Adjunctive use of metronidazole-minocycline ointment in the nonsurgical treatment of peri-implantitis: A multicenter randomized controlled trial

Comparative effectiveness of interventions for the treatment of peri-implantitis: A systematic review with network meta-analysis

STATEMENT OF PROBLEM

Extensive research has been carried out on the various aspects of diagnosing and treating peri-implantitis. However, clinical guidelines for the management of peri-implantitis based on high quality evidence are lacking.

PURPOSE

The purpose of this systematic review with network meta-analysis was to analyze the current evidence on nonsurgical and surgical interventions for the treatment of peri-implantitis and synthesize clinical guidelines based on high quality evidence.

MATERIAL AND METHODS

A search was conducted for trials published in Medline, Scopus, PubMed, and Cochrane Central Register of Controlled Trials from inception until July 2023. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023451056). A network meta-analysis was performed on data from randomized controlled trials that assessed nonsurgical and surgical interventions for the treatment of peri-implantitis. The interventions were ranked according to their efficacy using surface under the cumulative ranking (SUCRA) system. The grading of recommendations, assessment, development, and evaluations (GRADE) approach was used to assess the level of certainty of evidence.

RESULTS

A total of 45 articles were included in the quantitative analysis. The GRADE approach determined a moderate to high level of certainty of evidence. Among the nonsurgical interventions, mechanical debridement with adjunctive systemic antibiotics was significant in improving probing depth at 3 months and beyond 6 months, clinical attachment loss at 3 months, and clinical attachment loss beyond 6 months. Mechanical debridement with adjunctive topical antibiotics was significant in improving probing depth beyond 6 months, clinical attachment loss at 3 months, clinical attachment loss beyond 6 months, and radiographic bone loss beyond 6 months. Mechanical debridement with adjunctive photodynamic therapy was significant in improving probing depth beyond 6 months, clinical attachment loss at 3 months, clinical attachment loss beyond 6 months, and radiographic bone loss beyond 6 months. Mechanical debridement with adjunctive systemic antibiotics and photodynamic therapy was significant in improving probing depth beyond 6 months. Among surgical interventions, open flap debridement with implant surface decontamination and open flap debridement with decontamination and adjunctive photodynamic therapy were significant in improving probing depth at 3 months.

CONCLUSIONS

Mechanical debridement with adjunctive systemic antibiotics or photodynamic therapy results in improved clinical outcomes.

The Efficacy of Ten Different Adjunctive Measures in Patients with Nonsurgically Treated Peri-Implant Disease: A Network Meta-Analysis of Randomized Controlled Trials

Objective: This study aimed to evaluate the impact of 10 adjunctive measures on non-surgical therapy outcomes for peri-implant disease. Methods: We formulated the study question and keywords following the Population, Intervention, Comparator, Outcome framework. Randomized controlled trials were identified through searches in PubMed, Embase, the Cochrane Library, and the Web of Science. Two researchers assessed the quality of included literature according to the Cochrane Risk of Bias Assessment Tool. Data analysis and ranking were performed using Stata 15.0 software. Results: This study, involving 51 pieces of literature and 2660 samples, conducted a network meta-analysis (NMA), which revealed that photodynamic therapy (PDT) significantly reduced probing pocket depth values in patients with peri-implant mucositis (SUCRA = 96.3%) and peri-implantitis (SUCRA = 96.7%). In addition, it showed an improvement in bleeding on probing (BOP) values for peri-implantitis (SUCRA = 91.6%). Furthermore, diode lasers improved BOP values for peri-implant mucositis (SUCRA = 76.5%). Conclusions: According to the NMA results and the surface under the cumulative ranking curve (SUCRA), PDT and diode laser outperform other adjuncts in peri-implant disease.

Comprehensive treatment protocol for peri-implantitis: an up-to date narrative review of the literature

