The prevalence of peri-implant mucositis has been reported to be around 29.5% at the implant level and 46.8% at the patient level. Effective management of the biofilm is considered key to prevention and management with subgingival instrumentation being a key element. Studies have suggested that biofilm control is better when combined with adjunctive patient-delivered methods.
The aim of this review was to assess the efficacy of patient-performed or administered measures used adjunctively to submarginal instrumentation for the management of peri-implant mucositis.
Methods
A protocol was registered in the PROSPERO database. Searches were conducted in the PubMed, Scopus and Cochrane databases for randomised controlled trials (RCTs) of patient-performed or administered adjunctive measures for peri-implant mucositis involving at least 10 patients per group and follow up of at least 3 months. The primary outcome was bleeding on probing (BOP). Two reviewers independently screened and selected studies with 4 reviewers extracting data. The Cochrane risk of bias tool (RoB2) was used to assess quality. Weighted mean differences (WMDs) or mean differences (MD) with 95% confidence intervals (CIs) and predictive intervals were calculated. Meta-analyses were conducted were appropriate.
Results
- 14 parallel group RCTs reported in 16 papers involving 710 patients (403 test, 307 control) were included.
- 8 RCTs included smokers and non-smokers, with 6 RCTs specifically excluding smokers.
- There was variation in the definition of peri-implant mucositis across the studies and the periodontal diagnosis of the included patients was not clearly described.
- 12 RCTs reported data on 1 implant per patient.
- Only 3 studies reported on the brand of implant used and the width and length of implant was only reported in a single study.
- Adjunctive measures included antibiotics (3 RCTs), antiseptics (6 RCTs), probiotics (6 RCTs), and mechanical approaches [oral irrigators and interdental brushes] (2 RCTs).
- 9 studies were considered to be at low risk of bias and 5 at moderate risk.
- Overall at 3 months greater statistically significant reductions in BOP, Plague levels and probing pocket depth were seen in test groups compared with control groups (see table below).
| No. of comparisons (patients) | WMD/MD (95%CI) | Prediction Interval 95%CI | |
| BOP Overall | 16 (650) | 14.25 (9.06 to 19.45) | – 6.05 to 34.56 |
| BOP antibiotics | 3 (101) | 5.97 (1.34 to 10.59) | – 42.33 to 54.26 |
| BOP antiseptics | 5 (229) | 22.72 (19.4 to 26.04) | 12.7 to 32.74 |
| BOP probiotics | 6 (260) | 12.12 (3.2 to 21.03) | -17.63 to 41.87 |
| Plaque Index (PI) overall | 12 (473) | 15.89 (9.86 to 21.92) | 17.72 to 20.9 |
| PI antibiotics | 3 (101) | 14.74 (3.83 to 25.65) | -113.62 to 143.09 |
| PI antiseptics | 3(112) | 21.27 (13.34 to 29.20) | -71.08 to 113.62 |
| PI probiotics | 6 (260) | 14.2 (3.46 to 24.94) | -23.06 to 51.46 |
| Probing Pocket Depth (PPD) overall | 15(660) | 0.52 (0.01 to 1.03) | -1.67 to 2.71 |
| PPD antibiotics | 3 (101) | 0.79 (-0.35 to 1.92) | -13.44 to 15.02 |
| PPD antiseptics | 3 (139) | 0.35 (-0.45 to 1.15) | -9.72 to 10.42 |
| PPD probiotics | 7(309) | 0.62 (-0.30 to 0.42) | -2.66 to 3.9 |
- Greater reductions in BOP, plaque levels and PPD were also seen at six months (see table below).
| No. of comparisons (patients) | WMD/MD (95%CI) | |
| BOP Overall | 6 (277) | 11.13 (2.87 to 19.45) |
| BOP antibiotics | 2 (71) | 20.79 (15.24 to 26.34) |
| BOP antiseptics | 1 (48) | 4.8 (-10.05 to 19.65) |
| BOP probiotics | 3 (108) | 5.0 (-1.18 to 11.17) |
| Plaque Index (PI) overall | 6 (277) | 6.39 (0.98 to 11.81) |
| PI antibiotics | 2 (71) | 13.97 (4.10 to 23.84) |
| PI antiseptics | 1 (48) | -3.91 (-22.14 to 14.32) |
| PI probiotics | 3 (108) | 4.05 (-1.38 to 9.48) |
| Probing Pocket Depth (PPD) overall | 7 (273) | 1.05 (-0.04 to 2.14) |
| PPD antibiotics | 2 (74) | 1.52 (-0.64 to 3.67) |
| PPD antiseptics | 1 (48) | 0.10 (-0.41 to 0.61) |
| PPD probiotics | 4 (151) | 1.06 (-0.50 to 2.61) |
- Only 6 out of the 14 studies reported on disease resolution using varying definitions.
- 3 studies reported on radiographic bone levels and 2 on suppuration around implants.
- Patient-reported outcome measures (PROMs) and adverse events were reported by 5 studies.
Conclusions
The authors concluded: –
…significant clinical improvements can be obtained when professional submarginal instrumentation is combined with patient- performed or administered (by prescription) adjunctive measures, although a complete disease resolution may not be achieved.
Comments
The reviewers registered their protocol on PROSPERO and aimed to follow the PRISMA guidelines. Three major databases were searched and only RCTs included. A majority of the included studies (64%) were considered to be at low risk of bias although 12 of the 14 studies did not report an whether any supportive professional treatment was provided during the studies. While a reasonable number of studies were available for an overall assessment of adjunctive methods the number of studies for specific interventions is limited. The authors also highlight the variations in diagnosis and outcome measurement across the studies. The findings suggest that adjunctive measures are beneficial however only short term 3-6 months findings are available as only one of the included studies involved a 12 month follow up time. Future studies should include larger sample sizes, involve a minimum of 6 months follow up , use common diagnostic and reporting methods.
Links
Primary Paper
Gennai S, Bollain J, Ambrosio N, Marruganti C, Graziani F, Figuero E. Efficacy of adjunctive measures in peri-implant mucositis. A systematic review and meta-analysis. J Clin Periodontol. 2023 Feb 15. doi: 10.1111/jcpe.13791. Epub ahead of print. PMID: 36792063.
Other references
Dental Elf – 15th Mar 2023
Dental Elf – 8th May 2015
Peri-implant mucositis: adjuncts to improve professional plaque removal
