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HERRERA ET AL .
Background
loss were not uncommon events after 5 years. Data on PROMs and adverse events were rarely reported.
Intervention
Overall certainty of the evidence The certainty of evidence is graded as moderate based on the lack of direct comparisons between surgical and non-surgical therapy of peri- implantitis.
Surgical therapy of peri-implantitis includes flap elevation, removal of inflamed tissues and implant surface debridement/decontamination. In access flap procedures, soft tissue flaps are simply repositioned, while resective approaches aim at apically displacing flaps through soft tissue and/or hard tissue recontouring.
From evidence to recommendation — additional considerations
Available evidence
Acceptability PROMs were rarely reported. Limited data suggest a high degree of patient satisfaction at 1 year following surgical therapy. Adverse events reported were mostly related to the use of systemic antibiotics.
Number and design of included studies Thirteen studies ( n = 649 patients), with a follow-up range from 1 to 5 years (only two studies with a 5-year follow-up), were included (Karlsson et al., 2023). One study was an RCT comparing surgical ther- apy to non-surgical intervention. All datasets were prospective and a total of 10 originated from control arms within RCTs, while the remaining two were case series. All studies reported on reduction of PD and BOP. Clinically relevant end points (e.g., PD < 6 mm), PROMs, health economic parameters and adverse events were not consis- tently reported. Risk of bias The 13 studies were generally found to be at low RoB. In the two evaluations covering longer follow-ups ( ≥ 5 years; Carcuac et al., 2020; Heitz-Mayfield et al., 2018), loss to follow-up exceeded 20% and the overall rating was downgraded to ‘ fair ’ . Effect sizes and their clinical relevance Based on 18 studies ( n = 661 implants), the estimated reduction of PD was 2.2 mm (95% CI [1.8; 2.7]). Based on 8 studies ( n = 477), reduction of standardized mean BOP% was estimated at 27.0 (95% CI [19.8; 34.2]). Based on 12 studies ( n = 637), a standardized mean bone gain of 0.2 mm (95% CI [0.0; 0.5]) was estimated. Over 5-year observation periods, disease recurrence/progression was observed at 32% – 44% of treated implants. Corresponding implant loss was low in the short term but after 5 years ranged from 14% to21%. Consistency Results were consistent across studies in regard to changes in PD and MBL. Reduction of BOP was heterogenous across studies. Data were generated in various clinical settings, including university centres and private clinics. Balance of benefit and harm In general, considerable improvements in clinical and radiographic parameters were noted. However, disease recurrence and implant loss were not uncommon events after 5 years. Data on PROMs (two studies) and adverse events (three studies) were rarely reported.
Feasibility Related procedures are clinically demanding.
Ethical considerations Some decontamination procedures and grafting materials evaluated in the studies included have not been tested for safety. Economic considerations Health economic parameters were not evaluated in the identified studies. In general, surgical therapy of peri-implantitis is a costly pro- cedure. Some decontamination procedures and grafting materials may generate additional costs in the absence of documented benefit. Legal considerations Some decontamination procedures and grafting materials evaluated in the studies included have not been tested for safety and are consid- ered off-label.
R8.6. What is the efficacy of surgical treatment of peri-implantitis using access flap or resective procedures (resection of hard/soft peri-implant tissues aiming at reducing or eliminating pockets)?
PICOS question addressed by an SR
R8.6: Evidence-based recommendation In peri-implantitis patients in whom endpoints of non-surgical therapy (PD ≤ 5mmand ≤ 1 point of BOP) have not been achieved, we recommend performing access flap or resective surgery as both modalities are effective . Supporting literature (Karlsson et al., 2023) Quality of evidence Moderate Grade of recommendation GradeA — "" Strength of consensus Consensus (0% of the group abstained due to potential CoI)
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