This narrative review describes up-to-date treatment options for peri-implantitis and proposes a treatment protocol and flowchart based on the current scientific evidence. Peri-implantitis treatment should be based on the phased treatment protocol for periodontitis, which is a continuous flow of decisions for extraction, nonsurgical and surgical treatments with step-by-step re-evaluation. The protocol's goals are to fulfill the success criteria for peri-implantitis treatment (probing depth of ≤5 mm, and absence of bleeding on probing, suppuration, and progressive bone loss) and to halt disease progression. Fixtures with peri-implantitis can initially be classified as failed or failing. A failed implant needs to be removed. In contrast, nonsurgical and surgical treatments can be applied to a failing implant. Nonsurgical treatment should be the initial treatment for failing implants; however, sole nonsurgical treatment was regarded as inefficient for peri-implantitis. Recent studies have found that the adjunctive use of antibiotics to nonsurgical debridement increased the success of nonsurgical treatment for peri-implantitis. Surgical treatments can be classified into resective, access, and reconstructive surgeries. The technique should be selected according to the patient's bone defect configuration, which relate to regenerative potential. Various combinations of decontamination methods (e.g., mechanical, chemical, and pharmacological approaches) are required to achieve absolute surface decontamination. Clinicians should select an appropriate surface decontamination strategy according to the purpose of surgery. After signs of disease disappear and its progression is halted through active peri-implantitis treatment, it is necessary to enroll patients into maintenance programs. Compliance of patients with the maintenance program reduces the recurrence of peri-implantitis and sustains clinical success after treatment. Maintenance visits should include professional plaque control and hygiene care reinforcement for patients, and their interval should be set according to individual peri-implantitis risk. Clinicians should remind that peri-implantitis treatment is not a single procedure, but rather a continuing cycle of treatment and re-evaluation.

Calcium phosphate cement with minocycline hydrochloride-loaded gelatine microspheres for peri-implantitis treatment

OBJECTIVES

This study aimed to fabricate an antibacterial calcium phosphate cement (CPC) with minocycline hydrochloride (MINO)-loaded gelatine microspheres (GMs) as a local drug delivery system for the treatment of peri‑implantitis.

METHODS

CPC/GMs(MINO), incorporating MINO-loaded GMs into CPC, was developed and characterised using scanning electron microscopy (SEM), X-ray diffraction (XRD), and drug release profiling. The antibacterial activity against Porphyromonas gingivalis and Fusobacterium nucleatum was evaluated. Bone mesenchymal stem cells (BMSCs) were cultured in the extracts of the developed cements to evaluate osteoinductivity in vitro. Furthermore, a rabbit femoral model was established to evaluate osteogenic ability in vivo.

RESULTS

SEM and XRD confirmed the porous structure and chemical stability of CPC/GMs(MINO). The release profile showed a sustained release of MINO from CPC/GMs(MINO), reaching an equilibrium state on the 14th day with a cumulative release ratio of approximately 84%. For antibacterial assays, the inhibition zone of CPC/GMs(MINO) was 3.67 ± 0.31 cm for P. gingivalis and 7.47 ± 0.50 cm for F. nucleatum. Most bacteria seeded on CPC/GMs(MINO) died after 24 h of culture. In addition, CPC/GMs(MINO) significantly enhanced alkaline phosphatase activity, osteogenic gene expression, and BMSC mineralisation compared with CPC/GMs and the control group (P < 0.05). The in vivo results showed that CPC/GMs(MINO) possessed a higher quality and quantity of bone formation and maturation than CPC/GMs and CPC.

CONCLUSIONS

CPC/GMs(MINO) showed excellent antibacterial activity against pathogens associated with peri‑implantitis and demonstrated good osteoinductivity and osteogenic ability.

CLINICAL SIGNIFICANCE

Peri-implantitis is among the most common and challenging biological complications associated with dental implants. In this study, MINO-loaded GMs were incorporated into CPC, which endowed the composite cement with excellent antibacterial and osteogenic abilities, demonstrating its potential as a bone graft substitute for treating peri‑implantitis.

Clinical efficacy of adjunctive methods for the non-surgical treatment of peri-implantitis: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review (SR) was to evaluate the clinical efficacy of different adjunctive methods/therapies to the non-surgical treatment (NST) of peri-implantitis.

MATERIALS AND METHODS

The protocol of the review was registered in PROSPERO database (CRD42022339709) and was designed according to PRISMA statement. Electronic and hand searches were performed to identify randomized clinical trials (RCTs) comparing non-surgical treatment of peri-implantitis alone versus NST plus any adjunctive method/treatment. The primary outcome was probing pocket depth (PPD) reduction.

RESULTS

Sixteen RCTs were included. Only 2 out of 1189 implants were lost and follow-up ranged from 3 to 12 months. PPD reduction across the studies varied from 0.17 to 3.1 mm, while defect resolution from 5.3% to 57.1%. Systemic antimicrobials were associated to higher PPD reduction (1.56 mm; [95% CI 0.24 to 2.89]; p = 0.02) with high heterogeneity, and treatment success (OR = 3.23; [95% CI 1.17 to 8.94]; p = 0.02), compared to NST alone. No differences were found with adjunctive local antimicrobials and lasers for PPD and bleeding on probing (BoP) reduction.

