An in vitro study exploring a new method for managing peri-implant disease using the ten second technique

Abstract

This study investigated the in-vitro efficacy of the Ten-Second Technique (TST), a novel protocol designed for treating peri-implant disease. TST comprises a 10-second application of Hybenx^® gel on contaminated implant surfaces, followed by air polishing with sodium bicarbonate powder. This technique aims to provide an effective method for decontaminating implant surfaces, thereby mitigating dental implant complications and improving long-term outcomes. In the in vitro investigation, two failed dental implants explanted due to peri-implantitis were treated with the TST protocol. Scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDX) were employed to evaluate the protocol’s effectiveness in terms of biofilm removal, surface decontamination, and potential surface alterations. Statistical differences in surface contamination before and after TST application were assessed using One-Way ANOVA. Additionally, preliminary radiographic findings from a clinically treated case with TST suggested the technique’s potential for peri-implant tissue healing. In conclusion, the TST protocol demonstrates promising in vitro results for effectively decontaminating implant surfaces affected by peri-implant mucositis and peri-implantitis. The Ten-Second Technique holds potential as an efficient adjunct in both surgical and non-surgical treatment of peri-implant disease and may enhance routine implant maintenance protocols.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-025-08946-8.

Introduction

Current knowledge of the epidemiology and incidence of peri-implant disease indicates that it is prevalent among dental patients with implants. Studies have reported varying prevalence rates, with peri-implant mucositis affecting a significant proportion of patients, and peri-implantitis presenting at a lower yet notable frequency. For instance, a study by Ahn et al. found peri-implant mucositis in 39.7% and peri-implantitis in 16.7% of cases after a minimum of 7 years of implant loading¹. Another study reported lower prevalence rates of peri-implant mucositis (33.3%) and peri-implantitis (9.7%) in patients who underwent regular checkups². Conversely, a study in Western China identified peri-implant disease in 51.91% of patients and 44.35% of implants, with peri-implant mucositis and peri-implantitis at 45.80% and 7.63%, respectively³.

Risk factors for peri-implant disease have been identified, including smoking, poor oral hygiene, history of periodontitis, diabetes, and certain implant-related factors such as prosthetic design and implant surface characteristics^4,5. Smoking and prosthetic splinting were significantly associated with peri-implantitis, while poor oral hygiene and a history of periodontitis were strong risk factors for peri-implant disease^2,6. Other studies have corroborated these findings, highlighting the importance of patient- and implant-related factors in the development of peri-implant diseases^3,7,8. The dimensions of the keratinized mucosa surrounding the implants must also always be considered, which is a very important factor⁹. Occlusion may also play a role in the pathogenesis¹⁰. Recent data suggest also a genetic predisposition¹¹. The identification of consistent risk factors suggests that preventive measures and patient education are crucial for managing peri-implant health. Regular follow-ups and maintenance care are emphasized as key components in preventing the onset and progression of peri-implant diseases^2,12–14. Thus, clinicians should have a proactive approach to identifying potential issues, emphasizing the importance of maintaining good oral hygiene, including regular professional cleaning with implant monitoring in patients with dental implants and considering individual risk profiles, including possible genetic factors, when planning and managing implant therapies¹⁵.

The available treatments for peri-implant diseases encompass both non-surgical and surgical approaches. Nonsurgical treatments for peri-implant mucositis typically involve oral hygiene instructions, scaling, and prophylaxis, which usually respond well to these interventions¹⁶. Mechanical debridement combined with local antiseptic therapy, such as chlorhexidine digluconate, has been used for peri-implant mucositis, with significant short-term clinical improvements¹⁷. However, for peri-implantitis, which involves bone resorption, non-surgical management has less predictable outcomes, and adjunctive treatments, such as antimicrobials or Er: YAG laser therapy, may be employed, although complete disease resolution is not always achieved¹⁸. Surgical interventions are considered particularly for peri-implantitis and may include open-flap debridement, apically positioned flaps, and guided bone regeneration¹⁹. Some studies have suggested that surgical interventions may be beneficial as a first-line approach for certain peri-implant infections²⁰. Despite the variety of treatment modalities available, standardized protocols and further research are needed to optimize the treatment outcomes for peri-implant diseases.

