Management of Peri-implant Disease (Updated)

Hello my name is Paul Fletcher. I’m a periodontist
and an associate clinical professor at Columbia University where I teach implant dentistry
and periodontics on a post graduate level. I’m also a member of Specialized Dentistry
of New York. A group implant cosmetic specialty practice in New York City.This video is being
placed on YouTube at the request of those who attended my lecture on the management
of peri-implant disease. it summarizes the slides of the presentation so they can review
the material at their convenience. The video will also be valuable to any dental professional
who desires to learn a research based, in office and at home protocol for the treatment
of peri-implant mucositis.The final 10 minutes will be of special interest to any patient
who has been told they have bleeding or are beginning to lose bone around their dental
implants.Peri-implant disease is a very controversial topic There are researchers who don’t feel
they see Peri-implant disease all that often and it’s just a minor inconvenience, While
there are others who think it’s becoming a major problem.I’m one of those who are beginning
to feel we have a problem. I feel we have a problem because at Columbia University hardly
a week goes by when another student doesn’t approach me with a new case of peri-implant
disease. And in my private dental practice, where literally half of new patients we see
are due to some form of implant related issue. We’re also seeing a number of new cases of
peri-implant disease increasing.The research also seems to say we have a problem. The research
is telling us as the number of implants that have been placed increases and as the number
of years implants have been in place increases and as dentists with different skill sets
are beginning to place implants the incidence of peri-implant disease is increasing and
the prevalence of peri-implant disease is increasing.The difficulty is that the implant
research is very confusing because study methodologies vary. Some studies talk about differing thresholds
for peri-implant disease. Other studies put together different surfaces and designs and
equate them. Finally some studies look at patients with peri-implant disease whereas
other studies look at implants with peri-implant disease. And finally some studies look at
implant survival and equate it with implant success.So if we take a look at these implants
over here, these implants were placed thirteen years ago. When we take a look at them thirteen
years afterwards we can see the amount of bone loss around the implants. Now they definitely
survived but I’m not quite sure we can call these implants a success but I do know that
they definitely need treatment.From a historical perspective, we also have a problem. Periodontal
indices such as bleeding upon probing and pocket depth were originally felt when applied
to the peri-implant mucosa to be of a little clinical significance when measuring the success
or failure of osseointegrated implants. And they also say, the early research, peri-implant
disease is rare. Attached gingiva is only needed if the area is inflamed.Well the early
research was looking at smooth surface implants, where the implant abutment junction was above
the soft tissue in the crest of bone. And in today’s world we’re using rougher surface
implants where the implant abutment junction is right at the surface of the bone. And I’ll
tell you, in every lecture that I present there’s always somebody that asks me if
it’s ok to probe their dental implants and it’s definitely okay to probe your dental
implants. It’s very important in fact that you do gently probe around your dental implantsFrom
a microbiologic perspective, we also have an issue because implants are being placed
in patients with active periodontal disease. And the bacteria that cause periodontal disease
also cause peri-implant disease. And patients who lost their teeth due to periodontitis
have an increased risk of developing peri-implanttitus and we know that at this point in time.from
a histopathologic level, also we have a problem. Because the attachment apparatus around the
tooth shows inflammation at this point and we have perpendicular connective tissue fibers
attaching into a tooth. And you also have a periodontal ligament around a tooth where
anti inflammatory cells can migrate out of the periodontal ligament to help prevent the
spread of this inflammation.Where as around an implant we don’t have these perpendicular
connective tissue fibers and we also don’t have a periodontal ligament. Thus the apical
extension of the inflammatory cell infiltrate is more widespread and it extends into the
alveolar bone around the implants. And the peri-implant issue is less able to arrest
progressive plaque associated lesions.If we take a look at this histological photograph
here, we can see the parallel or circular orientation of the connective tissue fibers
may lead to a more rapid spread of the inflammation in the peri-mucosa.And because we get this
more rapid spread, we see rapid bone loss very very very quickly. So if you take a look
at this case here these implants were placed in the year 2000. In 2008, you can see the
levels of the bones are still high. In 2011, the patient returned to our office and you
can see the beginnings of peri-implant bone loss. She got lost, we didn’t treat her, she
came back three years later and take a look at the additional amount of bone loss that
had incurred just in that three year period. This is a problem.Because of this rapid bone
