10.59987/ads/2012.3-4.83-89
Aim. Peri-implant mucositis affects 39.4-80% of patients restored with dental implants. If left untreated it evolves in peri-implantitis. Thus far no predictable successful treatment has been reported for peri-implantitis, resulting in implant failure. Proper diagnosis and treatment of peri-implant mucositis is of crucial importance. This study aims to provide a comprehensive review of the available data regarding the effectiveness of peri-implant mucositis treatments in humans, parameters used for the diagnosis and treatment effect evaluation.
Materials and methods. A literature search for RCT and observational studies on peri-implant mucositis treatments in humans was conducted on Pubmed up to January 2012. CONSORT/STROBE and PRISMA checklists guided the evaluation of studies found and the writing of this review, respectively.
Results. Only 5 studies fulfilled the selection criteria. Few possibly effective treatments were studied. Diagnostic parameters reported were clinical only, while treatment effect evaluation was based on clinical and microbiological changes, except for one study reporting biochemical analysis. An evident heterogeneity characterized the follow-up intervals and methods used for reporting parameters changes.
Conclusions. Neither of studied treatments gave complete resolution of peri-implant mucositis. Different treatment strategies need to be studied. Authors suggest guidelines for a protocol of parameters used for determining the sample size, diagnosis and treatment effect, as well as follow-up periods, in order to permit evidence and comparison of different treatments effectiveness.
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                                                                                                          Review article


Peri-implant mucositis treatments in humans:
a systematic review




                                                                                                li
                                                                                             na
Blerina Zeza, DDS, MS                                           Key words: peri-implant mucositis, non-surgical treat-
Andrea Pilloni MD, DDS, MS                                      ment, diagnosis parameters, effectiveness evaluation
                                                                parameters, study in humans.




                                                                                          io
Department of Stomatology and Maxillofacial Sciences,
Chair of Periodontology, Sapienza University of Rome, Italy     Introduction




                                                                                       az
                                                                Peri-implant mucositis by definition is the inflammation
Corresponding author:                                           confined to peri-implant soft tissues only and is caused by
Blerina Zeza, DDS, MS                                           dental plaque accumulation (1-3). It is similar to its coun-




                                                                        n
Department of Stomatology and Maxillofacial Sciences,           terpart gingivitis (4), but with a stronger response (3), al-
Chair of Periodontology, Sapienza University of Rome, Italy     though soft tissues appear to be identical around im-




                                                                     er
Via Caserta, 6                                                  plants as well as around natural teeth (5). It is present in
00161 Rome, Italy                                               39.4-80% of patients restored with dental implants (6-8).
Phone: +39 3894385231                                           Only in the USA, counting for 30% of the global market,
                                                                1.3-2 million implants are being placed each year (9).
Email: bler.jeshil@hotmail.com

                                               nt               Peri-implant mucositis is reversible (3) but if left untreated
                                                                it may lead to peri-implantitis. Inflammation progressively
                                                                and rapidly (10) extends into tissues with weaker de-
                                             iI
Summary                                                         fence mechanisms than periodontal tissues due to lack of
Aim. Peri-implant mucositis affects 39.4-80% of pa-             periodontal ligament and a reduced number of fibroblasts
tients restored with dental implants. If left untreated it      and blood vessels (11). Peri-implantitis does not have any
                                           on

evolves in peri-implantitis. Thus far no predictable suc-       predictable successful treatment yet (12), ultimately caus-
cessful treatment has been reported for peri-implanti-          ing implant failure (5-11%) (13). The clinical importance
tis, resulting in implant failure. Proper diagnosis and         of peri-implant mucositis early diagnosis and effective
treatment of peri-implant mucositis is of crucial impor-        treatment is evident.
                                 i


tance. This study aims to provide a comprehensive re-           The main objective of the present study is to provide a sys-
                              iz


view of the available data regarding the effectiveness of       tematic review and collect data on the quality and quantity
peri-implant mucositis treatments in humans, parame-            of studies dealing with peri-implant mucositis, the parame-
ters used for the diagnosis and treatment effect evalu-         ters used for both the diagnosis and the evaluation of treat-
              Ed




ation.                                                          ment effects. This information may contribute in designing
Materials and methods. A literature search for RCT and
                                                                a protocol for the diagnosis, treatment effect evaluation
observational studies on peri-implant mucositis treat-
                                                                and guide future studies on data missing on this topic.
ments in humans was conducted on Pubmed up to Jan-
                                                                 We chose to enrol only RCTs and observational stud-
uary 2012. CONSORT/STROBE and PRISMA checklists
                                                                ies on humans because: (i) these types of studies pro-
guided the evaluation of studies found and the writing of
this review, respectively.                                      vide the most reliable data; (ii) the real benefits of med-
 IC