Various decontamination methods have been recommended for implant surfaces during peri-implant surgery, including mechanical, chemical, and laser approaches. Chemical agents suggested for decontamination include citric acid, chlorhexidine gluconate, hydrogen peroxide, sodium hypochlorite, phosphoric acid, tetracycline and other antibiotics^21–23. Generally, the use of antibiotics in implant decontamination is widespread, with current evidence indicating greater clinical advantages of local antibiotic administration in comparison to local chlorhexidine application, particularly when treatments are performed repeatedly over time^24,25. Among the available treatment modalities, Hybenx^® has been introduced as a decontaminating gel²⁶. This commercial formulation, composed of sulfonated phenolics, sulfuric acid, and water, facilitates the selective elimination of microorganisms and tissue debris, enhanced by it’s desiccant functionality. Nevertheless, it is necessary to deliver Hybenx^® precisely, in order to prevent damage to surrounding healthy mucosa. The primary mechanism of action of Hybenx^® is rooted in the Desiccation Shock Debridement (DSD) technology, which employs a novel category of non-antibiotic cleansers to eliminate pathogens and residual molecular matrix from infected tissue surfaces. This selectivity contributes to diminished bleeding, reduced pain, and lowered infectious burden in the treatment area. In previous studies by Lopez and coauthors, Hybenx^® was judged effective in decontaminating implant surfaces in instances of mucositis and peri-implantitis²⁷. The protocol presented here is a two-stage technique: the first stage is similar to that proposed by Lopez et al. (that is the initial application of Hybenx^® gel to the infected area), while the second one involves cleaning with air polishing using an air polishing device producing a water spray with sodium bicarbonate powder. After air polishing, any remaining gel residue is carefully removed using a suction unit.

Scanning electron microscopy and energy dispersive X-ray analysis on two implants failed due to peri-implantitis and radiographic investigations on a clinically treated case, were carried out to evaluate the effectiveness of the TST procedure.

Materials and methods

This study adhered to the Clinical Research Information System (CRIS) guidelines²⁸.

Implant surfaces were pretreated with ultrasonic ablation using an instrument with thin inserts (PIEZON^® PS [Perio Slim], EMS Italia S.r.l, Pero, Italy) to eliminate macroscopic remnants before applying Hybenx^® gel (EPIEN Medical, USA). The TST procedure was performed consistently for both surgical and non-surgical cases, differentiated by the presence of bone or tissue defects. After macroscopic debridement, Hybenx^® gel was applied for 10 s to contaminated implant surfaces. The gel was then rinsed for 30 s using an air-polishing device (PROPHYflex 4, KaVo Dental Italy S.r.l., Recco (GE) Italy) with 40 μm sodium bicarbonate powder water spray (Airflow Comfort, EMS Italia S.r.l., Pero, Italy). The reaction produced effervescent foam consisting of water, carbonium dioxide (CO₂), and sodium sulfate (Na₂SO₄), which was immediately aspirated to prevent oral dispersion. The cleansing effect of the foam removed debris, followed by a 1–2-minute water spray, until a visually clean surface was obtained.

In the present paper, the cleansing efficacy of the TST procedure was evaluated in vitro on two failed implants removed from two consecutive patients due to untreatable peri-implantitis. The two implants had diverse microstructured surfaces (“implant-1”: acid-etched and “implant-2”: sandblasted and acid-etched). The surfaces of the implants were treated by the same experienced periodontist (MDN) with the TST protocol, specifically with the complete sequence: ultrasonic inserts, Hybenx^® gel, and airflow with bicarbonate powder. To prevent cross-contamination, after extraction, both implants were washed with saline, blistered and steam sterilized. Steam sterilization did not remove any macroscopic residue from the experimental samples.

To assess the biofilm removal and surface decontamination achieved with the Ten-Second Technique protocol and to detect any surface modification scanning electron microscopy and energy dispersive X-ray analysis were carried out at a renowned research facility (CNR – ICMATE, Padua, Italy) before and after the TST procedure.

The sample morphology was studied using an FEI Quanta 200 FEG ESEM scanning electron microscope, supplied with a field emission gun, operating in high vacuum conditions and at an accelerating voltage variable in the range of 15 ÷ 25 kV, in relation to the observation needs. Four sides of each implant were analyzed (obtained by rotating the implant itself by 90°), at different magnifications. Secondary electron images were collected. EDX measurements were performed for qualitative and semiquantitative element investigation of the samples and were carried out by using an EDAX Genesis energy dispersive X-ray spectrometer. All EDX atomic percentages (at%) were reported as mean values, derived from four different measurements conducted on the four sides of each sample. Each acquisition was detected from 100 × area micrograph, accumulated for 100 s at 20 kV and a working distance of 10 mm. No sputtering or metallization were used for the sample preparation before observations.