CONCLUSIONS

Non-surgical treatment with or without adjunctive methods may reduce PPD and BoP even if complete resolution of the pocket is unpredictable. Among possible adjunctive methods, only systemic antibiotics seems to provide further benefits, but their usage should be considered with caution.

Efficacy of adjuvant metronidazole therapy on peri-implantitis: a systematic review and meta-analysis of randomized clinical studies

Peri-implant diseases are pathological conditions that affect the survival of dental implants. Etiological studies are limited, accepting a prevalence of 20% at the implant level and 24% at the patient level. The benefits of adjuvant metronidazole are controversial. A systematic review and meta-analysis of RCTs according to PRISMA and PICOS was performed with an electronic search over the last 10 years in MEDLINE (PubMed), WOS, Embase, and Cochrane Library. The risk of bias was measured using the Cochrane Risk of Bias tool and the methodological quality using the Jadad scale. Meta-analysis was performed with RevMan version 5.4.1, based on mean difference and standard deviation, with 95% confidence intervals; the random-effects model was selected, and the threshold for statistical significance was defined as p < 0.05. A total of 38 studies were collected and five were selected. Finally, one of the studies was eliminated because of unanalyzable results. All studies reached a high methodological quality. A total of 289 patients were studied with follow-up periods from 2 weeks to 1 year. Statistical significance was only found, with respect to the use of adjunctive metronidazole, in the pooled analysis of the studies (p = 0.02) and in the analysis of the radiographic values reported on peri-implant marginal bone levels, in the studies with a 3-month follow-up (p = 0.03). Discrepancies in the use of systemic metronidazole require long-term randomized clinical trials (RCTs) to determine the role of antibiotics in the treatment of peri-implantitis.

Antibiotics as Adjunctive Therapy in the Non-Surgical Treatment of Peri-Implantitis: A Systematic Review and Meta-Analysis

The role of antibiotics as adjunctive therapy in the non-surgical treatment of peri-implantitis is uncertain. The aim of this systematic review of randomized controlled trials was to assess the efficacy of antibiotic therapy, local or systemic, as an adjunctive to the non-surgical therapy of peri-implantitis. Primary outcomes were: implant success rate and complications, changes in radiographic bone level, probing pocket depth (PPD), probing attachment level (PAL), bleeding on probing (BOP) and peri-implantitis resolution. Six studies were included: two using topical and four systemic antibiotics. Adjunctive local antibiotics improved PPD (mean difference (MD) = 0.6 mm; 95% CI 0.42-0.78), BOP (MD = 0.15% (95% CI 0.10, 0.19)) and the success rate (risk ratio = 9.89; 95% CI 2.39-40.84). No significant difference in bone level and success rate were found with the use of systemic antibiotics, although they appeared to improve PPD (MD = 1.15 mm; 95% CI 0.31-1.99) and PAL (MD = 1.10 mm; 95% CI 0.13-2.08). Within the limitations of this review, the adjunctive local antibiotics showed improved outcomes in terms of success rate, PPD and BOP, while adjunctive systemic antibiotics improved PPD and PAL only. Peri-implantitis resolution was about 20-30% using adjunctive local antibiotics, whilst it ranged from 2% to 65% with adjunctive systemic antibiotics. Findings are still controversial, since they are based on few studies with high heterogeneity, at the uncertain or high risk of bias and involve few patients. Non-surgical debridement and maintenance periodontal support therapy remain pivotal and the adjunctive use of antibiotics for peri-implantitis cannot be routinely recommended, even considering the increasing concern on antibiotic resistance.