Results. Only 5 studies fulfilled the selection criteria. Few   ical intervention can only be ascertained in human
possibly effective treatments were studied. Diagnostic          studies (14). More specifically, the predictability of the
parameters reported were clinical only, while treatment         implant treatment and treatment of peri-implant inflam-
effect evaluation was based on clinical and microbiolog-        mation is related to predisposing factors as well, such as
C




ical changes, except for one study reporting biochemi-          smoking (15), diabetes mellitus (15), oral hygiene and
cal analysis. An evident heterogeneity characterized the        other, factors that differ between humans and animals
follow-up intervals and methods used for reporting pa-          (i.e. animals do not smoke or perform domiciliary oral hy-
rameters changes.                                               giene); (iii) animal studies are proposed to evaluate
©




Conclusions. Neither of studied treatments gave com-            side effects of a treatment/substance that if not harmful
plete resolution of peri-implant mucositis. Different           will be further tested in a human population. Peri-implant
treatment strategies need to be studied. Authors sug-           mucositis treatments are mainly of local non-surgical
gest guidelines for a protocol of parameters used for           type and previously tested for their effectiveness on pe-
determining the sample size, diagnosis and treatment            riodontal inflammation or inflammatory systemic dis-
effect, as well as follow-up periods, in order to permit        eases/disorders. Thus it can be considered safe and
evidence and comparison of different treatments effec-          more appropriate to study peri-implant mucositis treat-
tiveness.
                                                                ment in humans.



Annali di Stomatologia 2012; III (3/4): 83-89                                                                              83
B. Zeza et al.


Review of the current literature                                          Selection procedure
                                                                          Study selection process was divided in three steps: (i) find
Strategies for literature searching and identification                    articles based on the keywords used; (ii) read abstracts and
of studies                                                                exclude articles on animals, in vitro studies, narrative stud-
Firstly, we searched for the most recent review/meta-                     ies, reviews and studies on peri-implantitis; (iii) read full text




                                                                                                            li
analysis on peri-implant mucositis treatment. We found                    articles excluding those which included an incipient loss of
one article that compares the outcomes of peri-implant                    peri-implant bone in the diagnostic criteria, those which did




                                                                                                         na
inflammation treatments in humans with treatments in                      not report appropriately and fully the follow-up results and
animals (14), showing no statistically significant differ-                those that did not specify the diagnostic criteria for the peri-
ences between the two. This article was considered for                    implant mucositis. Each selected article was controlled ac-
three purposes: (i) to follow similar steps, when possi-                  cording to the STROBE and CONSORT checklist for ob-




                                                                                                      io
ble, in order to complete this previous work with more re-                servational studies and RCT, respectively. Jadad scale
cently published evidence; (ii) to guide the aim of our                   was used for the quantification of the RCTs quality.
work in making a more detailed review and meta-analy-
sis, if possible, not only focused on the treatment effi-                 Data selection




                                                                                                   az
cacy, but also on the diagnostic criteria, the influence of               From the enrolled articles there were selected data with re-
predisposing factors on the efficacy of the treatment                     gards to the diagnosis (diagnostic parameters) and treat-
etc. and (iii) to see if the remarks regarding the small                  ment of peri-implant mucositis (type of treatment, parame-
sample size, the lack of power report and study design                    ter used for the evaluation, follow-up periods and intervals




                                                                                    n
heterogeneity have been corrected in the articles pub-                    of evaluation, treatment effectiveness). Patients selection
lished afterwards.                                                        criteria and the evaluation of the influence of the predispos-




