003069.
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Sahrmann et al
Surface access in peri-implantitis defects
remains unclear, both the clinical and the
present in vitro study showed the superiority
of the PAD. Finally, it should be stated that,
although bacterial biofilm is the primary eti-
ologic factor of both peri-implantitis and peri-
odontitis, healing was shown to be possible
with an uncritical amount of uncleaned sur-
faces (Robertson 1990). Accordingly, in this
study, we assessed only one (the most impor-
tant) factor among a plurality of factors con-
tributing to the inflammative degradation
around teeth and implants.
With regard to the congruent results of the
different subgroups, the present in vitro
design constitutes a model that allows for
assessment of access to screw-shaped
implants, imitating the clinical situation
well within the limits of simplifying in vitro
analysis. Taken together, it provides presum-
ably less sensitive and more specific results
for debridement as compared to the clinical
situation, given the presumably stronger
adherence of ink as compared to biofilm.
Within the limitations of our study, the use
of glycine employing PAD seems to be highly
effective by means of implant surface
debridement. Moreover, this quickly
Heitz-Mayfield, L.J. & Lang, N.P. (2010) Compara-
tive biology of chronic and aggressive periodonti-
tis vs. peri-implantitis. Periodontology 2000 53:
167–181.
John, G., Becker, J. & Schwarz, F. (2013) Rotating
titanium brush for plaque removal from rough
titanium surfaces - an in vitro study. Clinical
Oral Implants Research doi: 10.1111/clr.12147
[Epub ahead of print].
Jung, R.E., Pjetursson, B.E. & Lang, N.P. (2008) A
systematic review of the 5-year survival and com-
plication rates of implant-supported single
crowns. Clinical Oral Implants Research 19:
119–130.
Kocher, T., Riedel, D. & Plagmann, H.C. (1997)
Debridement by operators with varying degrees of
experience: a comparative study on manikins.
Quintessence International 28: 191–196.
Mann, M., Parmar, D., Walmsley, A.D. & Lea, S.C.
(2012) Effect of plastic-covered ultrasonic scalers
on titanium implant surfaces. Clinical Oral
Implants Research 23: 76–82.
McCollum, J., O’Neal, R.B., Brennan, W.A., Van
Dyke, T.E. & Horner, J.A. (1992) The effect of
titanium implant abutment surface irregularities
on plaque accumulation in vivo. Journal of Peri-
odontology 63: 802–805.
Mengel, R., Buns, C.E., Mengel, C. & Flores-de-
Jacoby, L. (1998) An in vitro study of the
treatment of implant surfaces with different
instruments. International Journal of Oral &
Maxillofacial Implants 13: 91–96.
Mengel, R., Meer, C. & Flores-de-Jacoby, L. (2004)
The treatment of uncoated and titanium
performed technique seems favorable as it
did not cause distinct implant surface altera-
tions.
Conclusion
Powder abrasive device employing glycine
powder showed superior cleaning potential on
rough and smooth surfaces of threaded, screw-
shaped implants as compared to debridement
with ultrasonic or manual instruments.
However, none of the treatment modalities
were able to completely remove the stain in
any of the defect morphologies. The present
results were consistently found for all
defect angulations but became more distinct
as the defect angulation increased. Further-
more, implant surfaces were not visibly
altered by this timesaving debridement
modality.
Disclosure
The authors report no conflict of interest
related to the present study.
nitride-coated abutments with different instru-
ments. International Journal of Oral & Maxillo-
facial Implants 19: 232–238.
Mombelli, A. & Lang, N.P. (1994) Microbial aspects
of implant dentistry. Periodontology 2000 4:
74–80.
Mombelli, A., Moene, R. & Decaillet, F. (2012) Sur-
gical treatments of peri-implantitis. European
Journal of Oral Implantology 5(Suppl): S61–S70.
Ntrouka, V.I., Slot, D.E., Louropoulou, A. & Van
der Weijden, F. (2011) The effect of chemothera-
peutic agents on contaminated titanium surfaces:
a systematic review. Clinical Oral Implants
Research 22: 681–690.
Rasband, W.S. (1997) ImageJ. U. S. National Insti-
tutes of Health, Bethesda, MD, USA, http://rsb.
info.nih.gov/ij/.
Renvert, S., Roos-Jansaker, A.M. & Claffey, N. (2008)
Non-surgical treatment of peri-implant mucositis
and peri-implantitis: a literature review. Journal of
Clinical Periodontology 35: 305–315.
Robertson, P.B. (1990) The residual calculus para-
dox. Journal of Periodontology 61: 65–66.
Romanos, G.E., Gupta, B. & Eckert, S.E. (2012) Dis-
tal cantilevers and implant dentistry. Interna-
tional Journal of Oral & Maxillofacial Implants
27: 1131–1136.
Romanos, G.E. & Weitz, D. (2012) Therapy of peri-
implant diseases. Where is the evidence? Journal
of Evidence-Based Dental Practice 12: 204–208.
Roos-Jansaker, A.M., Renvert, S. & Egelberg,
J. (2003) Treatment of peri-implant infections: a
literature review. Journal of Clinical Periodon-
tology 30: 467–485.
5 | Clin. Oral Impl. Res. 0, 2013 / 1–6
Sahrmann et al
Surface access in peri-implantitis defects
Ruhling, A., Schlemme, H. & Plagmann, H.C.
(2002) Learning root debridement with curettes
and power-driven instruments. Part I: a training
program to increase effectivity. Journal of Clini-
cal Periodontology 29: 622–629.
Sahm, N., Becker, J., Santel, T. & Schwarz, F.
(2011) Non-surgical treatment of peri-implantitis
using an air-abrasive device or mechanical
debridement and local application of chlorhexi-
dine: a prospective, randomized, controlled clini-
cal study. Journal of Clinical Periodontology 38:
872–878.
6 | Clin. Oral Impl. Res. 0, 2013 / 1–6
Sahrmann, P., Ronay, V. & Schmidlin, P.R. (2013)
Cleaning potential of glycine air-flow application
in an in vitro peri-implantitis model. Clinical
Oral Implants Research 24: 666–670.
Sahrmann, P., Zehnder, M. & Thurnheer, T. (2012)
Effect of low direct current on anaerobic multispe-
cies biofilm adhering to a titanium implant surface.
Clinical Implant Dentistry and Related Research
doi: 10.1111/cid.12018 [Epub ahead of print].
Schmidlin, P.R., Sahrmann, P. & Jung, R.E. (2012)
Peri-implantitis prevalence and treatment in
implant-oriented private practices: a cross-
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
sectional postal and Internet survey. Schweizer
Monatsschrift f€ur Zahnmedizin 122: 1136–1144.
Stewart, P.S. & Costerton, J.W. (2001) Antibiotic
resistance of bacteria in biofilms. Lancet 358:
135–138.
Unursaikhan, O., Lee, J.S. & Choi, S.H. (2012) Com-
parative evaluation of roughness of titanium sur-
faces treated by different hygiene instruments.
Journal of Periodontal & Implant Science 42: 88–94.
Zitzmann, N.U. & Berglundh, T. (2008) Definition
and prevalence of peri-implant diseases. Journal
of Clinical Periodontology 35: 286–291.