Recommendations for the prevention of peri-implant diseases
Where does the need for this guideline come from? • Implementation of the 2018 classification of peri-implant diseases as well as the availability of defined clinical diagnostic criteria/parameters should facilitate the use of appropriate preventive and therapeutic interventions to prevent and treat peri-implant diseases. The application of this S3-level clinical practice guideline for “Prevention and treatment of peri-implant diseases” will allow a homogeneous and evidence-based approach to maintain peri-implant health, to prevent and treat peri-implant mucositis and peri-implantitis. What do patients need to know? • An essential prerequisite to prevention and therapy of peri-implant diseases is to inform the patient of the diagnosis, including causes of the condition, risk factors, treatment alternatives and expected risks and benefits including explanations regarding consequences of refused treatment. • This discussion should be followed by agreement on a personalized care plan. • The plan might need to be modified during the treatment journey, depending on patient preferences, clinical findings and changes to overall health.
How do we interpret these infographics? Blue colour:
Recommendations in favor of a particular strategy of treatment or specific procedure. Open recommendation in which the clinician is responsible for the final choice of a particular strategy of treatment or specific procedure based on specific patient characteristics. Uncertain recommendation for whose clarification further research is needed. Recommendations against a particular strategy of treatment or specific procedure.
Orange colour:
Red colour:
TABLE Strengh of recommendations: grading scheme (German Association of the Scientific Medical Societies (AWMF) and Standing Guidelines Commision, 2012)
Grade of recommendation a
Description
Syntax
We recommend We recommend not to
A
Strong recommendation
We suggest We suggest not to
B
Recommendation
O
Open recommendation May be considered a If the group felt that evidence was not clear enought to support a recommendation, statements were formulated, including the need (or not) of additional research.
Aim: This infographic presents recommendations for individual interventions used in the prevention and treatment of peri-implant diseases for preserving the health of peri-implant tissues and, thereby, extending the longevity of complication-free survival of dental implants when used to replace missing teeth. It aims to: inform sound preventive approaches peri-implant diseases, and thereby improve the overall quality of peri-implant interventions undertaken in Europe and worldwide; reduce dental implant loss arising due to peri-implantitis; reduce medical and dental costs and improve the quality of life of patients. (i) (ii) (iii)
General recommendations in the non-surgical step of peri-implantitis treatment
Sequence of peri-implantitis treatment
Recommended interventions
Recommended
Suggested
Recommended
Recommended
Recommended
It is recommended therapy to retain an individually acceptable implant/prosthesis as the first line of treatment. It is recommended to start the peri-impantitis therapy with a non-surgical step , followed by re-evaluation and, depending on the outcomes, progress to the surgical step or to supportive peri-implant care (SPIC).
Interventions for non-surgical treatment of peri-implantitis
Recommended interventions
Recommended
Suggested
Following interventions are recommended as part of the non-surgical peri-implantitis treatment:
Recommended
Recommended
Recommended
?
Risk factor control .
Prosthesis cleaning/removal/modification, control of biofilm retentive factors.
Oral hygiene (OH)instructions and motivation .
Recommended
Recommended
PD ≤ 4 mm Endpoint
Supra-marginal and sub-marginal instrumentation .
Concomitant periodontal therapy as needed.
Endpoints of non-surgical peri-implantitis treatment
Recommended interventions
Recommended
Suggested
Recommended
Recommended ?
Monitoring residual inflammation/suppuration and probing depths is recommended.
Patient satisfaction, good oral hygiene and prosthesis cleansability should also be considered.
Endpoints : residual probing depths ≤5 mm with no bleeding on probing (BOP) at more than one site and no suppuration. If they are not achieved, additional treatment is recommended.
Mechanical/physical cleaning/ decontamination
Mechanical methods for sub-marginal instrumentation in the non-surgical step of peri-implantitis treatment
Recommended
Not suggested
NOT suggested
NOT suggested
Recommended
Non-surgical supra- and sub-marginal instrumentation with curettes and/or sonic
Lasers are not suggested to be used, either adjunctively or as monotherapy.
It is suggested not to use air polishing .
/ultrasonic devices is recommended .
Chemical approaches for cleaning/decontamination
Not suggested
NOT suggested
NOT suggested
The use of antimicrobial photodynamic therapy (adjunctively or as monotherapy) is not suggested .