                                                                                 er
In a second step a further literature search was con-                     ing factors (smoking, prosthetic restoration margins, etc.) on
ducted in Pubmed up to January 2012 using the key                         the effectiveness of the treatment were considered as well.
words: peri-implant mucositis treatment, peri-implant mu-


                                                  nt
cositis AND laser therapy, peri-implant mucositis AND
antimicrobial therapy, peri-implant mucositis AND antibi-
otic therapy, peri-implant mucositis AND photodynamic
therapy, peri-implant mucositis AND mechanical therapy,
                                                                          Results and discussion

                                                                          Quantity, quality, impossibility to conduct a meta-analysis
                                                iI
peri-implant mucositis AND vector therapy, peri-implant                   Peri-implant inflammation has become a great challenge
mucositis AND xylitol, peri-implant mucositis AND cran-                   to periodontology and implantology worldwide. Actually,
berry juice therapy/phytotherapy, peri-implant mucositis                  the only manageable stage of peri-implant inflammation
                                              on

AND probiotics.                                                           is peri-implant mucositis. In the era of evidence-based
                                                                          medicine the clinician takes best decisions for patient
Selection limits                                                          management based on the best scientific evidence col-
Only RCT and observational studies were included. These                   lected in systematic reviews. Randomized clinical trials
                                     i


studies were conducted in adult human patients with at                    are considered the best scientific evidence. The key word
                                  iz


least one dental implant presenting signs of peri-implant                 “peri-implant mucositis treatment” corresponds to 56
mucositis (bleeding on probing with absence of peri-im-                   available scientifically trusted studies, compared to a list
plant bone loss) who were treated non-surgically and fol-                 of 5553 studies on gingivitis treatment. In this scarce lit-
                  Ed




lowed-up for at least 3 months. They reported data on the                 erature even fewer (only 5) were the RCT and observa-
modification of the parameters used for the evaluation of                 tional studies in humans reported according the CON-
the effect of the treatment applied.                                      SORT/STROBE checklist (Fig. 1). It was noticed that
 IC
C
©




    Figure 1. Diagram of the article selection process. The articles included in the review were only 5.


84                                                                                             Annali di Stomatologia 2012; III (3/4): 83-89
Peri-implant mucositis treatments in humans: a systematic review


both observational studies were conducted from the same                        of studies on peri-implant mucositis treatment in humans
group of study in populations with approximately the                           following a similar protocol for the sample size determina-
same characteristics. According to Jadad scale the se-                         tion, diagnosis, treatment effect evaluation and follow-up
lected RCTs were of high quality (Tab. 1). We decided to                       intervals in order to help comparison of the different treat-
limit the evaluation of the observation studies to the                         ments. The quality of future studies should be maintained




                                                                                                                         li
STROBE checklist only, as Newcastle-Ottawa-scale va-                           high. RCTs in periodontics have a median report quality
lidity assessment is still under development (16).                             score of 2 (17). Authors suggest a more updated evalu-




                                                                                                                      na
Our first intention was to conduct a meta-analysis to eval-                    ation of the report quality of researches in periodontics.
uate the effectiveness of peri-implant mucositis treat-
ment. This was not possible mainly because of the het-                         Treatment
erogeneity characterizing: (i) the type of parameters used                     Peri-implant mucositis has an infective nature as such its




                                                                                                                   io
for the diagnosis and treatment effect evaluation; (ii) the                    therapy should be anti-infective. Mechanical removal of
number of sites chosen for parameters measurement; (iii)                       dental plaque has been proven to be a successful treat-
the way the parameters were expressed, and (iv) the dif-                       ment but not completely resolving the inflammation (18).
ferent follow-up periods and intervals.                                        Consequently adjunctive treatments are proposed. In the




                                                                                                                az
Authors emphasize the need for an increase in quantity                         selected studies (Tabs. 2, 3) it was reported that the use


Jadad scale                      Heitz-Mayfield et al.,2011                Thöne-Mühling et al.,2010                        Ramberg et al., 2009




                                                                                         n
1. Randomisation
Reported                                     1                                           1                                            1




                                                                                      er
Adequately                                   1                                           1
Inadequately
Not reported