loss, you can see the type of bone loss we get is very aggressive around these dental
implants. We don’t see bone loss like this around a tooth. Around a tooth, you may have
bone loss on the mesial of one tooth or on the distal of another tooth; a vertical defect.
Around implants we get this circumferential bone loss completely around the tooth; 360
degrees.Another problem we have is the growth of oral biofilms are facilitated by the screw
shape design of the implant the design of the super structure and the surface modifications;
be it the rough surface of the implants. So we take a look at this case here and all of
us have implant cases like this. There’s no way that this patient can get underneath this
framework to keep this area clean. This is a problem. The weak links are the surface and the implant
abutment junction and the adhesion of microbes to bare and rough implant threads impedes
mechanical cleaning. So you take a look at this photograph over here and you can see
plaque and calculus in the threads of this implant. Now a normal curette can’t get in there to
clean this area. A normal root planing motion is occlusal gingival. In this case here you
have to go circumferentially around the threads of the implant and if this area wasn’t flapped
back you wouldn’t even be able to realize or recognize that you had plaque and calculus
in the threads of the implant. The implant abutment injunction is also a
problem because it’s been shown that microleakage occurs into and out of both internal hex and
morse taper connections. In today’s world that implant abutment injunction more often
than not is right at the crest of bone. So you can see the space here around this implant
abutment junction. And as the patient chews, that area flexes and bacteria pumps in and
out of that implant abutment junction causing issues. Cement is a real problem. It’s been shown
in this case by Wadhwani and Pineyro. They looked at 185 failed implants and they found
residual cement, excess cement, when they looked at it under magnification in 65% of
those failed implants. This is a problem and you can see the cement on this implant over
here causing the almost of bone loss that it caused around that implant. That’s a problem. The bottom line is, if the patient has a problem
you have a problem. And now we have to talk about how we go and deal with managing that
problem. So when we talk about the definition of peri-implant
disease, peri-impantitus is a destructive inflammatory reaction affecting the soft and
hard tissues of an implant in function. And in other words, besides affecting the gum
it affects the bone and there’s bone loss. On the other hand mucositis is a reversible
inflammatory reaction in the soft tissues surrounding a functioning implant. The key
word here is reversible. So if mucositis can be reversed, the important thing to realize
is treating mucositis will prevent peri-implantitis; plain and simple. So let’s take a little bit
more of a look at mucositis so we can get a little bit of a better understanding of
what’s involved and what the signs and symptoms are of mucositis. So mucositis is a irreversible inflammatory
infiltrate in the soft tissues surrounding a functional implant. The clinical signs are
inflammation, bleeding upon probing, 4+ millimeter pocketing, and possibly separation; pus. But
there’s no progressive bone loss when you take a look at an x-ray of an implant with
mucositis. So as far as suppuration is concerned, if
you probe 5 or 6 millimeters and you see no bleeding, it becomes important that you palpate
the gingiva around that implant surface. Because many times you’ll see purulence coming
from that sulcus in that pocket depth. This is because when you get to 5 or 6 millimeters,
the bacterial flora changes from an aerobic flora to an anaerobic flora. And that’s why
at 6 millimeters and 5 millimeters, you may start to see pus coming out from a pocket
around an implant. Finally, radiographic bone loss is stable
one year of functional loading. There is no progressive bone loss after the first year
with mucositis. Those are the signs and symptoms. Now when we take a look at an implant with
mucositis or peri-implantitis close up, and this is a scanning electron micrograph, what
we see here the pores of the implant and this is bacteria attached to the implant and embedded
in between the concavities of this implant in the pores of the implant. There’s no way
that you can get in there mechanically to remove this bacteria. It’s embedded. Mechanical
therapy alone is inadequate to predictably detoxify an implant surface. That means cleaning
an implant surface is not a  monotherapy but it’s a bitherapy. And besides mechanical cleaning what we’re
involved in is chemical detoxification of the implant surface. So the goal of our treatment
is surface decontamination both mechanical and chemical. And our objectives are basic microbiological
objectives. Disrupt the bacterial plaque biofilm, detoxify cell components affecting the growth
on the implant surface, and reduce the bacterial load by dilution to a level that will allow
healing. Basic microbiologic principles: dilute, disrupt, and detoxify; with our objectives
and our goals being to eliminate bleeding upon probing, the primary objective, reduce
pockets if possible, and stabilize bone levels, and that’s what we’re looking to accomplish
when we treat these areas mechanically and chemically. Now what we need in dentistry, as far as I’m
concerned, is we need a readily available, low cost method to detoxify an implant surface.
So that people all over the world can have access to these materials and medicaments
