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Overall certainty of the evidence Very low.
PICOS question addressed by an SR
R7.6: Evidence-based recommendation Quality of evidence Very low — twoRCTs ( n = 64 patients, n = 75 implants) with a minimum follow-up of 6 months, with low risk of bias Grade of recommendation GradeB — # Strength of consensus : Consensus (13.7% of the group abstained due to potential CoI)
From evidence to recommendation — additional considerations
Acceptability Patient perception and acceptance were assessed in one study, show- ing no statistically significant differences (Merli et al., 2020). Feasibility Implementation of therapy may be negatively influenced by the lack of retrievability and/or shape of the prosthetic suprastructure. Some- times sub-marginal delivery may not be possible due to the size of the nozzle. Ethical considerations Consider that the additional clinical benefit, if present, is small; that there is a potential risk of harm (subcutaneous emphysema); and that no clear benefit in terms of patient acceptability has been demonstrated.
Background
Intervention
To overcome challenges with conventional sub-marginal instrumenta- tion, alternative approaches have been assessed. Among them, air- polishing systems have been tested both as monotherapy and as adjuncts to conventional sub-marginal instrumentation.
Available evidence
Number and design of included studies Two RCTs ( n patients = 64, n implants = 75) assessed the sub-marginal peri-implant instrumentation with air-polishing (Merli et al., 2020; Sahm et al., 2011). One used air-polishing as monotherapy (Sahm et al., 2011), while the other combined ultrasonics and air-polishing (Merli et al., 2020).
Economic considerations Cost-effectiveness has not been evaluated in these studies.
Legal considerations So far, the manufacturer's indications are respected, and there are no legal considerations.
Risk of bias Both studies had low risk of bias.
7.3 | Non-surgical sub-marginal instrumentation — chemical approaches for cleaning/decontamination
Effect sizes and their clinical relevance Due to the heterogeneity of the treatment protocols, no meta- analysis was carried out. Both studies on air-abrasive decontamination showed PD and BOP reductions but no statistically significant differ- ences. Inter-group differences for BOP were observed with air- polishing as monotherapy (Sahm et al., 2011).
The SR by de Waal and co-workers evaluated chemical approaches for implant cleaning/decontamination, aiming to answer the follow- ing PICOS question: ‘ in adult patients with peri-implantitis (P), what is the efficacy of sub-marginal instrumentation combined with chemical surface decontamination (I) in comparison with sub- marginal instrumentation with or without placebo (C), in terms of changes in PDs and/or BOP (O), as reported in RCTs, non- randomized CCTs or prospective cohort studies, with a minimum of 6-month follow-up (S)? ’ Three RCTs were identified: two with low risk of bias and one with some concerns. Two RCTs assessed the benefits of aPDT as an adjunct to sub-marginal instrumentation, using either toluidine blue (Wang et al., 2019) or methylene blue (Alasqah, 2022) as pho- tosensitizers. One RCT assessed the efficacy of a desiccant material consisting of a gel of concentrated aqueous mixture of hydroxy- benzenesulphonic and hydroxymethoxybenzene acids and sulphu- ric acid (Merli et al., 2020).
Consistency Not feasible to be assessed.
Balance of benefit and harm One study reported higher levels of pain values during treatment and after 1 week for the glycine powder group as compared with mechanical instrumentation with ultrasonics (Merli et al., 2020). Cases of subcutaneous emphysema have been reported after the use of air-polishing devices (Alonso et al., 2017; Bassetti et al., 2014; Bruckmann et al., 2022). Among members of the expert panel, three groups had experienced such adverse events.
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