The use of desiccant antiseptic gel , adjunctively to sub-marginal instrumentation or as monotherapy, is not suggested .
Adjunctive therapies in non-surgical sub-marginal instrumentation
Not suggested
NOT recommended
NOT suggested
NOT suggested
The use of locally administered antimicrobials administered adjunctively or as monotherapy is not suggested .
The use of probiotics as an adjunct to sub-marginal instrumentation is not suggested .
The routine use of systemic antimicrobials as an adjunct to
nonsurgical treatment is not recommended .
Recommendations for the surgical management of peri-implantitis
General recommendations in the surgical step of peri-implantitis treatment
Not recommended
NOT recommended
It is recommended not to perform surgical treatment of peri-implantitis in patients not achieving and maintaining adequate levels of self-performed oral hygiene .
What is the level of professional expertise required for surgical treatment of peri-implantitis
Recommended interventions
Recommended
Recommended
It is recommended that dental teams offering implant therapy also possess the professional expertise to manage peri-implantitis. Since surgical treatment of peri-implantitis is complex, we recommend that it is provided by dentists with specific training or by specialists .
Endpoints of successful surgical therapy of peri-implantitis
Recommended interventions
Recommended
Recommended
x6 months
Endpoints · ≤1 site of bleeding on probing (BOP) , no suppuration on probing (SOP) , pocket depths (PD) ≤ 5 mm , no signs of progressive bone loss compared to pre-treatment bone levels · Clinical parameters are recommended to be recorded 6 months post-treatment and radiographs be obtained at 12 months. It is suggested that complication-free survival of the implant and implant-supported prosthesis and patient satisfaction (e.g., aesthetic appreciation) be included in thelong-term evaluation of treatment outcomes .
What considerations should be made about the implant-supported prosthesis when performing surgical treatment of peri-implantitis?
Recommended interventions
Not recommended
NOT recommended
Suggested
Suggested
Implant-supported prostheses that do not allow access for self-performed oral hygiene are recommended to be adjusted prior to surgical therapy .
It is suggested that implant-supported prostheses be removed , if feasible, in conjunction with surgical treatment of peri-implantitis to facilitate access and peri-implant tissue healing.
Indications of the surgical treatment of peri-implantitis
Recommended interventions
Recommended
Suggested
Recommended
Recommended
When the endpoints of non-surgical peri-implant therapy (pocket depth (PD) ≤ 5 mm, ≤ 1 site of bleeding on probing (BOP)) have not been achieved, surgical therapy is recommended .
Access flap or resective surgery are recommended .
Management of peri-implant osseous defects using reconstructive approaches
Open recommendation
Recommended interventions
Open
Recommended
Reconstructive procedures are suggested to be preferably applied at intra-osseous ≥3 mm in depth.
In the surgical management of osseous defects in peri-implantitis patients, access flap with/without reconstructive procedures (bone grafts with/without barrier membranes) may be considered.
What is the preferable mode of healing (submerged versus transmucosal) to be used in reconstructive procedures?
Open recommendation
Open
Open
?
We do not know whether a submerged or transmucosal healing protocol would influence the outcomes of reconstructive procedures .
Additional methods for implant surface decontamination
Not suggested
Open recommendation
NOT suggested
Open
Statement
Titanium brushes may be considered as an alternative/adjunct to standard decontamination.
The use of air-polishing/ Er:YAG laser for implant surface decontamination during surgical treatment of peri-implantitis is not suggested .
There is insufficient evidence to make any recommendation regarding the use of implantoplasty .
Not suggested
NOT suggested
The use of chlorhexidine/photodynamic therapy for implant surface decontamination during surgical therapy is not suggested .
Adjunctive use of local/systemic antimicrobials
Open recommendation
Not recommended
NOT recommended
Open
The use of systemic antimicrobials as adjunct to surgical therapy of peri-implantitis is not recommended .
There is insufficient evidence to make any recommendation on the use of local antibiotics as adjuncts in the surgical treatment of peri-implantitis.
This document is a graphic adaptation of the actual clinical practice guidelines and the reader is referred for the correct explanation to the original article: “Prevention and treatment of peri-implant diseases - The EFP S3 level clinical practice guideline” by Herrera and coworkers, Journal of Clinical Periodontology 2023 , https://onlinelibrary.wiley.com/doi/full/10.1111/jcpe.13823
www.efp.org
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