to detoxify the implant surface. Now as far as surface decontamination is concerned,
mechanical and chemical, the research talks about a lot of different ways to detoxify
an implant surface. There are mechanical ways and there are chemical ways to do this. But
some of them like the laser are very expensive. There are many many practitioners around the
world that can’t spend 75 to 100 thousand dollars on a dental laser. So we have to come
up with something that’s low cost and readily available. And as far as the different ways to detoxify
an implant surface; Esposito said it so well in 2012. What he said is while there is no
reliable evidence suggesting which is the most effective treatment for peri-implant
disease, that doesn’t mean that currently used treatments don’t work. So let’s take
a look at what we’re using, what I’m going to suggest that you use to detoxify the implant
surface. First we’re going to be using curettes. Now some curettes are problematic such as
stainless steel curettes. The curettes have to be softer than the implant because a metal
curette such as stainless steel will alter the implant surface. It will cause damage
to the oxide layer and it effects the surface chemistry and biocompatibility. And it will
scratch the implant and surface roughness will influence plaque growth. And we’ve seen
that multiple places and multiple times. So you have to use a titanium curette which is
equal in hardness to the titanium implant, a plastic curette, gold curette, or even a
carbon fiber curette but we’re going to use curettes to mechanically help detoxify the
implant surface. From a chemical standpoint what we’re going
to use chemically is something very simple and readily available worldwide; an excellent
antiseptic worldwide. And it’s sodium hypochlorite for chemical irrigation. But we’re going to
use highly diluted solution of sodium hypochlorite which is straight household bleach. 5 – 6%
household bleach. But looking at sodium hypochlorite what it’s been shown to do, is there’s an
80-fold decrease in the biofilm endotoxin when compared with water. It’s present naturally
in neutrophils, macrophages, and monocytes in our blood cells, so you can’t be allergic
to it, and it can’t be carcinogenic because it’s in the body. And there’s no visible histological
effect on periodontal healing; that’s been shown in the literature. It does not corrode
titanium implant surfaces and it’s been accepted as a safe mouthwash by the American Dental
Association. So all of these things are good and it’s a highly cytotoxic antiseptic. This
is good and this is what we want to use. So to make .25% sodium hypochlorite solution,
what you’re going to do is you’re going to mix 5 milliliters which is 1 teaspoon of household
bleach; 5-6% sodium hypochlorite in 4 ounces or 125 milliliters of water. Now four ounces
of 125 milliliters of water; the standard drinking cup that we use for our patients
has 5 ounces or 156 milliliters of water. So if you put in 5 mls or 1 teaspoon of household
bleach in one of the standard patient drinking cups and fill it 4/5ths of the way with water,
you will wind up having a .25% solution of sodium hypochlorite. Then we take a blunt
end monoject syringe (23 – 25 gauge needle with a blunt edge) and you fill the syringe
with a sodium hypochlorite and you irrigate around the surfaces of the implants subgingivly.
And that’s what we’re going to be using in our chemical irrigation process. And the treatment approach we’re going to
use is Cumulative Interceptive Supportive Therapy. Originally written about by Lang,
Mombelli, and Berglundh in the early 2000s and the late 1990s. And what it is, is a sequential
additive approach to treating peri-implant disease. And it starts out with mechanical
therapy and as things become more problematic, it adds antiseptic therapy then antibiotic
therapy and then surgical therapy. So with pocket depths 3 millimeters or less without
plaque or bleeding upon probing or even with bleeding upon probing and plaque, you use
mechanical debridement and polishing; Treatment A, just simple mechanical debridement. When
you get to pocket depth of 4 to 5 millimeters and you have bleeding upon probing, you use
mechanical debridement and then you add the antiseptic therapy or the sodium hypochlorite.
And we use that into the mix with bleeding upon probing when you have 4-5 milliliters
pocket depths. As you get greater than five millimeters in your pocket depths, you use
your antiseptic therapy, which is B, and you may add your antibiotic therapy, which in
this case can be the systemic or local antibiotic therapy. As things get worse, you think about
adding surgical therapy to your treatment approach. So what we’re going to use for local delivery
of anti-microbials will be minocycline microspheres or Arestin when we need it. What they do is
the Arestin is highly cytotoxic and will really kill almost all the bacteria involved in the
main bacteria in the spread of peri-implant disease. And it produces 1000 times minimum
inhibitory concentration of antibiotic for 5 days, 100 times for 14 days, and it shows
improvements in pocket depth, with bleeding upon probing, and microbiology at 6 months
but not 12 months. But we don’t even need it to be effective for 6 months because we’re
going to be seeing our patient every 3 months and we’ll talk about that as we move forward.
And pocket depths are only an improvement in the range of 1 millimeter. You don’t see
a lot of pocket depth improvement but we do see improvement and elimination of bleeding
