Esposito Marco, Grusovin Maria Gabriella, Worthington Helen V
Cochrane Oral Health Group, School of Dentistry, The University of Manchester, Coupland 3 Building, Oxford Road, Manchester, UK, M13 9PL.
Cochrane Database Syst Rev. 2012 Jan 18;1(1):CD004970. doi: 10.1002/14651858.CD004970.pub5.
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 (peri-implantitis) and ultimately to implant failure. Different treatment strategies for peri-implantitis have been suggested, however it is unclear which are the most effective.
To identify the most effective interventions for treating peri-implantitis around osseointegrated dental implants.
We searched the Cochrane Oral Health Group's Trials Register, 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authors of all identified RCTs, to more than 55 dental implant manufacturers and an Internet discussion group to find unpublished or ongoing RCTs.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 June 2011.
All RCTs comparing agents or interventions for treating peri-implantitis 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 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.
Fifteen eligible trials were identified, but six were excluded. The following interventions were compared in the nine included studies: different non-surgical interventions (five trials); adjunctive treatments to non-surgical interventions (one trial); different surgical interventions (two trials); adjunctive treatments to surgical interventions (one trial). Follow-up ranged from 3 months to 4 years. No study was judged to be at low risk of bias.Statistically significant differences were observed in two small single trials judged to be at unclear or 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 (95% confidence interval (CI) 0.40 to 0.82) and reduced probing pockets depths (PPD) of 0.59 mm (95% CI 0.39 to 0.79). After 4 years, patients with peri-implant infrabony defects > 3 mm treated with Bio-Oss and resorbable barriers gained 1.4 mm more PAL (95% CI 0.24 to 2.56) and 1.4 mm PPD (95% CI 0.81 to 1.99) than patients treated with a nanocrystalline hydroxyapatite.
AUTHORS' CONCLUSIONS: There is no reliable evidence suggesting which could be the most effective interventions for treating peri-implantitis. This is not to say that currently used interventions are not effective.A single small trial at unclear risk of bias showed 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 peri-implantitis. Another small single trial at high risk of bias showed that after 4 years, improved PAL and PPD of about 1.4 mm were obtained when using Bio-Oss with resorbable barriers compared to a nanocrystalline hydroxyapatite in peri-implant infrabony defects. There is no evidence from four trials that the more complex and expensive therapies were more beneficial than the control therapies which basically consisted of simple subgingival mechanical debridement. Follow-up longer than 1 year suggested recurrence of peri-implantitis in up to 100% of the treated cases for some of the tested interventions. As this can be a chronic disease, re-treatment may be necessary. Larger well-designed RCTs with follow-up longer than 1 year are needed.
口腔种植体长期成功的关键因素之一是维持其周围健康的组织。细菌菌斑的堆积会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（种植体周围炎），最终导致种植失败。针对种植体周围炎已提出了不同的治疗策略，但尚不清楚哪些最为有效。
确定治疗骨结合牙种植体周围种植体周围炎的最有效干预措施。
我们检索了Cochrane口腔健康小组试验注册库、Cochrane系统评价数据库、医学期刊数据库和Embase数据库。手工检索包括几本牙科杂志。我们查阅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和一个互联网讨论组，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2011年6月9日进行。
所有比较治疗牙种植体周围种植体周围炎的药物或干预措施的RCT。
由两位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和数据提取。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，连续结局采用平均差，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15项合格试验，但排除了6项。纳入的9项研究比较了以下干预措施：不同的非手术干预（5项试验）；非手术干预的辅助治疗（1项试验）；不同的手术干预（2项试验）；手术干预的辅助治疗（1项试验）。随访时间从3个月到4年不等。没有一项研究被判定为低偏倚风险。在两项被判定为偏倚风险不明确或高的小型单项试验中观察到了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，手动清创联合局部抗生素治疗使平均探诊附着水平（PAL）提高了0.61mm（95%置信区间（CI）0.40至0.82），探诊袋深度（PPD）降低了0.59mm（95%CI 0.39至0.79）。4年后，与使用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围骨下缺损>3mm的患者，PAL增加了1.4mm（95%CI 0.24至2.56），PPD增加了1.4mm（95%CI 0.81至1.99）。
没有可靠证据表明哪种干预措施对治疗种植体周围炎最有效。这并不是说目前使用的干预措施无效。一项偏倚风险不明确的小型单项试验表明，对于受严重形式种植体周围炎影响的患者，除手动龈下清创外使用局部抗生素在4个月期间使PAL和PPD额外改善了0.6mm。另一项偏倚风险高的小型单项试验表明，4年后，在种植体周围骨下缺损中，与纳米晶羟基磷灰石相比，使用Bio-Oss和可吸收屏障可使PAL和PPD改善约1.4mm。四项试验没有证据表明更复杂、更昂贵的治疗方法比基本上由简单龈下机械清创组成的对照治疗方法更有益。随访时间超过1年表明，对于某些测试干预措施，高达100%的治疗病例出现种植体周围炎复发。由于这可能是一种慢性病，可能需要再次治疗。需要开展设计更完善、随访时间超过1年的大型RCT。