In the clinical setting, the treated implants were checked preoperatively and followed over time with periapical radiographs (Durr VistaScan Mini View 2.0, DURR DENTAL ITALIA S.R.L., Concorezzo, MB, Italy), Ortopantomographs and CBCTs (Newtom Go, CEFLA S.C., Imola, BO, Italy).

Statistics

All quantitative data are shown as the mean ± standard deviation. One-Way Analysis of variance (ANOVA) and Tukey’s multiple comparison tests were used to assess statistical differences. A p < 0.05 was always taken to indicate statistical significance.

To evaluate whether the different faces of the implants have the same contamination, Tukey’s multiple comparison tests were also carried out between the different faces of each implant, both before and after the TST protocol.

Results

In the untreated implant-1 (Figs. 1a and 2a,c,e) and implant-2 (Figs. 3a and 4a,c,e), deposits/aggregates were clearly observable on the implant surface, attributable to the presence of a layer of contamination, as also reported in the literature^25,27. For both the implants analyzed, these deposits were present on the entire surface of the implant; however, SEM images appear to indicate greater contamination on the body and at the apex. Otherwise, the smoother area near the abutment seems to be less contaminated. In implant-1, a large formation can also be observed (Fig. 1a), containing high quantities of Ca and P, probably attributable to bone residues.

Fig. 1.

Complete images of the surface of implant-1 before (a) and after (b) TST treatment. Complete implant images were reconstructed using three SEM micrographs.

Fig. 2.

SEM micrographs at different magnifications of the surface of implant-1, in the central part of the implant, before (a, c, e) and after (b, d, f) the TST treatment.

Fig. 3.

Complete images of the surface of implant-2 before (a) and after (b) the TST treatment. Complete implant images were reconstructed using three SEM micrographs.

Fig. 4.

SEM micrographs at different magnifications of the surface of implant-1, in the central part of the implant, before (a, c, e) and after (b, d, f) the TST treatment.

After the TST protocol, the deposits previously present on the surface of the implants were completely removed, both on implant-1 (Figs. 1b and 2b,d,f) and on implant-2 (Figs. 3b and 4b,d,f). Following the TST protocol, the distinct microstructures of the implants became observable, whereas no treatment residues were left on the surfaces. Furthermore, no evident scratches were introduced on the surfaces due to the TST treatment.

Figure 5 shows high magnification secondary electron micrographs of the surface of implant-1 (a, b) and implant-2 (c, d) following the TST treatment. These images reveal that implant-1 and implant-2 exhibit distinct surface finishes: implant-1 displays an acid-etched surface, while implant-2 showcases a sandblasted and acid-etched surface.

Fig. 5.

High magnification SEM micrographs of the surface of implant-1 (a, b) and implant-2 (c, d) after the TST protocol.

Table 1 Shows the carbon at% recorded on the implant-1 and implant-2 surfaces, before and after the TST protocol. For both implants, the carbon content was statistically lower after treatment (p-value < 0.05), thus confirming that the protocol reduces contamination of the implant surface. Furthermore, to evaluate whether the different faces of the implants have the same contamination, Tukey’s multiple comparison tests were also carried out between the different faces of each implant, both before and after the TST protocol. The atomic percentage of carbon recorded on the different faces of the implants is not statistically different (p-value < 0.05), both before and after the decontamination procedure.

Table 1.

Carbon atomic percentages obtained by EDX analyses for untreated and TST-treated implant-1 and implant-2.

	Before TST protocol	After TST protocol
Implant-1 C at%	50 ± 5	6 ± 1
Implant-2 C at%	60 ± 2	10 ± 3

Radiographic imaging offers optimal visualization of bone, dental, and implant structures for the purposes of peri-implant diagnosis and monitoring²⁹. Figures 6 and 7 show the radiographic results of a typical case treated surgically with TST decontamination and a bone xenograft. Figure 6 displays three dental implants before the TST protocol that are evidently affected by peri-implant disease that is causing bone resorption, both marginally and on the implant threads. Figure 7 shows the radiographic inspection of the healed sites of the same patient 5 years after the TST treatment. It can be observed that all implants previously affected by peri-implant disease are now healthy and surrounded by newly formed bone (from the xenograft applied after the TST protocol) that totally covers the implant threads. Other clinical cases treated with the TST protocol show promising results, with apparent re-osseointegration and healing of the peri-implant disease and bony pockets. These results will be exhaustively presented in a different paper.

Fig. 6.

Clinical case before the treatment with the TST technique and xenografts. Pre-surgical panoramic X-ray (a). Pre-surgical periapical X-rays of the diseased sites of the same patient (b, c).