2. Double-blinding
Reported
Adequately
Inadequately
                                             1
                                             1   nt                                                                                   1
                                                                                                                                      1
                                               iI
Not reported                                                                             0

3. Withdrawal/Dropouts
                                             on

Reported                                     1                                           1                                            1
Not reported

Quality point                                5                                           3                                            4
                                   i


Table 1. Jadad scale for quality assessment of RCT (High quality RCT presenting ≥ 3 points).
                                iz


 * allocation concealment was reported in all the three studies

Study                          Type       Power                            Treatment                            No of patients/implants     Follow-up
                 Ed




                                             80%
                                        For a mean
                                         difference
Heitz-Mayfield et al., 2011    RCT       of 1.1mm       mechanical treatment +CHX gel vs mechanical                 15/15 vs 14/14           3 months
                                           in PPD                      treatment alone
                                          between
 IC




                                           groups

                                            78%
Thöne-Mühling M et al., 2010   RCT         Effect       full mouth disinfection vs full mouth mechanical             6/22 vs 5/14            8 months
C




                                          size 1.4                          treatment

                                         80% for a
                                         difference
Ramberg P. et al., 2009        RCT        between     0.3% triclosan dentifrice vs sodium fluoride dentifrice          30 vs 29              6months
©




                                           groups
                                         of 12% for
                                          the BOP

Màximo MB et al., 2009         Obs        P< 0.05     mechanical treatment + abrasive sodium corbonate                  12p/16i              3months
                                                                        air-powder

Duarte PM et al., 2009         Obs        P< 0.05     mechanical treatment + abrasive sodium corbonate                  10p/10i              3 months
                                                                        air-powder

Table 2. Description of the included studies.

Annali di Stomatologia 2012; III (3/4): 83-89                                                                                                          85
B. Zeza et al.


of CHX as a gel (19) or mouthrinse in the FMD (20) re-                      (main parameter chosen for the evaluation of the effect),
sulted in improved inflammation signs but not statisti-                     (ii) the difference of this parameter wanted to be seen be-
cally significant to be considered part of the treatment pro-               tween groups after treatment application, and (iii) the
tocol as adjunctive therapy. On the other hand, sodium                      power of the study. In the selected studies the parameters
carbonate abrasive air powder was demonstrated to be                        chosen where periodontal probing depth (Heitz-Mayfield




                                                                                                                li
an effective treatment (21,22). Randomized controlled                       et al., 2011; 80% of power for a 1.1 mm PPD difference be-
trials are required on this treatment. Finally, the everyday                tween control and test) and bleeding on probing [Ramberg




                                                                                                             na
use of triclosan vs fluoride dentifrice was suggested for                   et al., 2009 (80% power for a12% difference of BoP be-
the reduction of signs and symptoms of peri-implant in-                     tween groups); Thöne-Mühling et al., 2009 (78% power for
flammation (23). In this regard, further studies are needed                 and effect size of 1.4)], both parameters of periodontitis,
on the side effects of the regular use of triclosan dentifrice.             counterpart of peri-implantitis (Table 5).




                                                                                                          io
Table 5 summaries the parameters used for the evalua-                       Peri-implant mucositis presents a stage of inflammation
tion of the effectiveness. Authors noticed that no evi-                     not necessarily associated with increased PPD (10).
dence-based explanation was provided in any of the                          Determining the sample size on a parameter that could
studies for the different instruments selected for the me-                  not be present at all among selected patients could ef-




                                                                                                       az
chanical debridement.                                                       fect the final results of the treatment. On the other hand,
Further treatments such as photodynamic therapy, local                      provoked bleeding is always present and it is worldwide
chemical therapy, phytotherapy, xylitol therapy, probiotics                 accepted even as part of the definition of peri-implant
therapy previously tested or being studied currently for                    mucositis (10). To author’s knowledge, marginal bleed-




                                                                                      n
their effectiveness in gingivitis/periodontitis need to be                  ing is considered more appropriate than bleeding on
evaluated in peri-implant mucositis treatment. Surprisingly                 probing when dealing with inflammation confined to soft