upon probing. So this is the in-office protocol that we’re
going to follow for the management of peri-implant mucositis. In office regimen; maximum recall
– 3 months. As I said with 3 millimeters and no bleeding upon probing; gently probing for
resistance, evaluate plaque levels, prophy cup and polish. When you get 4 to 5 millimeters
without bleeding upon probing or suppuration, same thing; just continue to mechanically
debride with a curette. You can use an air polisher if you so choose to. But when you
to get to 4 to 5 millimeters bleeding upon probing or greater than 5 millimeters with
or without bleeding upon probing, what we’re going to use is our mechanical therapy and
then we’re also going to add our chemical therapy which is the sodium hypochlorite irrigation.
And you’re going to irrigate before you start debriding mechanically, and you’re going to
irrigate during the debridement mechanically, and then after you debride mechanically. And
the reason for this is the crevicular fluid changes over every 90 seconds. So every 90
seconds this is being washed out by the crevicular fluid and you have to get in there and re-irrigate.
So during the course of the irrigation, for a total of 5 minutes, that’s what you’re going
do. You then apply pressure and you apply pressure for 1 minute because you’ve cleaned
the surface of bacteria. The epithelium and the connective issue will adhere to any clean
surface so you then apply pressure for a minute to get epithelial re-adherence of the soft
tissue to the implant surface. You send a patient home and give them a home care regimen
to use and we’ll talk about that in a minute. And you see the patient 3 months afterwards
and when you see the patient 3 months afterwards, you re-evaluate and if they still have 4-5
millimeters with the bleeding upon probing or more you repeat the initial therapy and
then you add the minocycline microspheres or the Arestin into your protocol. You add
the next part of the cumulative interceptive supportive therapy and apply pressure. You
apply pressure again for a minute, you send the patient home, have them do their home
care regimen, the patient comes back 3 months later at a total of 6 months at the 6 months
re-evaluation and if you continue to see the bleeding upon probing, the next thing we’re
going to do incrementally is we’re going to remove the restoration and detoxify the underside
of the restoration because that’s probably contributing your problems. So maintenance protocol: restoration removal.
You remove the prosthesis if feasible. And once you do that, you remove the plaque, you
use sodium hypochlorite, steam clean, air polish, or sterilize the underside of this
restoration along with the screw access opening. Then you also detoxify the platform and screw
access opening on the implant and you’ll take a cotton pellet with sodium hypochlorite and
you go right around the platform of the implant and put sodium hypochlorite irrigation into
the screw access opening. Then you gently curette the pocket lining to remove any granulomatous
tissue or epithelium that’s down there. You replace the restoration and you apply pressure
for one minute. So when we take a look at this case that we’ve
been showing you all along removing it, this is the before; the 6 or 7 millimeter pocketing
and the bleeding upon probing and the inflammation; and this is what it looks like six months
post treatment you can see we’ve reduced the pocketing the bleeding has been significantly
reduced and the inflammation is gone. Let me show you another case. This patient
really was doing everything she could possibly do to keep this area clean. But it was probing
eight millimeters with bleeding upon probing; maxillary molar area. We take a look at the
x-ray. This is a sinus lifted area. There’s been no bone loss. But when we remove this
restoration, take a look at the amount of plaque that was underneath this restoration
sitting on the tissue, waiting to ultimately cause peri-implant bone loss. If the patient’s
host resistance gets low, this area would start to break down periodontally because
of this plaque sitting on right on that soft tissue. What we subsequently did is, and here you
can see what the area of mucositis looks like in the inflammation when the restoration is
removed; as opposed to this area which is healthier. And what you do here is you curette
this area, you irrigate, and you also remove the endotoxin with a cotton pellet from the
platform of the implant, you thoroughly clean the underside of the implant with the sodium
hypochlorite, and now what we’re using is an air polisher or whatever we can do to clean
off any residual areas here, but we’ll clean that very thoroughly. We then take the implant
restoration put it back in the patient’s mouth and apply pressure for a minute. And this is the one year follow up. Now if
you take a look over here, no longer bleeding upon probing, healthier tissue, still 5 millimeter
pocketing, because in the maxillary molar area many times we start out with 5 millimeter
pocketing. So we have 5 pocketing, just anatomically, and it has to be maintained and followed.
But again, 5 millimeter pocketing, no bleeding upon probing at the one year follow up. Here’s another case underneath the framework
of an implant. This patient came in with a soft tissue abscess. She was unable to keep
the area clean. We removed the framework and take a look the inflammation around all of
the implants even where there wasn’t an abscess. So what we subsequently did, is we wound up
cleaning the underside of this implant very thoroughly. In this case we used a cotton