Fig. 7.

Periapical X-rays of the healed sites of the same patient 5 years after the TST treatment. A: Periapical X-ray corresponding to the implants in Fig. 6b (a). Periapical X-ray corresponding to the implants in Fig. 6c (b).

Discussion

The global prevalence of peri-implantitis underscores the critical need for effective and accessible treatment protocols. The proposed methodology employing Hybenx^® gel for 10 s on the contaminated surface, followed by meticulous debridement using air polishing with a sodium bicarbonate powder water spray, presents a promising approach. Hybenx^® oral tissue decontaminant denatures the bacterial biofilm matrix through the desiccant action of sulfuric acid, while the sulfonated phenols (also present in this product) rapidly remove water from the biofilm matrix, resulting in biofilm desiccation. Consequently, the matrix containing bacteria coagulates, contracts, and detaches from the surface to which it was firmly attached. This chemical action facilitates the mechanical removal of biofilms and enables the elimination of bacteria. Clinical research and microbiological tests have demonstrated complete decontamination of dental and implant surfaces through biofilm desiccation. The second stage of the TST protocol incorporates air polishing with sodium bicarbonate powder, further enhancing the decontamination process. The effervescent foam generated during this stage effectively lifts and removes debris from the implant surface, thus contributing to a thorough cleansing effect. On the basis of promising clinical appearance and results, the authors believe that the second step (Airflow with sodium bicarbonate powder), strongly enhances the good cleaning properties of Hybenx^® alone that have been already shown in previous papers^27,30. The present SEM-EDX in vitro investigations on two failed and later TST-treated titanium dental implants confirmed the effective removal of the contamination layer from both examined implants, validating the efficacy of the TST treatment. Both implants initially exhibited significant surface contamination (Figs. 1a, 2a,c,e, 3a and 4a,c,e). The TST protocol successfully eliminated these contaminants, revealing the underlying implant surface, without introducing any additional surface defects or alterations (Figs. 1b, 2b,d,f, 3b and 4b,d,f). Literature suggests a correlation between surface carbon quantity and system contamination^31–34. The quantity of carbon present on the surface of the system can serve as an indicator of the extent of its contamination and lower carbon levels generally signify a cleaner system. EDX spectroscopy was used to assess the efficiency of TST protocol in removing the implant superficial contamination (carbon traces). The atomic percentages (at%) of carbon were considered before and after the in vitro TST treatment, for both implants. For each face of the implant, four EDX analyses were conducted (with the same analysis parameters) and three or four faces of the implant were analyzed from time to time. Box plots were constructed to visualize the data and outliers were eliminated in the comparative statistical treatment.

The present results regarding carbon levels (Table 1) suggest that the TST protocol effectively cleans the implant surface, providing a foundation for decontamination and regenerative procedures. Furthermore, the TST protocol effectively removes the contamination layer from both test implants, which exhibited different pristine surface microstructures: (i) acid-etched and (ii) sandblasted and acid-etched), indicating its versatility and potential for broad applications. Together with SEM-EDX outcomes, the radiographic results of a typical clinical case, treated surgically with TST decontamination and a bone xenograft, demonstrate the efficacy of the protocol in decontaminating implant surfaces prior to alveolar defect regeneration.

During the TST procedure, only negligible quantities of sodium sulfate are produced, which, considering the general safety of the compound, is safe. Sodium sulfate is widely used in toxicology to facilitate the elimination of harmful agents from organisms during drug poisoning incidents. Furthermore, it is important to note that sodium sulfate is considered safe for use in diverse scenarios. This neutral salt possesses remarkable cleansing properties and is frequently incorporated into cosmetic products, ointments, detergents, toothpastes, and soaps. Additionally, it is routinely employed as a food additive (E514) and in livestock feed. It is considered inert and non-toxic, with the sole exception being the inhalation of large quantities of anhydrous sodium sulfate, which may result in transient asthma or ocular irritation³⁵. Oral sodium sulfate is also increasingly utilized (in combination with other agents) for improving bowel preparation for colonoscopy procedures and is considered safe in this clinical scenario as well³⁶.