                                                                                   er
some of these therapies have been studied as treat-                         tissues only. Marginal bleeding bears the advantages of
ments of peri-implantitis (antibiotic and photodynamic                      probing depth when compared to other signs of inflam-
therapy) rather than peri-implant mucositis.                                mation. It is an objective sign of inflammation preceding


                                                  nt
The review provided here suggests that the effective-
ness of a treatment depends on the type of anti-infective
treatment itself, as well as on: (i) the sample size, (ii) pa-
rameters selected for the evaluation of the effectiveness,
                                                                            discoloration and swelling, easily measured by inserting
                                                                            an inexpensive instrument (periodontal probe) in the
                                                                            peri-implant/gingival sulcus in an angulation of approx-
                                                                            imately 60° with the long axis of the tooth/implant and
                                                iI
(iii) proper diagnosis, and (iv) considerations and elimina-                running it along the gingival margin. This angulation fa-
tion of the local predisposing factors. Thus, further re-                   cilitates the measurement of the parameter despite the
search is needed on already studied treatments as well                      quality of the prosthesis. Marginal bleeding is a more
                                              on

as anti-infective treatments hypothesized to be effective                   sensitive indicator of gingival inflammation and is less
for the resolution of peri-implant mucositis.                               likely to elicit false-positive bleeding than probing to the
                                                                            bottom of the pocket (25). Marginal bleeding can be
Sample size, diagnosis and treatment                                        used as the main clinical parameter when determining
                                          i


effect evaluation parameters                                                the sample size, treatment effect and peri-implant mu-
                                       iz


Sample size is an important factor when it comes to as-                     cositis diagnosis. Authors suggest: (i) a four grade mar-
sessing the validity of a study. Small sized samples may                    ginal bleeding index (Newbrun 1997 reporting Mombelli
give the impression that treatments compared are equally                    et al., 1967 classification), (ii) measured in six sites per
                     Ed




effective as long as statistically significant difference is                implant, (iii) reported as mean value of the implant, (iv)
missing (14).                                                               calculating the number of sites presenting each grade of
Sample size is determined based on: (i) the parameter                       BoP (19), to evaluate the reversibility of mucositis (% of
wanted to be positively influenced by the applied treatment                 sites completely recovered).
 IC




    Study            Age (mean ± SD)           Gender F:M        Periodontal history         Smoking                 General health
                                                                 exclusions

    Heitz-Mayfield   T/57          C/53       T/6:8      C/9:6   Untreated periodontitis,   T/2      C/2                   healthy
C




    et al., 2011                                                 FMNS>25%

    Thöne-Mühling M T/46.3         C/53.3     T/2:4      C/1:4   Untreated periodontitis    T/3      C/2            healthy, no antibiotics
    et al., 2010    ±10.1          ±11.3                                                                            within the last 6 month
©




    Ramberg P.       T/57 ± 7      C/58 ± 8   T/20:10 C/19:10    Untreated periodontitis    not reported            healthy, no antibiotics
    et al., 2009                                                                                                    within the last 1 month

    Màximo MB                55.8±17                  8F:4M      Untreated periodontitis     non smokers           healthy, non antibiotics
    et al., 2009                                                                                                   within the last 6 months

    Duarte PM                55.8±17                  6F:4M      Untreated periodontitis     non smokers            healthy, no antibiotics
    et al., 2009                                                                                                    within the last 6 month


    Table 3. Demographic data.


86                                                                                                Annali di Stomatologia 2012; III (3/4): 83-89
Peri-implant mucositis treatments in humans: a systematic review


Furthermore, dealing with patients that smoke, studies                       Predisposing etiologic factors
should consider that smoking interferes with the bleeding                    Dental plaque is worldwide accepted as the etiologic fac-
response of soft tissues, consequently smokers and non-                      tor of peri-implant mucositis. The quantity of plaque, neither
smokers when included in the protocol should be                              its dichotomous presence, are necessarily related with the
analysed separately (24). None of the studies (except                        presence of inflammation (25). The total bacterial count or




                                                                                                              li
Duarte et al., 2009 and Maximo et al., 2009 that ex-                         proportion of different complexes, or even specific types of
cluded smokers) made such a separation or mentioned                          microorganism can be analysed, but the presence of pu-




