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( n = 5) design reporting on a single treatment group ( n = 9) or multi- ple treatment groups ( n = 6), conducted in a university ( n = 12) or pri- vate practice ( n = 3). All studies that fulfilled the inclusion criteria regarding patient number ( ≥ 20 patients) and follow-up time ( ≥ 3 years) were focused on the medium- to long-term outcomes of peri- implantitis treatment. None of the studies meeting the inclusion cri- teria were specifically designed to evaluate or compare different SPIC protocols or SPIC frequencies and only one study was designed to evaluate the effect of SPIC on the secondary prevention of peri- implantitis. Risk of bias Most studies (87%) were assessed as having a low risk of bias, two studies (13%) showed some concerns, mainly regarding the inclusion of participants (lack of randomization information), treatment stan- dardization or definition of treatment success and disease recurrence. There was considerable heterogeneity between studies with respect to study design including: peri-implantitis case definitions, outcomes reported, outcome definitions for success and disease recurrence, peri-implantitis treatment methods and supportive care protocols. Effect sizes and their clinical relevance Definitions for peri-implantitis, treatment success and recurrence of disease varied considerably across the 15 studies, contributing significantly to the heterogeneity of the data. While all definitions of peri-implantitis included clinical parameters such as BOP, PD and radiographic bone loss, the defined thresholds for bone loss and PD were heterogeneous. Definitions for success were reported by 13 of the studies but also varied between studies. Therefore, a quantitative assessment of implant- and patient-level success was not possible. In nine studies, success was defined as PD < 5 mm with no BOP or suppuration and no further bone loss. In one study, success was defined as PD < 4 mm with no BOP or suppuration and no mobility. One study defined suc- cess as PD reduction, favourable soft tissue parameters and BOP decrease. Another study defined success as no further bone loss of >1.0 mm and no implant removal, and a further study defined success as radiographic evidence of >25% bone fill. The definition of disease ‘ recurrence ’ also varied significantly between the studies. In eight studies, ‘ further bone loss ’ was defined as one important criterion for recurrence, together with implant loss (two studies). In four studies, BOP was a criterion for recurrence and in one study disease recurrence included clinical outcomes not meet- ing the success criteria. Consistency The review found that peri-implant tissue stability reported at the patient level and at the implant level varied widely and that recur- rence of peri-implantitis was reported in up to 65.2% of treated implants receiving SPIC in studies with a follow-up of 3 years or more. While the SR (Stiesch et al., 2023) aimed to identify the most effective supportive care protocol in maintaining peri-implant tissue stability after peri-implantitis treatment, no comparison of protocols could be
made. Furthermore, as the studies were not specifically designed to evaluate supportive care protocols, detailed information regarding supportive care was lacking. Therefore, it was not possible to make any conclusion regarding the most effective supportive care protocol. However, the protocols included similar preventive and therapeutic principles of supportive periodontal care as described in the EFP S3-level treatment guideline for stages I – III periodontitis (Sanz et al., 2020). Regular removal of plaque from the treated implant was common to all protocols described. Several studies also specified the provision of full-mouth professional plaque removal and the reinforce- ment of OH instructions. Balance of benefit and harm The results of this review confirm that SPIC may result in peri-implant tissue stability after peri-implantitis treatment. However, disease recurrence may occur, requiring additional treatment or, in some cases, implant removal. The undesirable effects of SPIC have not been described in the included studies. Overall certainty of the evidence Currently, there is no high-quality evidence available to answer the PICOS of the SR. Based on the available literature, a meta-analysis was not possible. The overall evidence on the effect of SPIC on the secondary prevention of peri-implantitis is based on one RCT, seven prospective and five retrospective clinical trials. Provision of SPIC fol- lowing peri-implantitis therapy may prevent disease recurrence or progression. Insufficient evidence is available to identify (i) a spe- cific supportive care protocol for secondary prevention of peri- implantitis, (ii) the effect of adjunctive local antiseptic agents in the secondary prevention of peri-implantitis and (iii) the impact of fre- quency of supportive care provision. Future prospective random- ized controlled studies designed to evaluate supportive care protocols are needed.
From evidence to recommendation — additional considerations
Acceptability In most of the identified studies, the number of drop-outs was few and the study participants seemed to be compliant. Based on the find- ings of the SR (Stiesch et al., 2023), it may be assumed that the provi- sion of SPIC with a frequency between 3 and 6 months over a time span of 3 years is acceptable for patients following peri-implantitis treatment.
Feasibility There were no perceived barriers.
Ethical considerations As an example, in Germany, neither implant therapy nor SPIC is part of the statutory health insurance. Patients only receive access to SPIC through private health insurance or self-payment.
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