pellet with hydrogen peroxide, which can be used also, 50/50 dilute hydrogen peroxide
when you take these frameworks off to get totally around the implant and in between
the implant surfaces into the screw access opening to thoroughly clean totally as much
as you can around the framework and into the screw access opening. We relieve the area
that was inflamed and had the abscess on the acrylic, replaced the restoration back in
the patient’s mouth and this is the 3 month follow up. As it turns out, we had to remove
this framework for a prosthetic repair and when we removed, I took a look at the implants
and the implant abutment junction and you can see the difference in terms of the way
the tissue looked here as opposed to the way it looked originally. And as I say when I
lecture, this isn’t magic this is purely biology. You remove the bacteria, the issue will heal.
And that’s what we have to try to do. So finally, at home prevention and treatment
of mucositis. It’s all about controlling the biofilm. That’s what’s most critical and you
have to tell the patient our objectives are the we’ve cleaned the underside of the implant,
the subgingival aspect of the implant. Your responsibility is now to stop the supragingival
bacteria from migrating subgingival. So objectives: to minimize the subgingival migration of supragingival
biofilm and keep the subgingival biofilm below an inflammatory threshold. That’s what we’re
trying to accomplish. And here’s the at home regimen. Optimal home
care is imperative and you have to explain that to your patient. I find implant patients
to be much more compliant than my periodontal patients. These patients have lost their teeth,
they spent lot of money and time getting them replaced with implants and implant restorations,
now you’re telling them they may be in danger of losing the implants. So most of them are
ready to do anything they can to maintain the implants. And what we’re asking them to
do is really basically something very simple. All we’re asking them to do is brush their
teeth and rinse their mouth out. And we’re asking them to brush with a triclosan dentifrice.
This is Colgate Total toothpaste in the United States. Triclosan dentifrice the Total has
been shown to reduce the inflammation, bleeding upon probing, and five millimeter pockets
over the course of six months. Again we’re seeing the patient every three months. There’s
less plaque, there’s reduction in gram negative anaerobes also over six months; much research
on it. We’re also asking the patient to rinse their mouth out with a mouthwash. And they
can either use an essential oil mouthwash such as Listerine or a cetylpyridinium chloride
mouthwash such as Colgate Total mouthwash. The essential oil mouthwash, research shows
less plaque and bleeding upon probing than a control but no changes in probing depth.
But we are reducing the bacteria. And the good thing about the CPC mouthwash; it has
12 hours of substantivity. It stays on the mucous membrane surface and there’s no alcohol.
You’ll want to use that with patients that can’t use alcohol. Essential mouthwash: you
have to use the Listerine that has alcohol in it so to speak. So here’s the home care regimen. As I said,
optimal home care is imperative. The patient is to brush with triclosan toothpaste twice
a day. Morning and evening right before they go to sleep; definitely right before they
go to sleep. And then rinse with the essential oil or CPC mouthwash twice today once again
with one of the rinsings being right before they go to sleep at night because what happens
is, bacteria multiply when the salivary flow is reduced. So right before you go to sleep,
it’s necessary to do. The toothpaste will in fact clean the area around the implant,
where as the mouthwash is going to take care of the bacteria on mucus membranes, on the
soft tissue. in the back of the tongue, and on the throat. If you can get the patient
to floss, use an end tuft brush or interproximal brush is even better. And the final thing
you’re going to have the patient do is if they have a framework in their mouth that’s
difficult for them to get under there to keep clean, you’re going to give them a plastic
monoject syringe with a plastic needle to take home or a plastic tip to take home and
you’re going to tell them to irrigate with sodium hypochlorite in the monoject syringe
3 times a week around under the frameworks. And the concentration you’re going to tell
them to use is you’re going to tell them to take 1/2 teaspoon of sodium hypochlorite which
is 2.5 milliliters, just 1/2 a teaspoon and you’re going to tell them to put it into 16
ounces or 500 milliliters of water and make that type of solution and then use the monoject
syringe to irrigate as best they can under the frameworks of the implant. And that’s
what we tell our patients to do in order to treat their mucositis. To summarize early interceptive treatment
is imperative in the patient prone to periodontal disease especially. And the best treatment
for peri-implant disease in 2015 is prevention. So I can’t emphasize enough how important
it is that you give the patient an at home regimen for brushing around their implants
and treating their mouth to prevent mucositis from progressing to peri-implantitis. So I hope you got something out of the presentation.
Feel free if you have any additional questions to contact me. Specialized Dentistry of New
York at [email protected] and my phone number is 212-752-7937. I’ll be more than
happy to answer any questions you may have, and I hope you got something out of this presentation.

