Cochrane-Review: Behandling af peri-implantitis

Der er ikke evidens for, hvilken metode der er mest effektiv ved behandling af peri-implantitis. Men det betyder ikke, at de metoder, som vi anvender i dag, ikke virker. Sådan konkluderer et nyligt publiceret review fra Cochrane. Reviewet inkluderede ni studier. Der er udelukkende inkluderet randomiserede kontrollerede kliniske undersøgelser. Der blev fokuseret på såvel ikke-kirurgisk som kirurgisk behandling.

Observationsperioden varierede fra tre måneder til fi re år. Alle undersøgelser var karakteriseret ved varierende grad af bias.

Kommentar af professor, dr.odont., ph.d. Søren Schou, Tandlægeskolen i Aarhus:
– Som det konkluderes i denne oversigtsartikel, er der foretaget få undersøgelser, hvor effekten af forskellige behandlinger af peri-implantitis er sammenlignet. Der er imidlertid publiceret flere undersøgelser, hvor effekten af forskellige behandlinger er
vurderet uden sammenligning med andre behandlinger. Der er fokuseret på såvel kirurgiske som ikke-kirurgiske behandlinger.

Vores viden om behandling af peri-implantitis er på flere områder fortsat mangelfuld. Der er imidlertid i dag enighed om, at effekten af ikke-kirurgisk behandling i de fl este tilfælde er begrænset. Derfor involverer behandling af peri-implantitis
som hovedregel kirurgisk behandling.

Den kirurgiske behandling kan involvere en resektiv procedure mhp. pochereduktion eller en regenerativ procedure.

Vores viden om, hvornår der med fordel kan anvendes en resektiv procedure eller en regenerativ procedure, er fortsat mangelfuldt belyst. Valg af kirurgisk behandling afhænger blandt andet af lokalisation, defektmorfologi og tilstedeværelse af nabotænder eller -implantater.

Hvis der ønskes yderligere information om behandling af peri-implantitis, afholdt European Association for Osseointegration (EAO) i februar den 3. EAO-konsensuskonference.

Konsensusrapporterne er netop publiceret i Clinical Oral Implants Research. To af disse rapporter omhandler henholdsvis ikke-kirurgisk og kirurgisk behandling af peri-implantitis (1,2).

• Muthukuru M, Zainvi A, Esplugues EO et al. Non-surgical
  therapy for the management of peri-implantitis: a systematic
  review. Clin Oral Implants Res 2012;23(Supp 6):77-83.

• Renvert S, Polyzois I, Claffey N. Surgical therapy for the control
  of peri-implantitis. Clin Oral Implants Res 2012;23(Supp
  6):84-94.

Abstract

Background
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.

Objectives
To identify the most effective interventions for treating peri-implantitis around osseointegrated dental implants.

Search methods
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.

Selection criteria
All RCTs comparing agents or interventions for treating peri-implantitis around dental implants.

Data collection and analysis
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.

Main results
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.

Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: treatment of peri-implantitis. Cochrane Database of Systematic
Reviews 2012, Issue 1. Art. No.: CD004970. DOI:10.1002/14651858.CD004970.pub5.