                                                                                                           na
smoking cessation counciling as part of the therapy.                         tative periodontal pathogens around teeth does not neces-
Proper diagnosis influences the effect of treatment. Non                     sarily lead to periodontal tissue breakdown (26).
surgical treatment is effective on mucositis but not on                      Only three studies reported microbiological effect evalu-
peri- implantitis. The lack of peri-implant bone loss and                    ation (19-21). After treatment, a microbiological equilib-




                                                                                                        io
suppuration were unanimously chosen as differential di-                      rium compared to the baseline was noticed (19, 20). One
agnosis of peri-implant mucositis from peri-implantitis.                     study evaluated the influence of local predisposing factors
The reported diagnostic parameters (Tab. 4), clinical                        on treatment effect (19) while only the observational stud-
only, were PPD ≥ 4mm (23), BoP (all selected studies)                        ies (21, 22) explicitly included the elimination of this fac-




                                                                                                     az
and GI (20). In the enrolled studies no treatment gave a                     tors as treatment plan.
complete resolution of the inflammation on the entire                        Once it is professionally removed the continuing pres-
sample chosen. 38% (19) and 56.3% patients showed                            ence of dental plaque depends on patient’s compliance,
absence of BoP at 3 months after treatment with CHX gel                      and persistence of local predisposing factors such as




                                                                                       n
and abrasive sodium carbonate air-powder respectively.                       overcontoured restoration margins and other plaque re-
This could be related to various factors, such as im-                        tentive factors. Local treatment is suggested to include




                                                                                    er
proper sample size, ineffective treatment, persistence of                    the elimination or modification of local predisposing fac-
predisposing factors etc. Authors speculate that even                        tors. The further presence of plaque suggests lack of
within peri-implant mucositis different stages could be                      compliance. Authors suggest the use of mPIl, measured


compared to a more incipient stage. Biochemical    nt
distinguished. Perhaps if the inflammation reaches a
specific stage, it does not respond equally positively if

changes appear earlier than clinical changes in an inflam-
                                                                             in 6 sites, to reinforce oral hygiene in specific sites
                                                                             where more needed. Dental plaque indexed or microbi-
                                                                             ological measurements seems to be more appropriate
                                                                             for patient compliance monitoring and identification of lo-
                                                 iI
matory process. Further-more, based on the latest re-                        cal retentive factors than for the diagnosis or treatment
ports peri-implant mucositis reversibility after 3 weeks of                  effect evaluation of the presence of inflammation around
treatment is only biochemical indicating that clinical re-                   implants.
                                               on

covery takes a longer time to be established (3). Authors
speculate that the identification of inflammatory media-                     Follow-up period and intervals
tors would be important in the diagnosis of incipient                        Follow-up periods varied from 3 months (19, 21,22) to 6
stages of peri-implant mucositis and treatment effect                        months (23) and 8 months (20), emphasizing that in none
                                   i


evaluation. Only one study reported biochemical changes                      of the studies the interval or the follow-up selected was
                                iz


after treatment applied (23), concluding that the levels of                  explicitly justified. Follow-ups differed not only in length
TNF-a and the OPG/RANKL ratio may be modulated by                            but evaluation intervals as well. Actually, the 1st month re-
the treatment. Further studies are needed on this regard                     sults were reported only in two studies (19,20), 2nd, 4th and
                 Ed




and on the type of inflammatory mediators that could be                      8th month only in the Thöne-Mühling et al., 2010 study, the
the more appropriate for this purpose (see existing stud-                    6th month only in the Ramberg et al., 2009 and the 3rd
ies on AST, IL-1, etc.) (Tab. 5).                                            month from four studies (19,21-23).


