Laser and Peri-Implantitis: Why, When and How?

Integrate Lasers into Peri-Implantitis Treatment:

I've used lasers for more than seven years on over 400 implants with peri-implantitis. Through these experiences, I developed a treatment strategy and therapeutic approach, which I named the APARA Protocol (Assessment of Peri-implantitis Appearance and Repairing Approach) using lasers. This protocol can be used like a recipe, where each diagnostic class corresponds to a specific treatment.

My goal was to develop a very simple approach for daily practice. We shouldn’t have to think too much when we use lasers; it must be intuitive.

I chose two main wavelengths: 660nm Diode laser and Erbium YAG laser, because these wavelengths have no thermal effect, making them safe and easy to use for someone with limited experience in laser dentistry. The other wavelengths have a thermal effect, so while they are effective, they come with a learning curve and require more precautions.

Next, let's discuss decontamination — you’ll need a 660nm Diode laser for this process. To begin the protocol, a dye is needed, in this case, a blue-colored dye. Each color corresponds to a specific wavelength. To start, apply a few drops of the blue dye inside the pocket and then wait for three minutes.

Wait for the dye to fix on the membrane of the anaerobic bacteria. Then, rinse off the excess with water or saline. After that, activate the laser light. There is no thermal effect; this is a cold laser. Apply it for about one minute around each implant.

This means applying the laser for 10 seconds on six different sites, similar to periodontal charting. One minute is sufficient to kill the bacteria, and while the light is activated, the dye will absorb the light. This creates excess energy, leading to a reaction that produces free oxygenated radicals. These radicals act like little crocodiles, attacking and digesting the membrane of the anaerobic bacteria. This is how the bacteria are destroyed. Photodynamic therapy is a true bacteria killer.

Is antimicrobial photodynamic therapy a treatment by itself?  

It depends on the treatment. For non-surgical treatment, such as mucositis, it can be enough. First, clean with mechanical ultrasound or technique, and then eliminate the bacteria. However, when dealing with peri-implantitis, a surgical approach is necessary, as these lasers can't remove calculus.

Hard tissues, for example, stick to the implant surface, so an additional device is needed. In this case, the Erbium YAG laser is an excellent choice. This laser is my best friend, I use it every day. When using it, I require both the laser and the fiber, which features an articulated arm.

Here's the protocol: First, open the flap, and you can perform all procedures with the laser. I don't use blades, except to harvest connective tissue. Elevating a flap after cutting with the Erbium YAG laser is very easy because it's very, very efficient. Sometimes, granulation tissue can be strongly attached to the soft tissue, and the Erbium YAG laser is a great asset in these cases.

Next, remove the granulation tissue with the laser, as it will impact the granulation tissue. The soft tissues contain water, which will absorb the light of this laser; this absorption causes the water to explode. This is how you can cut tissues and even bone, as hydroxyapatite also absorbs the laser light. After removing the granulation tissue, you’ll be able to see the implant surface, and you need to remove the calculus. This is why a surgical approach is mandatory to treat peri-implantitis; otherwise, you won’t be able to see the calculus and everything that needs to be cleaned on the implant surface.

It is very easy to remove calculus and clean the implant surface with Erbium YAG laser. There are no metallic particles flying away, making this method very safe and gentle on the surface; the Erbium-YAG laser cannot cut metallic surfaces. This is a matter of absorption, as titanium doesn't absorb the light of Erbium-YAG lasers. It's similar to trying to cut meat with a butter knife—it’s simply not possible, so, it's very safe.

After everything has been cleaned, you will then impact the cortical bone by opening the haversian canals, which help blood flow around the implants. This blood is the natural and biological material for bone regeneration, and this is how Erbium YAG aids in the regeneration process.

So, is the Erbium YAG laser a treatment by itself? Yes, it can be used alone when treating peri-implantitis. While it’s beneficial to incorporate chemical effects with, such as photodynamic therapy, the Erbium YAG laser is the best option from a surgical approach.

At this stage, it’s possible to decontaminate chemically by using an Nd-YAG laser (or again a 660nm Diode laser with a dye for photodynamic therapy. The Nd-Yag laser doesn’t need a dye; instead, add hydrogen peroxide (10 volumes) inside the pocket. There is no need to wait before applying the light from the Nd-YAG laser.

This will create vasodilation, allowing blood to flow into the pocket around the affected implants. This blood is rich in anti-inflammatory and growth factors, which is why this laser is highly effective for enhancing healing.

Now, once everything is cleaned, what do you do next? The game is not over. Next, we must consider regeneration. So, should I use GBR or not? Absolutely not. Never place a foreign biomaterial on an affected implant. Even if you have perfectly decontaminated it with the laser, you can never be 100% sure that it is completely decontaminated.

This is a key point of the APARA protocol: please don't put GBR on an affected implant. Trust in nature. The blood is present because you used the laser first, and it is crucial to protect this blood, either with connective tissue grafts harvested from the palate or with a dermic cellular membrane. The goal is to protect the blood clot. After that, everything will be packed, and you must wait for two to three months to see some healing. There are different indications for deciding whether to do connective tissue grafts or membrane; however, that is another conversation. Both options yield good results.

Finally, let’s review a few cases.

To begin, Early Peri-Implantitis

Here is a straightforward case showing early peri-implantitis. The implant has lost 20% of the bone height—so, not much. The protocol is predictable and always follows the same step: first, photodynamic therapy and then you open the flap.

You will remove the granulation tissue using your Erbium YAG laser, impact the cortical bone, clean the implant surface, protect the blood clot with the membrane, and then close the flap.

That's it. After four months, you can observe the bone regeneration, without GBR, and the results will remain stable over time. My oldest case is seven years old, and the results continue to be very stable.

Another Case: Moderate Peri-Implantitis

In this case, I used connective tissue graft to protect the blood clot. After four months, I checked in to see if it had been cleaned properly and if everything was progressing in the right direction. As you can see in the first X-ray, there is already bone regeneration, and over time, there will be further bone enhancement.

My Oldest Case (which is Seven Years Old)

After four months and even after five months, the results remain the same. You achieve good regeneration with this protocol, and with proper maintenance, you can have stable results.

Conculsion:

How do we integrate lasers into peri-implantitis treatment? Using at least one laser is beneficial, depending on your non-surgical or surgical orientation. However, if you are open to using two complementary wavelengths, you can have outstanding results.

What if we could confidently answer the well-known question, “Doctor, will my implant last for a lifetime?” with, “Yes, ma’am, yes, sir. Your implants will last because I use lasers and have a comprehensive protocol that will take care of your implant for life.” I truly believe that together we can create this future.