Scientific evidence is a critical piece of care, but be aware that guidelines are only as good as the existing evidence and the judgment of the experts writing them.
In recent years, evidence-based research such as systematic reviews, meta-analyses, and randomized controlled trials has increased and replaced anecdotal or successful personal experience by practitioners. As you’ll see in the research I’m going to discuss about peri-implant diseases, scientific evidence has become an important aspect of care compared with expert opinion and clinical experience. We now talk about “best practice” instead of “the art of medicine/dentistry.”1
A clinical practice guideline presents an evaluation of the quality of the relevant scientific literature and benefit/potential harms of treatment. For example, the American Dental Association has published several clinical practice guidelines on a variety of topics, such as recommendations by the American Heart Association on the use of antibiotics to prevent infective endocarditis or fluoride toothpaste recommendations for children younger than 6 years. Guidelines assist clinicians in the decision-making process for best outcome and consider systematic appraisal of published evidence as well as clinical experience. These guidelines can also help clinicians defend themselves in a court of law.
When a reversible inflammatory lesion affects the soft tissues surrounding a dental implant in the absence of radiographic bone loss (with bleeding on probing [BOP] as a key tool to distinguish an unhealthy peri-implant mucosa), a clinician will diagnose peri-implant mucositis. Other factors associated with peri-implant mucositis onset include biofilm accumulation, smoking, and radiation therapy.2,3
When a clinician observes an irreversible pathological condition affecting hard and soft tissues around a dental implant, the resulting bone loss is referred to as peri-implantitis.2,3 Peri-implantitis sites exhibit BOP and/or suppuration besides inflammation and are also associated with increased probing depths and recession of the mucosal margin.3 Etiology includes peri-implant plaque biofilm, history of severe periodontitis, poor oral hygiene, and irregular or no supportive peri-implant care following surgery. Less conclusive evidence for peri-implantitis consists of the following factors: smoking, diabetes, submucosal cement following prosthetic restoration of the dental implant, and positioning of the implant in such a manner that limits access to oral hygiene including professional maintenance.3
General Framework Used in Clinical Practice Guideline Development
The clinical practice guideline (2023) for peri-implant diseases was developed by the European Federation of Periodontology and overseen by an expert workshop committee. The overall effort included 13 systematic reviews conducted in support of the guideline development process. After the 13 reviews were conducted on specific, focused questions (eg, the efficacy of adjunctive measures to treat peri-implant mucositis), evidence-based recommendations were debated, and a consensus was reached and voted on.3
The quality of evidence for each of 13 areas (focused questions pertaining to peri-implant disease) was included, which reflected the degree of certainty/uncertainty of the evidence and the robustness of study results. In addition, the recommendation was graded, which reflected the criteria used to form a judgment and strength of consensus. Risk of bias was also included in group discussions and clinical practice guidelines.
Clinical Practice Guideline Components
The clinical practice guideline for peri-implant diseases (prevention and treatment) includes the following components:
In highlighting some of the clinical practice guideline recommendations below, keep in mind that recommendations by the workshop committee were based on strength of available evidence and/or expert consensus and was graded according to quality and certainty. The clinical practice guideline is considered valid until 2028 and is free to read in its entirety.
1. Prevention, Diagnosis, and Treatment Sequence
Patients who receive a dental implant should be considered at risk for some type of peri-implant disease.3 During the 2014 European Workshop in Periodontology, 2 systematic reviews demonstrated a patient-level prevalence estimate for peri-implant mucositis and peri-implant implantitis. In one systematic review, meta-analyses from 11 studies demonstrated a patient-level prevalence estimate of 43% (95% CI, 32%-54%) for peri-implant mucositis and 22% (95% CI, 14%-30%) for peri-implantitis. Another systematic review included 47 studies and reported a prevalence of 46.83% (95% CI, 38.30%-55.36%) for peri-implant mucositis and of 19.83% (95% CI, 15.38%-24.27%) for peri-implantitis.3
Interventions to prevent peri-implant disease should begin at the treatment planning stage and continue throughout the life of the dental implant in the oral cavity. Known risk factors associated with peri-implant diseases should be controlled, such as poor oral hygiene, smoking, diabetes, and untreated periodontitis.
Perioperative interventions for the prevention of peri-implant diseases must include placing the dental implant(s) in an optimal position while considering local factors that prevent ideal placement and designing/installing prostheses that allow access for oral hygiene. Avoid submucosal cement and select screw-retained restorations instead.3
Peri-implantitis is an irreversible condition. Even after successful peri-implantitis therapy, a diagnosis of “stable” is made.3 Upon diagnosis, refer to an appropriate specialist and decide whether the affected tooth can be treated. The following key aspects in the management of peri-implant diseases are important to remember3:
2. Recommendations for Prevention of Peri-Implant Diseases
Risk assessment and controlling risk factors are necessary in preventing peri-implant diseases in individuals who are candidates for dental implants, who have received dental implants, and who currently have healthy peri-implant tissues. Workshop participants created prevention categories of primordial primary, secondary, and tertiary to interpret evidence and expert-based consensus.3
Primordial prevention refers to the concept of optimal oral and general health prior to implant placement, but there is no current definition of optimal health and no studies directly addressing primordial prevention of peri-implant diseases. Instead, recommendations are based on indirect evidence and expert opinion. Primary prevention refers to the prevention of disease onset following dental implant placement and loading. No studies existed to provide direct evidence for primary prevention.
Clinical guidelines should be based on a thorough evaluation of the evidence and generally include a rating of the quality of evidence and an assigned strength to recommendations. Grading of Recommendations Assessment, Development, and Evaluations guidance warns against making strong recommendations when the certainty of the evidence is low or very low.
In this section, recommendations are mostly expert-consensus based due to low certainty of available evidence, and I would strongly recommend reading each pico question addressed online. [Pico questions are a way to construct a well built question in research. More information on this is available in the clinical practice guideline document referenced below.] Clinical practice guidelines should be based on a thorough evaluation of the evidence and assigned a strength of recommendation. When the certainty of evidence is low or very low, strong statements are not usually made.
Please read the entire clinical practice guideline document in the Journal of Clinical Periodontology3 for components not covered in this article. What follows is a synopsis of the recommendations for the prevention component:
What follows are recommendations for supportive periodontal therapy that are labeled as secondary and tertiary prevention3:
Read Full Guideline Online
As noted earlier, you can read the clinical practice guideline in its entirety in the Journal of Clinical Periodontology.3 The guideline includes recommendations for peri-implant mucositis and peri-implant nonsurgical and surgical treatment management. Access is free.
Always keep in mind that clinical guidelines are only as good as the evidence and the judgment of the experts who are making them. However, the European Federation of Periodontology spent a lot of time evaluating studies and used a reliable system for grading quality of evidence and strength of recommendations.