Piperacillin-Tazobactam as an Adjuvant in the Mechanical Treatment of Patients with Periodontitis: A Randomized Clinical Study

In this study, the aim was to evaluate the effects of the adjuvant piperacillin-tazobactam solution in the mechanical treatment of periodontitis. A single-blind split-mouth randomized study, it included 24 participants. All of them presented periodontitis stage III according to the 2018 World Workshop classification and the presence of at least one of the following periodontal pathogens: Aggregatibacter actinomycetemcomitans; Porphyromona gingivalis; Treponema denticola; Tannerella forsythia; Prevotella intermedia. The study established two groups: a control group (SRP: scaling and root planing) and a test group (SRP plus local piperacillin-tazobactam). The final recruitment included 11 women (45.8%) and 13 men (54.2%). The age range was between 25 and 72 years, and the mean age was 57 ± 10.20 years. Clinical controls were performed at 2 weeks, 3 months, and 6 months, repeating the SRP and applying the piperacillin-tazobactam solution again at the 3-month appointment. The clinical attachment level decreased by a mean of 2.13 ± 0.17 mm from the baseline to 6 months in the test group versus 1.63 ± 0.18 mm in the control group. The mean probing pocket depth decreased from 1.32 ± 0.09 mm in the test group, versus from 0.96 ± 0.14 mm on the control side. The plaque index in the test group decreased by 0.46 ± 0.04, while it decreased by an average of 0.31 ± 0.04 in the control group. In conclusion, the local use of piperacillin-tazobactam as complementary therapy produces better clinical results in patients with periodontitis. However, these results are not maintained over time, and so a more persistent local application is necessary.

The efficacy of minocycline hydrochloride ointment versus iodoform gauze for alveolar osteitis: A prospective cohort study

Background

Alveolar osteitis (AO) is one of the most commonly encountered complication following tooth extraction, however, to date there is no standard methods of prevention and treatment. The study aims to investigate the efficiency of minocycline hydrochloride ointment (MHO) for the treatment of alveolar osteitis compared with traditional treatment with iodoform gauze (IG).

Methods/design

STROBE checklist was followed to report this study. All patients underwent tooth extraction either in our department or other hospitals, whom presented with postoperative pain, were screened out to meet the inclusion and exclusion criteria of this study about AO. Patients who fulfilled the inclusion criteria were enrolled in our prospective cohort study, and MHO or IG was administered. The Visual analog scale scores were used to assess the pain score of patients. The healing status of the extraction sockets was followed up. Differences in responses between groups were analyzed using Mann-Whitney U tests. Chi-square test was performed to explore the differences in the teeth position of AO.

Results

Of 41,371 patients underwent tooth extraction with post-operative follow-up in our departments, only 20 patients (0.05%) suffered from AO. 31 patients with AO, whose teeth were extracted in other places, were also enrolled. The incidence of AO was significantly higher in third molars than other teeth (P < 0.01). In 28 patients that were treated with MHO, the pain was relieved substantially on day 3 and almost painless on day 7. And only 25% of cases required dressing change more than once. Whilst 23 patients treated with IG, the pain was relieved on day 5, and 56.5% of cases required multiple dressing change. The difference between the two groups of VAS scores had statistical significance during treatment at 8 h, 24 h, 3d, 5d, and 7d. No allergic reaction or further infection occurred.

Conclusion

MHO has a safer and higher therapeutic effect in the treatment of AO compared with traditional treatment with IG. MHO may become a preferred treatment modality for AO.

Supplementary information

The online version contains supplementary material available at 10.1186/s12903-022-02468-9.

Local/Topical Antibiotics for Peri-Implantitis Treatment: A Systematic Review

Most studies indicate that the mechanical removal of the bacterial biofilm from the implant surface is the central goal of peri-implantitis therapy. However, controversial results in the treatment of peri-implantitis have led to the consideration of additional strategies that include surgical approaches and chemical adjuvants. Local/topical antibiotics, such as minocycline, azithromycin, tetracycline, amoxicillin, doxycycline, and metronidazole, may improve the efficacy of the definitive treatment of the disease, but the lack of conclusive findings prevents their use in clinical practice. This systematic review aimed to evaluate the effect of local/topical antibiotics for peri-implantitis treatment. Randomised controlled studies (RCT) on patients with peri-implantitis and comparing the efficacy of local/topical antibiotics vs. placebo or mechanical debridement were included. A systematic search strategy was carried out using three registered databases (PubMed, Web of Science, and Scopus). RoB2 was used to assess risk of bias. Five RCTs were identified (n = 250 patients and 333 implants). Contrast results emerged among the included studies, and a high heterogeneity level was observed. Risk of bias revealed some concerns for three studies out of five, while one study was judged at high risk. Only one study analysed the limitations of its findings. Overall, local antibiotic use can be considered a valid approach in the treatment of peri-implantitis. Therefore, future long-term clinical trials with standardised protocols and antibiotics with similar biological activity profiles should be tested to achieve a valid and definitive conclusion.