Study                              Bleeding            Marginal          Gingival           Periodontal     Suppuration        Bone loss
 IC




                                  on probing           bleeding           index            probing depth

Heitz-Mayfield et al., 2011       Dichotomous                                                                                   absence

Thöne-Mühling M et al., 2010      Dichotomous                        GI≥ 1 at least at                                         absence 2
C




                               at least at one site                 one site at baseline

Ramberg P. et al., 2009           Dichotomous                                               PPD≥4mm                             absence
©




Màximo MB et al., 2009            Dichotomous         Dichotomous                                             absence           absence

Duarte PM et al., 2009          Bop: 15 seconds
                               after gentle probing   Dichotomous                                             absence           absence1
                                  (Dichotomous)

Table 4. Diagnosis of the peri-implant mucositis in the included studies. MB: Marginal bleeding: presence (score 1) or absence (score 0)
of bleeding obtained by running a probe along the soft tissue margin without probe penetration inside the sulcus or pocket. Dichotomous:
presence(1)/absence(0). (2) Absence of bone loss during the last 2 years before baseline of the study. (1) Peri-apical intraoral radiographs
were obtained for each implant baseline using the paralleling technique and a radiographic positioner. The radiographs were analyzed
for peri-implant bone loss by the same examiner (PMD) using abutments and the threads of the implants as reference points.


Annali di Stomatologia 2012; III (3/4): 83-89                                                                                              87
B. Zeza et al.



Study                          Intervals   PPD          BOP                 MB              PI                MO analysis     BCH analysis CAL

                                           Form         Form

Heitz-Mayfield et al., 2011    Baseline/   Sum of       Mean number                                           Socransky
                               1 month     PPD(mm)      of sites with BOP                                     et al 1998




                                                                                                                   li
                               3 months    in 4 sites                                                         + S. aureus




                                                                                                                na
Thöne-Mühling M et al., 2010   Baseline/   Mean         mBI                                 Sillnes & Loe,    PCR
                               1/2/4/8     PPD(mm)                                          1964
                               months      In 4 sites

Ramberg P. et al., 2009        Baseline/   Mean         Mean % of sites                     Mean % of impl




                                                                                                             io
                               6 months    PPD (mm)     with BOP                            surf harbouring
                                           In 4 sites                                       plaque




                                                                                                          az
Màximo MB et al., 2009         Baseline/   Mean         Mean % of sites     Mean % of       Ainamo            Socransky
                               3 months    PPD (mm)     with BOP            sites with MB   & Bay, 1975       et al, 1998
                                           In 6 sites                                                         DNA-DNA
                                                                                                              hybridization




                                                                                      n
Duarte PM et al., 2009         Baseline/   Mean         Mean % of sites     Mean % of       Ainamo &                          IL-4, -10, -12,
                               3 moths     PPD (mm)     with BOP            sites with MB   Bay, 1975                         TNF-α, OPG, RANKL
                                           In 6 sites




                                                                                   er
Table 5. Parameters for the evaluation of the effect of treatments applied.




                                               nt
The clinical relevance of the follow-up period is to deter-
mine in terms of time: (i) the evidence of the treatment ef-
fect, (ii) the duration of this effect, and (iii) the frequencies
                                                                            Acknowledgement

                                                                            This study had no financial support. Authors report no
                                             iI
of the follow-up visits in the maintenance phase. It has                    conflict of interest.
been demonstrated that 3 weeks after plaque removal
only biochemical reversibility could be detected (3). Fur-
                                           on

thermore, re-evaluation after non-surgical therapy is sug-                  Clinical relevance
gested 6-8 weeks after the last step of initial phase of
treatment to permit tissue healing almost completed at 3                    Peri-implant mucositis treatment is the only way to prevent
months (27). In the enrolled studies it was noticed that sta-               the establishment of peri-implantitis and consequent im-
                                   i


tistically important improvements could be detected in the                  plant loss. This review provided a summary of the avail-
                                iz


first month after treatment, not always followed by simi-                   able data on peri-implant mucositis treatment. It was no-
lar improvement in the subsequent evaluations. Authors                      ticed little evidence on this matter and a lack of studies on
suggest that when evaluating the treatment effect prior to                  various possibly effective treatments. The comparison of
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6-8 weeks, the least invasive methods, such as biochem-                     the existing studies showed an evident heterogeneity.
ical evaluation, should be chosen. For one single applica-                  This observations were used to guide a protocol on future
tion treatments, authors find it reasonable to be followed                  studies on peri-implant mucositis treatment.
up for 3 months. A longer follow-up period would reflect
more the quality of the domiciliary oral hygiene rather than
to the direct effect of the treatment applied.                              References
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Annali di Stomatologia 2012; III (3/4): 83-89                                                                                            89
