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Overall certainty of the evidence Low.
PICOS question addressed by an SR
R7.9: Evidence-based recommendation Quality of evidence Low — two RCTs for chlorhexidine ‘ chips ’ with low risk of bias and two RCTs for minocycline microspheres Grade of recommendation GradeB — # Strength of consensus : Consensus (1.9% of the group abstained due to potential CoI)
From evidence to recommendation — additional considerations
Acceptability No specific information is available; however, local antimicrobials are normally easy to use by the practitioners. Conversely, some patients/ clinicians may not be willing to use antimicrobial products. Feasibility Some of the evaluated products may not be commercially available in some countries. For chlorhexidine ‘ chips ’ , only one brand/manufacturer is available (PerioChip ® , Dexcel Pharma, Or Akiva, Israel). For minocycline microspheres, the brand tested in the considered studies was Arestin ® (OraPharma, Bridgewater, NJ, USA).
Background
Intervention
Locally delivered antimicrobials may be used as an adjunct to sub- gingival instrumentation in patients with periodontitis, particularly in non-responding and recurrent sites (Herrera et al., 2020). The same principle may apply for non-surgical therapy of peri- implantitis.
Ethical considerations No applicable.
Available evidence
Economic considerations Economic costs and cost-effectiveness should be considered before their use. Economic cost may be relatively high (for chlorhexidine ‘ chips ’ , one chip may cost around € 30, while for minocycline microspheres, one car- tridge costs around $100, especially if multiple applications are needed). Some additional information is presented in Section 1. Legal considerations Some of the evaluated products have not been registered for use in some countries, and/or may not have been approved for this specific indication.
Number and design of included studies Two placebo-controlled RCTs with 6-month follow-up assessed the adjunctive effect of locally applied chlorhexidine ‘ chips ’ to the non- surgical sub-marginal instrumentation (Machtei et al., 2012, 2021). These studies used an intense regime with multiple, repeated applica- tions during the observation period. In addition, although they were not included in the SR, two RCTs evaluating locally applied minocy- cline microspheres were considered in the discussions (Renvert et al., 2006, 2008).
Risk of bias Two RCTs with low risk of bias.
R7.10. Do adjunctive systemically administered antibiotics improve the clinical outcomes of non- surgical treatment?
Effect sizes and their clinical relevance Results of two studies evaluating multiple applications of a biodegrad- able matrix containing chlorhexidine were pooled for meta-analyses, showing a statistically significant improved PD reduction (WMD = 0.2 mm; 95% CI [0.0; 0.5]; p = .031; I 2 = 0.0%; p = .570). No or very limited information was available for BOP or disease resolution.
PICOS question addressed by an SR
R7.10: Expert consensus-based recommendation Due to concerns about patients' health and the impact of systemic antibiotic use on public health, its routine use as an adjunct to non- surgical treatment in patients with peri-implantitis is not recommended . Supporting literature (Liñares et al., 2023) Quality of evidence Low — two RCTs, one with some concerns, and another with low risk of bias. Grade of recommendation GradeA — ## Strength of consensus — Strong consensus (0% of the group abstained due to potential CoI)
Consistency Not feasible due to the limited information available.
Balance of benefit and harm No increase in adverse effects was observed. PROMs were not reported. Harm versus benefit considerations on the use of locally delivered antibiotics need to be considered.
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