The TST protocol appears to be a promising approach for addressing the issue of implant decontamination in clinical settings, both for non-surgical maintenance care and as a pretreatment technique prior to regenerative procedures. Existing cleaning methods for dental implants are associated with several significant limitations that have long been a concern for dental professionals and patients. First, these traditional approaches are often time-consuming, necessitating extended chair time and potentially increasing patient discomfort during the procedure. These issues not only impact the efficiency of the dental practice but also contribute to the overall treatment costs. Second, many current cleaning methods, particularly implantoplasty, pose the risk of damaging the delicate tissues surrounding the implant with rotary instruments. This collateral damage can lead to complications, delayed healing, soft tissue retraction, and loss of keratinized mucosa, and in some cases, may compromise the long-term success of the procedure. Third, the efficacy of existing cleaning techniques in thoroughly removing contamination from implant surfaces is questionable. Bacterial biofilms and other contaminants adhere tenaciously to implant surfaces, particularly in areas that are difficult to access³⁷. The incomplete removal of these contaminants leads to persistent inflammation, relapse of peri-implantitis, and ultimately implant failure. Techniques that rely heavily on the individual skills of the dental surgeon may be ineffective in many cases. Furthermore, implantoplasty, which involves mechanically smoothing the implant to decontaminate the surface and further reduce bacterial adhesion, often results in the generation of significant amounts of titanium debris. This debris can remain in the surrounding tissue, potentially leading to discoloration. Additionally, implantoplasty inevitably reduces the mechanical resistance of the implant³⁸.

Considering these challenges, the TST protocol is a potential game-changer in treatment strategies for peri-implant diseases. This innovative approach aims to address the aforementioned issues comprehensively, offering a multifaceted solution for implant decontamination. The TST protocol is designed to be significantly speedier than traditional methods, potentially reducing the treatment time and improving patient comfort. This increased efficiency could also translate into cost savings for both dental practices and patients. Moreover, the TST protocol is safe for the surrounding tissues.

Some precautions, as always, are needed when using airflow polishing jets. Precautions for the use of polishing jets:

1. The polishing air jet should be directed perpendicular to the implant surface.

2. During surgery, the soft tissues should be protected with a periosteal elevator.

3. In non-surgical cases with inflamed tissues, especially when lacking a proper band of keratinized mucosa, soft tissues should be protected to avoid emphysema.

By minimizing collateral damage with respect to the conventional procedures, this method may promote faster healing and reduce the risk of post-treatment complications. Furthermore, this gentler approach could be particularly beneficial for patients with thin biotypes or for those at a higher risk of healing complications.

The TST protocol could significantly improve the standard of care for dental implant patients, offering a faster, safer, and more effective solution for the persistent challenge of dental (and other) implant contamination^39,40.

To the knowledge of the authors, this is the first time that Hybenx^® gel is used in combination with airflow with sodium bicarbonate powder for implant decontamination. Hybenx^® gel has been used with airflow previously, but with erythritol powder³⁰.

Limitations of this study

This is an in vitro study, and as such, although based on a technique already used in the clinical scenario, it cannot fully reflect it. In vitro implants can be decontaminated 360°, whereas in vivo (both surgically and non-surgically), access to all implant surfaces is often limited.

Another limitation of the in vitro design is the inability to assess the biological effects of the proposed decontamination protocol on the oral tissues and cells. Additional, clinical studies are necessary to fully validate the effectiveness of the TST protocol.

Conclusions

The TST protocol, incorporating Hybenx^® gel and sodium bicarbonate powder, presents a practical and effective method for the routine maintenance of implant surfaces, particularly in the context of peri-implantitis. SEM-EDX analyses and radiographic inspections validate its efficacy in achieving thorough decontamination. The minimal byproducts generated, including sodium sulfate, are considered safe and are promptly removed during the procedure. On the basis of this in vitro study, it seems that the TST protocol could be a valuable addition to the dental professional’s toolkit, providing a simple, efficient, and cost-effective approach to managing peri-implantitis.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

M.D.N.is responsible for the development of the technique, for clinical work and for treatment of the dental implant samples with the TST protocol. L.D.C. contributed to the clinical work and dental implant sample treatment. E.B. contributed by drafting the manuscript. F.V. carried out all experimental work and laboratory data collection on the samples, including statistical analysis (with the exclusion of the TST treatment itself) and contributed to drafting the manuscript.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files]. Additional photomicrographs, can be presented upon reasonable request by contacting the corresponding author.

Conflict of interest

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest.

Ethics approval

Ethics committee approval is not required for this study according to Regulation (EU) No. 746/2017 of the European Parliament and the decision of the European Council dated 5 April 2017 regarding in vitro medical device experimentation. This regulation repeals Directive 98/79/EC and Commission Decision 2010/227/EU.

Informed consent

An informed consent form was obtained from all participants to the study. The patients were treated in accordance with the principles of the WMA Declaration of Helsinki.