28 thoughts on “Management of Peri-implant Disease (Updated)

  • What are the Oral Systemic implications of these conditions?
    Never addressed by the so called "implantologist."
    Blood poisoning takes place in pus formations, does it not?
    Dr. Carlson

  • You know what I got out of this presentation, getting implants and going to dentists is a freaking nightmare; they are fast becoming hated figures.  Ask the public; we're scared shitless of them.  All they care about is becoming rich.  It has nothing to do with patient care/health.  First they make a fortune by hacking at our good teeth: veneers, crowns, fillings and bridges.  Then when they all fail, it's on to the implants, to make them richer.  Then when they fail (mostly inevitable if gum disease was present), it's on to 'fixing' the implants; they become richer still as the poor patient, if they've got any money left, has to continue with this treatment (abuse) until they pass on.  Oh, they might eventually end up with false teeth/dentures if they are lucky. You need to quit telling patients/the public that implants PREVENT bone loss; obviously it 's just another lie to make you richer.  I hate dentists.  They need to take their Hypocrite Oath and bin it. :-(((((

  • No implants! I bet you don't even tell the patients that if the ever need an MRI these things have to be removed. No thanks!

  • Thank you for this honest review of implants and what you spoke about is indeed more common then Dentists who do implants want to admit and I appreciate you clearly hold morals above dollars in your pocket like many others don't unfortunately. I am going to need a lower denture and my dentist is great and trustworthy but was very hyped about me getting implants for a fixed bridge but I opted for the denture to play it safe despite the better eating experience of having the implants. Please note my dentist does not do implants but was referring me to a very popular doctor in the area that comes recommended. Second issue which is a far second for me is the price difference. A lower denture in the US will run me under $2K where I was quoted some ridiculous number above $20K just to get my lower jaw done which is insanity for such a risk. This is just further confirmation that I did the right thing!!! Would I rather have some difficulty eating or osteomyelitis in my jaw that could kill me easily and potentially deform my face?? Easy answer!!! Thanks again for the great video!!!

  • I stopped watching the second he said the bacteria affecting teeth also affects implants!! That is simply not true!!!

  • Quick question — do you recommend patients using a monojet w/NaOCl around single implant restorations with the home care regimen? I know you stated for frameworks but was not sure if OK to also use with single implant restorations. Also would they continue with use of monojet for 3 months 3x/week?

  • I have no implants but i had a toxic rooth cananal .i have it extractef it but now i have problem with my wisdom tooth becoming unstable as it has become. I have a problem

  • Thanks alot. I'm 5th final year student in Australia and recently came across another medical student with an implant condition. I think it may have been Peri implantitis. I was wanting to know the dose and how you administer the local antibiotic cover. Also can general dentist remove the implant attachment to clean the underside if need be? Only cause I'm in a remote location of Australia.
    Thanks video was great information…

  • Dr Fletcher, this is a nice presentation, but periimplantitis is the same as periodontitis: both are 100% oral amebiasis and 25 % oral trichomoniasis. We published in France already. Have a phase contrast microscope and use our Bonner methode to diagnose and treat (saliva mount). Cordially. Dr Bonner Biofilm: Remember periodontitis is easy to prevent and cure manadging biofilm adequately. “Bacterial“ definition is an important mistake for, you cannot ignore part of science! Cordially Mark Bonner dmd

  • excellent presentation! It appears that Colgate Total has been reformulated and now has no triclosan. As of today, a person can buy old inventory of Total with Triclosnan, expiring in 2020 on Amazon. Colgate link:

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