Esposito M, Grusovin M G, Kakisis I, Coulthard P, Worthington H V
School of Dentistry, Department of Oral and Maxillofacial Surgery, University of Manchester, Higher Cambridge Street, Manchester, UK, M15 6FH.
Cochrane Database Syst Rev. 2008 Apr 16(2):CD004970. doi: 10.1002/14651858.CD004970.pub3.
One of the key factors for the long-term success of oral implants is the maintenance of healthy tissues around them. Bacterial plaque accumulation induces inflammatory changes in the soft tissues surrounding oral implants and it may lead to their progressive destruction (perimplantitis) and ultimately to implant failure. Different treatment strategies for perimplantitis have been suggested, however it is unclear which are the most effective.
To identify the most effective interventions for treating perimplantitis around osseointegrated dental implants.
We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of the identified randomised controlled trials (RCTs) and relevant review articles for studies outside the handsearched journals. We wrote to authors of all identified RCTs, to more than 55 dental implant manufacturers and an Internet discussion group to find unpublished or ongoing RCTs. No language restrictions were applied. The last electronic search was conducted on 9 January 2008.
All RCTs comparing agents or interventions for treating perimplantitis around dental implants.
Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. We contacted the authors for missing information. Results were expressed as random-effects models using weighted mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals (CI). Heterogeneity was to be investigated including both clinical and methodological factors.
Ten eligible trials were identified, but three were excluded. The following procedures were tested: (1) use of local antibiotics versus ultrasonic debridement; (2) benefits of adjunctive local antibiotics to debridement; (3) different techniques of subgingival debridement; (4) laser versus manual debridement and chlorhexidine irrigation/gel; (5) systemic antibiotics plus resective surgery plus two different local antibiotics with and without implant surface smoothening; and (6) nanocrystalline hydroxyapatite versus Bio-Oss and resorbable barriers. Follow up ranged from 3 months to 2 years. The only statistically significant differences were observed in two trials judged to be at high risk of bias. After 4 months, adjunctive local antibiotics to manual debridement in patients who lost at least 50% of the bone around implants showed improved mean probing attachment levels (PAL) of 0.61 mm and reduced probing pockets depths (PPD) of 0.59 mm. After 6 months, patients with perimplant infrabony defects > 3 mm treated with Bio-Oss and resorbable barriers gained 0.5 mm more PAL (borderline difference) and PPD than patients treated with a nanocrystalline hydroxyapatite.
AUTHORS' CONCLUSIONS: There is very little reliable evidence suggesting which could be the most effective interventions for treating perimplantitis. This is not to say that currently used interventions are not effective. The use of local antibiotics in addition to manual subgingival debridement was associated with a 0.6 mm additional improvement for PAL and PPD over a 4-month period in patients affected by severe forms of perimplantitis. After 6 months both augmentation therapies appeared to be successful but improved PAL and PPD (0.5 mm) were obtained when using Bio-Oss with resorbable barriers. In four trials, the control therapy which basically consisted of a simple subgingival mechanical debridement seemed to be sufficient to achieve results similar to the more complex and expensive therapies. Sample sizes were very small and follow up too short, therefore these conclusions have to be considered with great caution. Larger well-designed RCTs are needed.
口腔种植体长期成功的关键因素之一是维持其周围组织的健康。细菌菌斑的积聚可引发口腔种植体周围软组织的炎症变化，并可能导致其逐渐破坏（种植体周炎），最终导致种植失败。针对种植体周炎已提出了不同的治疗策略，但尚不清楚哪种最为有效。
确定治疗骨结合牙种植体周围种植体周炎的最有效干预措施。
我们检索了Cochrane口腔健康组试验注册库、Cochrane对照试验中央注册库（CENTRAL）、医学索引（MEDLINE）和荷兰医学文摘数据库（EMBASE）。手工检索包括几种牙科杂志。我们检查了已识别的随机对照试验（RCT）的参考文献以及相关综述文章，以查找手工检索杂志之外的研究。我们致函所有已识别RCT的作者、55多家牙科种植体制造商以及一个互联网讨论组，以查找未发表或正在进行的RCT。未设语言限制。最后一次电子检索于2008年1月9日进行。
所有比较治疗牙种植体周围种植体周炎的药物或干预措施的RCT。
两名综述作者独立重复进行合格研究的筛选、试验方法学质量评估及数据提取。我们就缺失信息与作者进行了联系。结果以随机效应模型表示，连续结局采用加权均数差，二分结局采用风险比，并给出95%置信区间（CI）。将对异质性进行调查，包括临床和方法学因素。
共识别出10项合格试验，但排除了3项。测试了以下程序：（1）局部使用抗生素与超声清创术；（2）辅助局部抗生素清创的益处；（3）不同的龈下清创技术；（4）激光与手动清创及洗必泰冲洗/凝胶；（5）全身用抗生素加切除性手术加两种不同局部抗生素，有无种植体表面平滑处理；（6）纳米晶羟基磷灰石与Bio-Oss及可吸收屏障。随访时间为3个月至2年。仅在两项被判定为高偏倚风险的试验中观察到具有统计学意义的差异。4个月后，在种植体周围骨丧失至少50%的患者中，手动清创辅助局部使用抗生素后，平均探诊附着水平（PAL）提高了0.61mm，探诊袋深度（PPD）降低了0.59mm。6个月后，与接受纳米晶羟基磷灰石治疗的患者相比，使用Bio-Oss和可吸收屏障治疗种植体周骨下缺损>3mm的患者，PAL和PPD增加了0.5mm（临界差异）。
几乎没有可靠证据表明哪种干预措施对治疗种植体周炎最为有效。这并非意味着目前使用的干预措施无效。对于患有严重形式种植体周炎的患者，在手动龈下清创的基础上加用局部抗生素，在4个月期间PAL和PPD额外改善了0.6mm。6个月后，两种增量治疗似乎都取得了成功，但使用Bio-Oss和可吸收屏障时，PAL和PPD改善了0.5mm。在四项试验中，基本由简单龈下机械清创组成的对照治疗似乎足以取得与更复杂、更昂贵治疗相似的结果。样本量非常小，随访时间过短，因此必须极其谨慎地考虑这些结论。需要开展更大规模、设计良好的RCT。
